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Event Notification Report for July 22, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/21/2009 - 07/22/2009

** EVENT NUMBERS **


45206 45209 45214 45215 45216 45217 45218 45219

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Hospital Event Number: 45206
Rep Org: NANTICOKE COOK MEMORIAL HOSPITAL
Licensee: NANTICOKE COOK MEMORIAL HOSPITAL
Region: 1
City: SEAFORD State: DE
County:
License #: 07-17618-01
Agreement: N
Docket:
NRC Notified By: MATTHEW RAJOTTE
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/15/2009
Notification Time: 12:54 [ET]
Event Date: 03/15/2009
Event Time: [EDT]
Last Update Date: 07/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
HAROLD GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL UNDEREXPOSURE DURING BRACHYTHERAPY

"A prostate seed implant was performed on March 5th, 2009, using needles preloaded with I-125 seeds. After implanting a total of 61 seeds, 22 seeds were found and then retrieved from the bladder. The patient later returned for a pelvic CT for post implant dosimetry. This dosimetry revealed an under dosing of the prostate with a D90 dose less than 80% of the prescribed dose. The seed distribution error was caused by the position of the needles in respect to depth when the seeds were released. The patient received no ill effect, but requires further therapeutic radiation in order to complete the prescription. The patient is currently scheduled for a second seed implant to complete the therapy."

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: 45209
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RADIOGRAPHIC SPECIALISTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02742
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/17/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: [CDT]
Last Update Date: 07/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
TERRENCE REIS (FSME)

Event Text

POSSIBLE RADIOGRAPHER OVEREXPOSURE

Texas Incident #8646

"On July 17, 2009, the Agency [Texas Department of Health] was notified by the licensee that they had been informed by their dosimetry processor that a radiographer had received an exposure exceeding the annual exposure limit. The licensee stated that the individual's thermoluminescent dosimeter was reading 9,000 millirem for the exposure period of June 9, 2009, through July 10, 2009. The licensee conducted a preliminary interview with the employee and was not able to determine how the exposure could have occurred. The radiographer stated that he had not received any dose rate alarms while performing his duties during the monitoring period. He also stated that his self reading pocket dosimeter had never indicated any unusual readings. The licensee's Radiation Safety Officer stated that the individual's duties during the exposure period were almost exclusively dark room operations grading film. The licensee is continuing to investigate and will provide additional information to the Agency [Texas Department of Health] as it becomes available."

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Other Nuclear Material Event Number: 45214
Rep Org: COBRA NATURAL RESOURCES
Licensee: COBRA NATURAL RESOURCES
Region: 1
City:  State: WV
County: MINGO
License #: 47-31260-01
Agreement: N
Docket: 030-37-5
NRC Notified By: BRUCE MCPHERSON
HQ OPS Officer: VINCE KLCO
Notification Date: 07/21/2009
Notification Time: 11:30 [ET]
Event Date: 07/21/2009
Event Time: 07:30 [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JOHN ROGGE (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

COURTESY NOTIFICATION OF AN ACCIDENT AFFECTING A GAUGE CONTAINING CALIFORNIUM-252

A licensee representative of Cobra Natural Resources LLC called concerning an accident at a coal mine loading facility where a device containing radioactive sources was stored. A train derailment of five empty coal cars at the mine damaged a "loadout" building where a process gauge with radioactive sources was stored. Due to debris at the site of the incident, the licensee is unable to reach the gauge but it appears intact and undamaged. The gauge contains four Californium-252 sources with at total activity of less than 80 mCi.

The licensee RSO is continuing to evaluate the situation.

* * * UPDATE FROM LICENSEE (BILL EMERSON) TO HUFFMAN AT 1605 EDT ON 7/21/09 * * *

The RSO for the licensee reports that its contractor, Thermo-Fisher, has been able to perform close-in area surveys of the device using a remote probe. The surveys confirmed that there is no contamination. Remote visual examination also revealed no indication of damage. The device, a Gamma-Metrics coal analyzer, is still not accessible due to personnel risk from the building debris but the licensee believes that there is no risk of damage to the device until it can be retrieved. The licensee has discussed this event with NRC Region 1 (Miller) and FSME (Villamar).

R1DO (Rogge) notified.

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Power Reactor Event Number: 45215
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: NEWTON LACY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/21/2009
Notification Time: 14:15 [ET]
Event Date: 07/21/2009
Event Time: 08:03 [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
STEVEN VIAS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS FOR DUTY REPORT - CONTRACT SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A non-licensed supervisory contractor employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access has been revoked. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45216
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: PAUL SALGADO
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/21/2009
Notification Time: 15:27 [ET]
Event Date: 05/25/2009
Event Time: 16:15 [CDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

OPTIONAL 60-DAY REPORT OF INVALID SPECIFIED SYSTEM ACTUATION

"On May 25, 2009, at 1615, a Unit 3 control fuse failed open causing multiple containment isolation valves for the atmospheric sampling system and containment ventilation/purge systems to close on a loss of power to the logic system. No actual valid containment isolation signals were received or processed by the containment isolation logic. Since this was an invalid signal, a telephone notification to the NRC Operations Center may be provided within 60 days after discovery of the event instead of submitting a written Licensee Event Report. [10 CFR 50.73(a)(2)(iv)(A)].

