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Event Notification Report for July 10, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/09/2009 - 07/10/2009

** EVENT NUMBERS **


45013 45084 45184 45187 45188

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45013
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/23/2009
Notification Time: 14:47 [ET]
Event Date: 04/22/2009
Event Time: 05:00 [EDT]
Last Update Date: 07/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
BINOY DESAI (R2DO)
JOHN THORP (NRR)
ERIC LEEDS (NRR)
JEFFERY GRANT (IRD)
LUIS REYES (RA)

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

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION - ALERT - DUE TO FIRE DAMAGE TO SAFETY-RELATED BREAKER

"At 1410 hours on April 23, 2009, it was identified that an ALERT classification had not been declared on April 22, 2009 as required by EPIP-1.01. North Anna Emergency Plan, Emergency Action Level H2.1 requires the declaration of an ALERT for a fire or explosion in any safe shutdown area and either plant personnel report visible damage to any safety-related structure, system or component within the area or affected system parameter indications show degraded performance. A description of the event is provided below.

"On April 22, 2009, at approximately 0500 hours, Operations personnel identified a strong odor in the North Anna Unit 1 Cable Vault area. Subsequent investigation identified that the odor was coming from circuit breaker 01-EE-BKR-1J1-2S-J1 associated with the "D" Control Rod Drive Mechanism (CRDM) Fan (1-HV-F-37D). Operations personnel locally opened the circuit breaker to place it in a safe condition. 1-HV-F-37D had tripped approximately 30 minutes prior to the event. 1-HV-F-37D is not safety-related and not required for safe shutdown however; the supply breaker is safety-related since it is located on an emergency bus. Operation personnel then opened the circuit breaker cabinet and a small (6-inch) flame was observed. Operations personnel used a CO2 extinguisher on the internals of the circuit breaker to quickly extinguish the small fire. Appropriate levels of management were informed. The breaker has been quarantined. The cause of the circuit breaker failure has not been identified. A Root Cause Evaluation is in progress. There were no injuries. The plant continues to operate at full power. As a result of identifying that the criterion for the EAL was exceeded and no longer exists, a notification is being made to the NRC Operations Center in accordance with 10CFR50.72(a)(1)(i).

"The NRC Resident Inspector has been notified and the State and local governments will be notified."

* * * RETRACTION FROM KEMP TO SANDIN AT 1105 ON 07/09/09 * * *

"On April 22, 2009, at approximately 0500 hours, operations personnel identified a strong odor in the North Anna Unit 1 Cable Vault area. Subsequent investigation identified that the odor was coming from circuit breaker 01-EE-BKR-1J1-2S-J1 associated with the 'D' Control Rod Drive Mechanism (CRDM) Fan (1-HV-F-37D). Operations personnel locally opened the circuit breaker to place it in a safe condition. 1-HV-F-37D had tripped approximately 30 minutes prior to the event. 1-HV-F-37D is not safety-related and not required for safe shutdown however; the supply breaker is safety-related since it is located on an emergency bus. Operation personnel then opened the circuit breaker cabinet and a small (6-inch) flame was observed. Operations personnel used a C02 extinguisher on the internals of the circuit breaker to quickly extinguish the small fire. A root cause evaluation is in progress.

"At 1447 hours on April 23, 2009, a one hour notification was made to the NRC Operations Center in accordance with 10CFR50.72(a)(1)(i), which identified that the criterion for a ALERT EAL was exceeded due to the small fire in the circuit breaker and subsequent damage to the breaker internals. The notification also stated that the condition no longer exists.

"Subsequent reviews have determined that the 'Initiating Condition' for the Emergency Action Level was not met and the event was not required to be classified as an ALERT. The initiating condition states -Fire or explosion affecting the operability of plant safety-related structures, systems or components required to establish or maintain safe shutdown. The 'D' Control Rod Drive Mechanism is not required to establish or maintain safe shutdown and the emergency bus remained operable during the event. The notification made to the NRC on April 23, 2009 is being retracted.

"The NRC Resident Inspector has been notified."

Notified the R2DO (Nease).

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General Information or Other Event Number: 45084
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: ALBEMARLE CORPORATION
Region: 4
City: MAGNOLIA State: AR
County:
License #: ARK-0717-0312
Agreement: Y
Docket:
NRC Notified By: STEVE E. MACK
HQ OPS Officer: VINCE KLCO
Notification Date: 05/20/2009
Notification Time: 16:23 [ET]
Event Date: 05/18/2009
Event Time: [CDT]
Last Update Date: 07/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The State provided the following information regarding a previously unreported event received via e-mail:

"On May 19, 2009, the Department was notified by the licensee of a stuck shutter. The gauge is a Kay-Ray Model 7063S, Serial S97D2115, containing 100 millicuries of Cesium-137. The gauge was originally installed in 1997. The stuck shutter was discovered during routine shutter checks on May 18, 2009. The licensee tried to release the shutter, but was unable to do so and is currently working to schedule a service provider for repair. The licensee is maintaining control of the area where the gauge is installed."

