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Event Notification Report for November 13, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/12/2009 - 11/13/2009

** EVENT NUMBERS **


45485 45486 45491 45492 45493 45494

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General Information or Other Event Number: 45485
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: KY-202-148-26
Agreement: Y
Docket:
NRC Notified By: ANGELA SHARYOCK
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/09/2009
Notification Time: 10:50 [ET]
Event Date: 08/28/2009
Event Time: [CST]
Last Update Date: 11/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY PATIENT RECEIVED MORE THAN PRESCRIBED DOSE

The following information was received via NMED report #090706:

"Hardin Memorial Hospital reported that a patient received 26.9% more dose than prescribed during prostate seed implant procedure on 8/28/09. The patient received I-125 brachytherapy seeds with a total activity of 1.26 GBq (34.054 mCi) instead of the prescribed 0.99 GBq (26.825 mCi). It is believed that the medical physicist calculated dose to the prostate using air kerma instead of milliCurie. All physicians and the patient have been notified of the mistake."

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: 45486
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON DICKINSON INFUSION THERAPY SYSTEMS INC
Region: 4
City: BROKEN BOW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: JIM DEFRAIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/09/2009
Notification Time: 16:54 [ET]
Event Date: 11/07/2009
Event Time: [CST]
Last Update Date: 11/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR SAFETY INTERLOCKS BYPASSED

A fuse blew during operation of an irradiator facility in Broken Bow, NE. This affected: the source up or down indication, the roof plug switch, the high temperature sensor, and the source movement light. The system could not be reset manually with the key. To verify the source was in the shielded position, an operator was sent to the roof and verified that there was no slack in the cables and the position of the cables indicated the source was in the shielded position. The interlocks were bypassed and an operator entered the cell. It was determined that there was a blown fuse and faulty wiring which were replaced. Operators did not receive any radiation dose from this event.

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Fuel Cycle Facility Event Number: 45491
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: JOE O'HARA
Notification Date: 11/12/2009
Notification Time: 11:47 [ET]
Event Date: 11/11/2009
Event Time: 15:00 [EST]
Last Update Date: 11/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
MARK LESSER (R2DO)
E. WILLIAM BRACH (NMSS)

Event Text

INCOMPLETE DOCUMENTATION OF CRITICALITY SAFETY CONTROLS IN INTEGRATED SAFETY ANALYSIS SUMMARY

"During a GNF-A ongoing review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), it was discovered at 3pm yesterday (11/11/09) that there may be an incomplete list of criticality safety controls associated with the Pellet and Rod Load Fabrication areas in the ISA Summary.

"At 7pm, it was determined that the list of Items Relied On For Safety (IROFS) was incomplete and the affected equipment was shut down pending revision of the ISA to document IROFS for these processes. Notwithstanding the documentation deficiency, the controls associated with moderator intrusion and geometry remained in place, functional, and maintained with appropriate management controls.

"While this discovery did not result in an unsafe condition, it is being reported on 11/12/09 pursuant to the reporting requirements of 10CFR70 Appendix A(b)(1) within 24 hours.

"Safety Significance of Events: Low safety significance - All process criticality safety controls remained intact and functioning for this processes.

"Safety Equipment Status: Pellet and Fuel Load fabrication areas are shutdown and will remain shutdown until the ISA review is completed.

"Status of Corrective Actions: Pellet and Rod Load Fabrication areas will remain shutdown pending final investigation results and identification of additional IROFS."

The licensee notified NRC Region 2 Inspector (Crespo) and will notify state and local authorities.

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Fuel Cycle Facility Event Number: 45492
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: ROBERT MAGLASANG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/12/2009
Notification Time: 16:09 [ET]
Event Date: 11/12/2009
Event Time: 11:15 [CST]
Last Update Date: 11/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
MARK LESSER (R2DO)
E. WILLIAM BRACH (NMSS)

Event Text

VIOLATION OF A NUCLEAR CRITICALITY SAFETY CONTROL

"At 1115 CST on 11/12/09, abandoned cell piping was reported in C-331 and C-335 cell housings. The 16-inch abandoned piping is from the cell recycle line that was replaced in the mid 1970s. NCS [Nuclear Criticality Safety] controls require that equipment openings with unknown uranium deposits shall be covered with water-proof covers that are fire resistant. Since the piping contains an unknown uranium mass, and was discovered without water-proof covers, the NCS control was violated.

"Since moderation is the primary criticality control, and where double contingency cannot be re-established within 4 hours, this is being reported to the NRC as a 4-hour Event Report in accordance with NRC BL 91-01 Supplement 1.

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

"PGDP Problem Report No. ATRC-09-2781; PGDP Event Report No. PAD-2009-19.

