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Event Notification Report for July 31, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/30/2009 - 07/31/2009

** EVENT NUMBERS **


45229 45232 45233 45238

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Power Reactor Event Number: 45229
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: Shawn Miller
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/27/2009
Notification Time: 09:52 [ET]
Event Date: 07/27/2009
Event Time: 07:52 [EDT]
Last Update Date: 07/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY DIMITRIADIS (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

TECHNICAL SUPPORT CENTER REMOVED FROM SERVICE FOR UPGRADES

"On Monday, July 27, 2009, at 0752, Seabrook Station is temporarily relocating its Technical Support Center (TSC) from the permanent location on the 75 foot level of the Control Building (CB) to an alternate location in the Online/Outage Control Center (OCC). This relocation is necessary to allow for installation of new equipment and upgrading of existing equipment in the TSC.

"The site Emergency Response Organization (ERO) has been notified of the modifications and has been instructed on the planned compensatory measure to be implemented during the temporary relocation.

"The NRC Resident Inspector has been notified of the relocation activities.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to loss of the emergency response facility.

"Seabrook Station will provide updates as necessary and will advise the NRC of the restoration of the permanent TSC."

The State of New Hampshire has been notified.

* * * UPDATE FROM MARK HANSEN TO JOE O'HARA AT 1635 ON 7/30/09 * * *

"On Thursday. July 30. 2009. Seabrook Station completed modifications of its Technical Support Center (TSC) and has restored the TSC permanent location on the 75 foot level of the Control Building (CB) to service. The permanent TSC was declared operable at 1456 on Thursday July 30, 2009.

"The site Emergency Response Organization (ERO) has been notified that the modifications to the permanent TSC have been completed, that compensatory measures are no longer necessary and that TSC personnel are to report to the permanent TSC in the case of a plant emergency.

"The NRC Resident Inspector has been notified that the permanent TSC has been restored to service."

The State of New Hampshire and the Commonwealth of Massachusetts have been notified. Notified R1DO (A. Dimitriadis).

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General Information or Other Event Number: 45232
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: PATISON EVANOFF ENGINEERING LLC
Region: 4
City: TUCSON State: AZ
County:
License #: 10-134
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/28/2009
Notification Time: 16:28 [ET]
Event Date: 07/27/2009
Event Time: 06:30 [MST]
Last Update Date: 07/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
PATRICE BUBAR (FSME)
ILTAB VIA EMAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The following information was received from the Arizona Radiation Regulatory Agency via email:

"At approximately 9:45 am, July 28, 2009, the Agency [Arizona Radiation Regulatory Agency] was notified that a Troxler Model 3411 had fallen out of the transporting vehicle on the way to the construction site. The operator had placed the device in the pickup truck at approximately 6:30 am on July 27, 2009, became distracted and failed to secure the device or to close the tailgate. The device, serial number 10308, apparently fell off the truck on the way to the construction site at Broadway and Jessica St. A search was instituted, but the device was not located and the Tucson Police were called at approximately 8:00 am July 27. Tucson Police report number 09 07270185 was prepared. As of the time cited above, the device has not been recovered. Press interest is expected. The Agency [Arizona Radiation Regulatory Agency] continues to investigate this event.

"The U.S. NRC, the State of CA, NV, UT, NM, CO and TX and Mexico are being notified of this event. "

Arizona Report Number 09-003

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: 45233
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: POMONA VALLEY HOSPITAL MEDICAL CENTER
Region: 4
City: POMONA State: CA
County:
License #: 0764-19
Agreement: Y
Docket:
NRC Notified By: STEPHEN DOERFLER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/28/2009
Notification Time: 19:00 [ET]
Event Date: 07/27/2009
Event Time: 18:00 [PDT]
Last Update Date: 07/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
PATRICE BUBAR (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST IODINE 125 SEEDS

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

"Pomona Valley Hospital Medical Center discovered an Iodine-125 seed shortage of 10 seeds (.449 mCi/seed) all in one cartridge on Monday July 27, 2009 at approximately 1800 hours during a permanent prostate seed implant. The physician performing the implant discovered the cartridge missing when he opened the sterilized package. These I-125 sources are used for permanent implant into the prostate for therapy.

