United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2008 > August 1

Event Notification Report for August 1, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/24/2008 - 08/01/2008

** EVENT NUMBERS **


44179 44219 44361 44363 44364 44365 44366 44367 44368 44369 44370 44371
44372 44373 44374 44377 44379

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44179
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVID JESTER
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2008
Notification Time: 05:21 [ET]
Event Date: 04/29/2008
Event Time: 23:13 [EDT]
Last Update Date: 07/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CAROLYN EVANS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 32 Power Operation 32 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE DUE TO SEAL LEAK

"On 04/29/08 at approximately 2313 during testing of the Unit 1 HPCI system, a main pump seal developed a leak requiring the HPCI system to be secured. HPCI testing was in progress per OPT 09.2, HPCI System Operability Test, following recent Unit 1 refueling outage. At the time of discovery, the Unit 1 HPCI system had been declared inoperable due to surveillance testing activities which removed HPCI from the standby lineup. When the pump seal leak developed, operators secured HPCI and isolated the leak by closing the pump suction isolation valves and the keep fill supply valves. Investigation into the cause of the pump seal leakage is underway and the Unit 1 HPCI system will be placed under clearance for repair.

"The initial safety significance of this condition is considered to be minimal. The Reactor Core Isolation Cooling (RCIC) system as well as the other Unit 1 ECCS systems are operable at this time. Actions have been taken to protect redundant safety systems.

"The Unit 1 HPCI system has been removed from service and secured. Investigation is underway to determine the cause of the HPCI main pump leakage. The HPCI system will be placed under clearance for repair."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 7/31/08 AT 1447 EDT FROM TURKAL TO HUFFMAN * * *

"The HPCI pump uses seal purge water piping in combination with mechanical seals to limit shaft leakage. Investigation of this event found that inadequate post-maintenance venting of piping between the discharge of the HPCI booster pump and the suction of the HPCI main pump led to the seal faces overheating and subsequent failure. The failure of the seal and the leakage associated with it would not have prevented HPCI from performing its required functions. Water intrusion into the oil system is the limiting impact of the seal failure. The HPCI main pump seal failure event has been evaluated and it was determined that, given a worst-case seal failure, the HPCI pump would be able to operate for greater than the required 4.1 hours and, thereby, satisfy its accident, as well as transient, response requirements. On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"Investigation of this condition is documented in the corrective action program in Nuclear Condition Report (NCR) 277188.

"The NRC resident was notified of this retraction."

The R2DO (Henson) has been notified.

To top of page
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: 07/25/2008
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)

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."

Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).

* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *

"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).


* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *

A 15-day written report of one of the medical events was submitted to NRC Region III.


Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)

* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).

* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *
Bur
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "

Notified R1DO (Dentel), R3DO (Lara), and FSME (White).

* * * UPDATE ON 7/22/2008 AT 1500 EDT FROM WILLIAMS TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional five patients on July 22, 2008. This brings the total number of medical events to 37 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III."

The licensee will notify NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events.

Notified R1DO (Dentel), R3DO (Riemer), and FSME (Burgess).

* * * UPDATE FROM GARY WILLIAMS TO JOE O'HARA 1145 EDT ON 7/25/08 * * *

"As the result of an ongoing review, medical events were discovered for an additional two patients on July 25, 2008. This brings the total number of medical events to 39 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (W.Cook), R3DO (M.Phillips), and FSME (C.Flannery)

To top of page
General Information or Other Event Number: 44361
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HARRINGTON GEOTECHNICAL ENGINEERING INC
Region: 4
City: ORANGE State: CA
County:
License #: 5657-30
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/23/2008
Notification Time: 16:32 [ET]
Event Date: 07/23/2008
Event Time: 10:35 [PDT]
Last Update Date: 07/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD DEESE (R4)
DENNIS RATHBUN (FSME)
ILTAB VIA E-MAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE

The following information was provided by the State via e-mail:

"On July 23, 2008, at approximately 10:35 a.m., [the] RSO for Harrington Geotechnical Engineering, Inc., notified RHB about a nuclear gauge (CPN model MC-3 S/N M35116478, 10 mCi Cs-137, 50 mCi Am:Be-241) that had been stolen at a residence (in Westminster, CA 92683, located near the intersection of Magnolia St. and McFadden Ave.) sometime between 8:00 a.m. and 8:30 a.m. Due to an urgent personal need, the operator left the truck outside the residence, with the gauge locked to the bed of the truck by a cable. The cable was cut by the perpetrator to remove the transport case containing the gauge. The Westminster Police Department was notified and a police report was generated (report number 08-06699). The RSO stated that the residence of the operator was in an area that had some gang activity. The RSO was informed of the requirement for a written report within 30-days. The RSO stated that he would place an ad in the newspaper and to offer a reward for the gauge. RHB will investigate this incident.

