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Event Notification Report for February 5, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/04/2009 - 02/05/2009

** EVENT NUMBERS **


44816 44818 44823 44824 44827 44828

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General Information or Other Event Number: 44816
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/30/2009
Notification Time: 12:13 [ET]
Event Date: 01/29/2009
Event Time: [CST]
Last Update Date: 01/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PERSONNEL CONTAMINATION FROM I-131 SPILL IN HOT LAB

"The radiation safety officer [RSO] for Northwestern Memorial Hospital called the Agency [State] to advise that a technician had spilled a significant quantity of I-131 in their hot lab. The technician was preparing a radioiodine therapy dose of 100 milliCi for ingestion by a patient when the spill of the liquid occurred. The technician had been removing the vial from the fume hood to perform a dose calibration when the material slipped from his hands and broke on the floor of the hot lab. The technician was contaminated on his hands, torso and legs. The material, although small in volume, was concentrated, such that even small drops of the liquid exhibit high dose rates. Initial decontamination efforts managed to reduce the contamination on the individual such that the contamination only remained on their hands. The initial measured dose rate was approximately 7 milliR/h.

"The spill victim was excluded from the cleanup process to reduce the possibility of a significant uptake to their thyroid. All individuals involved in the clean up as well as the technician took prophylactic KI. According to the RSO, decontamination will continue until only fixed contamination remains. He estimated that as much as 80% of the contamination had been contained/removed by the time of his call a few hours after the event. Dose rates in the area were initially over 50 milliR/h. Additional shielding was moved into the area so that medically necessary nuclear medicine procedures could be completed while the decontamination was finished. Dose rates behind the shielding indicated less than 1 milliR/h. Bioassays will be conducted during subsequent days to determine the extent of any uptake that has occurred for those involved.

"Arrangements were made for the radiopharmacy to be shut down and operations relocated to another temporary facility within the hospital. Waste generated from the initial decontamination effort was secured within the pharmacy hot lab in the fume hood. Access will be restricted to only those granted leave by the RSO to reenter the lab. Arrangements have been made for an Agency [State] inspector to go to the site to ascertain and verify the dose rates in the area, the extent of contamination and ensure that bioassays are being conducted properly. Depending on the results of those assessments, the Agency [State] may take additional action."

Incident number: IL0900010

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General Information or Other Event Number: 44818
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PRECIX, INC
Region: 1
City: NEW BEDFORD State: MA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/30/2009
Notification Time: 15:31 [ET]
Event Date: 01/28/2009
Event Time: [EST]
Last Update Date: 01/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
KEVIN HSUEH (FSME)
ILTAB via e-mail ()

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

Event Text

AGREEMENT STATE REPORT - TWO MISSING STATIC ELIMINATORS

The following report was received from the State via facsimile:

"Precix [the licensee] called the Agency [the State] on 1/28/09 to report 2 missing static eliminator devices. A follow-up letter dated 1/29/09 was received on 1/30/09. The letter indicates the missing devices are 'NRD' model P-2021 devices having serial numbers A2DR562 and A2EZ592. The licensee reports that at the end of their one year useful life, the units were removed from the system along with others and set aside in preparation for returning them to NRD for disposal. The licensee states they have conducted several searches for the missing devices and have not had any success finding them. The licensee thinks the 2 units inadvertently got separated from the other units being held for return to NRD and were disposed off in the non-hazardous waste stream."

This model static eliminator typically contains approximately 10 millicuries of Po-210.

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: 44823
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/02/2009
Notification Time: 12:25 [ET]
Event Date: 01/27/2009
Event Time: [EST]
Last Update Date: 02/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the State of North Carolina via facsimile:

"On January 27, 2009, a Therasphere (Y-90 microsphere) procedure was scheduled for a patient in Room 4, Special Procedures. The treatment was planned to deliver 110 Gy to the left lobe of the liver. The delivery apparatus was assembled according to manufacturer instructions, without incident. The treatment was initiated. During the first infusion, the Authorized User noticed fluid leakage at the outlet flow line and needle insertion at the source vial. The RSO was contacted. An attempt was made to continue the infusion. The liquid continued to leak at the outlet flow line and needle junction. No additional radioactivity was delivered to the patient. The procedure was terminated.

