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Event Notification Report for June 23, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/20/2008 - 06/23/2008

** EVENT NUMBERS **


44131 44219 44303 44304 44309 44310 44311

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44131
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TERRY DAMASHEK
HQ OPS Officer: JOE O'HARA
Notification Date: 04/10/2008
Notification Time: 16:22 [ET]
Event Date: 04/10/2008
Event Time: 10:15 [CDT]
Last Update Date: 06/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD DEESE (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

"ANALYSIS INDICATES CONTAINMENT COOLERS MAY NOT HAVE AUTOMATICALLY STARTED IN SLOW SPEED FOLLOWING POSTULATED MAIN STEAM LINE BREAK"

"Information provided by another plant identified a condition where Containment Fan Coolers may trip if running in fast speed and not start automatically in slow speed, following a Loss of Coolant (LOCA) or Main Steam Line Break (MSLB). Wolf Creek commenced evaluation to determine if our Containment Coolers were susceptible to this condition.

"Investigation and analysis as of this date indicate that in the case of a Main Steam Line Break, the coolers could trip while running in fast speed and not be able to be automatically started by the sequencer in slow speed due to present electrical design configuration. The peak containment pressure in this case would exceed the analysis of record by approximately 5 psig.

"For the spectrum of the smaller break LOCA's, where actuation is delayed until pressurizer low pressure Safety Injection or the Containment Hi 1 pressure signal, analysis shows that the Containment Pressures would not be exceeded if the Containment Fan Coolers did not automatically start in slow speed. For a Large Break LOCA, analysis shows that the Containment Cooler Fans would be shed prior to tripping, and would be automatically started in slow speed by the sequencer.

"Wolf Creek is currently in a defueled condition, for Refueling Outage 16. Continued evaluation and analysis of this issue is ongoing. This issue will be resolved prior to the plant entering Mode 4, where Technical Specification 3.6.6 requires Containment Fan Coolers be operable."

The information was originally received from Callaway.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1245EDT ON 06/20/08 FROM LANCE LANE TO S. SANDIN * * *

The licensee is retracting this event based on the following:

"Wolf Creek evaluated this concern and concluded that the condition did not exist at Wolf Creek. Further analysis of the Main Steam Line Break, if this concern had existed, showed that the calculated post-accident pressure and temperature peak values would not exceed the peak accident values in the Final Safety Analysis Report. Therefore, an unanalyzed condition did not exist and Wolf Creek is retracting the 50.72(b)(3)(ii)(B) notification."

The licensee informed the NRC Resident Inspector. Notified R4DO (Farnholtz).

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Hospital Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 06/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."

* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *

"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.

"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).

R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.

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.


* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *

"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

"VHA provided an initial update on June 6, 2008. This update reflects the most current information.

"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

"Patient notification:

"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).

* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *

"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.

"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.

"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program is suspended and an external review is in progress.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.

"Patient notification:

"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)

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General Information or Other Event Number: 44303
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: 'R' PLACE
Region: 4
City: HORDVILLE State: NE
County:
License #: GL0683
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JASON KOZAL
Notification Date: 06/18/2008
Notification Time: 08:28 [ET]
Event Date: 07/20/2007
Event Time: [CDT]
Last Update Date: 06/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
MICHELE BURGESS (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The state provided the following information via e-mail:

"The Department contacted the general licensee because the annual fee for the general license was overdue for two self illuminating signs. The signs were from Best Lighting (Model SLTURW10)(Serial # 166473 and 166474) with 7.03 curies [each] of H3 (in June of 2006). The general licensee hired an individual to remove the signs from the dining room and put them into the storage room in the caf during July of 2007.

"The general licensee went to the storage room in the second week of August 2007 to retrieve some stored items. Items were missing and additionally the two exit signs were also missing. The general licensee tried to contact the man who she hired to move the supplies and equipment. She did not find a phone listing. She sent him a letter to the address he had given her and the letter was returned as no such address."

Nebraska event number: NE080003.

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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General Information or Other Event Number: 44304
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KRAZAN & ASSOCIATES, INC
Region: 4
City: PUYALLUP State: WA
County:
License #: WN-I0431-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/18/2008
Notification Time: 17:40 [ET]
Event Date: 06/17/2008
Event Time: 16:30 [PDT]
Last Update Date: 06/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
JOSEPH HOLONICH (FSME)

Event Text

AGREEMENT STATE - DAMAGE TO TROXLER MOISTURE DENSITY GAUGE

The Washington State Department of Health, Office of Radiation Protection provided the following report via e-mail:

"The Licensee was working with a Troxler Model 3430, portable moisture density gauge, serial number 19739, having a 10 millicurie, Cesium-137 and a 40 millicurie, Americium-241/Beryllium sealed sources. The work was being done at a temporary job-site near Walla Walla, Washington. The gauge operator was taking measurements with the Cs-137 source rod inserted into the test hole. The operator walked away from the gauge to look for the next test site. While the operator was away, the gauge was struck by a front-end loader. The gauge operator cordoned off the area and contacted the Radiation Safety Officer. The RSO then contacted the Office of Radiation Protection (ORP) to make a verbal report. Two ORP staff were already in the vicinity and were rerouted to the incident scene. When staff arrived they reported the gauge had been visibly damaged. The plastic exterior was smashed with the source rod still in the test hole. The gauge's guide rod with the handle had been sheared-off by the front-end loader. ORP staff were able to push the source rod back into the gauge's shielded position. They also took a wipe sample from the source rod, the gauge exterior, and surveyed the soil where the source rod had been. No contamination was found. The gauge was placed back into its transport box. ORP staff took dose-rate readings on the outside of the box and found normal levels. The gauge was taken to the licensee's storage facility in Walla Walla where it awaits shipping instructions for returning it to Troxler.

