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Event Notification Report for April 10, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/09/2009 - 04/10/2009

** EVENT NUMBERS **


44968 44971 44973

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Power Reactor Event Number: 44968
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: DAVID DUNCAN
HQ OPS Officer: JOE O'HARA
Notification Date: 04/03/2009
Notification Time: 17:07 [ET]
Event Date: 04/03/2009
Event Time: 16:30 [EDT]
Last Update Date: 04/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3)

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

Event Text

PLANNED MAINTENANCE ON SPDS AND ERDS

"At 1630 hours on 04/03/2009, the SPDS and ERDS system was removed from service to support activities for a planned maintenance outage on the UPS vital bus power supply. The duration of work is expected to be approximately 24 hours. During this time, Control Room indications and alternate methods will be available. Since the SPDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii)."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE PROVIDED BY J. GROFF TO J. KOZAL ON 04/09/09 AT 1257 * * *

"Update to event #44968 regarding SPDS and ERDS system removed from service to support planned outage on the UPS vital power supply. Planned work which resulted in the removal from service of the SPDS and ERDS has been completed."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Daley).

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General Information or Other Event Number: 44971
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CORMETECH INC.
Region: 1
City: DURHAM State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: PETE SNYDER
Notification Date: 04/06/2009
Notification Time: 13:44 [ET]
Event Date: 04/02/2009
Event Time: [EDT]
Last Update Date: 04/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1)
ANGELA MCINTOSH (FSME)
ILTAB (E-MAIL) ()

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

Event Text

LOST AMMONIA ANALYZER

Cormetech Inc. was unable to locate an ammonia analyzer containing 10mCi of Ni-63 during a routine inspection on April 2, 2009. The manufacturer of the instrument is Environmental Technologies Group. The instrument is a FP-IMS/CEM Ammonia Analyzer Model 221.

The licensee is taking action to locate the item but it is believed that the item is lost.

NC Incident: 09-21

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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General Information or Other Event Number: 44973
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOSPITALS OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180077
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JOE O'HARA
Notification Date: 04/06/2009
Notification Time: 13:00 [ET]
Event Date: 12/15/2008
Event Time: [EDT]
Last Update Date: 04/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3)
ANGELA MCINTOSH (FSME)

Event Text

INCIDENT INVOLVING CO-60 GAMMA KNIFE DURING PATIENT TREATMENT

The following information was provided by the state via e-mail:

"During an inspection on March 17 through 19, 2009, the ODH [Ohio Department of Health] inspector identified through the licensee's radiation safety committee meeting minutes an incident involving the Co-60 Gamma Knife that occurred on December 15, 2008, at approximately 2:15 pm. During a patient treatment, the couch moved out of treatment position. The emergency stop button was activated and the system did not respond. The licensee's staff had to manually pull out the couch from the Gamma Knife and manually close the doors to the Gamma Knife to shield the source.

"According to the licensee, radiation exposure to all individuals involved with the incident was minimal. The incident DID NOT result in a medical event for the patient. The manufacturer (Elekta) was immediately contacted and the Gamma Knife was repaired. Patient treatment was resumed and completed without incident. According to Elekta, the Gamma Knife system experienced an illegal couch sensor error due to a known software bug problem.

"The licensee failed to notify the Ohio Department of Health, Bureau of Radiation Protection of this device failure and therefore this is determined to be non-compliant with the provisions of rule 3701:1-40-20 (B)(2)(a,b,c) of the Ohio Administrative Code."

Ohio State Reference Number: OH 2009-008

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Thursday, March 29, 2012