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Event Notification Report for November 24, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2008 - 11/24/2008

** EVENT NUMBERS **


44663 44664 44668 44673 44674 44675 44676 44678 44679 44680

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Hospital Event Number: 44663
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: NEW YORK HEALTHCARE SYSTEM
Region: 1
City: BROOKLYN State: NY
County:
License #: 03233853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS E. HUSTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/18/2008
Notification Time: 08:53 [ET]
Event Date: 09/18/2008
Event Time: [EST]
Last Update Date: 11/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH O'BRIEN (R3)
MICHELE BURGESS (FSME)

Event Text

TREATMENT SITE DOSE LESS THAN PRESCRIBED

"A medical event is reported for one patient treated by the VA New York Harbor Healthcare System in Brooklyn, New York. The event was discovered November 17, 2008. The basis for this event is that the D90 dose to the treatment site was slightly less than 80% of the prescribed dose. The treatment involved permanent implant prostate brachytherapy using Iodine-125 seeds. The patient implant date was September 18, 2008. A supplemental implant procedure was performed to achieve an acceptable D90. Adverse effects on the patient are not expected from this medical event.

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

"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. VHA permit number of permittee involved in event: Permit No. 31-62892-03. Address of permittee involved in this event: New York Harbor Healthcare System, 800 Poly Place, Brooklyn, New York, 11209."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 44664
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2008
Notification Time: 13:19 [ET]
Event Date: 11/18/2008
Event Time: 03:08 [CST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BRIAN BONSER (R2)
BRIAN SMITH (NMSS)

Event Text

FIRE WATER SPRINKLER SYSTEM OUT OF SERVICE

"At 0308 CST, on 11/18/2008, the Plant Shift Superintendent was notified that the C-337 High Pressure Fire Water (HPFW) Sprinkler System D-9 had been inspected by Fire Services and six sprinkler heads had visible corrosion on them. The system configuration was evaluated using EN-C-822-99-047, 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to TSR LCO 2.4.4.5. HPFW system D-9 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage. Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the true affect on operability.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

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

The site has implemented hourly fire patrols while this impairment is in affect.

* * * RETRACTION FROM TONY HUDSON TO HOWIE CROUCH @1536 EST ON 11/21/08 * * *

"The affected sprinkler heads were removed and subjected to testing in the plant laboratory. A total of nine heads (three of these heads were previously identified with corrosion) were removed and tested with five of the nine actuating as designed. Using these results, the plant's fire protection engineer concluded that adequate sprinkler coverage existed prior to the discovery and the system would have performed as designed to a fire demand."

The licensee has notified the NRC Resident Inspector. Notified R2DO (Guthrie) and NMSS EO (Smith).

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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: 11/21/2008
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.

* * * UPDATE FROM GERRY COUTURE TO HOWIE CROUCH ON 11/21/08 @ 1819 EST * * *

"As a result of further discussions and preliminary evaluations, Westinghouse wishes to provide a revised report pursuant to 10 CFR Section 70.50(b)(i). Section 70.24 requires that each licensee authorized to possess special nuclear material in specified quantities maintain in each area in which such special nuclear material is handled, used, or stored, a criticality monitoring system. Further specific guidance is contained in Regulatory Guide 3.71 approved by the NRC Staff. As previously reported, the process building or specific areas within may potentially contain more than the threshold amount of special nuclear material to trigger this requirement. If so, a report is required pursuant to the cited section in that previously installed criticality monitoring equipment has been disabled, i.e., removed, and such equipment would be required by regulation.

"This report is being made provisionally as there is insufficient time to definitively determine whether the entry conditions for the building as a whole have been met, i.e., whether 700 grams of uranium-235 are stored therein, and whether the building can be considered to be comprised of separate areas which could each be evaluated for the need to have criticality monitoring provisions. This report under 10 CFR 70.50(b)(2)(i) is subject to being withdrawn with an appropriate explanation and evaluation, if it is determined that the reporting threshold had not been met.

"Additional actions taken by the licensee in response to the event:

"1. Issued a Stop Work Order and assured all necessary personnel have been briefed to restrict access and all work activities associated with the Process Building.

"2. Procuring necessary instrumentation to utilize as the regulatory required equipment and upon concurrence from NRC, proceed with the radiological characterization of the Process Building.
"Discussions [are] ongoing with representatives of the USNRC Headquarters and Region III."

Notified R3DO (Hills) and NMSS EO (Smith).

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Power Reactor Event Number: 44673
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2008
Notification Time: 11:42 [ET]
Event Date: 09/25/2008
Event Time: 02:41 [EST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES DWYER (R1)

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

Event Text

LOOSE CONNECTION CAUSES HALF SCRAM WHILE SHUTDOWN

"On 9/25/2008 at approximately 0241 [EDT], the James A. Fitzpatrick Nuclear Power Plant was Shutdown in the refueling mode. The 'A' Reactor Protective System (RPS) Motor-Generator (MG) Set tripped. This resulted in a half-scram signal and Group II Primary Containment Isolation System [PCIS] actuation. The Group II PCIS isolation actuated valves in multiple systems.