"The Licensee is being cited by DOH for not keeping the gauge under constant surveillance and control while away from an approved storage location."

Washington Report WA-08-040

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Power Reactor Event Number: 44309
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE GORDY
HQ OPS Officer: JOE O'HARA
Notification Date: 06/20/2008
Notification Time: 00:15 [ET]
Event Date: 06/19/2008
Event Time: 17:35 [EDT]
Last Update Date: 06/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BINOY DESAI (R2)

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

Event Text

CONTROL ROOM VENTILATION INOPERABLE

"At 17:35 hours on June 19, 2008, the Control Room authorized post maintenance testing following replacement of solenoid valves affecting the 2B Control Room Emergency Ventilation (CREV) subsystem. This testing was required to restore this Subsystem to OPERABLE following maintenance. This test inputs a Simulated high radiation signal into the logic for Control Building HVAC system and ensures that the Control Room Emergency Ventilation subsystem automatically aligns to the Radiation/Smoke Protection mode. During performance of this test, the Control Building Exhaust Fan Damper (2D) failed to close and the associated Control Building Exhaust Fan failed to trip as expected. These functions are required to occur to maintain a positive pressure in the Control Building during a high radiation in the Control Building ventilation intake plenum or during smoke intrusion into the Control Building. Since Brunswick has a shared control room, Unit 1 and Unit 2 entered Technical Specification (TS) 3.7.3,'Control Room Emergency Ventilation (CREV) System,' Required Action B.1 (i.e., be in Mode 3 within 12 hours).

"At 1910, the 2A Control Room Emergency Ventilation (CREV) subsystem was manually placed in the Radiation/Smoke Protection mode. This action fulfilled the Control Room Emergency Ventilation safety function and allowed the 2A Control Room Emergency Ventilation (CREV) subsystem to be declared OPERABLE. Required Action B.1 of Technical Specification (TS) 3.7.3 (be in Mode 3 within 12 hours) was exited.

"This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented the fulfillment of the safety function of a system needed to mitigate the consequences of an accident.

"The safety significance of this event is considered minimal. The condition with the Control Building Exhaust Damper (20) is intermittent. The solenoid valve for this damper was recently replaced on 5/3/2008. The post maintenance test included ensuring this damper would close on demand and was completed satisfactory. In addition, this same test was performed on the other division of CREV logic on 5/17/2008, the Control Building Exhaust Damper and Exhaust Fan functioned as required. In addition, the exhaust damper and fan operated properly, when manually operated from the Control Room, while manually placing the CREV system in service.

"All systems functioned as required except for the Control Building exhaust fan.

"2A Control Building Emergency Ventilation (CREV) subsystem placed in the Radiation/Smoke. The NRC Resident Inspector has been notified. Repair options for the Control Building Exhaust Damper are being developed."

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Fuel Cycle Facility Event Number: 44310
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: ROD J.COOK
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/21/2008
Notification Time: 21:35 [ET]
Event Date: 06/20/2008
Event Time: 23:25 [CDT]
Last Update Date: 06/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
BINOY DESAI (R2)
GORDON BJORKMAN (NMSS)
FOUO EMAIL ONLY ()

Event Text

NOTIFICATION TO KENTUCKY ERT DUE TO EXCEEDING PERMIT LIMITS AT OUTFALL

"At 1750, 6/21/2008 CDT, the Kentucky Emergency Response Team (Report Number 2008-2125) was notified of the following issue. The C-637 RCW (Recirculating Water) 'H' Supply loop was being repaired and a residual RCW leak from the valve vault was being pumped back to the pump house basin when the portable pump shutdown causing an overflow condition at a Commonwealth of Kentucky permitted outfall 002. The Commonwealth of Kentucky's permit limit for the outfall is 1 mg/L for total phosphorus and the chlorine level is to be below detectable limits. Contrary to this, the total phosphorus level was slightly above 1 mg/L and residual chlorine was approximately 0.1to 0.3 mg/L. Control of the RCW leak in the valve vault was re-established.

"This event is reportable as 'USEC shall notify NRC of any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'

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

"PGDP Problem Report No. ATRC-08-1840: PGDP Event Report No. PAD-2008-20:"

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Power Reactor Event Number: 44311
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DEAN BRUCK
HQ OPS Officer: JOE O'HARA
Notification Date: 06/23/2008
Notification Time: 03:26 [ET]
Event Date: 06/23/2008
Event Time: 03:00 [EDT]
Last Update Date: 06/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (R3)

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

Event Text

LOSS OF EMERGENCY RESPONSE CAPABILITY - TSC IS UNAVAILABLE

"UNAVAILABILITY OF TSC CHARCOAL FILTER FOR SCHEDULED MAINTENANCE

"At 0300 on Monday, June 23,2008, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) ventilation system charcoal filter was removed from service for planned charcoal bed maintenance. The balance of the TSC ventilation is not affected by the charcoal bed maintenance and remains available.

"Under certain accident conditions the TSC may become unavailable due to the inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary based upon results of procedurally required monitoring of TSC radiological conditions.

"Charcoal filter maintenance is scheduled to complete at 1000 on Wednesday, June 25, 2008.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss an emergency response facility."

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