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Event Notification Report for June 29, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/26/2009 - 06/29/2009

** EVENT NUMBERS **


45149 45150 45159 45166 45169 45170

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General Information or Other Event Number: 45149
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH SCIENCES UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: 90013
Agreement: Y
Docket:
NRC Notified By: BONNY WRIGHT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/23/2009
Notification Time: 11:15 [ET]
Event Date: 05/07/2009
Event Time: [PDT]
Last Update Date: 06/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDER DOSAGE

The licensee notified the State of Oregon of a misadministration of "Sirspheres" during the treatment for liver cancer. The dosage of radioisotope Y-90 administered was 34.2% less than that prescribed.

The patient was informed of the under dosage. The patient may be rescheduled to receive an additional treatment. The State is investigating.

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: 45150
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: LONGVIEW FIBRE
Region: 4
City: LONGVIEW State: WA
County:
License #: R0205
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: VINCE KLCO
Notification Date: 06/23/2009
Notification Time: 11:06 [ET]
Event Date: 06/15/2009
Event Time: [PDT]
Last Update Date: 06/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

"On 15 Jun 2009 a fixed gauge fell off a digester blow line, about 4 feet onto a grating platform. Licensee staff working in the area noticed the gauge and alerted their supervisor and radiation safety officer. After ensuring the shutter was closed and the source [CS-137; .4092 Ci] was still present, the device (containing its source) was moved to a secure location. Licensee performed wipe surveys to check for leaking / contamination. Meter surveys confirmed the presence of the source, and also the absence of elevated dose rates. There is concern that the welds failed that attached the device to the mounting on the pipe. The manufacturer [Ohmart Vega] has been notified and will assist in arranging return of device (containing its source) and further assessment of cause of failure. The manufacturer uses same model [SR-1A] and serial [#6339] for both source and device."

The Washington State incident number is WA-09-034.

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General Information or Other Event Number: 45159
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: VCA ALL-CARE ANIMAL REFERRAL CENTER
Region: 4
City: FOUNTAIN VALLEY State: CA
County:
License #: 4640
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/24/2009
Notification Time: 13:30 [ET]
Event Date: 06/22/2009
Event Time: [PDT]
Last Update Date: 06/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A POTENTIAL PERSONNEL OVEREXPOSURE DUE TO EQUIPMENT MALFUNCTION

The State of California provided the following information via email:

"During a teletherapy treatment of a cat on 6/22/09, an apparent malfunction of the MDS-Nordion Model C-146 teletherapy device resulted in the radiation beam not terminating at the end of the treatment. Two entries into the treatment room were apparently made with the radiation beam on, one by a technologist (who wore dosimetry), and one by a veterinarian (who did not wear dosimetry). The veterinarian was exposed to the beam when he removed the cat from the treatment table. The technologist reportedly did not enter the beam. The technologist's dosimetry was submitted to the dosimetry vendor for emergency evaluation.

"The veterinarian indicated that he was aware of the location and size of the radiation treatment beam when he removed the cat, and only his lower arms entered the beam. The beam was approximately 70 R/minute at the treatment site. The veterinarian estimated his time in the beam at one and one-half to two minutes. A re-enactment will be conducted as soon as the veterinarian returns to the office from a trip he is on the rest of the week.

"A state inspector arrived at the licensee facility at 0630 on 6/24/09 to investigate this event. The licensee has suspended use of the teletherapy device pending the results of the onsite investigation."

California 5010 Number: 052309

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Power Reactor Event Number: 45166
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BRIEN STRIZZI
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/26/2009
Notification Time: 13:36 [ET]
Event Date: 06/26/2009
Event Time: 13:00 [EDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAMELA HENDERSON (R1DO)
JOHN THORP (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ONSITE FATALITY

"At approximately 1015 [EDT] a Dominion employee was transported via ambulance to Lawrence Memorial hospital where he was later pronounced dead from an apparent cardiac arrest. The death was not occupationally related and occurred outside the Protected Area. The individual was treated by the onsite first responders who administered CPR and AED (automatic external defibrillator). State [of Connecticut] and local notifications were made.

"OSHA is being notified of the event under the requirements of 29 CFR 1904.

"The licensee notified the NRC Senior Resident Inspector."

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Power Reactor Event Number: 45169
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: BILL HART
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/26/2009
Notification Time: 23:45 [ET]
Event Date: 06/26/2009
Event Time: 20:05 [PDT]
Last Update Date: 06/27/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DALE POWERS (R4DO)
ELMO COLLINS (RA)
JIM WIGGINS (NRR)
JOHN LUBINSKI (NRR)
BRIAN MCDERMOTT (IRD)
PAM VESTAL (DHS)
IRWIN CASTO (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 73 Power Operation 0 Hot Shutdown

Event Text

UNUSUAL EVENT DECLARED BASED ON FIRE LASTING GREATER THAN 15 MINUTES

At 1949 PDT, a small fire was observed between the #1 and #2 bearings on the main turbine involving some lube oil leakage and lagging. The fire brigade was dispatched and at 1953 PDT, the reactor was manually scrammed. At 2005 PDT, the licensee declared an Unusual Event (EAL 9.2.U.1) based on a fire lasting greater than 15 minutes. At 2006 PDT, the fire was reported out. The manual scram was uncomplicated and all systems functioned as required. The reactor is being cooled by normal feedwater and discharging decay heat to the condenser. The licensee is cooling down the reactor to Mode 4. Currently reactor pressure is 495 psi. The licensee has stationed a re-flash watch at the fire location and is assessing any damage that may have occurred. The only damage currently reported involves lagging at the fire location.

The NRC Resident Inspector, State and local authorities have been notified.

* * * UPDATE FROM BILL HART TO HOWIE CROUCH @ 0128 EDT ON 6/27/09 * * *

The licensee terminated the NOUE at 2159 PDT. The termination criteria was the fire is out, a re-flash watch stationed and the plant is stable and transitioning to Mode 4.

The licensee has made State and local notifications and has notified the NRC Resident Inspector.

Notified R4DO (Powers), IRD (Grant), NRR ET (Lubinski), FEMA (Casto) and DHS (Vestal).

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Power Reactor Event Number: 45170
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILLY JOHNSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/27/2009
Notification Time: 17:58 [ET]
Event Date: 06/27/2009
Event Time: 13:20 [EDT]
Last Update Date: 06/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GERALD MCCOY (R2DO)

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

AUXILIARY BUILDING GAS TREATMENT SYSTEM RENDERED INOPERABLE

"On June 27, 2009, Plant Operations was starting up the U2 [Unit 2] Auxiliary Building General Ventilation System upon completion of U2 damper maintenance. During startup of the U2 Auxiliary Building Ventilation System, the operator started the U2 General Exhaust fan followed by the startup of the U2 General Supply fan. During the time span of less than 1 minute, when the U2 General Exhaust fan was running but before the U2 General Supply fan was running, the differential pressure condition across a set of Auxiliary Building Secondary Containment Enclosure (ABSCE) doors caused the doors to come off of the tracks and therefore created an ABSCE breach. A breach of this magnitude renders both trains of Auxiliary Building Gas Treatment System (ABGTS) inoperable.

"Upon identification of the failed doors at 1320 EDT on June 27, 2009 the plant entered TS Condition 3.7.12.B for 2 trains of ABGTS being inoperable. Repairs to re-establish the integrity of the ABSCE were immediately initiated and TS Condition 3.7.12.B was exited at 1649 EDT, approximately 3 and 1/2 hours later.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as a condition that could have prevented the safety function of structures or systems that are needed to : (C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident."

The licensee has notified the NRC Resident Inspector.

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