Event Notification Report for October 07, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/06/2008 - 10/07/2008
EVENT NUMBERS
4454644547445484454944551
Power Reactor
Event Number: 44546
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/07/2008
Notification Time: 13:13 [ET]
Event Date: 10/07/2008
Event Time: 06:35 [EDT]
Last Update Date: 10/07/2008
Notification Time: 13:13 [ET]
Event Date: 10/07/2008
Event Time: 06:35 [EDT]
Last Update Date: 10/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN CARUSO (R1)
JOHN CARUSO (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
SPECIFIED SYSTEM ACTUATION DUE TO LOSS OF POWER DURING TESTING
"On October 7, 2008 at approximately 0635, the James A. FitzPatrick Nuclear Power Plant was shutdown and operating in the Cold Shutdown mode (Mode 4). Testing was in progress on the trip and lockout (86) relay associated with circuit breaker 71-10402, normal station service transformer T-4 feeder breaker to electrical bus 10400. While technicians were performing the test, the 10400 bus, which was feeding power to the 10600 Emergency Bus, lost power. This loss of power to the 10600 bus resulted in an automatic actuation of the 'B' and 'D' Emergency Diesel Generators. The generators started, force paralleled, and closed in to the 10600 Bus as designed. As a result of the loss of the 10600 bus the 'B' Reactor Protection System (RPS) also lost power resulting in a half scram signal and a Group II Primary Containment Isolation System (PCIS) actuation. This actuation resulted in closing containment isolation valves in multiple systems and isolating Reactor Water Clean-up (RWCU). Based on these system actuations the event is reportable under Criterion 10 CFR 50.72(b)(3)(iv).
"The event has been entered into the corrective action program and a Licensee Event Report (LER) will be filed within 60 days as required by 10 CFR 50.73(a)(2)(iv).
"The [NRC] Resident Inspector has been briefed and the State Public Service Commission (PSC) will also be notified."
At the time of the event, the 'B' shutdown cooling system was in service. Shutdown cooling was lost for approximately 35 minutes which resulted in a 6 degree rise in water temperature. At that time, the licensee calculated 19.5 hours to boil. Shutdown cooling has been restored.
"On October 7, 2008 at approximately 0635, the James A. FitzPatrick Nuclear Power Plant was shutdown and operating in the Cold Shutdown mode (Mode 4). Testing was in progress on the trip and lockout (86) relay associated with circuit breaker 71-10402, normal station service transformer T-4 feeder breaker to electrical bus 10400. While technicians were performing the test, the 10400 bus, which was feeding power to the 10600 Emergency Bus, lost power. This loss of power to the 10600 bus resulted in an automatic actuation of the 'B' and 'D' Emergency Diesel Generators. The generators started, force paralleled, and closed in to the 10600 Bus as designed. As a result of the loss of the 10600 bus the 'B' Reactor Protection System (RPS) also lost power resulting in a half scram signal and a Group II Primary Containment Isolation System (PCIS) actuation. This actuation resulted in closing containment isolation valves in multiple systems and isolating Reactor Water Clean-up (RWCU). Based on these system actuations the event is reportable under Criterion 10 CFR 50.72(b)(3)(iv).
"The event has been entered into the corrective action program and a Licensee Event Report (LER) will be filed within 60 days as required by 10 CFR 50.73(a)(2)(iv).
"The [NRC] Resident Inspector has been briefed and the State Public Service Commission (PSC) will also be notified."
At the time of the event, the 'B' shutdown cooling system was in service. Shutdown cooling was lost for approximately 35 minutes which resulted in a 6 degree rise in water temperature. At that time, the licensee calculated 19.5 hours to boil. Shutdown cooling has been restored.