"Post procedure survey readings of the source vial indicated that approximately 65% of the intended radioactivity was delivered to the patient. This resulted in a dose of 70 Gy delivered to the left lobe of the liver.

"The Authorized User indicated that no adverse clinical symptoms are expected. This was the second treatment for this patient.

"The manufacturer (MDS Nordion) was notified of the device problem on 01/28/09.

"All liquid and contamination was contained by Radiation Safety personnel."

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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Power Reactor Event Number: 44824
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JIM KONRAD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/02/2009
Notification Time: 16:21 [ET]
Event Date: 02/02/2009
Event Time: 14:00 [EST]
Last Update Date: 02/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (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

TECHNICAL SUPPORT CENTER NON-FUNCTIONAL

"On February 2, 2009, at 1400, the Technical Support Center (TSC) heating, ventilation, and air conditioning system was discovered to be nonfunctional. Initial investigation revealed an electrical fault in the supply fan motor. Fermi is making this notification in accordance with 10CFR 50.72(b)(3)(xiii). In the event that TSC activation is necessary, the Emergency Offsite Facility (EOF) will be used. Activation and use of the EOF as a backup facility for the TSC is included in Fermi's Radiological Emergency Response Preparedness Plan, and drills have been held performing both the TSC and EOF functions from the EOF. Fermi will notify the NRC upon completion of corrective maintenance."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM KONRAD TO CROUCH @1609 EST ON 02/04/09 * * *

"Corrective maintenance activities on the TSC HVAC system are complete and the TSC is now available for use."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Ring).

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Power Reactor Event Number: 44827
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BRIAN FINCH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/03/2009
Notification Time: 14:55 [ET]
Event Date: 02/03/2009
Event Time: 13:37 [EST]
Last Update Date: 02/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN WHITE (R1)

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

SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system)'.

"At 0539 EST on Tuesday, February 3, 2009, the Control Room discovered that the plant process computer was not updating and subsequently observed the Safety Parameter Display System (SPDS) Computer Display was not updating data. This was discovered during periodic Control Room monitoring. The last data update on the SPDS display was at 0537 EST.

"Information Technology Department personnel are investigating the cause of the loss of SPDS capability. The Information Technology Department personnel have been unsuccessful in recovering within the 8 hour restriction.

"No other Control Room emergency assessment capabilities have been adversely affected. All Control Room panel indicators and annunciators are responding properly."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM HICKS TO KLCO @ 2215 EST ON 02/04/09

"On Wednesday, February 04, 2009 at 1319 EST, the Plant Process Computer (PPC) was successfully restarted. The performance of the PPC and SPDS was monitored for approximately eight hours. SPDS was declared operable at 2130, restoring full emergency assessment capability."

The licensee will notify the NRC Resident Inspector. Notified R1DO (White).

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Power Reactor Event Number: 44828
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RANDY FORTIER
HQ OPS Officer: VINCE KLCO
Notification Date: 02/04/2009
Notification Time: 14:20 [ET]
Event Date: 02/04/2009
Event Time: 13:20 [CST]
Last Update Date: 02/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (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

SIRENS OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"The Prairie Island Nuclear Generating Plant is making an ENS notification in accordance with 10 CFR 50.72(b)(3)(xiii) due to planned maintenance on the Goodhue County radio repeaters. This maintenance will result in unavailability of 51 of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) for approximately 3 hours. The maintenance is scheduled to occur on the afternoon of 02/04/2009.

"The Goodhue County Sheriff's Office has been notified to implement the established process of back-up route alerting if required.

"Upon completion of the maintenance a cancel test will be performed to verify availability of the Goodhue County sirens and an update to this notification will be provided.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM R. FORTIER TO HOWIE CROUCH @ 1735 EST ON 02/04/09 * * *

The cancel test was performed by the Goodhue County Sheriff's Office to all Goodhue County sirens successfully. All sirens have been returned to service.

The licensee will be notifying the NRC Resident Inspector. Notified R3DO (Ring).

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Thursday, March 29, 2012