"Safety significance of events: Although the NCS control to cover the pipe openings was violated, it was not exposed to a liquid moderator. The geometry of the pipe is safe for a maximum enrichment that may be in the pipe. During the plant modifications that replaced the cell recycle lines, the maximum plant enrichment was 2.0 wt. % U235. There are no indications, based on quarterly NDA scans, that the piping contains greater than a safe mass of uranium. Therefore, the safety significance of the event is low.

"Potential criticality pathways involved: The maximum plant enrichment at the time the piping was in operation was a maximum 2.0 wt. % U235. The piping is contained in housing without fire suppression. The single parameter pipe diameter for that enrichment is greater than 16 inches. In order for a criticality to be possible, the pipe would have to contain greater than a critical mass. A large amount of moderator would have to enter the horizontal pipe opening. Greater than a critical mass would then have to be washed from the pipe due to the unlikely moderator release at the pipe opening. The washed material would then have to accumulate in an unsafe geometry.

"Controlled parameters: Moderation.

"Estimated amount, enrichment, form of licensed material: The assay of any material is less than or equal to 2.00 wt. % U235.

"Nuclear Criticality safety control(s) or control systems(s) and description of the failures or deficiencies: The first leg of double contingency relies on control of moderation. Moderator intrusion associated with sprinkler activation is controlled by limiting fire sprinkler head activation temperatures at the ceiling and bypass heights. The analysis also determined that significant moderator intrusion into open fissile piping due to inadvertent spills, RCW/oil line leaks, or other mechanism is unlikely. These controls were not violated and an unlikely moderator release event has not occurred at the pipe opening. The second leg of double contingency is also based on moderation. Piping exceeding 10.25 inches that contains an unknown or greater than safe mass deposit is required to have openings covered with fire resistant waterproof covers. Since the piping is nominal 16 inches in diameter, contains an unknown uranium mass, the NCS control was violated. Since the openings are not covered resulting in a loss of NCS control and there are two controls on one parameter, the process condition was not maintained.

"Corrective actions to restore safety systems and when each was implemented: Control access to the area. Exempt the pipe from NCS controls based on enrichment determination, cover the pipe openings, or quantify the uranium mass in the pipe."

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Power Reactor Event Number: 45493
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHOENSTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/12/2009
Notification Time: 22:00 [ET]
Event Date: 11/12/2009
Event Time: 19:00 [EST]
Last Update Date: 11/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK LESSER (R2DO)

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

Event Text

NOTIFICATION TO US COAST GUARD AND COMMONWEALTH OF VIRGINIA OF HAZARD TO NAVIGATION

"Surry Power Station maintenance activities at the James River intake structure were supported with a barge from Crofton Industries using stop logs (referred to as caissons, each with dimensions of 24'x6'x3'and weighing 11,000 pounds empty) to seal water ingress into intake bays. On November 12, 2009, due to the potential for damage from high winds and tide, the barge and four of the caissons were towed by tug boat from the intake structure, across the James River, to Fort Eustis. At 1650 hours, mid-way across the river, one of the caissons broke free from the tug. The tug operator attempted to secure the partially submerged caisson, but was unsuccessful. The tug operator noted the location and completed the transfer of the barge and caissons to Fort Eustis.

"At approximately 1900 hours, Crofton Industries informed Surry Power Station that in accordance with the Marine Safety Office Notification Procedure, they communicated with the US Coast Guard, notifying them of the incident and the approximate location of the caisson. In addition, at 2030 hours, Surry made a courtesy notification of the incident to the Virginia Department of Emergency Services. This report is being submitted due to the notification of other government agencies under 10CFR50.72(b)(2)(xi). In addition, the Site NRC Resident was also notified of this event."

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Power Reactor Event Number: 45494
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOE BENNETT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/12/2009
Notification Time: 22:36 [ET]
Event Date: 11/12/2009
Event Time: 17:11 [CST]
Last Update Date: 11/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK LESSER (R2DO)

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

Event Text

HPCI INOPERABLE DUE TO EXCESSIVE WATER IN STEAM DRAIN

"The HPCI [High Pressure Coolant Injection] system was declared inoperable after completion of a scheduled surveillance due to an excessive amount of water in the turbine exhaust line. The line was being drained in response to the alarm 'HPCI TURB EXH DRAIN POT LEVEL HIGH', indicating that there was a high level in a drain pot attached to the turbine exhaust line. An investigation is in progress to determine the source of the water in the turbine exhaust line.

"This event is reportable within 8 hours in accordance with 10CFR 50.72(b)(3)(v) as an event or condition that at the time of discovery could have prevented the fulfillment of a safety function. It also requires a 60 day written report in accordance with 10CFR 50.73(a)(2)(vii)

"The NRC Resident Inspector has been notified.

"SR number associated with this report: 91546."

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