| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/31/2009 - 08/03/2009 ** EVENT NUMBERS ** |
 | Power Reactor | Event Number: 45230 | Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JIM KONRAD
HQ OPS Officer: JOHN KNOKE | Notification Date: 07/27/2009
Notification Time: 10:39 [ET]
Event Date: 07/27/2009
Event Time: 09:35 [EDT]
Last Update Date: 07/31/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
ROBERT DALEY (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text TECHNICAL SUPPORT CENTER TEMPORARILY UNAVAILABLE FOR USE
"On July 27, 2009, Fermi 2 is removing the Technical Support Center (TSC) from operation to facilitate maintenance activities for furniture and facility upgrade. During this work the facility will not be available for use. Fermi 2 is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event TSC activation is necessary the Emergency Operations Facility (EOF) will be utilized. Activation and use of the EOF as a back up for the TSC is included in Fermi 2's Radiological Emergency Response Preparedness Plan. The Emergency Call Out System (ECOS) is designed to facilitate contacting TSC personnel to respond directly to the EOF in the event of an emergency. Fermi 2 will notify the NRC upon completion of this work which is expected to be July 31, 2009."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM JEFF GROFF TO JOE O'HARA AT 1414 EDT ON 7/31/09 * * *
"Update to Event #45230 regarding unavailability of the Technical Support Center (TSC) for planned furniture and facility upgrade. The work to upgrade the facility has been completed satisfactorily. The TSC has been restored as an Emergency Response facility. The facility had been removed from operation on July 27, 2009 at 0935 EDT. The TSC was restored to operation at 1330 EDT on July 31, 2009."
The NRC Resident Inspector has been notified.
Notified R3DO(Daley). |
| 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. |
| 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. |
| General Information or Other | Event Number: 45234 | Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: COLE & ASSOCIATES TRAINING AND CONSULTING
Region: 4
City: KENT State: WA
County:
License #: WN-R0979
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: BILL HUFFMAN | Notification Date: 07/29/2009
Notification Time: 11:40 [ET]
Event Date: 07/22/2009
Event Time: [PDT]
Last Update Date: 07/29/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAIR SPITZBERG (R4DO)
GLENDA VILLAMAR (FSME)
ILTAB VIA EMAIL ()
CANADA VIA EMAIL ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE - LOST OR STOLEN X-RAY FLUORESCENCE DEVICE
The following report was sent from the State of Washington via email:
"On 22 July, 2009 [the Washington State Office of Radiation Protection] received a report of a missing XRF device. On 20 July, 2009, an employee at Cole & Associates, failed to report to work and has yet to contact employer's office as to their whereabouts. The employee has not been seen nor heard from. The employee was performing inspections at the Veterans Hospital in Tacoma, Washington, the employee's home town. The employee had in their possession a Thermo Fischer Scientific Niton XL 309 X-ray Fluorescence (XRF) device, serial number U2615TRO459, with an 14 millicurie Cadmium-109 source dated 11/15/2008.
"The XRF device is used exclusively for lead analysis in paint. Thermo Fisher Scientific has been notified and will alert the licensee if anyone turns in the unit in to them. A report was also filed with the Kent police."
Washington Report WA-09-049. Cadmium-109 has a half life of 462 days.
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. |
| 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: 08/02/2009 | 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)
DENNIS VIA (FEMA)
JOHN FROST (DHS)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | A/R | 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.
* * * UPDATE AT 0218 ON 8/2/2009 FROM DEAN YARBROUGH TO MARK ABRAMOVITZ * * *
"At 2059 on July 30, 2009, a reactor trip of Unit 2 at Braidwood occurred. A loss of offsite power occurred and an Unusual Event was declared at 2108. NRC Headquarter Operations was notified at 2155 (ENS call # 45238).
"Power from System Auxiliary Transformer (SAT) (credited offsite power supply) 242-2 was restored to buses 241 and 242 (safety related buses) at 0036 on August 2, 2009.
"The Unusual Event was terminated at 0036 on August 2, 2009. This call is being made due to the termination of the Unusual Event declared on July 30, 2009.
"An Event Summary Report is required by Exelon procedures within 24 hours of termination of the Unusual Event and will be communicated to the Headquarter Operations later today."
The initial event was the result of the actuation of the SAT sudden pressure relay. When the transformer tripped, a slow automatic bus transfer resulted. When the RCPs [Reactor Coolant Pump] and condensate pumps were reenergized, they tripped on overcurrent causing the reactor trip. The sudden pressure relay has subsequently tripped during testing and may have caused the initial event. The licensee reported no damage to the plant. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Daley), IRD (McDermott), NRR (Howe), DHS (An), and FEMA (Biscoe).
* * * UPDATE AT 1617 ON 8/2/2009 FROM SCOTT BUTLER TO VINCE KLCO * * *
The Event Summary Report was received and documented the following technical conclusions:
"The Unusual Event declaration was caused by a sudden pressure relay on SAT 242-1 causing a lockout of both SATs followed by a trip of Unit 2 due to the 2C RCP tripping during the automatic bus transfer for bus 258. This led to a loss of offsite power to Unit 2. It is currently unknown why the sudden pressure relay on SAT 242-1 actuated. Troubleshooting on the sudden pressure relay is in progress."
The licensee will notify the NRC Resident Inspector.
Notified the R3DO (Daley). Notified the IRD (McDermott) and NRR (Howe) via e-mail. | |