Other Nuclear Material
Event Number: 44547
Rep Org: WAL-MART
Licensee: WAL-MART
Region: 4
City: BENTONVILLE State: AR
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RICH DAILEY
HQ OPS Officer: HOWIE CROUCH
Licensee: WAL-MART
Region: 4
City: BENTONVILLE State: AR
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RICH DAILEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/07/2008
Notification Time: 16:54 [ET]
Event Date: 10/07/2008
Event Time: 00:00 [CDT]
Last Update Date: 01/16/2009
Notification Time: 16:54 [ET]
Event Date: 10/07/2008
Event Time: 00:00 [CDT]
Last Update Date: 01/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DALE POWERS (R4)
MARK DELLIGATTI (FSME)
ILTAB (e-mail)
DALE POWERS (R4)
MARK DELLIGATTI (FSME)
ILTAB (e-mail)
LOST TRITIUM EXIT SIGNS
Wal-Mart is conducting a worldwide audit of their tritium exit signs. This morning they discovered three missing signs.
The first missing sign was located at the store in Noblesville, Indiana. The serial number is 301651, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
The second sign was located at the store in Charlotte, Michigan. The serial number and manufacturer were unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
The third sign was located at the store in Yankton, South Dakota. The serial number is 293214, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
All three stores were searched for the signs without success.
* * * UPDATE PROVIDED BY RICHARD DALEY TO JASON KOZAL ON 10/09/08 AT 1308 * * *
Three additional signs were discovered missing in the state of Michigan:
1. At a store located at 995 Razorback Dr., Houghton, MI 49931. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).
2. At a store located at 10772 West Carson City Rd., Greenville, MI 48838. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).
3. At a store located at 7021 SW Nedge Ave, Portage, MI 49002. The serial number is 357889, the manufacturer is Isolite (11.5 Ci of tritium).
All three stores were searched for the signs without success.
Notified R3DO (Lara), and FSME (Burgess) and ILTAB via email.
* * * UPDATE AT 1400 EDT ON 10/10/08 FROM RICH DAILEY TO S. SANDIN * * *
An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 280802. It was last inventoried in Spring 2008 at Wal-Mart Store #5039 which is located in Camden, DE.
Notified R3DO (Lara), FSME (Einberg) and ILTAB via email.
* * * UPDATE AT 1422 EDT ON 10/14/08 FROM RICH DAILEY TO JOE O'HARA * * *
An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 277880. It was last inventoried in Spring 2008 at Wal-Mart Store #1833 which is located in Fredericksburg, VA.
Notified R1DO (Jackson), R3DO (Phillips), FSME (Vontill) and ILTAB via email.
* * * UPDATE AT 1305 EDT ON 10/21/08 FROM RICH DAILEY TO JEFF ROTTON * * *
Two additional missing exit signs were identified during the on-going inventory.
1. 1 sign at store #566, 1115 American Way, Booneville, IN 75237. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 306432.
2. 1 sign at store #3548, 910 Walcott Street, Waterbury, CT 06705. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 266092.
Notified FSME (Burgess), R3DO (Hironori Peterson), R1DO (Cahill), and ILTAB via email.
* * * UPDATE ON 10/24/08 AT 1735 EDT FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Missouri. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Location: Dexter, Missouri, Serial number - 314882, Curie content - 11.5.
2. Location: Dexter, Missouri, Serial number - 314890, Curie content - Unknown.
Notified FSME (Mauer), R4DO (Deese) and ILTAB via email.
* * * UPDATE ON 10/28/08 AT 0900 EDT FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a tritium exit sign missing from a store in Virginia. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Location: Norton, Virginia, Serial number - 316467, Curie content - 11.5.
Notified FSME (Einberg), R1DO (Cobey) and ILTAB via email.
* * * UPDATE ON 10/29/08 AT 1713 EDT FROM DAILEY TO KOZAL * * *
Wal-Mart Corporate Office reported a total of 3 tritium exit signs missing from two stores in Michigan, and 1 sign from a store in Indiana. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Store number 1791 Location: 7083 West 48th Street, Freemont, MI 49412, Serial Number: Unknown, Manufacturer - Isolite, Activity - 11.5 Ci.
2. Store number 1791 Location: 7083 West 48th Street, Freemont, MI 49412, Serial Number: 256573, Manufacturer - Isolite, Activity - 11.5 Ci.
