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Event Notification Report for October 6, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/05/2009 - 10/06/2009

** EVENT NUMBERS **


45393 45396 45397 45399 45400 45412 45413

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General Information or Other Event Number: 45393
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ACCURATE NDE & INSPECTION
Region: 4
City: BROUSSARD State: LA
County:
License #: LA-10207-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: VINCE KLCO
Notification Date: 09/30/2009
Notification Time: 09:41 [ET]
Event Date: 08/25/2009
Event Time: [CDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL EXCESSIVE EXPOSURE

This information was received from the State by facsimile

"On September 23, 2009, Accurate NDE reported an over-exposure to an industrial radiographer. On August 25, 2009, Accurate NDE was informed by Landauer that an employee's badge showed a dose of 4990 mrem for the July 2009 wear period. This put the radiographer's yearly dose up to 6243 mrem for 2009. The employee stated to Accurate NDE that there was no equipment malfunctions or unusual circumstances during the month of July. The radiographer also stated that his pocket dosimeter did not go off scale during radiographic operations. A review of the daily radiation dose revealed nothing abnormal according to Accurate NDE. This incident is under investigation."

Louisiana Incident Number: LA090018

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General Information or Other Event Number: 45396
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MARTHA JEFFERSON HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-137-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: JOE O'HARA
Notification Date: 09/30/2009
Notification Time: 15:41 [ET]
Event Date: 09/30/2009
Event Time: [EDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN A THERAPEUTIC DOSE VICE A DIAGNOSTIC DOSE

The following information was received from the Commonwealth of Virginia by facsimile:

"On September 30, 2009 a patient was given a therapeutic dose of I-131(100 mCi) instead of a diagnostic dose as prescribed (4 mCi). The patient was previously given a therapeutic dose in August of 2008 and a follow up diagnostic visit was scheduled for September 30, 2009. During scheduling, the dose was incorrectly entered as therapeutic instead of diagnostic. The licensee notified the patient's physician and consulted with the patient. The licensee notified their risk management group and has begun an investigation into the event. The licensee was informed to provide RMP [Radioactive Materials Program] with a written report within 15 days.

"Event Report Number: VA-09-04."

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: 45397
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/01/2009
Notification Time: 13:04 [ET]
Event Date: 09/21/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO EMBRYO GREATER THAN 5 REM

The following was received via E-mail:

"On September 30, 2009 the licensee's radiation safety officer contacted the Agency [Illinois EMA] to advise that a dose to an embryo likely to have exceeded 5 Rem occurred as a result of an administration of I-131 to a mother under going thyroid treatment. Twenty five milliCi of I-131 was administered on September 21, 2009. As per hospital protocol, the patient had undergone [pregnancy] screening consisting of interviews and a urine based pregnancy test with negative results. Eight days subsequent to the administration, the patient missed an expected [menstrual] cycle and conducted a home based [pregnancy] test with positive results. Those test results were confirmed with a positive serum based test on that same day administered by her physician.

"The authorized user estimates the embryo would potentially have progressed as much as 3 weeks at that time. TEDE estimates are roughly 6.7 Rem to the embryo, with no thyroid likely to have developed at this stage of pregnancy. The confirmed presence or absence of permanent functional damage is unknown, but the expectation is that there would no effect on the embryo. The patient was advised of this information the same day and further advised that a spontaneous termination was still a potential due to the early developmental stage involved although the radionuclide would not likely play a role in that outcome.

"As a matter of practice, the radiation safety office is investigating details regarding this specific event to ensure all expected procedures were followed. Based on the initial report, no apparent violations are noted, nor any failures made that would have prevented the event from occurring. A formal report will be submitted within the required 15 days. At this time, no general corrective measures are anticipated but the event will be used as an opportunity for refresher training and a risk audit."

Illinois Report #: IL-0900074.

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General Information or Other Event Number: 45399
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL COMPANY
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/01/2009
Notification Time: 15:43 [ET]
Event Date: 09/30/2009
Event Time: 18:00 [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE

The following was received via E-mail:

"On October 1, 2009, the Agency [TX Dept. of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting a routine shutter check on an Ohmart/Vega Corp. SHF1 nuclear gauge containing 20 millicuries of Cesium (Cs) 137, the shutter failed to close. The RSO stated that the gauge had been installed on the vessel in June of 2009. He was performing the check now to get this gauge into the same inspection schedule as the other gauges they use. He stated that the gauge is stuck open in the normal operating position and a survey conducted in the area indicated that dose rates were normal. He stated that there was no other damage to the gauge. He stated that he thought the mechanism may have become fouled from work conducted on a piece of equipment in the area. The manufacturer was contacted and is scheduled to perform repairs and training on October 21, 2009. The gauge is currently tagged 'Do Not Operate.' Additional information will be provided as it is received."

See similar event report EN# 45400 involving an Ohmart gauge with a stuck open shutter.

Texas Incident #: I-8675.