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.

To top of page
Power Reactor Event Number: 44363
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DOUG HOLT
HQ OPS Officer: JOE O'HARA
Notification Date: 07/24/2008
Notification Time: 15:03 [ET]
Event Date: 07/24/2008
Event Time: 15:02 [EDT]
Last Update Date: 07/24/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MARK LESSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 98 Power Operation

Event Text

TECH SPEC REQUIRED SHUTDOWN DUE TO LOSS OF ESSENTIAL RAW COOLING WATER PUMP WITH 2 EDG'S OOS

"WBN Unit 1 experienced a failure of the B-A ERCW pump on July 21, 2008, at 2:46 p.m. EDT. The plant entered LCD 3.7.8, Condition A, for one ERCW train inoperable and LCD 3.8.1, Condition C, with two required DGs in Train A inoperable concurrently. Required Actions for LCO 3.7.8 and LCD 3.8.1 required restoration of the inoperable ERCW train and one DG to OPERABLE status in 72 hours, respectively. Plant shutdown was initiated in accordance with LCD 3.7.8, Condition B and LCD 3.8.1, Condition G when the above Required Actions were not met. The root cause of the pump failure is unknown at this time. An event team has been set-up to determine cause of pump failure. Currently, the unit is performing a control shutdown, and all systems are functioning as expected."

The licensee does not expect the ERCW pump to be returned to service and will downpower at 15% per hour. The licensee expects to be in Mode 3 by 2030 EDT. All required safety systems for safe shutdown are operable.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM BEN HUNT TO JOE O'HARA AT 2046 ON 7/24/08 * * *

"The TS required shutdown has been terminated on 7/24/08 at 1910 EDT, based on the receipt of an Emergency TS change. The plant exited LCO 3.8.1, Condition C and LCO 3.7.8, Condition A, and entered new LCO 3.7.8, Condition C. The revised TS will allow continued operation for an additional 7 days based, in part, on the implementation of an NRC approved Temporary Alternation. It is expected that the failed ERCW pump will be repaired within the new 10 day allowed outage time as specified in the Emergency TS change for LCO 3.7.8, Condition C (3 days were already used due to the inoperability of the B-A ERCW Pump occurred on 7/21, this leaves approximately 7 days left in the new action time.)"

The licensee notified the NRC Resident Inspector.

Notified R2DO(Lesser).

To top of page
General Information or Other Event Number: 44364
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: NEUTRON PRODUCTS INC
Region: 1
City: DICKERSON State: MD
County:
License #: MD-3102503
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2008
Notification Time: 10:57 [ET]
Event Date: 07/21/2008
Event Time: 18:20 [EDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OCCUPATIONAL OVEREXPOSURE

On July 22, 2008, the State of Maryland was informed by the Teletherapy Operations Manager for Neutron Products, Inc. that one of their teletherapy service engineers performing an Alcyon Co-60 source exchange in Brazil had received a potential overexposure.

During the source exchange, the engineer's electronic dosimeter alarmed. Immediate actions were taken to properly secure the source. Preliminary dosimetry readings for the service engineer indicated a potential whole body exposure of approximately 5,211 mrem and extremity reading at the right wrist exceeding 10R (off scale high). The service engineer's film badge was sent for immediate processing to Global Dosimetry with expected results available for evaluation by Thursday, 7/24.

The results from Global Dosimetry for the service engineer prior to the incident are as follows:

Monthly whole body (DDE, mrem) - 13,465 + 92 (Jan. - May) = 13,557
Left wrist (SDE, mrem) - 73,356 + 236 (Jan. - May) = 73,592
Right wrist (SDE, mrem) - 746 + 488 (Jan. - May) = 1,234

Brazilian regulatory personnel were onsite at the hospital at the time the incident occurred and were briefed within one (1) hour by the service engineer.