"During the event all systems operated as designed.

"Power was restored to 'A' RPS using the alternate power supply and the Group II PCIS isolation was reset.

"The cause of the event was determined to be a loose connection on the 'A' RPS MG Set voltage regulator. The Voltage regulator was replaced and the RPS System was returned to its normal line-up.

"The event is reportable under 10 CFR 50.73(a)(2)(iv)(A) 'Any event or condition that resulted in manual or automatic actuation of ... (B)(2) general containment isolation signals affecting containment isolation valves in more than one system'. A telephone notification is being made in lieu of an LER, pursuant to 10 CFR 50.73 (a)(1) as an invalid signal."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44674
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2008
Notification Time: 11:42 [ET]
Event Date: 10/14/2008
Event Time: 11:06 [EST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES DWYER (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text

FAULTY VOLTAGE REGULATOR CAUSES HALF SCRAM

"On 10/14/2008 at approximately 1106 [EDT], the James A. FitzPatrick Nuclear Power Plant was operating at approximately 99% power in Mode 1. The 'A' Reactor Protective System (RPS) Motor-Generator (MG) Set tripped. This resulted in a half-scram signal and Group II Primary Containment Isolation System [PCIS] actuation. The Group II PCIS isolation actuated valves in multiple systems.

"During the event all systems operated as designed.

"Power was restored to 'A' RPS using the alternate power supply and the Group II PCIS isolation was reset.

"The cause of the event was determined to be a failure of the 'A' RPS MG Set voltage regulator. The voltage regulator was replaced and the RPS System was returned to its normal line-up. Initial troubleshooting on the failed voltage regulator determined that a Silicone Control Rectifier failed. The voltage regulator was sent off-site for further analysis to determine the cause of failure. The event is reportable under 10 CFR 50.73(a)(2)(iv)(A) 'Any event or condition that resulted in manual or automatic actuation of ...(B)(2) general containment isolation signals affecting containment isolation valves in more than one system'. A telephone notification is being made in lieu of an LER, pursuant to 10 CFR 50.73 (a)(1) as an invalid signal."

The voltage regulator had been replaced approximately three weeks before this failure. (See EN #44673)

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44675
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MURRELL EVANS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2008
Notification Time: 14:08 [ET]
Event Date: 11/21/2008
Event Time: 11:08 [PST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHUCK CAIN (R4)

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

OFFSITE NOTIFICATION AND MEDIA BRIEFING DUE TO POTENTIAL DISCOVERY OF OFFSHORE FAULT NEAR PLANT

"As part of the ongoing seismic monitoring program, PG&E [Pacific Gas & Electric] in conjunction with the US Geological Survey (USGS) is studying a pattern of seismic activity in close proximity to the Diablo Canyon Power Plant (DCPP). The discovered pattern of seismic activity suggests a potential offshore fault near DCPP. PG&E and the USGS were previously unaware of this potential fault. Initial evaluation shows that the potential fault is closer to DCPP and much smaller than the Hosgri fault, which is the current bounding seismic feature for DCPP.

"Initial assessment indicates that the ground motion from this potential fault is expected to be bounded by the existing seismic design basis for DCPP. The possible impact of this potential fault, including potential ground deformation is the subject of an ongoing evaluation. Given the available data, PG&E and the USGS estimate that it will take up to a year to determine if a seismic fault exists.

"This issue was discussed with US NRC Region IV and Office of US NRC Nuclear Reactor Regulation on November 21, 2008. PG&E is planning a media briefing."

The licensee has notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 44676
Rep Org: MALLINCKRODT
Licensee: MALLINCKRODT
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 02-04206-01
Agreement: N
Docket:
NRC Notified By: JAMES SCHUH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2008
Notification Time: 14:27 [ET]
Event Date: 11/21/2008
Event Time: 13:25 [CST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JAMES DWYER (R1)
KENNETH O'BRIEN (R3)
ILTAB VIA E-MAIL ()

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

Event Text

LOST I-131 MEDICAL PHARMACEUTICAL

10 packages of medical pharmaceuticals were shipped on 11/19/2008 from Mallinckrodt in Maryland Heights, MO to destinations in Virginia, Maryland, and Pennsylvania. One package did not arrive at the destination: a Mallinckrodt pharmacy in Folcroft, PA. Three couriers were used to ship the packages: transport from Mallinckrodt to the airport, ship by air, and transport to the pharmacies. All of the couriers have searched for the missing package without success.

Source: I-131, 109 mCi

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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Other Nuclear Material Event Number: 44678
Rep Org: NOAA
Licensee: NOAA
Region: 4
City: IDAHO FALLS State: ID
County:
License #: 05-11997-01
Agreement: N
Docket:
NRC Notified By: RHONDA CARPENTER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2008
Notification Time: 18:04 [ET]
Event Date: 11/18/2008
Event Time: [MST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
CHUCK CAIN (R4)
TERRENCE REIS (FSME)

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

Event Text

LEAKING SEALED SOURCE

"On the morning of Nov. 18, 2008, routine semiannual ECD [Electron Capture Device] leak tests were conducted in the FRD [Field Research Division] laboratory at 1750 Foote Dr., Idaho Falls, ID. A wipe test on the inlets and outlets of the above source showed the presence of 0.011 microcuries of contamination. The wipe was counted on a Ludlum 3030 Alpha Beta Sample Counter that was specifically calibrated for Ni-63 by the Idaho National Laboratory Health Physics Instrumentation Laboratory. Annual calibration was completed on Nov. 12, 2008. The limit of detection for the instrument was calculated as 0.00031 microcurie of Ni-63.

