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Event Notification Report for April 30, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/29/2009 - 04/30/2009

** EVENT NUMBERS **


45011 45018 45019 45023 45028 45029 45030 45031

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General Information or Other Event Number: 45011
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/23/2009
Notification Time: 11:46 [ET]
Event Date: 04/22/2009
Event Time: 09:00 [CDT]
Last Update Date: 04/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - MEDICAL MISADMINISTRATION

The following was received from the agreement state with a state control number of KY0901:

"At 1400 on 4/22/2009, the RSO of a medical licensee reported the misadministration of a radiopharmaceutical to a seven-month-old infant. The infant was scheduled for a renal scan and was ordered to receive a 2 mCi dose tagged with Tc-99m. The patient was inadvertently administered a 35 mCi dose of Sestamibi/Tc-99M.

"Event date: 4/22/2009. Discovery date: 4/22/2009. Report date: 4/22/2009.

"Licensee Reporting Party Information: University of Kentucky, Lexington KY 40506, License number: 202-049-22.

"Site of event: Lexington, KY.

"Event type: MD2 - Medical event.

"Event cause: Human error."

The patient was informed on 4/22/2009.

The intended diagnostic study was renal-glomerular filtration with dimercaptosuccinic acid (DMSA) radiopharmaceutical, with a 2 mCi (74 MBq) Tc-99m radionuclide.

The given diagnostic study was cardiac perfusion with sestamibi/cardiolite radiopharmaceutical, with a 34.9 mCi (1291.3 MBq) Tc-99m radionuclide. The dose exceeded the prescribed dose by 1650%. It is estimated that the heart received a dose of 2.84 rem, and the whole body does was 6.84 rem. The effect on the patient is unknown at this time.

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: 45018
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: VIRGINIA COMMOMWEALTH UNIVERSITY
Region: 1
City: RICHMOND State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: PETE SNYDER
Notification Date: 04/24/2009
Notification Time: 15:32 [ET]
Event Date: 04/24/2009
Event Time: [EDT]
Last Update Date: 04/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
DUNCAN WHITE (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

"On April, 23, 2009, the Virginia Department of Health (VDH) was notified by Virginia Commonwealth University (VCU) that a Nuclear Radiation Developments, Inc. 'Ionotron' containing an Am-241 source has been lost. The source is a model number A-001 with an activity of 20 microcuries on 12/75.

"The source was last inventoried on February 27, 2009. Since then, VCU began to clean up this storage location and placing unwanted material in a barrel for disposal through RSO, Inc. The barrel was picked up on April 1, 2009.

"VCU found the source missing when they went to take a picture for its disposal through the SCATR program. It is believed that the source was placed into the barrel and has been disposed of by RSO, Inc.

"VCU will submit the 30 day written report to VDH."

This report is VA number: VA-09-01.

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: 45019
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BF GOODRICH
Region: 1
City: TUSCALOOSA State: AL
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/24/2009
Notification Time: 16:33 [ET]
Event Date: 04/24/2009
Event Time: 11:20 [CDT]
Last Update Date: 04/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
DUNCAN WHITE (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - TWO MISSING GENERAL LICENSED DEVICES

The following information was received via facsimile from the Alabama Office of Radiation Control:

"On the morning of April 24, 2009 at approximately 1120 am CDT, the Alabama Office of Radiation Control received a phone call from representatives of BF Goodrich in Tuscaloosa, Alabama advising the [State] Agency of the discovery of two missing general licensed devices containing radioactive material. The representatives of BF Goodrich indicated that on April 23, 2009, two NDC model 103 profile gauges containing 150 millicuries each of Am-241 were discovered to be missing. The gauges were installed at the facility but had not been in use for an extended period of time. The shutter for each of the devices were reported as closed. The serial numbers reported were 13311 and 13312. The gauges were possessed and used under a general license registration. Representatives of BF Goodrich continue to investigate the incident and will provide a written report within 30 days."

Alabama Incident 09-15


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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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: 04/29/2009
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."

* * * UPDATE FROM RONALD T. GREEN TO DONALD NORWOOD ON 4/29/09 AT 1355 EDT * * *

"As of 1320 on 04/29/2009, the BVPS Unit 1 plant computer and the data communication link to the Emergency Response Data System (ERDS) were returned to service.

