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Event Notification Report for September 18, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/17/2009 - 09/18/2009

** EVENT NUMBERS **


45090 45176 45351 45354 45356 45357 45359 45360

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Fuel Cycle Facility Event Number: 45090
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/22/2009
Notification Time: 12:42 [ET]
Event Date: 05/20/2009
Event Time: 15:00 [EDT]
Last Update Date: 09/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
MATTHEW HAHN (ILTA)
ANTHONY McMURTRAY (IRD)
JAMES RUBENSTONE (NMSS)
ROBERT HAAG (R2DO)

Event Text

LICENSE CONDITION REPORT INVOLVING SNM ACCOUNTABILITY

"Facility: Westinghouse Electric Company LLC (WEC), Commercial Fuel Fabrication Facility, Columbia SC,
low enriched (less than or equal to 5.0 wt.% U-235) fuel fabricator for commercial light water reactors. License: SNM-1107.

"Time and Date of Event: May 20, 2009, approximately 1500.

"Reason for Notification & Sequence of Events:

"Notification made based on Materials License Number SNM-1107, Safeguards Conditions Section 1.0 Material Control and Accounting, SG-1.1 which states in part; 'The licensee shall follow Chapters 1.0 through 9.0 of its 'Fundamental Nuclear Material Control Plan for the Columbia Fuel Fabrication Facility.' The Fundamental Nuclear Material Control Plan, Section 2.2.2 contains specific requirements for notification for issues related to resolving item and/or material control anomalies.

"The Environment, Health and Safety (EH&S) Department was informed that a small scrap fuel pellet container containing uranium, which is Special Nuclear Material (SNM), could not be readily located. The anomaly was identified by operations personnel conducting a routine weekly audit of SNM-bearing items. Initial investigation and search efforts did not locate the SNM, which was in a small container (approximately 8 inches in diameter x 8 inches tall) used for routine processing, commonly called a 'polypak.'

"Personnel independent of the affected area conducted a Material Balance Inventory, which concluded that the SNM did not leave the area. The Material Balance results and findings were reviewed by an independent contractor, a Material Control and Accounting expert who agreed with the conclusion and methodology used. Based on this material balance and other investigative actions conducted by WEC, there is no indication that the material left the affected area, and the SNM was processed through the normal scrap process flow.

"Safety Basis: There are no actual or potential health or safety consequences to the workers, the public or the environment.

"As Found Condition: See Reason for Notification.

"Summary of Activity

- Operations in the affected manufacturing area were halted and the area was extensively and systematically searched by Operations, Management and EH&S personnel.

- The empty container was located within the affected manufacturing area.

- Retraining on item control requirements for production personnel was completed prior to restart of production activities.

- Enhanced accountability and control measures for item control of scrap containers was completed prior to restart of production activities.

- An investigative review team was assembled and interviewed personnel in the affected manufacturing areas to determine the cause of the item control discrepancy.

- The event was entered into the WEC Corrective Action Process and a formal Root Cause Analysis was completed.

- Interim corrective actions have been completed and longer term corrective actions have been initiated to reduce the likelihood of a repeat occurrence based on the results and recommendations of the Root Cause Analysis."

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General Information or Other Event Number: 45176
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2009
Notification Time: 17:27 [ET]
Event Date: 06/30/2009
Event Time: 11:30 [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL WORKER OVEREXPOSURE

The following information was received via facsimile:

"A worker was working in a hot cell when a F-18 [radio-isotope] was mistakenly delivered to the hot cell. [The] initial estimated worker dose [was] 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. [The] worker has been taken off Rad work and is being monitored"

A Commonwealth of Massachusetts investigation is pending.

* * * UPDATE ON 8/13/2009 AT 1130 FROM TONY CARPENITO TO MARK ABRAMOVITZ

The following report was received via e-mail:

"On 6/30/09, 1.6 Curies of Fluorine-18 was mistakenly delivered to a shielded vial within the cyclotron facility hot cell while a worker was performing routine maintenance within the hot cell. Delivery was intended for a different hot cell. The total worker exposure time was less than 3 minutes. The worker was removed from radiation work and dosimeters were sent out for immediate processing. Same day notification was made from the licensee to the Agency [Massachusetts Radiation Control Program]. The licensee submitted an independent consultant written report, dated 7/8/09, to the Agency [Massachusetts Radiation Control Program] on 7/27/09. The worker's effective dose equivalent was conservatively determined to be not more than 0.170 Rem, the maximum extremity not more than 26.9 Rem, and the eye dose equivalent not more than 1.2 Rem. These dose values were assigned to the worker. The worker was returned to radiation work with cumulative dose closely monitored.

"Licensee's formal descriptions of cause, contributing and precipitating factors, and corrective actions are pending.

