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Event Notification Report for October 31, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/30/2008 - 10/31/2008

** EVENT NUMBERS **


44522 44607 44609 44613 44615 44616

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Hospital Event Number: 44522
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/25/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: [CDT]
Last Update Date: 10/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)

Event Text

MEDICAL DOSE LESS THAN 80% OF 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 seed implant brachytherapy programs.

"As the result of these ongoing reviews, possible medical events were discovered on September 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.

"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)

"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients are under review by medical experts.

"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"Additional Information

"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.

"VHA permit number of permittee involved in event: Permit No. 23-08786-01."

* * * UPDATE AT 1945 ON 10/8/2008 FROM EDWIN LEIDHOLDT TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number.

"A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event."

Notified the R3DO (Lara) and FSME (Einberg).

* * * UPDATE AT 1058 EDT ON 10/30/08 FROM HUSTON TO CROUCH * * *

"This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi.

"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).

"A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility.

"A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."

Notified R3DO (Kozak) and FSME (Burgess).

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.

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General Information or Other Event Number: 44607
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: WAL-MART
Region: 4
City: MUSKOGEE State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JASON KOZAL
Notification Date: 10/28/2008
Notification Time: 11:48 [ET]
Event Date: 10/21/2008
Event Time: [CDT]
Last Update Date: 10/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
MICHELE BURGESS (FSME)
ILTAB (VIA EMAIL) ()

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

Event Text

MISSING TRITIUM EXIT SIGNS

The state provided the following via e-mail:

"On October 21, 2008 the Oklahoma Department of Environmental Quality was notified of missing GL radioactive material by the environmental services manager for Wal-Mart. The devices are Tritium exit sign (TES) light modules. The last known location for these TES were in Wal-Mart stores identified below. The Corporation had inventoried TES in Wal-Mart stores several weeks earlier. When company employees prepared to remove the TES's for disposal, they were unable to locate three of the TES. Information concerning the TES follows.

"Store # 00130, 1000 West Shawnee St., Muskogee, OK 30316, Serial# - Unknown, Manufacturer -Unknown, Curie Content - Unknown

"Store # 03295, 6310 South Elm Place, Broken Arrow, OK 74011, Serial# - Unknown, Manufacturer -Unknown, Curie Content - Unknown

"Store # 03295, 6310 South Elm Place, Broken Arrow, OK 74011, Serial# - 277852, Manufacturer -Isolite, Curie Content - 20"


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.

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General Information or Other Event Number: 44609
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DELEK REFINING LIMITED
Region: 4
City: TYLER State: TX
County:
License #: L02289
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 10/28/2008
Notification Time: 17:09 [ET]
Event Date: 10/28/2008
Event Time: 09:00 [CDT]
Last Update Date: 10/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
CHRISTIAN EINBERG (FSME)

Event Text

CS-137 SOURCE DISCONNECTED FROM LEVEL DETECTOR OPERATING ROD

"At 1515 on 10/28/08, the Agency was notified by the licensee of an event involving a Thermo Measure Tech Model 5191 level measurement gauge. The licensee had noted that the gauge was no longer reading properly and sent a maintenance crew to the area to perform repairs. While conducting repairs, an individual from the safety group came by to perform radiation surveys. The survey indicated elevated levels of radiation so the safety representative had the area evacuated and roped off. The licensee contacted the manufacturer who sent technicians to the facility to investigate. They found that radiation levels were in fact elevated and determined that the source had separated from the operating rod. The source is still located in the gauge housing, but is not currently shielded. The source is a 260 milliCurie (calculated based on decay) Cesium (Cs) -137 source. The licensee has started their investigation including time and distance studies with workers who were in the area. The gauge is located in an area of the plant not frequented by workers. The manufacturer is scheduled to remove the gauge from the vessel and send it to their facilities for further inspection on 10/29/08."

* * * UPDATE FROM ART TUCKER TO PETE SNYDER ON 10/30/08 AT 0833 EDT * * *

The Agreement State of Texas provided the following information via e-mail:

"The licensee contacted the [Texas Department of State Health Services (TDSHS)] on October 29, 2008, and informed them that the gauge had been removed from the tank it was mounted on by the manufacturer. The Cs-137 source was found in the gauge housing. The gauge and source were packaged for transportation back to the manufacturer's facility for inspection and repair. The [TDSHS] will be provided the results of the inspection when it is completed."