* * * UPDATE FROM ALAN JACOBSON TO JOHN KNOKE AT 0739 EDT ON 07/28/08 * * *

"Per our telephone conversation of today [between the state and the licensee], this is to update our initial verbal and written Twenty-Four Hour Notifications made July 22, 2008 regarding the incident in Sao Paulo, Brazil, and to summarize our employee's written account thereof.

"On July 21, 2008 at approximately 6:20 pm EDT, Neutron Products employee #502, informed us via telephone that he may have received an over-exposure while performing a source exchange on an Alcyon II teletherapy unit located in Sao Paulo, Brazil. On July 21, 2008, employee #502 and a radiation worker from Brazil were in the process of transferring the expended cobalt-60 source from the Alcyon II unit into Neutron's transfer cask in accordance with Specification P-9, Appendix XI. After engaging the source holder with the removal tool, #502 transferred the source holder from the Alcyon II unit head into the transfer cask. Once the source holder was in the transfer cask, #502 continued making preparations to complete the removal sequence.

"Employee #502 had completed all the steps of the removal sequence and was in the process of removing the removal tool from the transfer cask, when it was determined by audible alarms and before the tool was completely out of the cask, that the cobalt-60 source was still connected to the end of the removal tool. At that point, #502 reinserted the removal tool back into the cask and repeated the steps again to make sure that the Source was disengaged from the removal tool. Once he was sure that the source was no longer attached to the removal tool, the tool was removed from the cask, and all the covers installed. The transfer cask now contains both the expended and new sources.

"Immediately after the container was secured, both men read their SRD's and reported their dose as follows: #502: WB-5,211 mrem, Left Wrist-300 mrem, and Right Wrist-off Scale (10R dosimeter); Brazilian Worker: WB-533 mrem, Left Wrist-off scale (10R dosimeter), and, Right Wrist-4,100 mrem. The TLD's were sent via FED-EX to Global Dosimetry Solutions in Irvine, CA, for emergency reading and the results are as follows: #502: Monthly WB DDE-13,465 mrem, Quarterly WB DDE-11,126 mrem, Left Wrist SDE-73,356 mrem, and Right Wrist SDE-746 mrem. Brazilian Worker: Monthly WB DDE-702 mrem, Quarterly WB DDE-1,559 mrem, Left Wrist SDE-3,030 mrem, and Right Wrist SDE-8,542 mrem.

"Employee #502 will be returning home sometime this weekend. He will not be involved in any radiation work for the remainder of the year."

Notified R1DO (Trapp) and FSME (M. Burgess)

To top of page
Power Reactor Event Number: 44365
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LEE JOHNSON
HQ OPS Officer: JOE O'HARA
Notification Date: 07/25/2008
Notification Time: 14:07 [ET]
Event Date: 07/25/2008
Event Time: 09:17 [EDT]
Last Update Date: 07/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MONTE PHILLIPS (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

POSITIVE RANDOM FITNESS FOR DUTY TEST

"A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

"The licensee notified the NRC Resident Inspector.

"This event is being reported pursuant to 10 CFR 26.719 (b)(2)(ii)."

To top of page
Fuel Cycle Facility Event Number: 44366
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: JOE O'HARA
Notification Date: 07/25/2008
Notification Time: 16:24 [ET]
Event Date: 07/25/2008
Event Time: 16:00 [EDT]
Last Update Date: 07/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
MARK LESSER (R2)
EUGENE PETERS (NMSS)
FUELS GRP VIA EMAIL ()

Event Text

STATE AGENCY NOTIFIED OF DISCHARGE OF AMMONIA EXCEEDING STATE LIMITS

"Reason for Notification: On 7/25/08, chemical laboratory analysis of the NPDES liquid effluent 24-Hour composite sample indicated that the wastewater discharged from the Columbia plant during the previous 24 hour period contained 115.9 lbs of ammonia which exceeds the Daily Maximum Discharge Limit for Ammonia of 100 lbs/day. The average for ammonia discharge this month is approximately 20 lbs/day and is within the permit monthly average of 50 lbs/day.

"Liquid discharges from the Columbia Plant are regulated with regard to chemical pollutants through the SC-DHEC/EPA administered NPDES Permit #SC 0001848. WEC is required to notify SC-DHEC within 24 hours of becoming aware of non-compliance with effluent limitations.

