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Event Notification Report for June 30, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/29/2009 - 06/30/2009

** EVENT NUMBERS **


45119 45149 45159 45160 45172 45173

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45119
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE MCDANIEL
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/10/2009
Notification Time: 01:02 [ET]
Event Date: 06/09/2009
Event Time: 18:52 [CDT]
Last Update Date: 06/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GEOFFREY MILLER (R4DO)

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

DOOR FOR SECONDARY CONTAINMENT BOUNDARY LEFT OPEN

"This notification is being made pursuant to NRC regulation 10 CFR 50.72(b)(3)(v)(D), any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"At 1852 [CDT] on June 9, 2009, River Bend Station personnel discovered that a normally closed auxiliary building door was open. This door serves as part of the secondary containment boundary. At discovery, immediate action was taken to close the door. This action restored the secondary containment to the design configuration. Investigation determined that the door was last accessed at 1242 on June 9 and was most probably left open at that time. Further action is being taken to investigate the cause of the event.

"Secondary containment leak tightness is required to ensure that the release of radioactive materials from the primary containment is restricted to those leakage paths and associated leakage rates assumed in the accident analysis, and that fission products entrapped within the secondary containment structures will be treated by the Standby Gas Treatment System prior to discharge to the environment. With the subject door being open, the function of secondary containment would be impacted. A second door is located in the same exterior passage way as the secondary containment door found open. This door was closed during the period of time the secondary containment door was open. This second door serves a security function. However, it potentially could serve to perform the secondary containment function. An evaluation is being performed to determine the actual impact of the condition on the secondary containment function. However, based on the identified condition, this report is being made as a condition that could have prevented fulfillment of a safety function."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM D. WILLIAMSON TO D.PARK AT 1325 ON 6/29/09 * * *

"(This event was reported by River Bend Station on 6/10/09 at 0102 [EDT]. This update is being provided for the purpose of retracting that notification.)

"Subsequent investigation determined that the secondary containment door was left open for unknown reasons some time after 0800 on the morning of June 9. At the 1242 observation by the persons exiting the building, the door was open and it was left in that condition. However, a separate exterior door in that same passageway serves the security function, and it has been confirmed that, other than for routine access, the security door remained closed and locked during the time that the interior pressure boundary door was open.

"An engineering analysis has determined that the as-found condition did not defeat the function of secondary containment. While the security door is not air-tight, the maximum potential leakage past it under postulated accident conditions has been evaluated.

"An existing engineering calculation provides a means to determine the maximum size of a breach in the auxiliary building boundary such that the draw-down requirement prescribed by Technical Specifications is maintained. That calculation uses the additional flow area of an identified breach, in addition to the most recent test results of the standby gas treatment system (that system establishes and maintains a negative pressure in the building as part of the its design).

"Measurements taken on the door found that the potential flow area around it totaled 35 square inches. The current test results indicate that the standby gas treatment system can support the safety function of the auxiliary building with an analytical breach size of 230 square inches. As there is significant margin between the measured gap around the security door and the analytical value, this event was well bounded by the assumptions of the design basis of the building. As such, this event did not constitute a loss of the safety function of secondary containment."

The licensee notified the NRC Resident Inspector. Notified the R4DO (D.Powers).

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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: 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: 06/29/2009
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

* * * UPDATE FROM ROBERT GREGER TO VINCE KLCO (VIA EMAIL) ON 6/29/09 @ 1919 * * *

"The current best estimate for the dose to the veterinarian has changed to less than one rem (both whole body and extremity). This is based on an on-site re-enactment of the event today that confirmed a significantly lower exposure time and dose rate for the event than was originally believed to have existed. "

Notified FSME (Foster) and R4DO (Powers).

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General Information or Other Event Number: 45160
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HOAG MEMORIAL HOSPITAL PREBYTERIAN
Region: 4
City: NEWPORT BEACH State: CA
County:
License #: 0272-30
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/24/2009
Notification Time: 14:57 [ET]
Event Date: 03/20/2009
Event Time: [PDT]
Last Update Date: 06/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A POTENTIAL OVEREXPOSURE DURING GAMMA KNIFE TREATMENT