"The site NRC Resident Inspector has been notified."

Notified R1DO (Krohn).

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Power Reactor Event Number: 45028
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: CURT STEFFES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/28/2009
Notification Time: 19:34 [ET]
Event Date: 04/28/2009
Event Time: 18:34 [CDT]
Last Update Date: 04/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

PROCESS COMPUTER REPLACEMENT IMPACTING ERDS AND SPDS

"During the current Unit 1 refueling outage, the plant process computer system will be taken out of service for approximately three weeks to support a planned modification which will install a new (upgraded) plant process computer system. During this timeframe, ERDS [Emergency Response Data System] and SPDS [Safety Parameter Display System] will be unavailable on Unit 1 which will remain in a shutdown condition. The computer outage will also render ERDS and SPDS unavailable on Unit 2 for approximately eight hours. Should the need arise, plant status information will be communicated to the NRC, [State, and local responders] using other available communication systems. The computer outage is expected to commence at 2200 CDT on 4/28/2009, and the process computer will be restored prior to Unit 1 startup currently scheduled for 05/21/2009.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a Major Loss of Assessment Capability."

The licensee will update this report when ERDS and SPDS is restored to Unit 2.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM C. STEFFES TO JOE O'HARA AT 0558 ON 4/29/09 * * *

"Follow-up notification - U2 ERDS and SPDS is restored as of 0315 CDT 4/29/09."

The licensee notified the NRC Resident Inspector.

Notified R3DO(Hills)

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Power Reactor Event Number: 45029
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES W. FULLER
HQ OPS Officer: JOE O'HARA
Notification Date: 04/28/2009
Notification Time: 23:50 [ET]
Event Date: 04/28/2009
Event Time: 21:59 [EDT]
Last Update Date: 04/29/2009
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):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 18 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP INITIATED AS A RESULT OF A LOSS OF CONDENSATE FLOW

"At 2159 Sequoyah Unit 1 was manually tripped from 18% reactor power. The manual trip was in response to automatic isolation of all intermediate pressure feedwater heater strings resulting in a loss of all condensate flow. The feedwater heater strings isolated following a manual trip of the main turbine. The main turbine was manually tripped in response to a failed open moisture separator reheater relief valve. At the time of the event Sequoyah Unit 1 was raising power following a refueling outage.

"Following the reactor trip, all safety-related equipment operated as designed. Auxiliary feedwater automatically actuated as expected on loss of the operating main feedwater pump.

"The plant is currently being maintained in Mode 3 at NOT/NOP, approximately 547 F and 2235 psig, with auxiliary feedwater supplying the steam generators and steam dumps to main condenser removing decay heat.

"Maintenance activities have been initiated to repair the MSR relief valve."

Electrical lineup is normal with all safety related equipment operable. Licensee is investigation the cause for the relief valve failure.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45030
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 04/30/2009
Notification Time: 00:13 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
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 Y 100 Power Operation 100 Power Operation

Event Text

TONE ALERT RADIOS OUT OF SERVICE

"At 2230 on April 29, 2009, with the James A. Fitzpatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09].

"This Impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The National Weather Service is currently working to determine the cause of the failure and time frame for system restoration.

"The County Alert Sirens which also function as pert of the Public Prompt Notification System remain operable.

"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.

"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified.

"UPDATE: Notified by Oswego County that the Tone Alert Radios were restored 00:12 on 04/30/2009."

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Power Reactor Event Number: 45031
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN DRISCOLL
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2009
Notification Time: 00:48 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
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 Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

TONE ALERT RADIOS OUT OF SERVICE

"At 2230 on April 29, 2009. with Nine Mile Point Unit 1 and Unit 2 operating at 100% reactor power, Oswego County Emergency Management notified the Unit 1 and Unit 2 Control Rooms that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09]. At 0015 on April 30. Oswego County Emergency Management notified the Control Rooms that the Tone Alert Radios had been restored to service as of 0012, April 30, 2009.

"This impacted the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF [James A. Fitzpatrick see EN# 45030] Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The County Alert Sirens which also function as part of the Public Prompt Notification System remained operable.

"The loss of the Tone Alert Radios constitutes a significant loss of emergency offsite communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.

"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012