"The physicist last saw the 7 cartridges and 100 seeds in the Hot Lab, located in the basement of the hospital on Friday July 24, 2009 at approximately 1050. Of the 100 seeds in the order, he assayed the cartridge with 9 seeds plus 1 for a total of 10 seeds. Once he completed the assay he re-loaded the cartridge with all 10 seeds, and placed the cartridge back in the storage block with the other 6 cartridges (containing 15 seeds each), and returned the storage block to the lunch box (used for carrying the cartridges to surgery). He placed the lunch box behind the loading shield and secured the Hot Lab, anti-room and exterior door before leaving the area.

"On Monday at approximately 1510 the lunch box was retrieved form the locked Hot Lab and taken, with the seeds inside, to the Operating Room (OR). Possession of the lunch box was transferred to an RN, who called Sterile Processing to retrieve the seeds from her desk for sterilization. A staff member from Sterile Processing retrieved the lunch box from RN's desk (located in the surgery suite area) to prepare for sterilization. The Sterile Processing staff member had to be directed on how to wrap the seeds as he had never prepared the seeds for sterilization before. The wrapped seeds were taken back up to Surgery and placed in Sterilizer #34. Once the sterilization process was complete, the seed package was delivered to OR #2 where the implant procedure was being performed.

"Once the physician discovered the missing cartridge during the procedure, the Medical Physicist and RSO, was notified and immediately went to the Hot Lab in attempt to locate the missing cartridge. The RSO contacted the physicist by phone who confirmed all 100 seeds in 7 cartridges were accounted for on Friday morning when he assayed them. The RSO also interviewed the staff member who prepared the seeds for Sterile processing to ask him if he dropped the lunch box and perhaps lost a cartridge, which the staff member denied. The RSO then took the spill meter (TBM survey meter) and surveyed Sterile Processing and both elevators. The Hot Lab was taken apart and thoroughly surveyed, as well as the anti-room and packaging materials. No evidence of radioactive materials was found.

"The implant procedure concluded without incident. The dosimetry plan for the patient called for 90 seeds which they had available. At the completion of the implant we had no seeds left over. All 90 seeds were implanted into the patient and the patient is doing well. In no way was the patient's care compromised by this set of missing I-125 seeds.

"Bard [Brachytherapy, Inc], the manufacturer of the sources was called to verify the shipment was in fact complete, but at 2100 hours their time July 27, 2009, no one was available. The hospital was able to contact Bard, located in Carol Stream, Illinois the following day concerning a preliminary investigation of the order. According to Bard's records the assembler of the order pulled 100 seeds off the line and 7 cartridges from inventory. None of their other customers reported receiving 10 seeds not ordered. Bard will not provide a formal report of our order until it has passed their legal department.

"Last night (July 27, 2009) Security was notified and started a formal investigation of the incident. The Hospital Administration, the Chief of Security, and the Manager of Sterile Processing were notified and explained the seriousness of the situation. Today (July 28, 2009) Pomona Valley Hospital Medical Center is continuing to search for the seeds and taking statements from all the involved associates.

"The Lot Number for the sources is: BBTG0030."

Note that this report was edited to remove reference to the names of the employees involved.

California Report number 072809.

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: 45238
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID BRAGLIA
HQ OPS Officer: VINCE KLCO
Notification Date: 07/30/2009
Notification Time: 22:55 [ET]
Event Date: 07/30/2009
Event Time: 21:08 [CDT]
Last Update Date: 07/30/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ROBERT DALEY (R3DO)
BRIAN McDERMOTT (IRD)
ALLEN HOWE (NRR)
MARK SATORIUS (R3)
JIM WIGGINS (NRR)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO A LOSS OF OFFSITE POWER FOR GREATER THAN 15 MINUTES

Unit 2 automatically tripped from 100% reactor power as a result of the over-current trip of the 2C Reactor Coolant Pump. Both station auxiliary transformers on Unit 2 subsequently tripped offline. All control rods fully inserted on the trip. Auxiliary feedwater auto-started and maintained Steam Generator water level. The unit is stable in Mode 3. The Emergency Diesel Generators auto started and loaded supplying both emergency busses with power. All systems functioned as required. There was no affect on Unit 1.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, November 05, 2012
Monday, November 05, 2012