3. Store number 2238 Location: 1879 East Sherman Blvd., Muskegon, MI 49444 Serial Number: 254487, Manufacturer - SRB, Activity - 20 Ci.
4. Store number 2339 Location: 2801 North Western Ave, West Lafayette, IN 47906, Serial Number: 295648, Manufacturer - Isolite, Activity - 11.5 Ci.
Notified FSME (Einberg), R3DO (Kozak) and ILTAB via email.
* * * UPDATE ON 11/05/08 AT 1828 EST FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Hawaii and 1 sign from a store in Connecticut. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises.
The device information is as follows:
1. Store number 5274 Location: 1131 Kuala Street, Pearl City, HI 96782, Serial Number: 33526, Manufacturer - Isolite, Activity - 11.5 Ci.
2. Store number 2331 Location: 155 Waterford Parkway North, Waterford, CT 06385, Serial Number: 286501, Manufacturer -SBR, Activity - Unknown
Notified FSME (Suber), R4DO (Campbell), R1DO (Caruso) and ILTAB via email.
* * * UPDATE ON 11/11/08 AT 0818 EST FROM DAILEY TO KOZAL * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing. One in New Jersey and 1 sign from a store in Virginia. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises.
The device information is as follows:
1. Store number 1742 Location: 3501 Rt 42, Turnersville, NJ 08012 Serial number: 162266, Manufacturer: Foreverlight, Activity: Unknown.
2. Store number 1726 Location: 171 Burgess Road, Harrisonburg, VA 22801 Serial number: 288780, Manufacturer: SRB, Activity: 20 Ci.
Notified FSME (Suber), R1DO (Trapp) and ILTAB via email.
* * * UPDATE ON 11/12/08 AT 1432 EST FROM WENDY WIDENER TO JOHN KNOKE * * *
1. Store number 2449 Location: Ave Rafael Cordero Caguas, Puerto Rico 00725 Serial number, Manufacturer and Activity Unknown.
2. Store number 3219 Location: 731 East Rochambeau Rd Williamsburg, VA 23188 Serial number: 275031, Manufacturer: SRB, Activity: Unknown
3. Store number 4755 Location: 750 Ke'eaumoku St. Honolulu, HI 96814 Serial number: 315483, Manufacturer: Isolite, Activity: Unknown.
4. Store number 4755 Location: 750 Ke'eaumoku St. Honolulu, HI 96814 Serial number: 315484, Manufacturer: Isolite, Activity: Unknown.
Notified R1DO (Trapp) and R4DO (Whitten), FSME (Burgess), ILTAB email
* * * UPDATE ON 11/13/08 AT 1229 EST FROM WENDY WIDENER TO JOHN KNOKE * * *
1. Store number 1811 Location: 1170 North Military Hwy Norfolk, VA 23502 Serial number, 294096 Manufacturer SRB Activity Unknown.
2.Store number 1811 Location: 1170 North Military Hwy Norfolk, VA 23502 Serial number, 294111 Manufacturer SRB Activity Unknown.
3. Store number 3734 Location: 1207 Princeton Street Vermillion, SD 57069 Serial number Unknown, Manufacturer: Isolite, Activity: Unknown.
Notified R1DO (Trapp) and R4DO (Whitten), FSME (Burgess), ILTAB by email
* * * UPDATE AT 0928 EST ON 12/1/08 FROM WENDY WIDENER TO S. SANDIN * * *
1. Store number 2518 Location: 700 Marketplace Blvd., Hamilton, NJ 08691 Serial number, 280984 Manufacturer SRB Activity 20 Ci Tritium.
Notified R1DO (Doerflein), FSME (Burgess) and ILTAB via email.
* * * UPDATE AT 1555 EST ON 1/5/09 FROM W. WIDENER TO W. HUFFMAN * * *
A Wal-Mart corporate representative reported that Wal-Mart was unable to account for an additional 2439 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout 14 non-agreement States and the Commonwealth of Puerto Rico. Wal-Mart had previously reported between September 16 and December 1, 2008, to the NRC a total of 29 unaccounted for tritium exit signs in several of the non-agreement states (see also EN #44495). The Wal-Mart representative informed the NRC that they had exhausted their search for the tritium exit signs and considered them to be lost and/or missing. The NRC was provided a listing from Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content if known.
