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Event Notification Report for October 22, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/21/2009 - 10/22/2009

** EVENT NUMBERS **


45436 45442 45446 45452 45453 45454

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Hospital Event Number: 45436
Rep Org: UNIVERSITY OF MICHIGAN HOSPITAL
Licensee: UNIVERSITY OF MICHIGAN HOSPITAL
Region: 3
City: ANN ARBOR State: MI
County:
License #: 21-00215-04
Agreement: N
Docket: 030-0198
NRC Notified By: MARK DRISCOLL
HQ OPS Officer: JOE O'HARA
Notification Date: 10/15/2009
Notification Time: 16:42 [ET]
Event Date: 10/14/2009
Event Time: 17:00 [EDT]
Last Update Date: 10/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
MARK DELLIGATTI (FSME)

Event Text

PATIENT RECEIVED APPROXIMATELY 76% OF THE PRESCRIBED DOSE

A three year old boy was undergoing a palliative treatment for a cancer related illness with I-131. The boy was prescribed 180.5 milliCuries of I-131 by his physician. During the treatment, a technician noticed that there were air bubbles in the intravenous tubing leading to the boy and stopped the treatment. Upon subsequent investigation, it was revealed that the patient only received 138 milliCuries of the prescribed 180.5 milliCuries of I-131, which is approximately 76% of the prescribed dose. The patient's physician has been notified, and is making a decision whether to inform the boy's parents. The licensee is investigating the cause of the incident.

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: 45442
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THRUBIT LLC
Region: 4
City: HOUSTON State: TX
County:
License #: 06030
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/16/2009
Notification Time: 14:15 [ET]
Event Date: 10/15/2009
Event Time: [CDT]
Last Update Date: 10/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
MARK DELLIGATTI (FSME)

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

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL LOSS OF RADIOACTIVE MATERIAL DURING SHIPMENT

The following information was received from the State of Texas via email:

"On October 16, 2009, at 11:35 AM, the licensee notified the Agency [State of Texas] that a 1.78 curie Cesium (Cs)-137 sources, and a 10.8 millicurie California (Cf) -252 source was lost in transport. The sources were picked up by a common carrier on October 14, 2009, for delivery to their facility in Oklahoma City, Oklahoma. At 1600 on October 15, 2009, the licensee was informed that the sources had not arrived in Oklahoma City. The RSO contacted the shipper and was informed that they believed that the sources had been placed on a truck going to Albuquerque, New Mexico. At about 3:00 AM on October 16, 2009, the licensee was notified that the sources were not on the truck going to Albuquerque. The shipper stated that they would contact all of their facilities (290 of them) to look for the packages. The Cs-137 source is in a container that weighs 320 pounds and labeled as Yellow II with a TI of 0.2. The Cf-252 source is in a container that weighs 185 pounds, is labeled as a Yellow II and a TI of 0.6. The RSO went to the shippers facility in Houston and searched for the packages. He did not find them. The shipper will contact the licensee as soon as the sources are located. The license will provide additional information as it is received."

The State of Oklahoma was informed of the missing shipment.

Texas Incident No.: I-8679

* * * UPDATE AT 1951 EDT ON 10/16/09 FROM ART TUCKER TO S. SANDIN * * *

The following update was received from the State of Texas via email:

"On October 16, 2009, at 1715 CT, the licensee contacted the Agency and informed them that at 1657 CT, the licensee was contacted by the shipping company and informed that the two sources had been located at their facility in Kansas City, Mo. The shipping company will deliver the sources to the licensee's facility in Oklahoma City on October 17, 2009."

Notified R4DO (Cain) and FSME EO (Delligatti).

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

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Fuel Cycle Facility Event Number: 45446
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: JENNIFER WHEELER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/19/2009
Notification Time: 17:00 [ET]
Event Date: 10/13/2009
Event Time: [EDT]
Last Update Date: 10/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
RANDY MUSSER (R2DO)
JANE MARSHALL (NMSS)
FUELS OUO GROUP ()

Event Text

NITROUS OXIDE (NOx) GENERATION RATE HIGHER THAN EXPECTED AFTER ALUMINUM FINES WERE INTRODUCED

"Bldg 333's U-Aluminum Bowl Cleaning system is designed to remove uranium from centrifuge bowls by circulating nitric acid through the bowls. The system has historically produced NOx (nitrous oxide, etc) during the nitric acid dissolution process. Safety controls designated as Items Relied On For Safety (IROFS) include a NOx detection system (IROFS BPF-43) with sensors located at the nitric acid knockout column's siphon break potential NOx release point if process ventilation fails and at employee working level.

"On October 13, 2009, NFS began using the Bowl Cleaning system to dissolve U-Al fines (very small particles of U-AI) rather than adding them to the normal dissolver column. The fines were loaded into strainers and placed directly into the bowls to be dissolved with nitric acid. After the dissolution process began, the Operator noticed that the temperature of the system was increasing and that NOx (in the form of a brown cloud) was beginning to form inside the Bowl Cleaning station containment vessels. The system was shutdown. The NOx detector designated as an IROFS alarmed and the facility was evacuated. Immediate corrective actions included building, and health and safety personnel re-entry in SCBA to validate shutdown conditions and remote monitoring of NOx levels in Bldg 333. Based on re-entry data and remote NOx detector readings, NOx levels inside the building (outside of containment) were not significant.

