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Event Notification Report for March 20, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/19/2009 - 03/20/2009

** EVENT NUMBERS **


44225 44911 44916 44920

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General Information or Other Event Number: 44225
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: WALMART
Region: 4
City: ENID State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2008
Notification Time: 13:54 [ET]
Event Date: 06/06/2003
Event Time: [CDT]
Last Update Date: 03/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4)
CINDY FLANNERY (FSME)

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

Event Text

THREE BROKEN TRITIUM EXIT SIGNS

The Walmart in Enid, Oklahoma performed an inventory of their generally licensed tritium, exit signs and confirmed that three were broken. Walmart suspects that the signs have been broken since sometime in 2003. On May 1, 2008, contractors performed surveys of the area. One wipe was high enough to require remediation (82,000 dpm). The broken exit signs were removed on May 2, 2008.

* * * UPDATE PROVIDED FROM RALPH JOHNSON TO JOE O'HARA AT 0914 ON 3/19/09 * * *

Walmart in Oklahoma performed an inventory of their generally licensed tritium exit signs and confirmed that a total of twelve were broken.

Notified R4DO(Hay) and FSME(McIntosh).

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General Information or Other Event Number: 44911
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WESTERN PENNSYLVANIA HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0121
Agreement: Y
Docket:
NRC Notified By: JENNIFER KELLY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/17/2009
Notification Time: 09:05 [ET]
Event Date: 03/17/2009
Event Time: [EDT]
Last Update Date: 03/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DEFRANCISCO (R1)
ANGELA MCINTOSH (FSME)

Event Text

PENNSYLVANIA AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the State of Pennsylvania via email:

"A female patient was to receive HDR twice a day for a total of 10 treatments with an expected dose of 34Gy via mammosite treatment. A dummy wire was inserted into the balloon to check and measure the tube length for dosage calculations. A CT scan was performed daily to verify the position of the treatment site. Treatment calculations were done, reviewed, approved, and treatment began Monday, February 23, 2009.

"[On] Friday, February 27, 2009, a different therapy physicist was checking the patients charts and thought that there may have been an error.

"[On] Monday, March 2, 2009, the original physicist checked the findings of the different therapy physicist and discovered that there had been an error in the placement of the source during the treatment. The source was not fully inserted into the balloon, but was 3cm from where it should have been, thereby resulting not only in a large difference in the tumor dose received (approx. 30% of intended) but also in a severe dosage to non-intended areas of the patient.

"The physicist, RSO and two licensee's radiation oncologist reviewed the situation once it was discovered. The patient is being followed for any sequelae (pathological conditions) to the event. It was reported that erythema (dilated capillaries) is developing consequential to the event. Follow ups are expected to occur weekly. The oncologist has discussed the event with the patient."

PA Case # PA090011

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

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Hospital Event Number: 44916
Rep Org: BILLINGS CLINIC
Licensee: BILLINGS CLINIC
Region: 4
City: BILLINGS State: MT
County:
License #: 25-01051-01
Agreement: N
Docket:
NRC Notified By: CHRISTOPHER FITZ
HQ OPS Officer: JOE O'HARA
Notification Date: 03/19/2009
Notification Time: 10:49 [ET]
Event Date: 03/13/2009
Event Time: [MDT]
Last Update Date: 03/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MICHAEL HAY (R4)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()

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

Event Text

LOST THREE VIALS OF XENON - 133

The RSO for the licensee reported the hospital inadvertently disposed of 78 millicuries of Xenon-133 through the solid waste system. The hospital believes that a housekeeper may have thrown it away as solid waste. Couriers delivered the material without the knowledge of the hospital on 3/13/09. Later that same day, the licensee believes that the housekeeper picked up the boxes that the material was located inside of and mistakenly threw them away as waste. A search of the facility was conducted without success. The licensee is not taking any action to recover the material from the dump. All trash is compacted on site into a common container. The trash has already been taken to the landfill and buried. The licensee is not taking any action to recover the material from the dump. The licensee has taken corrective actions with the couriers and designated a new storage area for the material in a restricted area. Housekeeping will no longer be handling the boxes. This licensee does not consider the loss be a threat to the health and safety of the community.

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 44920
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2009
Notification Time: 21:39 [ET]
Event Date: 03/19/2009
Event Time: 15:32 [CDT]
Last Update Date: 03/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
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

Event Text

UNPLANNED START OF A COOLING WATER PUMP DURING TESTING

"In preparation for planned maintenance of 12 Diesel Driven Cooling Water Pump (Train A), 121 Cooling Water Pump was aligned as a safeguards replacement pump per plant procedures. Maintenance steps were then completed to a point allowing testing and 12 DDCLP was restored. The Operations procedure steps to enter the Cooling Water LCO 3.7.8 Condition A and realign 121 CL Pump away from being a safeguards replacement were missed and permission was granted to perform testing. 12 DDCLP was locally started per the PM and then tripped as directed from rated speed at 1513. The pump trip resulted in a cooling water pressure transient that automatically started 121 CLP and is reportable under 10CFR 50.72(b)(3) as an unplanned safety related system actuation. 121 CLP operated normally and there were no adverse plant effects from the transient.

"During the investigation of the automatic start, it was recognized that with 121 CLP still aligned as a safeguards replacement and 12 DDCLP running locally, a Safety Injection signal and start of 22 Diesel Driven Cooling Water Pump (Train B) would result in 121 CLP trip. LCO 3.7.8 Condition A was entered for one safeguards pump OOS and 121 CLP was returned to OPERABLE status at 1613. 121 Cooling Water Pump was shut down and returned to standby at 1936.

"Maintenance activities and testing for 12 DDCLP have been suspended pending investigation and corrective actions. 121 CLP remains aligned as a safeguards replacement and both cooling water headers have operable safeguards pumps."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012