Notified R1DO (Burritt), R2DO (Blamey), R3DO (Duncan), R4DO (Lantz), FSME EO (Burgess) and ILTAB via email.
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
Wal-Mart is conducting a worldwide audit of their tritium exit signs. This morning they discovered three missing signs.
The first missing sign was located at the store in Noblesville, Indiana. The serial number is 301651, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
The second sign was located at the store in Charlotte, Michigan. The serial number and manufacturer were unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
The third sign was located at the store in Yankton, South Dakota. The serial number is 293214, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.
All three stores were searched for the signs without success.
* * * UPDATE PROVIDED BY RICHARD DALEY TO JASON KOZAL ON 10/09/08 AT 1308 * * *
Three additional signs were discovered missing in the state of Michigan:
1. At a store located at 995 Razorback Dr., Houghton, MI 49931. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).
2. At a store located at 10772 West Carson City Rd., Greenville, MI 48838. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).
3. At a store located at 7021 SW Nedge Ave, Portage, MI 49002. The serial number is 357889, the manufacturer is Isolite (11.5 Ci of tritium).
All three stores were searched for the signs without success.
Notified R3DO (Lara), and FSME (Burgess) and ILTAB via email.
* * * UPDATE AT 1400 EDT ON 10/10/08 FROM RICH DAILEY TO S. SANDIN * * *
An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 280802. It was last inventoried in Spring 2008 at Wal-Mart Store #5039 which is located in Camden, DE.
Notified R3DO (Lara), FSME (Einberg) and ILTAB via email.
* * * UPDATE AT 1422 EDT ON 10/14/08 FROM RICH DAILEY TO JOE O'HARA * * *
An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 277880. It was last inventoried in Spring 2008 at Wal-Mart Store #1833 which is located in Fredericksburg, VA.
Notified R1DO (Jackson), R3DO (Phillips), FSME (Vontill) and ILTAB via email.
* * * UPDATE AT 1305 EDT ON 10/21/08 FROM RICH DAILEY TO JEFF ROTTON * * *
Two additional missing exit signs were identified during the on-going inventory.
1. 1 sign at store #566, 1115 American Way, Booneville, IN 75237. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 306432.
2. 1 sign at store #3548, 910 Walcott Street, Waterbury, CT 06705. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 266092.
Notified FSME (Burgess), R3DO (Hironori Peterson), R1DO (Cahill), and ILTAB via email.
* * * UPDATE ON 10/24/08 AT 1735 EDT FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Missouri. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Location: Dexter, Missouri, Serial number - 314882, Curie content - 11.5.
2. Location: Dexter, Missouri, Serial number - 314890, Curie content - Unknown.
Notified FSME (Mauer), R4DO (Deese) and ILTAB via email.
* * * UPDATE ON 10/28/08 AT 0900 EDT FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a tritium exit sign missing from a store in Virginia. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Location: Norton, Virginia, Serial number - 316467, Curie content - 11.5.
Notified FSME (Einberg), R1DO (Cobey) and ILTAB via email.
* * * UPDATE ON 10/29/08 AT 1713 EDT FROM DAILEY TO KOZAL * * *
Wal-Mart Corporate Office reported a total of 3 tritium exit signs missing from two stores in Michigan, and 1 sign from a store in Indiana. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart last inventoried these signs April 2008 and is declaring these signs to be missing.
The device information is as follows:
1. Store number 1791 Location: 7083 West 48th Street, Freemont, MI 49412, Serial Number: Unknown, Manufacturer - Isolite, Activity - 11.5 Ci.
2. Store number 1791 Location: 7083 West 48th Street, Freemont, MI 49412, Serial Number: 256573, Manufacturer - Isolite, Activity - 11.5 Ci.
3. Store number 2238 Location: 1879 East Sherman Blvd., Muskegon, MI 49444 Serial Number: 254487, Manufacturer - SRB, Activity - 20 Ci.