"When the high count was observed, the smear was immediately sealed in a ziplock plastic bag. The work area where the wipe was done was immediately checked for contamination. Tools (tweezers, pens, notepad) used, table tops, gloves, and the Ludlum instrument itself were wiped with smears and each one counted. The counts on all smears were much less than the instrument limit of detection indicating zero activity.

"Once it was established that no measurable contamination was present in the environment, steps were taken to isolate the detector. Immediately after the wipe test was completed, all inlets and outlets were recapped and the detector replaced in the locked cabinet where it had been stored. The detector was then removed from the cabinet again and all six sides of the rectangular housing were wiped with a smear. This was counted and showed zero activity indicating that no contamination was on the outside of the detector housing. The detector was placed in a plastic ziplock bag and put in a paint can. The plastic bag containing the smear that counted high was also placed in the can. The can was closed and the outside wiped and counted, again showing zero activity. Further wipe tests were then conducted on the inside of the storage cabinet where the detector was stored, the tables around the gas chromatograph (GC) where the detector was last used and the interior surfaces of the GC. All counts indicated zero activity. Based on these contamination tests, we believe that all leakage is contained within the device which is isolated in the paint can. There was no exposure to the public and neglible exposure to the personnel conducting the leak tests.

"The detector had been taken out of service on August 23, 2007. It had passed all wipe tests prior to that date. The detector remains in the paint can in a locked metal cabinet inside the FRD laboratory. It will remain out of service until it can be repaired. We have contacted the manufacturer and other companies and are investigating options for repair of the unit.

"Source identification: Valco model 140BN Electron Capture Detector (ECD), serial number N206 (General License device, Sealed Source Registry No. TX-658-D-102-G, 5 millicuries Ni-63)"

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Power Reactor Event Number: 44679
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BILL DUVALL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2008
Notification Time: 12:26 [ET]
Event Date: 11/22/2008
Event Time: 10:18 [EST]
Last Update Date: 11/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EUGENE GUTHRIE (R2)

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

Event Text

MANUAL REACTOR SCRAM AFTER FEED PUMP TRIP

"Manual Rx Scram initiated due to a loss of condensate/feedwater. Condensate Booster Pump 1A tripped due to low suction pressure and then both Reactor Feed-pumps tripped. Both HPCI and RCIC initiated on low level and restored reactor water level to normal band 5 to 50 inches.

"Both Reactor Water Recirculation Pumps tripped due to low level at RWL [Reactor Water Level] - 60". Lowest RWL was approximately minus 70 inches and a group two isolation occurred at RWL 3 inches. All group two 2 valves closed as required.

"The cause of the low condensate booster suction pressure is under investigation."

Rods fully inserted on the scram. No safety or relief valves lifted after the scram. Reactor water level is being maintained with normal feed and decay heat is being removed to the main condenser. The plant is in its normal shutdown electrical lineup.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44680
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WILLIAM BAKER
HQ OPS Officer: PETE SNYDER
Notification Date: 11/23/2008
Notification Time: 18:13 [ET]
Event Date: 11/23/2008
Event Time: 12:00 [CST]
Last Update Date: 11/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
EUGENE GUTHRIE (R2)

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

Event Text

PRESSURE BOUNDARY LEAK

"During performance of Unit 1 vessel leak test in accordance with 1-SI-3.3.1.A - ASME Section XI System Leakage Test of the Reactor Pressure Vessel and Associated Piping, a pressure boundary leak was discovered on an instrument line connected to the reactor pressure vessel. This instrument line is a ASME Code Class 1 equivalent component (nozzle safe end) on pressure vessel nozzle N11B and connecting upstream of primary containment penetration X-29B. This caused entry into Technical Requirements Manual (TRM) 3.4.3 - Structural Integrity - Condition A - in which the applicability is at all times and the required action is to immediately restore the structural integrity of the affected component to within its limit or maintain the reactor in MODE 4 or 5 or the reactor coolant system less than 50?F above the minimum temperature required by NDT considerations, until each indication of a defect has been investigated and evaluated. The plant is currently in MODE 4.

"This event is reportable within 8 hours under 10CFR50.72 (b)(3)(ii)(A) Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded. This event is also a reportable within 60 days under 10CFR50.73(a)(2)(ii)(A) any event or condition that resulted in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded. The NRC Resident Inspector has been notified. This condition has been documented in the BFN Corrective Action program as PER# 157918.

"Unit 2 and 3 remain at 100% power and are not affected by this event."

Page Last Reviewed/Updated Monday, November 05, 2012
Monday, November 05, 2012