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Event Notification Report for February 20, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/19/2009 - 02/20/2009

** EVENT NUMBERS **


44853 44863 44864 44865

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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: 44863
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID LANTZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/19/2009
Notification Time: 10:07 [ET]
Event Date: 02/19/2009
Event Time: 05:30 [CST]
Last Update Date: 02/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
DALE POWERS (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Hot Standby

Event Text

POWER SUPPLY FAILURE RESULTING IN A TECH SPEC REQUIRED SHUTDOWN

"The plant was operating in MODE 1 at 100% power. At 0228 on 2/19/09, a power supply to cabinet SA036D, Channel 1 of the Engineered Safety Features Actuation System (ESFAS) failed. As a result of the failure, both trains of control room ventilation isolation signal (CRVIS), containment purge isolation signal (CPIS), and fuel building isolation signal (FBIS) inadvertently actuated. The cause of the failure of SA036D is under investigation. Technical Specification (TS) Action 3.3.2.Q was entered which requires the plant to be in MODE 3 in 6 hours and MODE 4 in 12 hours. Load reduction began at 0530. MODE 2 was entered at 0750. MODE 3 was entered at 0817.

"All systems functioned properly.

"The NRC Resident Inspector has been notified."

The licensee is replacing the entire power supply and will investigate the cause.

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Power Reactor Event Number: 44864
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DENNIS HARRIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/19/2009
Notification Time: 11:52 [ET]
Event Date: 02/19/2009
Event Time: 10:21 [CST]
Last Update Date: 02/19/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DALE POWERS (R4)
ERIC LEEDS (NRR)
THEODORE QUAY (NRR)
ELMO COLLINS (R4 R)
WILLIAM GOTT (IRD)
CASSANDRA McKENTRY (DHS)
DENNIS VIA (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO MAIN GENERATOR HYDROGEN GAS LEAK

"An Unusual Event was declared at 1021 CST due to toxic, corrosive, flammable gasses in amounts that have or could adversely affect normal plant operations. Licensee estimated that a plume of hydrogen gas 20 feet high was leaking in the Turbine Building at the North Generator Bearing. Licensee entered EAL HU3.1. There was no release above normal operating limits (0.1 Mr/hr at EAB). No offsite response required. Gas is being dissipated via emergency degassing of Main Generator. Presently, the Main Generator degas has been completed and no flammable environments remain. The Unusual Event will stay in effect until the area is accessible to personnel, as evaluated by chemistry."

There was no fire or personnel injury related to this event. The Plant was already in Mode 3 due to an earlier event requiring a Technical Specification Action 3.3.2.Q shutdown.

The licensee has notified the NRC Resident Inspector, and local, state and other government agencies. No media press release was anticipated.

* * * UPDATE FROM DAVID HURT TO JOHN KNOKE AT 1255 EST ON 02/19/09 * * *

"The hazard was eliminated by 1055 on 2/19/2008. The Unusual Event was closed out at 1115. The state and counties (Callaway, Gasconade, Montgomery, and Osage) were notified of the event closeout at 1126. A news release will be made by Ameren Corporate Communications."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Powers), DHS ( Cassandra McKentry) and FEMA (Mike Eaches).

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Power Reactor Event Number: 44865
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DANIEL HAUTALA
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/19/2009
Notification Time: 18:40 [ET]
Event Date: 02/19/2009
Event Time: 11:20 [MST]
Last Update Date: 02/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
DALE POWERS (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

INJURED WORKER TRANSPORTED TO OFFSITE MEDICAL FACILITY

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On February 19, 2009, at approximately 11:20 Mountain Standard Time (MST), an employee of Arizona Public Service (APS) was injured while working at the Palo Verde Independent Spent Fuel Storage Installation (ISFSI) which is considered to be a radiologically controlled area (RCA). The ISFSI is located within the owner controlled area but outside the plant's protected area. The ISFSI has been evaluated as having a very low probability for contamination, so administrative controls are used to allow workers access into the ISFSI and return to the appropriate Unit RCA egress point located in the protected area where personnel monitoring for contamination is performed prior to leaving the site. Upon exiting the ISFSI area, the individual was initially transported to the Palo Verde Medical Clinic to attend to the injury. Subsequently, the individual was transported to an offsite medical facility for further evaluation. The individual was not monitored for contamination prior to being transported offsite. The individual and the transporting vehicle were frisked offsite and found to be free of contamination. There were no exposures from licensed material and no consequence to the public or environment."

Injured person was an employee of licensee. Employee was transported to the hospital via private owned vehicle.

The NRC Resident Inspector was notified.

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Thursday, March 29, 2012