4. Store number 2339 Location: 2801 North Western Ave, West Lafayette, IN 47906, Serial Number: 295648, Manufacturer - Isolite, Activity - 11.5 Ci.
Notified FSME (Einberg), R3DO (Kozak) and ILTAB via email.
* * * UPDATE ON 11/05/08 AT 1828 EST FROM DAILEY TO KLCO * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Hawaii and 1 sign from a store in Connecticut. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises.
The device information is as follows:
1. Store number 5274 Location: 1131 Kuala Street, Pearl City, HI 96782, Serial Number: 33526, Manufacturer - Isolite, Activity - 11.5 Ci.
2. Store number 2331 Location: 155 Waterford Parkway North, Waterford, CT 06385, Serial Number: 286501, Manufacturer -SBR, Activity - Unknown
Notified FSME (Suber), R4DO (Campbell), R1DO (Caruso) and ILTAB via email.
* * * UPDATE ON 11/11/08 AT 0818 EST FROM DAILEY TO KOZAL * * *
Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing. One in New Jersey and 1 sign from a store in Virginia. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises.
The device information is as follows:
1. Store number 1742 Location: 3501 Rt 42, Turnersville, NJ 08012 Serial number: 162266, Manufacturer: Foreverlight, Activity: Unknown.
2. Store number 1726 Location: 171 Burgess Road, Harrisonburg, VA 22801 Serial number: 288780, Manufacturer: SRB, Activity: 20 Ci.
Notified FSME (Suber), R1DO (Trapp) and ILTAB via email.
* * * UPDATE ON 11/12/08 AT 1432 EST FROM WENDY WIDENER TO JOHN KNOKE * * *
1. Store number 2449 Location: Ave Rafael Cordero Caguas, Puerto Rico 00725 Serial number, Manufacturer and Activity Unknown.
2. Store number 3219 Location: 731 East Rochambeau Rd Williamsburg, VA 23188 Serial number: 275031, Manufacturer: SRB, Activity: Unknown
3. Store number 4755 Location: 750 Ke'eaumoku St. Honolulu, HI 96814 Serial number: 315483, Manufacturer: Isolite, Activity: Unknown.
4. Store number 4755 Location: 750 Ke'eaumoku St. Honolulu, HI 96814 Serial number: 315484, Manufacturer: Isolite, Activity: Unknown.
Notified R1DO (Trapp) and R4DO (Whitten), FSME (Burgess), ILTAB email
* * * UPDATE ON 11/13/08 AT 1229 EST FROM WENDY WIDENER TO JOHN KNOKE * * *
1. Store number 1811 Location: 1170 North Military Hwy Norfolk, VA 23502 Serial number, 294096 Manufacturer SRB Activity Unknown.
2.Store number 1811 Location: 1170 North Military Hwy Norfolk, VA 23502 Serial number, 294111 Manufacturer SRB Activity Unknown.
3. Store number 3734 Location: 1207 Princeton Street Vermillion, SD 57069 Serial number Unknown, Manufacturer: Isolite, Activity: Unknown.
Notified R1DO (Trapp) and R4DO (Whitten), FSME (Burgess), ILTAB by email
* * * UPDATE AT 0928 EST ON 12/1/08 FROM WENDY WIDENER TO S. SANDIN * * *
1. Store number 2518 Location: 700 Marketplace Blvd., Hamilton, NJ 08691 Serial number, 280984 Manufacturer SRB Activity 20 Ci Tritium.
Notified R1DO (Doerflein), FSME (Burgess) and ILTAB via email.
* * * UPDATE AT 1555 EST ON 1/5/09 FROM W. WIDENER TO W. HUFFMAN * * *
A Wal-Mart corporate representative reported that Wal-Mart was unable to account for an additional 2439 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout 14 non-agreement States and the Commonwealth of Puerto Rico. Wal-Mart had previously reported between September 16 and December 1, 2008, to the NRC a total of 29 unaccounted for tritium exit signs in several of the non-agreement states (see also EN #44495). The Wal-Mart representative informed the NRC that they had exhausted their search for the tritium exit signs and considered them to be lost and/or missing. The NRC was provided a listing from Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content if known.
