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Event Notification Report for April 27, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/24/2009 - 04/27/2009

** EVENT NUMBERS **


44987 45005 45007 45017 45020 45021 45022 45023

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General Information or Other Event Number: 44987
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL LABORATORIES
Region: 4
City: WEST MONROE State: LA
County:
License #: LA-7211-L01A
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/14/2009
Notification Time: 12:20 [ET]
Event Date: 04/13/2009
Event Time: [CDT]
Last Update Date: 04/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
ANGELA MCINTOSH (FSME)
ILTAB email ()

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

Event Text

AGREEMENT STATE REPORT - THEFT OF A TROXLER NUCLEAR GAUGE

State submitted this report via email:

"The owner of Global Laboratories, called the Louisiana Department of Environmental Quality on April 14, 2009 to report the theft of a work truck that had a Troxler Nuclear Gauge chained in the back of the truck. The Troxler Gauge 3440 (s/n 27805) contained 40 mCi of Am-241 (s/n 47-24434) and 8 mCi of Cs-137 (s/n 750-1721). According to Mr. Kent, the gauge was locked in the case and the case was doubled chained in the bed of the truck. Mr. Kent reported the theft to the West Monroe Police Department on April 13. 2009 at approximately 3:30PM and also contacted the Ouachita Sheriffs Office. Mr. Kent is offering a $500.00 reward for the return of the Troxler Nuclear Gauge. An investigation is ongoing and any further information will be forwarded to the NRC."

Transport vehicle description: White 2000 GMC Z71 license plate number B412958

Event Report ID No. LA090012


* * * UPDATE FROM SCOTT BLACKWELL TO HOWIE CROUCH ON 4/17/09 @ 1512 EDT * * *

The State of Louisiana reports that the stolen work truck has been recovered but the gauge is still missing. Law enforcement agencies continue to investigate.

Notified R4DO (Whitten), FSME (Einberg) and ILTAB via email.


* * * UPDATE FROM SCOTT BLACKWELL TO KARL DIEDERICH ON 4/24/09 @ 1537 EDT * * *

The State of Louisiana reports that the stolen gauge has been found and the licensee has taken possession of it. It was found in a sheriff's evidence room, and appears undamaged. Complete surveys will be performed Monday 4/27/09.

Notified R4DO (Gaddy), FSME (White), and ILTAB via email.

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: 45005
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HAHNEMANN UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0927
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/21/2009
Notification Time: 10:26 [ET]
Event Date: 12/22/2008
Event Time: [EDT]
Last Update Date: 04/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
ANGELA MCINTOSH (FSME)

Event Text

MIS-ADMINISTRATION OF I-125 SUBCUTANEOUSLY VICE INTRAVENOUSLY

The following abnormal occurrence information was received via e-mail:

"PA NMED PA090013.

"Date and Place: 12-22-2008; Hahnemann University Hospital, Philadelphia, PA.

"Procedure/Dose (Actual vs. Intended), Nature, and Probable Consequences: Patient prescribed 50 mCi of Iodine-125 monoclonal antibody to be administered intravenously. On December 22, 2008 the injection was made subcutaneously when patient's port was not located properly during the injection. Estimated skin dose is 360-710 rads.

"Notification: Patient was notified at the time of the event that the injection was subcutaneous rather than intravenous.

"Health Effect: Doctor is confident that the therapeutic effects of this dosage have still been received by the patient. There have been no noted skin effects reported to date.

"Cause or Causes: The nurse did not have the port completely visualized and admitted to not palpating the site as well as possible

"Actions Taken to Prevent Recurrence: Staff was retrained in December 2008 that patients with ports are to disrobe completely and be palpated to ensure that the injection is occurring within the port.

"State Agency: Just received notification of medical event, follow-up inspection to be performed by the State.

"This event is closed for the purpose of this report."

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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General Information or Other Event Number: 45007
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CANCER CARE NORTHWEST PET CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: M0227
Agreement: Y
Docket:
NRC Notified By: BRANDON KETTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/21/2009
Notification Time: 14:39 [ET]
Event Date: 04/14/2009
Event Time: [PDT]
Last Update Date: 04/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION

The following information was obtained from the State of Washington via email:

"On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.

"The aluminum connector to needle 13 detached from the plastic guide tube. It is possible that the source wire or the dummy wire, during retraction, snagged on the seam between the aluminum connector and the plastic guide tube. The HDR is connected to the plastic guide tube, the plastic guide tube is attached (glued) to the aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.

"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.

Isotope and Activity involved: Iridium-192, 185.2 GBq (5.0 curies). Source serial number: 02-01-0080-001-0121.

Overexposures: The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient.

Washington Incident Number: WA-09-015

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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Power Reactor Event Number: 45017
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE DEBOARD
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/24/2009
Notification Time: 15:15 [ET]
Event Date: 04/24/2009
Event Time: 11:41 [CDT]
Last Update Date: 04/24/2009
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):
JAMNES CAMERON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DURING INSTRUMENT CALIBRATION

"At 1141 CT, Braidwood Unit 2 experienced an automatic Reactor Trip. The Reactor Trip red first out annunciator was Over Temperature Delta Temperature (OTDT). At the time of the Reactor Trip the Instrument Maintenance Department was performing a scheduled calibration of a Pressurizer Pressure channel (2PT-456) which is in the B loop of reactor protection. During the calibration a spike occurred on the D loop of reactor protection. Specifically, the RCS [Reactor Coolant System] temperature for the D loop. This caused a Reactor Trip on a 2 of 4 coincidence.

