United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2008 > April 21

Event Notification Report for April 21, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/18/2008 - 04/21/2008

** EVENT NUMBERS **


44110 44139 44147 44148 44149 44151 44152

To top of page
General Information or Other Event Number: 44110
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PROVIDENCE EVERETT MEDICAL CENTER
Region: 4
City: EVERETT State: WA
County:
License #: WN-M0135-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2008
Notification Time: 18:19 [ET]
Event Date: 03/28/2008
Event Time: [PDT]
Last Update Date: 04/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
KEITH McCONNELL (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A PARTIAL EQUIPMENT FAILURE OF AN HDR UNIT DURING A SOURCE EXCHANGE

The following information was received from the State of Washington via email (quotations omitted for ease of reading):

STATUS: New

Licensee: Providence Everett Medical Center
City and State: Everett, WA
License Number: WN-M0135-1
Type of License: Medical
Date and time of Event: 28 March 2008
Location of Event: Everett, WA

ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

A Varian Medical Systems (varian) representative was attempting a routine source exchange at the licensee's facility. There were no patients or Medical Center staff involved in the source exchange process. The varian rep noted some trouble with making the "old" source enter the exchange container. After several attempts the rep realized the transfer was not proceeding as expected. The rep telephoned staff at Varian Corporate headquarters for assistance. The decision was made to cut the source wire near the source and place the source assembly into the emergency shielded source container (emergency pig). After the wire was snipped and the cut piece placed into the emergency pig, the rep performed a survey and noticed that the radiation levels were less than expected. At this time the licensee and the Varian rep both notified the Office of Radiation Protection of the event by telephone.

The room was locked and barrier tape placed across the door. A Varian recovery team was called for and arrived at the Medical Center, with the source designer, on Saturday, 29 March 2008.

An Office of Radiation Protection investigator also joined the team on Saturday to direct the onsite investigation and recovery.

The investigation determined that both the dummy wire and the source wire had tried to exit the HDR unit simultaneously. The wires become stuck in the "home switch" part of the HDR. When a wire was cut it had been the dummy wire and not the source assembly wire. The cutoff dummy wire had been placed into the emergency pig which had given lower then the expected dose rate readings.

On Saturday, the recovery team successfully retracted the source into the HDR. Testing is underway to determine why the HDR source exchange process had allowed both wires to be sent out at once. A comprehensive written report is expected from the manufacturer within the next few days.

Notification Reporting Criteria: WAC 246-220-250 Equipment Failure.

Isotope and Activity involved: HDR Sealed Source: Ir-192, approximately 185 GBq (5 Curies).

Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None

Lost, Stolen or Damaged? (mfg., model, serial number): Varian HDR source model VS2000 (not lost, not stolen, possibly damaged).

Disposition/recovery: Source recovered 29 March 2008 by Varian recovery team.

Leak test? No "official" leak test yet but several contamination wipe surveys were performed during the course of the recovery. All of these were negative.

Vehicle: N/A

Release of activity? None

Activity and pharmaceutical compound intended: N/A

Misadministered activity and/or compound received: N/A

Device (HDR, etc.) Mfg., Model; Varian VariSource Ix (Trademark) HDR

Exposure (intended/actual); consequences: None to patients and the public. The highest exposure received by a recovery team member was 87 mRem.

Was patient or responsible relative notified? N/A

Was written report provided to patient? N/A

Was referring physician notified? N/A

Consultant used? No

Event Report # WA-08-020.

* * * UPDATE VIA E-MAIL FROM ARDEN SCROGGS TO JASON KOZAL ON 04/18/08 AT 1836 * * *

"A written report was received [by the state] from the manufacturer.

"The Varian report concluded the cause of the incident was 'the service engineer mistakenly extending the active source wire while the dummy wire was already in the same pathway. This action jammed the dummy and source wires at the home switch and prevented the active wire from properly retracting to the tungsten safe when commanded.'

"[The manufacturer] also concluded the likelihood of a licensee / operator recreating this type of event was nil, since the conditions which allowed this to happen are only present when the factory service engineer is working on the unit.

"This was originally reported as an equipment failure but now appears to be an error by the manufacturer's representative."

Notified R4DO (Clark) and FSME (Von Till).

