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Event Notification Report for April 18, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/17/2008 - 04/18/2008

** EVENT NUMBERS **


44120 44136 44137 44139

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44120
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN GARECHT
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/04/2008
Notification Time: 17:39 [ET]
Event Date: 04/04/2008
Event Time: 12:59 [EDT]
Last Update Date: 04/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SAM HANSELL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

ACCIDENT MITIGATION - COMMON CONTROL ROOM EMERGENCY AIR CONDITIONING SYSTEM

"Salem Unit 1 was placed in a configuration that affected the ability to mitigate the consequences of an accident due to an inadvertent actuation of the common control room emergency air conditioning system (CREACS). CREACS was actuated as a result of an invalid Control Room air intake duct radiation monitor initiated on April 4, 2008 at 1259 hours. Salem Unit-2 is currently defueled. Salem Unit 1 is in Mode 1 at 100% power. Unit 1 has two shutdown LCOs in effect. The first is for the CREACS system, which is shared between Unit 1 & 2, being aligned for single train operation with the Unit 2 CREACS train out of service per LCO 3.7.6. The second shutdown LCO is for two outside air intake dampers being inoperable for scheduled maintenance. With Unit 2 having an invalid Radiation Monitor signal, the CREACS system actuates in accident pressurized mode. This mode of actuation starts the CREACS fans, isolates the Control Room Envelope from the normal control room ventilation system and aligns the two sets of CREACS outside air intake dampers. With a Unit 2 Radiation Monitor signal, the Unit 2 CREACS intake dampers close and the Unit 1 CREACS intake dampers open. These damper positions are locked in until manually reset. With only one train of CREACS operable, the dose analysis indicates that the requirements of General Design Criterion (GDC) 19 can only be met during the worst case design basis accident if the Unit 1 CREACS intake dampers are closed and the Unit 2 CREACS intake dampers open. Therefore, until the CREACS intake dampers were reset and realigned, Salem Unit 1 would not have been able to mitigate the consequences of an accident and is reportable in accordance with 10CFR50.72(b)(3)(v)(D). The CREACS system actuation was reset after the failed radiation monitor (1R1B ch II) was removed from service and the dampers were re-aligned to their pre actuation alignment at 1316 hours, restoring Salem Unit 1 to within the assumptions of the dose analysis. Total duration in the condition was 17 minutes.

"The only piece of major equipment out of service on Salem Unit 1 is the 15 Service water pump which is out of service for scheduled maintenance."

The Licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY ERIC POWELL TO JASON KOZAL ON 04/17/08 AT 2113 * * *

"On April 4, 2008 Salem Unit 1 was placed in a configuration that was contrary to the current dose analysis of record due to an inadvertent actuation of the common control room emergency air conditioning system (CREACS). CREACS was initiated as a result of an invalid actuation of a Control Room air intake duct radiation monitoring channel (1R1B ch II). At the time of the actuation, the Unit 2 train of CREACS was out of service due to scheduled maintenance leaving only the Unit 1 CREACS train operable. Unit 1 was at 100% power and Unit 2 was defueled. With one train of CREACS out of service at the start of an accident the dose analysis of record requires that the CREACS emergency intake dampers for the unit having the accident to close and for the opposite units emergency intake dampers to open. The actuation of the radiation monitoring channel 1R1B channel II caused the Unit 1 emergency intake dampers to open which was contrary to the dose analysis of record.

"Subsequent to this event, an evaluation was performed utilizing the assumptions of the dose analysis of record with the exception of the actual measured engineered safety feature system leakage outside containment and the atmospheric dispersion factors (x/Q) associated with the Unit 1 CREACS intake. Based upon this evaluation, the CREACS system with one filtration train operable and the emergency intakes open on Unit 1 would have been able to maintain doses to the Control Room operators below the limits of GDC-19 and the dose analysis of record. Since the CREACS system was capable of performing its accident mitigation function, this event is being retracted."

The licensee will notify the NRC Resident Inspector.

Notified R1DO (Schmidt)

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General Information or Other Event Number: 44136
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City:  State: MS
County: HOLMES
License #: MS-493-01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2008
Notification Time: 10:02 [ET]
Event Date: 04/09/2008
Event Time: 07:00 [CDT]
Last Update Date: 04/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - MISSISSIPPI - TRAFFIC ACCIDENT INVOLVING TRUCK CARRYING TC-99M

The State provided the following information via email:

"DRH [Mississippi Division of Radiological Health] received a phone call from Cardinal Health RSO on 4-9-08 about a transportation accident involving one of their transport vehicles and an 18 wheeler on Hwy 49 South near Tchula, MS. The accident happened around 7:00 AM. The Cardinal driver had already made his deliveries to the facilities and only had the return packages (used doses) from the day before. According to RSO, driver hit the rear of the 18 wheeler after he made a sudden stop on the highway. According to RSO, all packages stayed secured and braced and their was no contamination or contents spilled out of the packages. Another driver was in route to location to pick up the other driver and the radioactive packages to return them to the Flowood facility."

The material being transported was used doses of Tc-99m and there was no spillage or cleanup required.

MS Report No. MS-493-01

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General Information or Other Event Number: 44137
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2008
Notification Time: 11:22 [ET]
Event Date: 12/11/2007
Event Time: [CDT]
Last Update Date: 04/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MISSISSIPPI - MISADMINISTRATION INVOLVING AN HDR TREATMENT

The State provided the following information via email:

"On 3-26-08, licensee's RSO notified DRH [Mississippi Division of Radiation Health] of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. "

MS Report No. MS-08004

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 44139
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CARDINAL HEALTH
Region: 1
City: GAINESVILLE State: FL
County:
License #: 3453-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/15/2008
Notification Time: 11:26 [ET]
Event Date: 03/19/2008
Event Time: [EDT]
Last Update Date: 04/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
MICHELE BURGESS (FSME)
ILTAB VIA EMAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE - FLORIDA - MISSING DOSE OF TC-99M

The State provided the following information via facsimile:

"Cardinal Health reported that they are missing a single dose of Tech-99m, 25 mCi's since 19 March 2008. Customer reported item was not in ammo box upon receipt. Cardinal Health has searched premises with no indication. Procedures were reviewed and found to be correct. Corrective action consisted of a staff meeting to reiterate the requirement to follow proper procedure when packaging and shipping radioactive material. Incident referred to materials office for further investigation. This office will take no further action."

FL Rpt No: FL08-056

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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