"After the reactor trip occurred, all four steam generators reached their low-2 Reactor Trip setpoints and pressurizer pressure reached its low pressure Reactor Trip setpoint all of which is an expected response on a trip from full power. Steam Generator levels and Pressurizer pressure have been restored. Both the 2A and 2B Auxiliary Feedwater pumps auto started on the low-2 steam generator levels as expected. All control rods fully inserted into the core.

"No secondary relief valves lifted and no secondary steam released as a result of the Reactor Trip. Steam Generators are now being filled by the 2A Main Feedwater pump and the Auxiliary Feedwater pumps have been placed in standby. The main steam dumps are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature.

"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for RPS actuation, 4 hour notification, and per 10 CFR 50.72(b)(3)(iv)(A) for automatic actuation of the Auxiliary Feedwater System, 8 hour notification.

"The electrical line up transferred to the normal shutdown configuration with the standby diesel generators and safety systems available. There is no Unit 1 impact.

"The licensee plans on issuing a press release and has notified the NRC Resident Inspector."

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Power Reactor Event Number: 45020
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEN HETZEL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/25/2009
Notification Time: 16:02 [ET]
Event Date: 04/25/2009
Event Time: 10:48 [CDT]
Last Update Date: 04/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)

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

ERDS UNAVAILABILITY DUE TO PLANT PROCESS COMPUTER FAILURE

"The Unit One Plant Process Computer failed at 1048 CDT. The failure disabled plant data information inputs to the NRC Emergency Response Data System (ERDS). ERDS unavailability was validated by the NRC. ERDS was not restored within one hour, which necessitates this ENS notification per 50.72(b)(3)(xiii). The Plant Process Computer was restored at 1342, which restored ERDS."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45021
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: HERB TRITT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/25/2009
Notification Time: 20:50 [ET]
Event Date: 04/25/2009
Event Time: 18:05 [EDT]
Last Update Date: 04/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
PAUL KROHN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL SCRAM FOLLOWING LOSS OF COOLING TO MAIN TRANSFORMER

"Oyster Creek inserted a manual reactor scram due to a loss of cooling to one of its main transformers. All systems responded normally during the reactor scram. The NRC Resident Inspector has been notified. "

The manual scram was described as uncomplicated. All control rods fully inserted. No safeties or PORVs lifted during the transient. There were no electrical power issues besides the problem associated with the main transformer cooling. Normal feedwater cooling was maintained to the reactor and decay heat removal is to the main condenser. There were no ESF actions during the transient.

The loss of cooling was to one of Oyster Creeks' two main transformers. Power to the transformer cooling system components (oil cooling pumps and cooling fans) was lost when the control power transformer to the cooling system components failed. The licensee manually scrammed because sustained operation at power would not be possible with loss of cooling to the main transformer and operation with one of the main transformers de-energized is also not possible.

The licensee will continue to cold shutdown to perform other maintenance activities while shutdown.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45022
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2009
Notification Time: 13:46 [ET]
Event Date: 04/26/2009
Event Time: 10:00 [EDT]
Last Update Date: 04/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
PAUL KROHN (R1DO)

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

Event Text

NDT REVEALS CIRCUMFERENTIAL INDICATIONS ON RCS HOT LEG DRAIN PIPING

"On April 26, 2009 at approximately 1000 hours during the Beaver Valley Power Station Unit No. 1 (BVPS-1) refueling outage, ultrasonic (UT) examinations were performed on pipe base material per the Materials Reliability Project (MRP) MRP-146 recommendations. The MRP recommendations were to address industry operating experience for similar indications identified by other utilities. Two circumferential UT indications approximately 3/8 inches in length were recorded in the base material adjacent to a socket weld on the horizontal portion of line BV-1 RC-41 which is a two (2) inch drain line that connects to the 'A' Reactor Coolant System (RCS) Hot Leg. The function of this piping is to drain the applicable loop during maintenance periods. The indications are not through wall and there was no evidence of leakage. Similar 2 inch drain lines on the other loops have been inspected satisfactorily.

"The plant is currently shutdown and in Mode 6. The affected RCS loop is not required to be Operable and is currently isolated and drained. Repairs are currently being planned and will be completed prior to
startup.

"This is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 45023
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVE GIBSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2009
Notification Time: 21:31 [ET]
Event Date: 04/26/2009
Event Time: 15:45 [EDT]
Last Update Date: 04/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)

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

Event Text

ERDS AND PLANT COMPUTER UNAVAILABLE DURING MAINTENANCE ON COMPUTER ROOM COOLING

"At 1545 on 04/26/2009, the Emergency Response Data System (ERDS) at the Beaver Valley Power Station (BVPS) Unit 1 was removed from service. The ERDS is a direct near real-time electronic data link between the licensee's onsite computer system and the NRC Operations Center that provides for the automated transmission of a limited data set of selected parameters. The ERDS supplements the existing voice transmission over the Emergency Notification System (ENS) by providing the NRC Operations Center with timely and accurate updates of a limited set of parameters from the licensee's installed onsite computer system in the event of an emergency.

"The BVPS Unit 1 plant computer and ERDS was removed from service due to planned maintenance on the River Water cooling to the air conditioning for the computer room. The maintenance is scheduled to be completed in approximately 48 hours. This is being reported pursuant to 10 CFR 50.72(b)(3)(xiii).

"Until the ERDS communication is restored, BVPS Unit 1 would utilize its pre-planned backup information flow path in event of an emergency as provided in Procedure 1/2-EPP-IP-1.4, Attachment G when the ERDS system is not operational.

"The BVPS Unit 2 ERDS is not affected and remains operational.

"The NRC Resident has been notified."

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