"Laboratory analysis of similar U-AI fines material was conducted October 14-October 16. It behaved in the laboratory in the same manner as what was observed during the operational event. Based on the lab testing, a NOx generation rate specific for the fines material was estimated. Based on engineering calculations, it was determined that the NOx generation for the fines was significantly higher than the previously analyzed NOx generation for the U-AI ingots. The previous Nox evaluation for the U-Al Bowl Cleaning station resulted in an intermediate occupational consequence. Using the generation rate specific for the fines results in high occupational consequences.

"On October 19, 2009, based on the revised Nox generation rate, it was determined that insufficient lROFS were in place and that the performance criteria of 10 CFR 70.61 were not met.

"a) Radiological Hazards involved including: High- enrichment Uranium: quantity Approx 1,000 g; Isotope: U-235 quantity Approx 710 g

"b) Chemical Hazards involved including: Chemical: Nox gas; Quantity: Approx. 1.85 lbs.

"c) Discuss the actual or potential health and safety consequences to the workers, the public, and the environment, including relevant chemical and radiation data for actual personnel exposures to radiation or radioactive materials or hazardous chemicals produced from licensed materials. Include in the discussion below the concentration of chemicals and duration of exposure, if any: Potential worker and public exposure to Nox. Process ventilation and Nox detection worked as designed. No actual exposure to workers or the public were recorded.

"d) Discuss the sequence of occurrences leading to the event, including degradation or failure of structures, systems, equipment, components and activities of personnel relied on to prevent potential accidents or mitigate their consequences: See above.

"e) Discuss whether the remaining structures, systems, equipment components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences are available and reliable to perform their function: IROFS BPF-43 is in place and functioned correctly during the event. Operating personnel responded to the alarm as specified in the operating procedure and evacuated the facility.

"External conditions affecting the event: None.

"Additional actions taken in response to the event: Discussed situation with Operations, Safety management and with the NRC Resident Inspector. The U-Al Bowl Cleaning system is currently not operating."

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Power Reactor Event Number: 45452
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL BRILL
HQ OPS Officer: VINCE KLCO
Notification Date: 10/21/2009
Notification Time: 21:21 [ET]
Event Date: 10/21/2009
Event Time: [EDT]
Last Update Date: 10/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JAY HENSON (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 28 Power Operation 28 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY NON-LICENSED SUPERVISOR

A non-licensed contractor supervisor refused to take a random drug and alcohol test. The individual's unescorted access was immediately terminated and the individual removed from the site.

Contact the HOO for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45453
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVE DEES
HQ OPS Officer: VINCE KLCO
Notification Date: 10/21/2009
Notification Time: 21:29 [ET]
Event Date: 10/21/2009
Event Time: 17:55 [CDT]
Last Update Date: 10/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NEIL OKEEFE (R4DO)
BRIAN McDERMOTT (IRD)
SAMSON LEE (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

FATALITY AND TRANSPORT OF A POTENTIALLY CONTAMINATED INDIVIDUAL OFFISTE

"At approximately 1755 CDT on 10/21/09, control room personnel were notified of a potentially contaminated individual suffering from a personal medical emergency inside the containment building. The individual was treated by the onsite first responders who administered CPR and AED (Automatic External Defibrillator). At 1816 [CDT], Coffey County medical personnel arrived on site. The individual was transported via ambulance to the Coffey County Hospital where the individual was pronounced dead at approximately 1900 [CDT] from an apparent cardiac arrest. A WCNOC [Wolf Creek Nuclear Operating Corp.] health physics technician accompanied the individual to the hospital and determined that the individual was not contaminated. The individual was a supplemental employee supporting refueling activities.

"OSHA will be notified of the work place fatality. State and Local Government Agencies will be notified. No news release is planned."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45454
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICH KRESS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/21/2009
Notification Time: 23:39 [ET]
Event Date: 10/22/2009
Event Time: 00:01 [EDT]
Last Update Date: 10/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (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

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR VENTILATION SYSTEM AND CHARCOAL FILTER MAINTENANCE

"At 00:01 on Thursday, October 22, 2009, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) ventilation system air conditioning and filtration systems will be removed from service for a scheduled maintenance activity. The Motor Control Center providing electrical power to several TSC ventilation components will be de-energized to facilitate replacement of the U1 CD Emergency Diesel Generator room ventilation supply fan starter (1-88X-DGS-2).

"Under certain accident conditions the TSC may become unavailable due to the inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary based upon results of procedurally required monitoring of TSC radiological conditions.

"The TSC ventilation system availability is scheduled to be restored at 08:00 on Thursday, October 22, 2009.

"The licensee has notified the NRC Resident Inspector.

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

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