"Notification is being made based on 10CFR70 Appendix A, Section (c), Concurrent Reports: 'Any event or situation, related to the health and safety of the public or onsite 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, shall be reported to the NRC Operations Center concurrent to the news release or other notification.'

"Summary of Activity: Following recognition of the problem, Westinghouse has immediately responded to terminate flow of process wastewater. Discharge of process waste will be resumed following verification that discharges will meet permit limits. This event is entered into the plant Corrective Action Process. (CAPS#08-207-0011).

"Conclusions: Problem was self identified by Westinghouse personnel. At no time was the health or safety to any employee or member of the public in jeopardy."

To top of page
Power Reactor Event Number: 44367
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RICKY GIVENS
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/27/2008
Notification Time: 08:30 [ET]
Event Date: 07/27/2008
Event Time: 03:40 [CDT]
Last Update Date: 07/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK LESSER (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

CABLE TRAY FIRE NEAR COOLING TOWER "C" SWITCHGEAR

"Security notified Limestone County Sheriffs dispatch at 0340 CDT that Browns Ferry had experienced a fire and arc-over event at the area of cooling tower switchgear 'C'.

"At about 0225 CDT a fault occurred in the cable tray between the 161 kV supply transformer and the 4 kV cooling tower 'C' switchgear resulting in clearing of the 161 kV line and a subsequent fire. The fire was extinguished at 0236 CDT by on-site responders. At 0340 CDT, Limestone County Sheriff department was contacted by site security and informed of the event and asked to increase patrols in the area of the county road adjacent to Browns Ferry. It was known that the event was likely due to operational issues and not sabotage but the final determination had not been made at that time. Limestone County Sheriff was contacted again at 0520 CDT and informed that the problem was operational and that their assistance is not required.

"There are no safety related plant equipment reportability issues resulting from this event. The reportability is solely due to notification of an outside agency.

"This condition is reportable within 4 hours according to 10 CFR 50.72(b)(2)(xi). Any event or situation, related to the health and safety of the public or onsite 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 onsite fatality or inadvertent release of radioactive contaminated materials."

Licensee has notified NRC Resident Inspector.

To top of page
General Information or Other Event Number: 44368
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXON MOBIL CHEMICAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2349-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/28/2008
Notification Time: 10:46 [ET]
Event Date: 08/01/2005
Event Time: [CDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE MALFUNCTION

This report was received from the state by facsimile.

"Exxon Mobil Chemical Company had an incident occur in August of 2005 and did not report the event. The event was discovered while an inspector was performing a reciprocity inspection on Ronan Engineering at Exxon on July 9, 2008. Ronan was contacted to package a nuclear gauge for transport and disposal. In August 2005, Exxon had a problem with a ThermoMeasure Tech 'SA-10' device that contained four 1000 mCi sources of Cs-137. The sources were QSA model CDC.93 with serial numbers 4421GN, 4424GN, 4425GN, and 4426GN in a rod configuration. In August 2005, the sources could not be returned to the shielded position to perform a shutter check. The facility returned the sources to the normal detent position for operation and continued to use the gauge. Ronan Engineering determined that the sources were encountering friction from the vessel source well. The vessel source well is part of the vessel and not part of the Ronan gauge. The gauge and sources were safely returned to the source holder, locked out, surveyed and leak tested on July 11, 2008. The gauge was shipped to ThermoMeasure Tech on July 11, 2008 for disposal."

Event Report ID: LA0800015

To top of page
General Information or Other Event Number: 44369
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: NEW IBERIA State: LA
County:
License #: LA-9098-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/28/2008
Notification Time: 11:20 [ET]
Event Date: 07/25/2008
Event Time: [CDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

This report was received from the state by facsimile.

"On July 25, 2008, TEAM Industrial Services reported that a source was stuck in the guide tube and could not be returned to the shielded position. The industrial radiography camera involved is a AEA 880 Delta with serial number D2847. The source involved is an AEA source with serial number 45020B that is 49.8 Ci of Ir-192. While the source was in the collimator, the stand that was being used to x-ray welds fell on the guide tube. The radiographers attempted to return the source to the shielded position but could not. The radiographers then returned the source to the collimator and set up a 1 mr/hr boundary around the source. They called the Radiation Safety Officer for TEAM. TEAM contacted QSA Global to retrieve the Ir-192 source. The source was retrieved on July 25, 2008 at 5:30 PM. The guide tube and stand have been taken out of service. The camera and crank-outs are being sent to QSA Global to be inspected."