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

"The licensee reported a patient undergoing a gamma knife stereotactic radiosurgery (Elekta Instruments AB, Gamma Knife Perfexion, serial number 6021) on March 20, 2009 received a significant dose to an untargeted area due to an error in the imaging process used for treatment planning. The fiducial marker box (coordinate markers) used to register the CT images was misaligned (the CT locator box had not been firmly seated on the targeting frame as it should have been) which resulted in a target shift of approximately 2.0 mm. Due to the small size of the target (7mm x 4mm x 3mm) and the small size of the radiation shots (4 mm collimators), this shift of the 2.0 mm resulted in only about 52% of the target receiving the prescribed dose of 11 Gy. Therefore, a significant portion of this dose (48%) was shifted to normal tissue (temporal bone) outside of the intended treatment volume. This was a single fraction treatment. The patient is not expected to have any adverse consequences from this event. The physician did not feel additional treatment was advisable. The physician counseled the patient regarding this misadministration. Corrective actions taken by the licensee include: 1) additional training for the CT technologists on the correct placement of the fiducial box; 2) for all ongoing similar treatments, the medical physicist will double check the box placement; and 3) the policies and procedures were updated.

"On June 22, 2009, RHB-Brea RAM received a written report from Hoag Hospital that was dated April 1, 2009, and was faxed to RHB-Sacto on April 3, 2009 at 4 PM. The report was mailed from RHB-Sacto on June 12, 2009 to the RHB-Brea X-ray office and date stamped by that office on June 15, 2009 at 12:45 PM. The report stated they were reporting a misadministration which occurred on March 20, 2009 and that this event was previously reported on the evening of March 20, 2009 by telephone. Per the licensee, they had left a voice message on the answer phone at RHB-Sacto on the night of the incident instead of reporting the incident to the 24/7 radiological emergency assistance center."

CA 5010 Number: 032009

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: 45172
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JULIOUS WHITWORTH
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/29/2009
Notification Time: 12:53 [ET]
Event Date: 06/29/2009
Event Time: 11:34 [EDT]
Last Update Date: 06/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO POSSIBLE RELEASE OF FUEL OIL TO THE ENVIRONMENT

"A notification to the Tennessee Department of Environment and Conservation (Chattanooga Field Office) was made at 1134 [EDT], 29 June 2009, pursuant to a failed pressure test on an underground section of diesel generator fuel oil transfer piping. This section of piping is not required for operability of the emergency diesel generators. The section of piping has been isolated. Efforts are in progress to determine if fuel oil was released to the environment."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45173
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: AL SWEAT
HQ OPS Officer: VINCE KLCO
Notification Date: 06/29/2009
Notification Time: 20:45 [ET]
Event Date: 06/06/2009
Event Time: 22:46 [EDT]
Last Update Date: 06/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
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

INVALID CONTAINMENT VENTILATION ISOLATION SYSTEM ACTUATION

"This telephone notification is provided in accordance with 10CFR50.73(a)(1), to report an invalid actuation reportable per 10CFR50.73(a)(2)(iv)(A), 'Any event or condition that resulted in manual or automatic actuation of any system in paragraph (a)(2)(iv)(B) ' General containment isolation signals affecting containment isolation valves in more than one system is identified in paragraph (a)(2)(iv)(B). Although the Containment Ventilation Isolation signal affects multiple containment isolation valves in several systems, at the time of the invalid actuation, only containment isolation valves associated with the containment area radiation monitor were open. Therefore, this notification is being conservatively made. NUREG 1022 Revision 2 identifies the information that needs to be reported as discussed below.

"(A) The specific train(s) and system(s) that were actuated.

"On June 6, 2009 at 2246 hours, with Unit 1 in Mode 1, a containment area radiation monitor failed high, resulting in an invalid A and B train automatic Containment Ventilation Isolation (CVI). Four containment isolation valves, associated with a containment radiation air monitor, that was in-service at the time of the actuation, closed. Additionally, valves (non-containment isolation valves) in the Auxiliary building closed in response to the actuation.

"(B) Whether each train actuation was complete or partial.

"The actuation was considered complete. The CVI signal automatically isolated all valves that were open at the time of the actuation.

"(c) Whether or not the system started and functioned successfully.

"The Containment Ventilation Isolation signal automatically actuated and functioned successfully. The CVI signal was not in response to actual plant conditions and is therefore considered invalid.

"In reviewing this CVI actuation it was also discovered that on July 6, 2007 a similar CVI had occurred on Unit 1 when a circuit board associated with the containment vent radiation monitor failed. The failure resulted in an actuation of CVI train A and Train B. The actuation was considered complete since all valves that were open at the time of the actuation isolated as required. The CVI was not in response to actual plant conditions and was therefore considered invalid."

The licensee will notify the NRC Resident Inspector.

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