Notified R1DO (Burritt), R2DO (Blamey), R3DO (Duncan), R4DO (Lantz), FSME EO (Burgess) and ILTAB via email.
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
Hospital
Event Number: 44548
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER - CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: HOWIE CROUCH
Licensee: VA MEDICAL CENTER - CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/07/2008
Notification Time: 19:59 [ET]
Event Date: 10/07/2008
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2009
Notification Time: 19:59 [ET]
Event Date: 10/07/2008
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
MARK DELLIGATTI (FSME)
JULIO LARA (R3)
MARK DELLIGATTI (FSME)
MEDICAL EVENTS DUE TO DOSE RECEIVED LESS THAN PRESCRIBED DOSE
"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate iodine-125 seed implant brachytherapy programs.
"As the result of these ongoing reviews, medical events were discovered on October 7, 2008, for 6 patients treated at the VA Medical Center in Cincinnati, Ohio.
"These 6 medical events involved seed distributions in the patients that resulted in D90 doses less than 80% of the prescribed doses. These circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045.
"A 15-day written report on these 6 medical events will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events."
* * * UPDATE AT 1520 EDT ON 07/23/09 FROM ED LEIDHOLDT TO S. SANDIN * * *
"Following the notification of the NRC on October 7, 2008, of the six medical events described in Event Report No. 44548, the NHPP initiated a reactive inspection on October 16, 2008. As a result of this inspection and related clinical reviews, the NHPP is notifying NRC of one additional medical event at the Cincinnati VA Medical Center, for a total of 7 medical events at this facility. This event, also involving prostate brachytherapy with I-125 seeds, was discovered on July 22, 2009. Like the previous six medical events, this additional medical event involves a D90 dose less than 80% of the prescribed dose.
"We note that the D90 doses for all seven events were based upon CT scans performed one day after the implants, when the prostate is subject to edema from the procedure which often causes underestimation of the true D90. Furthermore, the prescribed doses were 160 gray, instead of the more common 145 gray. Thus, most if not all of these patients likely received clinically adequate dose distributions, despite the percent-wise slightly low D90s. Adverse biological effects to these patients are not expected.
"The facility has notified the patient.
"A written report on this additional medical event will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify the NRC Project Manager, Cassandra Frazier, of NRC Region III."
Notified R3DO (Hills) and FSME EO (Villamar).
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.
"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate iodine-125 seed implant brachytherapy programs.
"As the result of these ongoing reviews, medical events were discovered on October 7, 2008, for 6 patients treated at the VA Medical Center in Cincinnati, Ohio.
"These 6 medical events involved seed distributions in the patients that resulted in D90 doses less than 80% of the prescribed doses. These circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045.
"A 15-day written report on these 6 medical events will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events."
* * * UPDATE AT 1520 EDT ON 07/23/09 FROM ED LEIDHOLDT TO S. SANDIN * * *
"Following the notification of the NRC on October 7, 2008, of the six medical events described in Event Report No. 44548, the NHPP initiated a reactive inspection on October 16, 2008. As a result of this inspection and related clinical reviews, the NHPP is notifying NRC of one additional medical event at the Cincinnati VA Medical Center, for a total of 7 medical events at this facility. This event, also involving prostate brachytherapy with I-125 seeds, was discovered on July 22, 2009. Like the previous six medical events, this additional medical event involves a D90 dose less than 80% of the prescribed dose.
"We note that the D90 doses for all seven events were based upon CT scans performed one day after the implants, when the prostate is subject to edema from the procedure which often causes underestimation of the true D90. Furthermore, the prescribed doses were 160 gray, instead of the more common 145 gray. Thus, most if not all of these patients likely received clinically adequate dose distributions, despite the percent-wise slightly low D90s. Adverse biological effects to these patients are not expected.
"The facility has notified the patient.
"A written report on this additional medical event will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify the NRC Project Manager, Cassandra Frazier, of NRC Region III."
