Event Notification Report for November 16, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/13/2009 - 11/16/2009

** EVENT NUMBERS **


45485 45496 45498 45499

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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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Other Nuclear Material Event Number: 45496
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/13/2009
Notification Time: 10:30 [ET]
Event Date: 11/12/2009
Event Time: 15:30 [YST]
Last Update Date: 11/14/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JEFF CLARK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

FAILURE TO FULLY RETRACT THE SOURCE OF A RADIOGRAPHY CAMERA

Technicians were performing radiography at the Kuparuk Oil Field in Prudhoe Bay, Alaska when the source in an Industrial Nuclear Corporation (INC) IR-100 radiography camera, serial number 6643 was unable to be fully retracted. This was caused by a frozen lock on the device which occurred due to weather conditions of blowing snow and freezing rain. A certified technician serviced the lock. The lock was returned to fully functional condition and the source was returned to the safe and secure position. The device has a 101 Ci Ir-192 source. No personnel over exposures occurred.

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Power Reactor Event Number: 45498
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BRIEN STRIZZI
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/15/2009
Notification Time: 08:57 [ET]
Event Date: 11/15/2009
Event Time: 08:26 [EST]
Last Update Date: 11/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
DARRELL ROBERTS (R1)
JEFFERY GRANT (IRD)
SHER BAHADUR (NRR)
BRUCE BOGER (NRR)
TODD KUVIA (FEMA)
DWAIN KETTLES (DHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

UNIT 2 DECLARED AN UNUSUAL EVENT DUE TO A LOSS OF ANNUNCIATORS

At 0826 EST, Millstone Unit 2 declared a NOUE, due to a loss of power to the control room main board annunciators. Power was lost to the non-vital power supply, VR-11&21, during heater drain pump post maintenance testing, which caused the loss of power to the main control board annunciators. Charging and letdown systems are secured. Additional watchstanders were stationed during the annunciator outage. Power was restored to the main control board, and the licensee is in the process of terminating the NOUE. The NRC remained in Normal Mode.

The NRC Senior Resident Inspector has been notified. The State of Connecticut has been notified.

* * * NOTIFIED BY BRIEN STRIZZI TO DONG PARK AT 0922 EST ON 11/15/09 * * *

Millstone Unit 2 terminated the NOUE at 0859 EST after power was restored to the main control board annunciator.

Notified R1DO (Cahill), R1RA (Roberts), IRD MOC (Grant), NRR ET (Boger), NRR EO (Bahadur).
The NRC Senior Resident Inspector has been notified. The State of Connecticut has been notified as well as DHS and FEMA.

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Power Reactor Event Number: 45499
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: LEWIS ROGERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/16/2009
Notification Time: 02:24 [ET]
Event Date: 11/15/2009
Event Time: 22:42 [EST]
Last Update Date: 11/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK LESSER (R2DO)

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

Event Text

MANUAL REACTOR TRIP DUE TO MAIN GENERATOR OIL LEAK

"At 2242 [EST] on 11/15/09, the reactor was manually scrammed from 100% power due to a large oil leak on the main generator seal oil system. Condenser vacuum was broken immediately following the reactor trip, and the main turbine stopped rotating at 2324 [EST]. Following the reactor trip, the 'B' steam generator Main Steam Isolation Valve (MSIV) failed to fully close on demand, but was closed due to field actions at 2303 [EST]. The reactor remained stable at NOP/NOT following the reactor trip. Offsite power remained available throughout the event.

"This condition is being reported as actuation of the reactor protection system in accordance with 10CFR 50.72(b)(2)(iv)(B)."

All control rods fully inserted and decay heat is being removed through the S/G relief valves to the atmospheric dumps. No known primary to secondary leakage exists. The plant remains stable in Mode 3.

The licensee notified the NRC Resident Inspector.

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