Event Report ID: LA0800016

To top of page
Power Reactor Event Number: 44370
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JERRY GOSMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/28/2008
Notification Time: 13:32 [ET]
Event Date: 07/28/2008
Event Time: 08:50 [CDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PATTY PELKE (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

Event Text

OFFSITE NOTIFICATION DUE TO A SODIUM HYPOCHLORITE SPILL

"At approximately 0850 [CDT] on July 28, 2008 Xcel Energy notified the State of Minnesota's Duty Officer of a 53 gallon 12% Sodium Hypochlorite spill at the Prairie Island plant. The spill was due to a leak in the chemical piping. The release was stopped but only partially contained within the berms of the building. Some of the Sodium Hypochlorite seeped through the berms concrete walls and into the environment. The amount escaping the containment berm was less than the reportable quantity but was being reported since a portion did reach the soil."

The licensee informed both the State and the NRC Resident Inspector.

To top of page
Other Nuclear Material Event Number: 44371
Rep Org: MEMORIAL HOSPITAL - SHERIDAN, WY
Licensee: MEMORIAL HOSPITAL - SHERIDAN, WY
Region: 4
City: SHERIDAN State: WY
County:
License #: 49-10982-02
Agreement: N
Docket:
NRC Notified By: THOMAS NANCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/28/2008
Notification Time: 14:26 [ET]
Event Date: 07/18/2008
Event Time: 10:00 [MDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

MEDICAL ERROR - WRONG CHEMICAL USED IN PATIENT TREATMENT

On the date described [07/18/08] an outpatient reported to the Nuclear Medicine Department for a Nuclear Medicine whole body bone scan. The technician drew up and injected the patient with 24.3 mCi mTc99 Sestamibi, I.V. instead of the proper cold kit which would have been Medronate. The error was not discovered until the patient returned 3 hours later for scanning and it was observed that the isotope was not properly tagged. Upon investigation, the reason for the poor tag was discovered. The patient was informed as well as the Department Manager, and the on-duty staff Radiologist. It was agreed by all that the patient would return on 07/21/08 to perform the study properly. According to the Radiation Absorbed Dose Table, the patient received the following:

Gallbladder Wall - 1.6 Rads, Small Intestine - 2.4 Rads, Upper Large Intestine Wall - 4.32 Rads, Lower Large Intestine Wall - 3.12 Rads, Stomach Wall - 0.48 Rads, Heart Wall - 0.40 Rads, Kidneys - 1.6 Rads, Liver - 0.48 Rads, Lungs - 0.24 Rads, Bone Surfaces - 0.56 Rads, Thyroid - 0.56, Testes - 0.24 Rads, Red Marrow - 0.40 Rads, Urinary Bladder Wall - 1.6 Rads, Total Body - 0.40 Rads.

It is believed that there was no ill effect on the patient. The technician has been re-instructed on the extreme importance of checking all the labels previous to preparing, drawing up and delivering any radioisotopes.

The licensee is still in the process of confirming that the ordering physician has been notified of this incident.

To top of page
Research Reactor Event Number: 44372
Facility: REED COLLEGE
RX Type: 250 KW TRIGA MARK I
Comments:
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: STEPHEN FRANTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/29/2008
Notification Time: 14:30 [ET]
Event Date: 07/24/2008
Event Time: 14:00 [PDT]
Last Update Date: 07/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
NEIL O'KEEFE (R4)
DAN HUGHES (NRR)

Event Text

TEST REACTOR EXCEEDED LICENSED POWER LIMIT DURING CALIBRATION

"Performing calorimetric power calibration of nuclear instruments with a new fuel element installed per SOP-44. Indicated power was 230kW. Calculated power after 70 minutes was 281kW, in excess of licensed power of 250kW. Also, due to miscalibration the 110% scrams on linear and percent power would not occur until an actual power of 124%. Reactor power was lowered and another calibration confirmed the error. The reactor was shutdown and the NRR Project Manager (Dan Hughes) was called."