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General Information or Other Event Number: 45400
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: EQUISTAR CHEMICALS LP
Region: 3
City: MORRIS State: IL
County:
License #: IL-01737-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2009
Notification Time: 16:19 [ET]
Event Date: 09/30/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE

The following information from the State of Illinois Emergency Management Agency via e-mail:

"On September 30, the facility's radiation safety officer contacted the Agency to advise that a fixed gauge had failed to operate as intended. While performing routine safety and shutter condition checks, attempts to close the shutter on the level gauge were not successful. The gauge is operated in an elevated, open environment on a polymer process vessel and there are no occupiable workstations in the area. The safety officer reports that they believe the shutter could be rotated to the closed position if additional force were applied to the shutter arm. However, previous experience has shown such actions could result in the arm becoming sheared from the shutter. Attempts to apply additional lubricant and remove debris from the pathway not otherwise readily observed, did not improve the extent of closure.

"The process vessel involved is continuously operated and not scheduled for any routine maintenance at this time. The licensee continues to operate the line at this time with the shutter open. Warning notices have been posted near the gauge regarding the shutter operation and all operational supervisors and personnel responsible for the line have been made aware of the condition. Should an emergency condition exist the licensee is prepared to remove the gauge from the vessel and apply additional shielding. Arrangements are pending with the manufacturer to come on-site to perform an evaluation of the three year old device and make the necessary repairs or replace the device as necessary. Similar failures of this device have been noted in the past. The manufacturer states the common cause for those failures is poor or non-existent maintenance, operation of the gauge outside of its approved conditions and/or attempting to force operation of the shutter handle.

"The licensee indicated the necessary written report would be filed within the next 30 days. "

The gauge involved is an Ohmart Model SHF2 (S/N 74932) with a 80 millicurie Cs-137 source.

See similar event report EN#45399 involving an Ohmart gauge with a stuck open shutter.

Illinois Report Number IL0900075.

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Power Reactor Event Number: 45412
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN DRISCOLL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/05/2009
Notification Time: 14:41 [ET]
Event Date: 10/05/2009
Event Time: 11:58 [EDT]
Last Update Date: 10/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
SAM HANSELL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL SCRAM AND HIGH PRESSURE COOLANT INJECTION FOLLOWING A LOSS OF FEEDWATER LEVEL CONTROL

"At 1158 on Monday, October 5, 2009, Nine Mile Point Unit One was manually scrammed from approximately 100% rated power due to failure of the Feedwater Level Control System, in anticipation of a reactor scram. Following the manual scram insertion at 11:58, High Pressure Coolant Injection (HPCI) System automatically initiated on low Reactor Vessel (RPV) level. At 11:59, RPV level was restored above the HPCI System low level actuation setpoint, and the HPCI System initiation signal was reset. At Nine Mile Point Unit One, a HPCI System actuation signal on low RPV level is normally received following a reactor scram, due to level shrink.

"Unit 1 has commenced cooldown, in preparation for the forced outage to commence repairs. Reactor water level is being controlled in the normal operating band; reactor temperature is 450?F and reactor pressure is approximately 500 psig.

"10 CFR 50.72(b)(2)(iv)(B) requires reporting within 4 hours when any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical.

"10 CFR 50.72(b)(3)(iv)(A) requires reporting within 8 hours when a valid actuation of the High Pressure Coolant Injection System occurs."

All control rods fully inserted. All systems functioned as required following the reactor scram. The reactor is currently stable in Mode 3. HPCI has been secured. Makeup water is being provided by the Reactor Feedwater System and decay heat removal is through the bypass valves to the condenser. There was no impact on Unit 2 and the plant is in a normal post-scram electrical lineup.

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 45413
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: CALVIN PITTMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/05/2009
Notification Time: 15:55 [ET]
Event Date: 10/04/2009
Event Time: 15:00 [CDT]
Last Update Date: 10/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(1) - UNPLANNED CONTAMINATION
Person (Organization):
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)

Event Text

UNPLANNED CONTAMINATION DURING STARTUP

"On 10/04/2009 at 1500 C-331 unit 2 cell 2 was being charged and placed on stream and had just gone above atmospheric pressure when a Maintenance Mechanic observed smoke coming from the cell instrument cubicle and determined it to be UF6 outleakage from cell process instrumentation. To stop the release the cell was immediately taken back below atmospheric pressure. Investigation revealed that a UF6 release had occurred inside the instrument cubicle. The amount of material released has not yet been determined. Decontamination is underway but has not been completed inside the cabinet. The area outside the cabinet has been decontaminated. No injuries or personnel exposure occurred as a result of this event. This is being reported based on 10 CFR 76.120(c)(1)(i) (unplanned contamination event).

"PGDP Problem Report Nos. ATRC-09-2435; PGDP Event Report No. PAD-2009-016. Responsible Division: Operations

"PGDP Assessment and Tracking Report No. ATR-09-2435; PGDP Event Report No. PAD-2009-16; Worksheet No. Responsible Division: Operations

"The NRC Senior Resident Inspector has been notified of this event."

Decontamination is expected to be completed on 10/6/2009.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012