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Event Notification Report for February 19, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/18/2009 - 02/19/2009

** EVENT NUMBERS **


44848 44853 44860

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Fuel Cycle Facility Event Number: 44848
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHAKELFORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/12/2009
Notification Time: 16:30 [ET]
Event Date: 02/12/2009
Event Time: 12:15 [EST]
Last Update Date: 02/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
JONATHAN BARTLEY (R2)
MICHAEL WATERS (NMSS)
REBECCA TADESSE (FSME)
FUELS OUO (EMAIL) ()

Event Text

CONTAMINATED WORKER SENT TO OFFSITE HOSPITAL FOR TREATMENT

"Operator was changing a filter in a glove box when he noticed liquid on his sleeve. Safety Department was notified and operator was found to be contaminated above limits. Decontamination attempts were unsuccessful due to nitric acid burn on forearm. Several small holes/cuts in rubber glovebox glove were identified. Operator was sent to medical facility for further evaluation. Operator was treated for second degree burns at medical facility and released.

"There were no exposures from licensed material. There were no actual consequences to the public or environment.

"Personal protective equipment was used by the worker. Emergency safety shower was available and utilized. Locker room shower was also available and utilized."

The NRC Resident Inspector was notified.

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Hospital Event Number: 44853
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
Region: 4
City: LOS ANGELES State: CA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: PETE SNYDER
Notification Date: 02/13/2009
Notification Time: 21:09 [ET]
Event Date: 02/12/2009
Event Time: [PST]
Last Update Date: 02/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GEOFFREY MILLER (R4)
SONIA BURGESS (R3)
REBECCA TADESSE (FSME)

Event Text

BRACHYTHERAPY SEEDS MISPLACED IN PATIENT

"A medical event was discovered on February 12, 2009, for a patient treated at the VA Greater Los Angeles Healthcare System, Los Angeles, California.

"The medical event involved a patient who had undergone permanent implant prostate seed brachytherapy on February 12, 2009, using iodine-125 seeds. Approximately five seeds were mistakenly placed more than one centimeter from the prostate toward the perineum. This treatment result is interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(3).

"The causes and clinical effects are under review. At this time, it is not believed that the misplaced seeds will cause any adverse deterministic effects to the patient.

"The permittee is aware of the requirements in 10 CFR 35.3045 regarding notification of the patient and referring physician. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, NRC Region III, of the medical event.

"The permit number for the facility involved in this medical event is VHA Permit No. 04-00181-04."

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: 44860
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOE BENNETT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/18/2009
Notification Time: 08:03 [ET]
Event Date: 02/18/2009
Event Time: 03:51 [CST]
Last Update Date: 02/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHARLIE PAYNE (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 Shutdown

Event Text

TURBINE TRIP DUE TO POWER LOAD UNBALANCE SIGNAL ON MAIN GENERATOR RESULTING IN REACTOR SCRAM

"At 0351 on 2/18/09, the Unit 1 reactor automatically scrammed due to actuation of the Reactor Protection System from a turbine trip due to a power load unbalance signal on the main generator. The cause of the power load unbalance signal was due to a generator neutral over voltage condition of which the cause is unknown and the investigation is continuing. All systems responded as expected to the turbine trip. One Safety Relief Valve (SRV) opened due to the reactor pressure transient, and then reactor pressure was automatically controlled by the Main Turbine Bypass valves. No Emergency Core Cooling System (ECCS), or Reactor Core Isolation Cooling (RCIC) reactor water level initiation set points were reached, all expected containment isolation and initiation signals were received, and reactor water level is being automatically controlled by the feedwater system.

"This event is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B) for any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector has been notified."

All control rods fully inserted. The plant electrical system is in normal shut down alignment. No Diesel Generators started as a result of this event. There was no ECCS injection to the reactor vessel.

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