Texas Event Number: I - 8576.

Notified R4DO (Spitzberg), FSME (Burgess).

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Power Reactor Event Number: 44613
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ANTHONY JARDINE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/30/2008
Notification Time: 05:10 [ET]
Event Date: 10/30/2008
Event Time: 00:20 [EDT]
Last Update Date: 10/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (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

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT OF SERVICE

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii) as a condition that results in a major loss of emergency offsite communications capability. On October 30, 2008, at approximately 0020 hours EDT, 120 VAC non-essential electrical power was lost to the plant computer due to high temperature in the computer room (approximately 80 degrees F). This resulted in the Integrated Computer System (ICS), the Safety Parameter Display System (SPDS), and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) being out of service.

"At 0028 hours, back-up computer room ventilation equipment was placed in service, and at 0040 hours, the electrical system high temperature shutdown was reset with the computer room temperature at 77 degrees F. At 0217 hours, the computer room high temperature alarm was reset with the room at 72 degrees F. The 120 VAC electrical power was restored to the plant computer room at approximately 0245 hours. The ICS, SPDS, and CADAP equipment functions are in process of restoration. Restoration is expected during dayshift hrs. on 10/30/08. A follow up to this notification will be made when ERDS is restored.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM DAVE O'DONNELL TO JOE O'HARA AT 1406 EDT ON 10/30/08 * * *

The ERDS system has been tested and restored to service.

The NRC Resident Inspector has been notified.

Notified R3DO(Kozak).

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Power Reactor Event Number: 44615
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TERRY BACON
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/30/2008
Notification Time: 16:23 [ET]
Event Date: 10/30/2008
Event Time: 14:17 [CDT]
Last Update Date: 10/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 1 Startup 0 Hot Standby

Event Text

REACTOR MANUALLY TRIPPED DUE TO FAILURE IN ROD CONTROL SYSTEM

"During the performance of 030 (post refueling start-up testing), control rods were being inserted for dynamic rod worth measurement. An urgent failure occurred in the rod control system which caused Group 1 rods in Control Bank A to stop inserting while Group 2 rods continued to insert.

"Reactor was manually tripped following the receipt of rod control alarms due to rod misalignment within Control Bank A. All rods inserted as expected."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44616
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ANDREW SMOLINSKI
HQ OPS Officer: JOE O'HARA
Notification Date: 10/30/2008
Notification Time: 16:40 [ET]
Event Date: 10/30/2008
Event Time: 09:30 [CDT]
Last Update Date: 10/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAURA KOZAK (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

NON-FUNCTIONAL STEAM EXCLUSION BARRIER

"On 10/30/08 at 0930 an RP Technician transiting though a steam exclusion door found a kickplate degraded. The kickplate is held on by two screws and one screw was missing. When the door was opened, the kickplate rotated and became lodged in the staircase grating. This prevented the door from closing until the technician physically lifted the plate out of the way to close the door. The door was open for less than a minute. This kickplate is not part of the door seal itself so when the door is closed it is functional. The kick plate was taped up as a temporary fix and access was restricted through the door until permanent repairs were complete. Permanent repairs were completed on the door at 1116 on 10/30/08. While the door was open and could not close automatically, the barrier was non-functional. In accordance with TRM 3.0.9 Section A.1 all equipment supported by that steam exclusion barrier was immediately declared inoperable. This zone includes both trains of ECCS and support equipment (i.e., SI, RHR, ICS, CCW, etc ). TS 3.0.c was entered and exited during the time the door was open with both trains of ECCS inoperable.

"Therefore, this is reportable under 10 CFR 50.72 (b)(3)(v), 'Any event or condition that at the time of discovery could have prevented the fulfillment of a safety function', and under 10 CFR 50.72(b)(3)(ii)(B) 'any event or condition that results in the nuclear plant being in an unanalyzed condition that significantly degrades plant safety'."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012