"The Agency [Massachusetts Radiation Control Program] considers this situation to still be OPEN."

Notified the R1DO (Cook) and FSME (McIntosh).

* * * UPDATE ON 9/17/2009 AT 0949 FROM CARPENITO TO HUFFMAN * * *

The following update was received via e-mail:

"9/16/09 Update: A subsequent on-site Agency inspection was performed. On 8/27/09, the licensee submitted report of cause, contributing and precipitating factors, and corrective actions.

"Cause: Pre-event re-configuration of transport tubing during an earlier calibration effort was not returned to original configuration and operators were not aware of the routing change.

"Precipitating and Contributing Factors: Licensee procedures related to use of personnel dosimeters, functioning survey instruments, and hot cell door closure, were not followed.

"Corrective Actions: Licensee to implement procedural changes and retraining of staff.

"The Agency considers this situation to be closed."

Notified the R1DO (Jackson) and FSME (McIntosh).

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General Information or Other Event Number: 45351
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: CAPITAL X-RAY
Region: 4
City: TULSA State: OK
County:
License #: OK-11114-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JASON KOZAL
Notification Date: 09/15/2009
Notification Time: 10:14 [ET]
Event Date: 09/15/2009
Event Time: [CDT]
Last Update Date: 09/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - POTENTIAL OVEREXPOSURE EVENT

The following was provided by the State via e-mail:

"A radiographer assistant employed by the company for about ten months may have been overexposed. The licensee processes dosimetry every two weeks. The employee's badge for 8-1 to 8-15 returned a reading of 3.077 rem deep dose for the two week period. This placed the employee's total exposure for the calendar year at 3.93 rem. The licensee removed the worker from being involved with licensed materials and initiated an investigation. The worker's badge for 8-16 to 8-31 had already been submitted for processing. On 9/3/09, the licensee was contacted by the dosimetry provider and informed that the worker's deep dose for 8-16 to 8-31 was 12.542 rem. This placed his total annual dose at 16 rem. No unusual exposures on the worker's pocket dosimeter had been recorded at any time. The dosimetry provider indicates the badge exposures are 'irregular'.

"The licensee contacted Oklahoma DEQ and initiated a thorough investigation. During the period in question, the radiographer assistant had worked with only one radiographer. All work was done at temporary job sites at industrial facilities. The radiographer and assistant insisted that there had been no unusual events or possibility of exposure, that the worker's alarming rate meter had not alarmed, and that pocket dosimeter readings for the period had been normal. The worker insisted he had not been exposed, and he believed someone else had exposed his dosimetry. The company does not allow assistant radiographers to have keys to cameras, and the worker is not approved for unescorted access to IC quantities of radioactive material. Both workers agreed that the assistant radiographer had never had a key to a camera, but investigation revealed that the assistant radiographer had left the worker alone with the unlocked camera while he went to the restroom. The licensee has counseled the radiographer not to do this, and has informed all radiography staff that assistant radiographers must not be left alone with unlocked radiography cameras. The licensee has contacted local medical assistance, and is told that because of the (relatively) low level of the exposure, and it being spread into at least two components, locally-available blood testing will not reliably detect the exposure.

"Since receipt of the dosimetry report, the licensee is not allowing the worker to work near radioactive materials or x-ray. The licensee does not believe the worker was actually exposed to radioactive material, and wants to use chromosome analysis to test this theory. The State has encouraged the licensee to take steps to investigate whether the exposure was to the badge only, or to the worker."

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Power Reactor Event Number: 45354
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: BRIAN ROKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/16/2009
Notification Time: 17:10 [ET]
Event Date: 09/16/2009
Event Time: 10:36 [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DON JACKSON (R1DO)

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

Event Text

EMERGENCY SIRENS OUT OF SERVICE

"On September 16, 2009, at approximately 1036 hours, as a result of a regularly scheduled test of the Indian Point Energy Center (IPEC) Alert Notification System (ANS) 18 of 172 sirens did not pass the test. The sirens were not tested and declared as functional within one hour and in accordance with the reporting guidelines the event is reportable under 10CFR50.72(b)(3)(xiii) as a major loss of offsite response capability (i.e., a loss of 10% or more of the total number of sirens for more than one hour).

"Preliminary investigations and troubleshooting determined 14 sirens failed to indicate via the ANS computer system successful siren activation due to an incorrect software data adjustment for these 14 sirens. ANS technicians corrected the software error for these 14 sirens and are continuing to investigate the cause of the failure of the remaining 4 sirens to activate. To validate that the software error for the 14 sirens was corrected, a functional test of 1 of the 14 sirens was conducted. The test indicated the siren was functional but investigation and troubleshooting is continuing to validate this.