To top of page
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

To top of page
Power Reactor Event Number: 44147
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TODD CHAMBERLAIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/18/2008
Notification Time: 06:20 [ET]
Event Date: 04/18/2008
Event Time: 06:02 [EDT]
Last Update Date: 04/18/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3)
TIM McGINTY (NRR)
BRIAN McDERMOTT (IRD)
JIM WIGGINS (ET)
JIM CALDWELL (R3 R)
BURCKHARDT (FEMA)
BARNES (DHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO SEISMIC ACTIVITY

"At 06:02 on April 18 2008, DC Cook Units 1 and 2 entered the Emergency Plan for a confirmed seismic event based on ground motion felt by plant personnel. An immediate notification to the NRC is required under 10 CFR 50.72(a)(3) for entry into the Emergency Plan. The ground motion sensed by plant personnel was confirmed with the National Earthquake Center. A magnitude 5.4 preliminary (Richter scale) earthquake was confirmed in Southern Illinois at LATITUDE 38.481 North/LONGITUDE 87.826 West.

"The Earthquake Abnormal Operating Procedures were entered for both Units. Ground motion was not felt by the control room operating crews, but was noted and reported by other plant personnel. Plant Process Computer trends of Unit 1 RWST level, South Boric Acid Storage Tank Level and North Chemical and Volume Control System Hold Up Tank Level indicated ground motion. No damage to plant equipment was noted during the initial evaluation of plant status. Investigation of the plant impact of the sensed ground motion is in progress.

"The NRC Resident Inspectors were notified by phone call. Current Plant status: Unit 1 is shutdown in Mode 6 with Residual Heat Removal Cooling. Unit 2 is operating in Mode 1 at 100% power. AEP system Operations was contacted and the GRID was described as stable and no electrical operations relating to the earthquake event.

"The Seismic Monitoring system was INOPERABLE as required by TRO 8.3.2, Cond. B, during the event for routine surveillance. This surveillance has been in progress since 03/26/08. No alarms were generated by the seismic monitoring system during this event."

* * * UPDATE AT 0910 EDT ON 04/18/08 FROM CHRIS KELLEY TO S. SANDIN * * *

At 0905 EDT on 04/18/08, the licensee terminated the Unusual Event based on completion of system walk downs which confirmed no damage to the facility.

The licensee informed the NRC Resident Inspector. Notified R3DO (Kozak), NRR (MJ Ross-Lee), IRD (McDermott), FEMA (Liggett) and DHS (Barnes).

* * * UPDATE AT 0958 EDT ON 04/18/08 FROM BRAD LEWIS TO S. SANDIN * * *

"A press release regarding the declaration of the emergency was issued and a subsequent press release is planned to address the termination. The offsite notifications are being reported under 10 CFR 50.72(b)(2)(xi)."

The licensee informed the NRC Resident Inspector.

Notified R3DO (Kozak).

* * * UPDATE AT 1203 EDT ON 4/18/08 FROM TIMMOTHY WICE TO JASON KOZAL * * *

"At 11:45 on April 18, 2008, D.C. Cook Units 1 and 2 entered the Emergency Plan for a confirmed seismic event based on ground motion felt by plant personnel. An immediate notification to the NRC is required under 10 CFR 50.72(a)(3) for entry into the Emergency Plan. The ground motion sensed by plant personnel was confirmed with the National Earthquake Center. A magnitude 4.6 (preliminary on Richter scale) earthquake-aftershock was confined in Southern Illinois at LATITUDE 38.483 North/LONGITUDE 87.39 West at 10:14 CDT / 11:14 EDT.

"The Earthquake Abnormal Operating Procedures were entered for both Units. Ground motion was not felt by the control room Operating crews, but was noted and reported by other plant personnel. No damage to plant equipment was noted during the initial evaluation of plant status. Investigation of the plant impact of the sensed ground motion is in progress.

"The NRC Resident Inspectors were notified in person. Current Plant status: Unit 1 is shutdown in Mode 6 with Residual Heat Removal Cooling. Unit 2 is operating in Mode 1 at 100% power. AEP System Operations was contacted and the GRID was described as stable with no electrical operations relating to the earthquake event.

