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Event Notification Report for November 20, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/19/2008 - 11/20/2008

** EVENT NUMBERS **


44666 44667 44668

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Power Reactor Event Number: 44666
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: LEONARD SMITH
HQ OPS Officer: JOE O'HARA
Notification Date: 11/19/2008
Notification Time: 06:59 [ET]
Event Date: 11/19/2008
Event Time: 04:25 [CST]
Last Update Date: 11/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
EUGENE GUTHRIE (R2)

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

AUTOMATIC REACTOR TRIP

"On 11/19/08 at 0425 CST was operating at 100 power when the reactor tripped with no complications. All safety systems operated properly with the plant in Hot Standby. The cause of the reactor trip is under investigation. There is no radioactive release from the site."

Uncomplicated trip event. Farley Unit 1 is shutdown with all rods in. No relief valves lifted. All other safety related systems are operable. There are no EDG's running. Reactor Pressure is 2247 psig; reactor temperature is 551 degrees Fahrenheit. Decay heat path is via turbine bypass valves to the condenser. AFW is feeding the S/G's. No ECCS systems injected.

There is no affect on Unit 2.

Licensee is investigating a potential fault in the switchyard.

The licensee will notify the NRC Resident Inspector.

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Hospital Event Number: 44667
Rep Org: WALTER REED ARMY MEDICAL CENTER
Licensee: WATER REED ARMY MEDICAL CENTER
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01738-02
Agreement: N
Docket:
NRC Notified By: COL. MARK MELANSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/19/2008
Notification Time: 13:08 [ET]
Event Date: 11/14/2008
Event Time: 09:00 [EST]
Last Update Date: 11/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MARIE MILLER (R1)
MICHELE BURGESS (FSME)

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

Event Text

BRACHYTHERAPY SEEDS TEMPORARILY LOST AND UNACCOUNTED FOR

"On 10 NOV 08, a patient was admitted for a brachytherapy treatment. The patient received 77.8 mCi of Ir-192 in the form of eight nylon ribbons, each ribbon containing 7 seeds, for a total of 56 seeds (each seed containing 1.39 mCi of iridum-192).

"The initial dose rate was 50 cGy/hour with a prescribed dose of 4500 cGy to be delivered over a 90 hour treatment time.

"On 14 NOV 08 at 0900, when the sources were scheduled to be removed, it was discovered that three ribbons (containing 29.2 mCi of Ir-192) were missing. It was later learned that the ribbons were improperly removed from the room when a physician improperly changed the bandage on the patient (the ribbons were stuck to the bandage with tape).

"A search was made of the trash compactor located on the back loading dock. The compactor had just been unloaded at 0600 hours on 14 NOV 08. A survey of the trash compactor discovered the sources (all three ribbons with all 21 seeds) at 1210 [hrs.] on 14 NOV 08. Hence, the sources were placed in the compactor between 0600 and 0900 on 14 NOV 08.

"Verification of the sources was visually made by the therapy physicist (the sources did not have serial numbers or other indentifying markings). As a precaution, leak tests were performed on the previously missing sources and the results did not indicate any detectable activity.

"Based upon interviews of the medical and the housekeeping staff, the following events occurred:

"a. The physician improperly removed the bandage (and the sources stuck to the bandage with tape) and threw it in the trash can located within the room..

"b. The housekeeping staff improperly entered the patient's room and removed the trash from the trash can, placing it in a larger barrel. The barrel was then taken to the loading dock and emptied into the trash compactor. All of this occurred between 0600 and 0900. The compactor is situated in an unoccupied area of the back loading dock (no break areas or smoking areas).

"c. The maximally exposed individual in this scenario was the housekeeping worker who removed the trash and took it to the compactor on the loading dock:

i. The dose rate at one meter from the sources was measured as 13 mR/h.
ii. The sources were assumed to be 0.5 meters from the custodial worker.
iii. The transit time from the room to the compactor was 20 minutes (based upon interview with the custodial worker).
iv. The estimated dose to the worker is 17.3 mRem [based on a provided calculation].

"A complete investigation is being made of the incident and will be reported at the next scheduled meeting of the Walter Reed Army Medical Center Radiation Safety Committee currently scheduled for 4 DEC 08."

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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Fuel Cycle Facility Event Number: 44668
Facility: WESTINGHOUSE HEMATITE
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 3
City: HEMATITE State: MO
County: JEFFERSON
License #: SNM-33
Agreement: N
Docket: 07000036
NRC Notified By: GERRY COUTURE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/19/2008
Notification Time: 21:04 [ET]
Event Date: 11/19/2008
Event Time: 16:00 [CST]
Last Update Date: 11/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
KENNETH O'BRIEN (R3)
BRIAN SMITH (NMSS)

Event Text

RADIOACTIVE CONTAMINATION GREATER THAN EXPECTED

"10CFR70, Appendix A: A condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed.

"The residual radioactivity contained within these buildings is primarily in the form of surface contamination. The results of previous characterization data indicate that the residual mass was approximately 250 grams of U-235. However, the preliminary results of more recent characterization surveys and sampling have provided information that suggests the inventory of residual mass may be higher than previously estimated.

"Based on the results of recent radiological surveys performed within the process buildings, small quantities of uranium contamination have been identified in partially dismantled piping and ventilation filter housings. The potential for exposure to workers and to members of the public is minimal since the uranium is present in the form of contamination fixed to interior surfaces of the building, piping and interiors of equipment that remains within the building.

"Recent radiological surveys performed within the process buildings have revealed the potential for small quantities of uranium contamination in partially dismantled piping and ventilation filter housings. These radiological surveys were performed to gather additional information to support work planning associated with building demolition. This condition does not represent degradation or failure of structures, systems, equipment, components, or activities of personnel relied on to prevent potential accidents or mitigate their consequences.

"No structures, systems, equipment, components are relied upon to prevent potential accidents. The activities of personnel have been curtailed to include only the performance of radiological characterization necessary to refine and complete the estimate of the U-235 mass.

"Additional actions taken by the licensee in response to the event:
1. Restricted access to the buildings during non-work hours.
2. Limited access to the building during working hours to those personnel performing radiological characterization activities necessary to refine and complete the estimate of the U235 mass, and those engaged in minor maintenance activities not associated with the interior surfaces of piping and equipment.
3. Provided instructions to personnel allowed access that piping, remaining equipment and any other component that may contain residual U-235 are not to be disturbed in any manner except for actions necessary to support completion of radiological contamination estimates; re-configuration of these shall not occur."

The licensee suspects that the contamination is in the order of 700g U-235. Contact readings were less than 1.5 mR/hr.

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