"Reverse 911 has been and remains available to alert the public should there be an actual event requiring the ANS. The condition was recorded in the IPEC corrective action program. The event remains under investigation."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM BRIAN ROKES TO JOHN KNOKE AT 1435 ON 09/17/09 * * *

Two sirens were repaired making a total of 156 sirens operable. No further reporting is forthcoming.

Licensee has notified the NRC Resident Inspector. The R1DO (Don Jackson) was notified.

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Power Reactor Event Number: 45356
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM TODD
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 14:01 [ET]
Event Date: 09/17/2009
Event Time: 13:52 [EDT]
Last Update Date: 09/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER FUNCTIONALITY OUT OF SERVICE

"A condition is being reported per Technical Requirement Manual 13.13.1 Emergency Response Facilities Action B.2. The backup power supply Functionality of the Technical Support Center (TSC) will be out of service due to planned maintenance on the SAS Battery. Pre job briefings and steps for restoration in case of emergency have been included in the work plan. Alternate facilities are available to provide emergency response functions. A 10CFR50.54(q) evaluation has been performed for this planned Maintenance activity."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE AT 0355 EDT ON 9/18/09 FROM SWEAT TO HUFFMAN * * *

"In reference to EN# 45456, Plant Vogtle Technical Requirement Manual 13.13.1 Emergency Response Facilities Action B.2 has been exited. The backup power supply for the Technical Support Facilities (TSC) has been returned to service and Is now fully functional."

R2DO (Bonser) notified.

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Power Reactor Event Number: 45357
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: BRIAN JOHNSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 15:25 [ET]
Event Date: 09/17/2009
Event Time: 11:30 [CDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION TO MINNESOTA POLLUTION CONTROL AGENCY

"Approximately one cup of hydraulic oil entered the plant waterway while operating the 122 Emergency Intake Bypass Gate. While troubleshooting a limit switch issue with the bypass gate, a leak developed on the lower seal for the hydraulic cylinder. An oil sheen was noticed on the plant side of the Intake Screen House and has been cleaned up with absorbents. No oil sheen was detected on the Mississippi River side of the Intake Screen House or in the plant discharge canal. The Minnesota Pollution Control Agency and the National Response Center were notified."

The licensee has notified the NRC Resident Inspector. Licensee will be contacting local and other government agencies.

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Power Reactor Event Number: 45359
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: EDWARD CARRERAS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/17/2009
Notification Time: 16:16 [ET]
Event Date: 09/17/2009
Event Time: 13:00 [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DON JACKSON (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

EMERGENCY RESPONSE DATA SYSTEM INOPERABLE FOR GREATER THAN EIGHT HOURS

"At 1300 hrs. on Thursday, September 17, 2009, TMI Unit 1 determined that there had been a degradation of the emergency preparedness response capabilities when a loss of the Emergency Response Data System (ERDS) was identified. While preparing for a future job in the same cabinet where the ERDS modem is located, technicians identified that the phone line for the ERDS modem was not connected.

"At 1400, the phone line was reconnected to the modem. After coordination with the NRC Operations Center testing personnel, a test of the ERDS system was initiated. At 1414, an active link was established. A successful ERDS link was confirmed with the NRC Operations Center. At 1426, the ERDS link was terminated.

"Work was performed on different equipment in the cabinet containing the ERDS modem on approximately September 1, 2009. It is probable that the phone line was inadvertently disconnected from the ERDS modem at that time. The last scheduled quarterly test was successfully completed on July 9, 2009. TMI 1 has determined that this event is reportable to the NRC as an 8-hour non-emergency report in accordance with 10 CFR 50.72 (b)(3)(xiii). "

The licensee has notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 45360
Rep Org: US ARMY
Licensee: US ARMY
Region: 4
City: TRACY State: CA
County:
License #: 21-01222-05
Agreement: Y
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 17:15 [ET]
Event Date: 09/16/2009
Event Time: [PDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Event Text

FOUR DEFECTIVE MOISTURE DENSITY GAUGES

As part of the pre-operational check at the Defense Distribution Depot in Tracy, CA, operators discovered that four of their CPN Model MC-1 Moisture Density Gauges were defective. The 4 moisture density gauges were manufactured approximately 30 years ago and each contains two sources; 10 mCi Cs-137 and 50 mCi Americium-241/Be (nominal). These gauges will not be returned to the manufacturer for evaluation and repair, but rather disposed of at an approved facility. The 4 units are currently locked in their storage containers, and those containers are locked inside another locked cabinet at the Defense Distribution Depot in Tracy, CA.

The four gauges serial number and the reason for being defective are as follows:

1) s/n M17092033 - Locking mechanism does not work.
2) s/n M17112087 - Locking mechanism does not work.
3) s/n M17092041 - Handle broken.
4) s/n M17071988 - Broken guide tube.

The licensee notified NRC Region 3 Office.

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