"This phone notification is being made in lieu of a written 60 day LER as allowed in 10 CFR 50.73(a)(1) to report the invalid actuation of multiple containment isolation valves that occurred as described above. The fuse is associated with the inboard containment isolation logic. This is considered a partial actuation and all components operated as expected. Troubleshooting identified that a relay failed and, in turn, had caused the fuse to open. The relay and fuse were replaced and the systems restored to their normal lineup. The NRC Resident has been informed that this notification is being made.

"No further notifications or reports will be issued."

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Other Nuclear Material Event Number: 45217
Rep Org: ORDER OF ST. FRANCIS HOSPITAL
Licensee: ORDER OF ST. FRANCIS HOSPITAL
Region: 3
City: ESCANABA State: MI
County:
License #: 21-16481-01
Agreement: N
Docket:
NRC Notified By: SHAN MARLETTE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/21/2009
Notification Time: 15:41 [ET]
Event Date: 07/21/2009
Event Time: 11:45 [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
DAVID HILLS (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

EXTERNAL CONTAMINATION ON SHIPMENT OF RADIOPHARMACEUTICALS

The licensee reported they received a shipment of Thallium-201 from Covidien (formerly Mallinckrodt) that had external contamination greater than regulatory limits. The packaged was swiped during receipt and had 25,000 dpm of contamination. The limit is 220 dpm. External radiation levels were 0.1 mR/hr at one meter which was consistent with the shipping documents. The package is currently wrapped in plastic in secure storage at the licensee facility where it will remain until decayed and then will be properly disposed of by the licensee.

The shipper and shipping company was notified of the contamination event. The driver and the vehicle were surveyed and no contamination was found. No personnel at the receiving facility were reported to be contaminated.

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Power Reactor Event Number: 45218
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: TIM SEILKOP
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/21/2009
Notification Time: 16:42 [ET]
Event Date: 07/21/2009
Event Time: 09:30 [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN VIAS (R2DO)

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

Event Text

ABILITY TO ACTIVATE EMERGENCY SIRENS TEMPORARILY LOST

"At 0930 on 7/21/09, during routine backup diesel generator surveillance testing of the Princeton Radio Tower, the automatic electrical power transfer switch failed in an intermediate position [during] restoration to its normal electrical alignment. The Turkey Point Plant Alert Notification System is located at the Princeton Tower. The failure of the automatic transfer switch in the intermediate position resulted in a temporary loss of power to the Alert Notification System repeaters. The remote telemetry monitoring at the Tower functioned as designed and provided prompt notification of the situation to FPL personnel. An FPL Radio technician was promptly dispatched to assess the condition. The Alert Notification System (redundant activating transmitters) was deemed unavailable during this time. The Princeton Radio Tower electrical power transfer switch was manually positioned to align the Alert Notification System repeaters to their normal power supply at 1035 on 7/21/09, restoring availability. The ability to manually transfer the Alert Notification System repeaters' electrical power supply was not impacted by this failure. The Alert Notification System was tested satisfactory once the system was returned to service. An investigation to determine the failure of the automatic transfer switch is ongoing.

"The failure of this system is considered a major loss of offsite communications capability and is reportable under 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45219
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOHN OHRENBERGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/21/2009
Notification Time: 17:15 [ET]
Event Date: 07/21/2009
Event Time: 14:05 [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (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

LOSS OF EMERGENCY RESPONSE CAPABILITY - TSC/OSC IS UNAVAILABLE DUE TO HVAC SYSTEM TROUBLE

"Unavailability of TSC/OSC Heating, Ventilation and Air Conditioning (HVAC) System.

"At 1405 hours on Wednesday, July 21, 2009, the Pilgrim Nuclear Power Station (PNPS) Technical Support Center (TSC) / Operations Support Center (OSC) HVAC system was discovered to be nonfunctional. During initial troubleshooting, the breaker providing power to the supply fan mechanically tripped and will not be reset until troubleshooting certifies the breaker is acceptable for use. This event occurred during scheduled preventative maintenance (PM) of the system.

"Under certain accident conditions, the TSC/OSC may become unavailable due to inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC/OSC personnel to alternate locations.

"The licensee has notified the NRC Senior Resident Inspector/Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an emergency response facility."

The licensee notified the Commonwealth of Massachusetts Emergency Management Agency.

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Thursday, March 29, 2012