"The Seismic Monitoring system was INOPERABLE as required by TRO 8.3.2, Condition B during the event for routine Surveillance. This Surveillance has been in progress since 03/26/08. No alarms were generated by the seismic monitoring system during this event. One of four channels is currently out of service. The three remaining seismic monitor channels indicated no ground acceleration above the lowest instrument activation level of 0.02g.

"D.C. Cook intends to issue a press release regarding the declaration of the Notification of Unusual Event emergency classification. The offsite notifications are being reported under 10 CFR 50.72(b)(2)(xi)."

* * * UPDATE AT 1616 EDT ON 4/18/08 FROM FRANK BAKER TO JASON KOZAL * * *

"At 16:00 on April 18, 2008, DC Cook terminated the Unusual Event specified in EN 44147 for the aftershock response described above. A press release regarding the emergency event termination is anticipated. The offsite notifications are being reported under 10 CFR 50.72(b)(2)(xi)."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Kozak), NRR EO (Ross-Lee), IRD (McDermott), DHS (Gomez), FEMA (Burckhardt).

To top of page
Power Reactor Event Number: 44148
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: CLIFF ZIELINSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/18/2008
Notification Time: 06:23 [ET]
Event Date: 04/18/2008
Event Time: 06:03 [EDT]
Last Update Date: 04/18/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
LAURA KOZAK (R3)
BRIAN McDERMOTT (IRD)
JIM CALDWELL (R3)
TIM McGINTY (NRR)
JIM WIGGINS (NRR)
TOM BARNES (DHS)
LORI BURCKHARDT (FEMA)

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

UNUSUAL EVENT DUE TO SEISMIC ACTIVITY

The earthquake in southeastern Illinois was felt on site. No damage has been reported. All secondary system walkdowns have been completed. Primary system walkdowns are in progress.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM P. PITCHER TO P. SNYDER AT 1144 on 4/18/07 * * *

Palisades continues in the Unusual Event after detecting an aftershock from the previous earthquake. Palisades is continuing checks per their procedures for the circumstances at the site.

* * * UPDATE FROM TODD PLAUGHER TO JASON KOZAL AT 1438 on 4/18/07 * * *

The licensee has exited the Unusual Event at 1431 on 4/18/08.

The licensee notified the NRC Resident Inspector.

Notified R3DO (Kozak), NRR EO (Ross-Lee), IRD (McDermott), DHS (Gomez), FEMA (Burckhardt)

To top of page
Fuel Cycle Facility Event Number: 44149
Facility: WESTINGHOUSE HEMATITE
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 3
City: HEMATITE State: MO
County: JEFFERSON
License #: SNM-33
Agreement: N
Docket: 07000036
NRC Notified By: MATTHEW FEATHERSTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/18/2008
Notification Time: 11:45 [ET]
Event Date: 04/04/2008
Event Time: [CDT]
Last Update Date: 04/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LAURA KOZAK (R3)
TIM MCCARTIN (NMSS)
CYNTHIA FLANNERY (FSME)
ILTAB via email ()

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

Event Text

MISSING DEPLETED URANIUM SOURCE

"On April 4, 2008, a condition was identified at the Hematite Decommissioning Project that potentially involves missing licensed material in a quantity greater than 10 times the quantity specified in 10 CFR 20, Appendix C. Specifically, although it cannot yet be determined with certainty, it appears that a small depleted uranium pellet used as a detector source is missing. The radioactive source was one of several installed and used in Eberline, Model DA-1, gamma detectors to provide an indication of continuous operability. From the available documentation, it appears that the detectors were installed in 1993, well before Westinghouse acquired the facility in 2000.

"If it is confirmed that the radioactive source indeed is missing and is of the type, quantity, and form of other similar detector sources present at the facility, the source is a depleted uranium pellet in a solid oxide form, with a total mass of approximately 5.5 grams. The total uranium mass of the source is approximately 4.85 grams. The uranium-235 (U-235) activity in the source is approximately 0.037 microcuries, which is a quantity greater than ten (10) times the 10 CFR 20, Appendix C, limit for U-235 of 0.001 microcuries.