Notified R3DO (Hills) and FSME EO (Villamar).
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.
Power Reactor
Event Number: 44549
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRIS MILLER
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRIS MILLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/07/2008
Notification Time: 23:13 [ET]
Event Date: 10/07/2008
Event Time: 20:00 [CDT]
Last Update Date: 10/07/2008
Notification Time: 23:13 [ET]
Event Date: 10/07/2008
Event Time: 20:00 [CDT]
Last Update Date: 10/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xii) - OFFSITE MEDICAL
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
DALE POWERS (R4)
DALE POWERS (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
INJURED, CONTAMINATED INDIVIDUAL TRANSPORTED TO HOSPITAL
"A contractor fell and was injured while working inside the condenser. He was working in a contaminated area and is being transported via ambulance to River Regional hospital. The individual's protective clothing was slightly contaminated but his body was not contaminated. The State of Mississippi and Claiborne County are government agencies that have been notified of this incident."
The individual's protective clothing read approximately 80 counts above background. A Radiation Protection technician is accompanying the contractor to the hospital. He is suspected to have suffered a broken ankle and broken arm. The licensee is investigating the accident.
The licensee notified the NRC Resident Inspector.
"A contractor fell and was injured while working inside the condenser. He was working in a contaminated area and is being transported via ambulance to River Regional hospital. The individual's protective clothing was slightly contaminated but his body was not contaminated. The State of Mississippi and Claiborne County are government agencies that have been notified of this incident."
The individual's protective clothing read approximately 80 counts above background. A Radiation Protection technician is accompanying the contractor to the hospital. He is suspected to have suffered a broken ankle and broken arm. The licensee is investigating the accident.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 44551
Rep Org: COLORADO DEPT OF HEALTH
Licensee: WAL-MART
Region: 4
City: AURORA State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GREG STASINOS
HQ OPS Officer: JOHN KNOKE
Licensee: WAL-MART
Region: 4
City: AURORA State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GREG STASINOS
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/08/2008
Notification Time: 11:40 [ET]
Event Date: 10/07/2008
Event Time: 14:27 [MDT]
Last Update Date: 10/08/2008
Notification Time: 11:40 [ET]
Event Date: 10/07/2008
Event Time: 14:27 [MDT]
Last Update Date: 10/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DALE POWERS (R4)
MARK DELLIGATTI (FSME)
ILTAB (via e-mail)
DALE POWERS (R4)
MARK DELLIGATTI (FSME)
ILTAB (via e-mail)
AGREEMENT STATE REPORT - LOST EXIT SIGNS CONTAINING TRITIUM
"I [state] received a call from a Wal-Mart Representative on 10/7/08 at 2:27pm on the Colorado Emergency Response and Incident Reporting Line to report three (3) exit signs containing tritium have been lost from two different Wal-Mart locations in the Denver area. Wal-Mart is in the midst of a nationwide effort to replace old tritium containing signs and its believed these signs have been removed but not accounted for during this process.
"One sign is missing from a Wal-Mart store in Aurora located at 5650 S. Chambers Rd. Serial number of the sign is 274282.
"Two signs are missing from a Wal-Mart store in Lakewood located at 7455 W. Colfax. Ave. Serial numbers of signs from that store are 280691 and 280712.
"Each sign is believed to have contained 10.5 - 11.0 curies of tritium."
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
"I [state] received a call from a Wal-Mart Representative on 10/7/08 at 2:27pm on the Colorado Emergency Response and Incident Reporting Line to report three (3) exit signs containing tritium have been lost from two different Wal-Mart locations in the Denver area. Wal-Mart is in the midst of a nationwide effort to replace old tritium containing signs and its believed these signs have been removed but not accounted for during this process.
"One sign is missing from a Wal-Mart store in Aurora located at 5650 S. Chambers Rd. Serial number of the sign is 274282.
"Two signs are missing from a Wal-Mart store in Lakewood located at 7455 W. Colfax. Ave. Serial numbers of signs from that store are 280691 and 280712.
"Each sign is believed to have contained 10.5 - 11.0 curies of tritium."
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