To top of page
Other Nuclear Material Event Number: 44373
Rep Org: ENGINEERING CONSULTING SERVICES
Licensee: ENGINEERING CONSULTING SERVICES
Region: 1
City: CHANTILLY State: VA
County:
License #: 45-24974-01
Agreement: N
Docket:
NRC Notified By: OMER DUZYOL
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/29/2008
Notification Time: 15:38 [ET]
Event Date: 07/29/2008
Event Time: 14:00 [EDT]
Last Update Date: 07/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD BARKLEY (R1)
KEVIN HSUEH (FSME)

Event Text

MOISTURE DENSITY GAUGE RUN OVER BY COMPACTOR

At approximately 1400 EDT on 07/29/08 a CPN moisture density gauge, model #MC1DR - S/N M36056763, containing a Cs-137 10mCi and Am-241:Be 50 mCi source was run over by a compactor at a construction site at 7152 Heller Loop in Springfield, VA. The sources remained in the safe stored position during the incident, however, the Cesium source rod was broken off. The device was secured and removed from the construction site after a rad survey confirmed readings less than 0.4 mr/hr at 1 meter.

To top of page
Power Reactor Event Number: 44374
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEE KELLY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/29/2008
Notification Time: 19:09 [ET]
Event Date: 07/29/2008
Event Time: 14:00 [PDT]
Last Update Date: 07/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NEIL O'KEEFE (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

PRESS RELEASE CONCERNING IMPACT OF EARTHQUAKE ON SOUTHERN CALIFORNIA EDISON ASSETS

On July 29, 2008, SCE issued a press release regarding the earthquake that occurred on the same day. Along with information on other facilities, the press release included information on San Onofre Nuclear Power Plant and stated:

"The earthquake was felt at the San Onofre Nuclear Generating Station site. There were no safety issues reported and no indications of any damage. The plant continues to operate normally."

The NRC Resident Inspector has been notified.

To top of page
Power Reactor Event Number: 44377
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TERRY BACON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/31/2008
Notification Time: 11:03 [ET]
Event Date: 07/31/2008
Event Time: 08:17 [CDT]
Last Update Date: 07/31/2008
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):
PATTY PELKE (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DURING TESTING

"Unit one (1) experienced a reactor trip during SP-1003 Analog Protection Functional Test. The yellow Tave channel was in test when the red Tave channel bistable failed causing an OTDT reactor trip. Applicable emergency operating procedures were entered and completed. The plant is now implementing 1C1.3, the normal plant shutdown procedure.

"All systems performed as expected with exception of 11 turbine driven auxiliary feed (AFW) pump auto started and tripped 50 seconds later on low suction / discharge pressure which the plant is continuing to investigate. All rods inserted and all other AFW system components are operating as expected."

Decay heat removal is from Main and Auxiliary Feedwater to the Steam Dump system. No safety or relief valves actuated. The plant is in a normal electrical lineup.

The licensee notified the NRC Resident inspector.

To top of page
Power Reactor Event Number: 44379
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: MARK JENKIN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/31/2008
Notification Time: 21:59 [ET]
Event Date: 07/31/2008
Event Time: 13:45 [CDT]
Last Update Date: 07/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PATTY PELKE (R3)

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

Event Text

POSTULATED HIGH-ENERGY LINE BREAK THAT COULD DISABLE BOTH TRAINS OF COMPONENT COOLING

"At 1345 Prairie Island staff declared both trains of Unit 2 Component Cooling (CC) system inoperable due to discovery that a postulated high energy line break (HELB) in the Turbine Building that could fail a CC line in the turbine building that would affect both trains of CC. The inoperability of Unit 2 CC caused entry into Technical Specification LCO 3.0.3. The CC line in question is not automatically isolated on a safety injection signal and the loss of CC inventory would eventually affect both trains of CC. Since a Unit 2 HELB could directly result in a loss of both trains of CC (a system that is required to meet the single failure criterion), the CC system does not meet the single failure criterion in the as-found configuration. Thus, in accordance with the guidance in NUREG 1022, this condition is reportable per 10 CFR 50.72(b)(3)(ii).

"The CC line in the Turbine Building was isolated at 1614 on 7/31/08 returning Unit 2 CC to operable status. Unit 2 remained at 100% power."

The isolated line went to a chemistry lab cooler that can be isolated during operation. The condition was discovered during a high-energy line break vulnerability walk-down. A similar line on Unit 1 was already isolated.

The NRC Resident Inspector has been notified.

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