* * * UPDATE FROM ROBERT PEMBERTON TO JOE O'HARA AT 1538 ON 7/9/09 * * *

The State provided the following information via e-mail:

"The following are the findings of the Arkansas Department of Health, Radioactive Materials Program, concerning event Number 45084 at Albemarle Corporation in Magnolia, AR. From information provided by Albemarle Corporation and ThermoFisher Scientific, the Department has determined that this event was caused by the use of an improper lubricant that deposited a residue, over time, and interfered with the rotation of the shutter. The technician noted, at the time, that the gauge housing had been installed upside down, and that this may have contributed to the shutter sticking. Both ThermoFisher's report, dated June 11, 2009, and Albemarle Corporation's report, dated June 15, 2009, concur with the Department's observations; that the technician was able to close the shutter and then reinstalled the gauge in its proper orientation. No personnel exposures occurred during this incident. The Department has concluded that the root cause of this incident is improper maintenance. The Department considers this incident to be closed. "

Notified R4DO(Hay) and FSME EO(Vontill).

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Hospital Event Number: 45184
Rep Org: GAMMA KNIFE CENTER OF THE PACIFIC
Licensee: GAMMA KNIFE CENTER OF THE PACIFIC
Region: 4
City: HONOLULU State: HI
County:
License #: 53-1196602
Agreement: N
Docket:
NRC Notified By: RONALD FRICK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/03/2009
Notification Time: 18:42 [ET]
Event Date: 07/02/2009
Event Time: 14:00 [HST]
Last Update Date: 07/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
GREG PICK (R4DO)
DUNCAN WHITE (FSME)

Event Text

MEDICAL EVENT - GAMMA KNIFE MISADMINISTRATION

A gamma knife treatment was prescribed for a patient being treated for multiple brain metastatic sites using an 8 mm collimator. The prescribed dose was 24 gray. The treatment was prescribed for 7 discrete sites in the brain. After the second discrete site had been treated it was found that an 18 mm collimator was being used to administer the treatment instead of the prescribed 8mm collimator.

After discovery, the collimator was changed to the 8 mm collimator. Treatment to the remaining 5 discrete sites was administered with the 8 mm collimator.

Both the patient and the patient's physician were notified of the use of the wrong collimator. The licensee states that there should be no clinical effects to the patient as a result of this misadministration.

The previous patient had been treated using the 18 mm collimator as the prescribed collimator.

Investigation into this event is continuing and a written report will follow.

In an effort to prevent recurrence, the licensee will send a notice to all authorized users, neurosurgeons and medical physicists that they should each independently check collimator size before each treatment is started.

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: 45187
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKINELMER
Region: 1
City: BOSTON State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: JOE O'HARA
Notification Date: 07/06/2009
Notification Time: 16:55 [ET]
Event Date: 07/01/2009
Event Time: [EDT]
Last Update Date: 07/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
DUNCAN WHITE (FSME)
ILTAB VIA EMAIL ()

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

Event Text

LOST SHIPMENT OF YTTRIUM Y-90

The following was provided from the Commonwealth of Massachusetts via fax:

"Shipment [was] made [by common carrier] from North Billerica to Stanford Medical Center, Palo Alto, CA on 6/23/09. The quantity was 10 milliCuries of Y-90. The package was reported missing as of July 1, 2009."

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 45188
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PIKETON State: OH
County: PIKE
License #: GDP-2
Agreement: Y
Docket: 0707002
NRC Notified By: RON CRABTREE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/07/2009
Notification Time: 01:57 [ET]
Event Date: 07/07/2009
Event Time: 00:54 [EDT]
Last Update Date: 07/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
RANDY MUSSER (R2DO)
EARL EASTON (NMSS)

Event Text

4-HOUR REPORT DUE TO NOTIFICATION OF OHIO EPA BECAUSE OF BOILER OPACITY LIMIT BEING EXCEEDED

"At 2130 hours, 07/06/09, the PORTS Plant Shift Superintendent's (PSS) Office was notified of an operational upset at the X-600 Steam Plant Facility due to a loss of power on the #3 (operating) Boiler. The operational upset resulted in three separate six minute periods, where the permissible opacity limit was exceeded, while power was being restored to the boiler. The PORTS PSS Office notified the Ohio Environmental Protection Agency (OEPA) of this incident, at 0054 hours, 07/07/09. This notification to another government agency is reportable to the NRC as a 4-hour Event, per the United States Enrichment Corporation (USEC) Nuclear Regulatory Event Reporting Procedure UE2-RA-RE1030, Appendix D, Section P (Miscellaneous) which states: 'USEC shall notify NRC of any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials'."

The licensee notified the Paducah NRC Resident Inspector.

* * * RETRACTION FROM ERIC SPAETH TO JOE O'HARA AT 1427 EDT ON 7/9/09 * * *

"PORTS [Nuclear Regulatory Affairs] NRA has reviewed the basis for the above NRC event notification and recommends that event notification #45188 be retracted. The following provides the basis for this recommendation. NUREG-1022, Event Reporting Guidelines 10 CFR 50.72 and 50.73 was reviewed. In essence, the following sentence from the NUREG provides sufficient clarification of the reporting criteria to assess the applicability of the steam plant opacity exceedances: 'The purpose of this criterion is to ensure the NRC is made aware of issues that will cause heightened public or government concern related to the radiological health and safety of the public or on-site personnel or protection of the environment.' The significance of opacity exceedances as they might impact the public or on-site workers was discussed with environmental compliance personnel. It was concluded that beyond any regulatory issues, opacity exceedances of limited duration pose no significant health or environmental concerns. Based on the specifics of this event and the additional guidance provided by the NRC, more specifically that NRC is most concerned about events or situations that would cause heightened public or government concern, the opacity exceedances reported to the OEPA should not trigger a 4 hour NRC report."

The licensee notified the NRC Resident Inspector.

Notified R2DO(Nease) and NMSS EO(Tschiltz)

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Thursday, March 29, 2012