Event Notification Report for June 09, 2008

EMERGENCY OPERATIONS FACILITY POWER OUTAGE

"The Emergency Operations Facility (EOF) became unavailable when a storm took down the power line supplying the building that houses the EOF. The emergency diesel generator failed to start, leaving the EOF without power. Notification being made in accordance with 10CFR50.72(b)(3)(xiii). If EOF actuation is necessary, the alternate EOF will be utilized."

The licensee is investigating the failure of the backup emergency diesel generator to start.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 0335 ON 6/12/2008 FROM JIM KONRAD TO MARK ABRAMOVITZ * * *

Power had been restored to the EOF at the time of the initial notification. Power was unavailable on 6/9/2008 from 2007 to 2312, a period of three hours and five minutes.

The licensee notified the NRC Resident Inspector.

Notified the R3DO (Louden).

UNPLANNED CONTAMINATION

On June 9, 2008, the Radiation Safety Officer (RSO) was notified that a vial containing standard reference material was discovered broken in one of the research laboratories. The reference material contained numerous isotopes of plutonium. It has not been determined how or when the breakage occurred.

National Institute of Standards and Technology (NIST) Health Physics personnel responded to the area and determined that low levels of contamination were spread outside of the laboratory into the adjoining hallway. At this time, the hallway has be decontaminated. The lab is isolated and will be undergoing decontamination.

The two researchers who discovered the broken vial were contaminated on their hands and were properly decontaminated. They will be undergoing bioassay and urinalysis to determine if an uptake occurred. Air samples were taken in the lab and are in the process of being counted to determine if an airborne problem existed.

The NIST RSO contacted NRC Region IV (Cain and Campbell).

* * * UPDATE AT 0038 ON 6/26/2008 FROM LARRY GRIMM TO MARK ABRAMOVITZ * * *

Received from the National Institute of Standards and Technology via e-mail.

"Since the initial incident report, NIST has done the following to mitigate the incident.

"1. NIST Boulder requested assistance from NIST Gaithersburg. Management sent expert Health Physics and Occupational Health and Safety personnel, as well as radiation detection equipment to Boulder.
"2. Hallways and areas potentially affected by the spill were again thoroughly surveyed to assure that no contamination existed outside the affected, sealed laboratory. This survey found two minor contamination spots in a stairwell, which easily cleaned up with soap and water. One office, which had contamination known from the earliest survey (Tuesday morning 6/10/08) was sealed pending future decontamination.
"3. Air monitoring equipment was installed in the adjacent hallway as a precaution in the unlikely event of air leakage from the contaminated laboratory. To date, airborne contamination has not been detected by this equipment nor has any airborne contamination been detected by other subsequently installed air monitoring equipment outside of the contaminated laboratory.
"4. Bioassay tests were initiated on personnel either known to have trace external contamination or determined to be potentially contaminated. Small sample bioassay tests have shown no internal contamination of individuals; however NIST is awaiting the results of more sophisticated bioassay tests.
"5. Using personal protective equipment, NIST Health Physicists made entries to the contaminated laboratory on 6/14/08 and 6/15/08 to investigate the cause and extent of the spill. They found contamination in the laboratory sink and subsequently learned that a researcher who worked directly with the plutonium sample had used that sink to wash his hands during the incident. This prompted NIST to alert city wastewater officials of a potential discharge of plutonium from the sink to the sanitary sewer system.
"6. For help in determining what might have been released to the sanitary sewer NIST requested help from the National Nuclear Security Administration's Radiological Assistance Program (RAP) on 6/16/08. RAP and its associated Department of Energy TRIAGE team have the ability to determine radioactive material activity quantities by taking radiation measurements with sophisticated equipment and computer programs.
"7. Further bioassays samples were collected from individuals and sent out for analysis. NIST is awaiting the results of these tests. Some individuals have also received additional medical tests on the advice of physicians specializing in exposure to plutonium.
"8. Planning with RAP personnel for entry to the laboratory ensued and the RAP team arrived 6/20/08. Entry occurred the same day and the RAP team collected the necessary data. The subsequent report of the RAP/TRIAGE analysis as well as NIST radiation measurements and calculations on dose rate data indicates that at least 76% - 87% of the spilled material can be accounted for. As many smaller areas of contamination have not been analyzed, NIST expects that more of the material will be accounted for during future entries and testing.
"9. Prior to entering the contaminated laboratory, air sampling had not shown airborne contamination. In the course of repeated entries to the contaminated lab room, air sampling equipment placed by the RAP team detected airborne contamination, likely as a result of the team's activities. The team ceased operations and subsequent air sampling showed that radiation readings had returned to normal background levels in the spill room laboratory. Since responding to the incident, NIST Health Physicists have monitored and found no evidence of any releases of contaminated air to the atmosphere."

Notified the R4DO (Proulx) and FSME (Camper).

WASHINGTON AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

The following information was received from the State of Washington via email:

"On 9 June 2008 a patient presented for a prescribed bone scan (normally, Tc-99m, 30mCi, MDP), but instead received 23mCi of Tc-99m Sestamibi (heart scan).

"The dose was administered. No useful imaging or diagnostic information could be obtained from this procedure. The bone scan will be rescheduled. The licensee will submit a written report, containing cause and proposed corrective actions within 15 days. The licensee's written report dated 23 June 2008 indicates the cause to be human error by the nuclear medicine technologist. The licensee believes current procedures in place are adequate, providing staff adheres to those procedures. The technologist in question will now 'take a time out' prior to each injection to review the dose to be injected, the dose ordered, and to fully and thoroughly check the markings in place on syringes and vials to prevent such an occurrence. No media attention thus far.

"According to the manufacturer's product insert, the patient in this case could be expected to receive a maximum of: 4.14R to the Upper Large Intestinal Wall (the most for any single organ), and a whole body dose of 383 mR. No physical consequences are anticipated."

Licensee notified patient and referring physician.

* * * UPDATE ON 06/30/2008 AT 1644 EST FROM FSME (ZELAC) TO ROTTON * * *

The NRC has reviewed this event and determined it is not a reportable medical event.

60 DAY REPORT - INVALID ACTUATION OF MAIN STEAM ISOLATION SYSTEM

"This 60-day optional report, as allowed by 10 CFR 50.73 (a)(1), is being made under the reporting requirement in 10 CFR 50.73 (a)(2)(iv)(A) to describe an invalid actuation of a specified system, specifically the Main Steam (SM) System. On June 9, 2008, at 1631 with Unit 1 in Mode 5, an invalid signal was generated on Train B of the SM system during Engineered Safety Features testing. During the performance of returning the Solid State Protection System (SSPS) to 'normal', the SSPSB mode selector switch was placed to operate. A Unit 1 Feedwater and Main Steam isolation occurred. Part of the 'return to normal' sequence is to place the SSPS Input Error Inhibit switch to the inhibit position. The technician failed to insure the inhibit switch 'snapped' into position and trip signals were generated when the Output Test relay switch was placed to Operate. The SM system was returned to standby readiness. This was considered a partial system/train actuation. During this event, the SM system performed as expected. This event was entered into the site specific corrective action program for resolution."

The licensee has notified the NRC Resident Inspector, and will be notifying the State, local and other government agencies.