"For reasons discussed further below, the circumstances under which the apparent loss of licensed material may have occurred cannot be determined with certainty. With the facility in a decommissioning status, it is possible that the source was separated from its detector during decommissioning activities performed since the site ceased fuel fabrication activities in 2001. Subsequently, the probable disposition of the source may have been its having been packaged and shipped either as Special Nuclear Material inventory removed from the site or as radioactive waste. Either situation is credible since significant decommissioning activities in the site Process Buildings has involved the removal of remaining Special Nuclear Material inventory and contaminated process equipment.

"As of the date of this report, immediate actions have included the following:

"(1) Similar detector sources from gamma detectors that no longer are needed/used have been removed and properly stored.

"(2) On April 7, 2008, a physical search and radiological surveys were conducted in an attempt to determine if the potentially missing radioactive source remains in the Process Building area. The source was not found.

"(3) An investigation is ongoing to confirm whether the licensed material is indeed missing. This investigation includes searching through Radiation Protection records for additional information regarding the source and any potential evidence of its disposition. It is noted that the ongoing investigation is challenged by: (1) the subject source and similar radioactive sources have not been formally tracked within an inventory and tracking system; (2) a change in facility ownership in 2000; and (3) site management and staff turnover since decommissioning started, such that individuals who may have had first hand knowledge of the cause and/or disposition of the subject radioactive source are no longer at the facility.

"The investigation into this event is continuing, and any further details will be provided in the written report that Westinghouse will submit within 30 days of this telephone report pursuant to 10 CFR 20.2201 (b)."

The licensee informed NRC Region 3 and the NRC Headquarters Program Manager.

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

To top of page
Fuel Cycle Facility Event Number: 44151
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: TONY HUDSON
HQ OPS Officer: JASON KOZAL
Notification Date: 04/18/2008
Notification Time: 14:45 [ET]
Event Date: 04/17/2008
Event Time: 16:44 [CDT]
Last Update Date: 04/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
KATHLEEN O'DONOHUE (R2)
TIM MCCARTIN (NMSS)

Event Text

24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING AN EXCESSIVELY LARGE CONTAINER FOUND IN A FISSILE CONTROL AREA

"An open and unattended Rad bag (greater than 5.5 gallon capacity), containing a valve stem fixture, was found in the C-400 G-17 valve disassembly FCA (Fissile Control Area) in violation of NCSA GEN-015. NCSA GEN-015 limits the volume of portable containers taken into an FCA to less than 5.5-gallons. The purpose of the requirement is to limit the accumulation of fissile waste to approved containers. Although NCSA GEN-029 allows the use of larger than 5.5-gallon containers for small equipment items, these containers are required to be fastened or taped closed or attended while open. This bag was not fastened / taped and was unattended.

"The valve stem fixture had been placed within the Rad bag for contamination control purposes while being transported into the area. The fixture contained no fissile material; there was no fissile equipment within the FCA; and no fissile work being performed within the FCA.

"The NRC Senior Resident Inspector has been notified of this event."

"PGDP Problem Report No. ATRC-08-1 147; PGDP Event Report No. PAD-2008-11."

To top of page
Power Reactor Event Number: 44152
Facility: SURRY
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: HUNTER SCHILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/21/2008
Notification Time: 00:37 [ET]
Event Date: 04/20/2008
Event Time: 22:16 [EDT]
Last Update Date: 04/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 37 Power Operation 0 Hot Shutdown

Event Text

UNIT 1 MANUAL REACTOR TRIP DUE TO MAIN TURBINE VIBRATIONS

"While ramping the Unit 1 Turbine following a forced unit outage, vibrations on the number 4 bearing increased to 13.9 mils. The ramp was stopped and a rapid load reduction was initiated. Due to sustained vibrations (>14.1 mils) after ramping the turbine down, the Unit 1 reactor was manually tripped. Unit 1 has been stabilized at Hot Shutdown.

"All three auxiliary feedwater pumps automatically initiated as designed on low-low steam generator level following the trip. Currently RCS temperature is being maintained stable at 547 degrees. All systems functioned as required following the reactor trip. There were no radiation releases due to this event, nor were there any personnel injuries or contamination events. This event is being reported in accordance with 10 CFR 50.72 (b)(2)(iv) and 10 CFR 50.72 (b)(3)(iv)."

Upon exiting the refueling outage in 11/07 the main turbine had a vibration issue of about 11 or 12 mils. Unit 2 was not affected during this event. Offsite power was lined up normally.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012