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Event Notification Report for November 23, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/20/2009 - 11/23/2009

** EVENT NUMBERS **


45502 45506 45507 45508 45512 45513 45514 45515

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General Information or Other Event Number: 45502
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON COMMUNITY HOSPITAL
Region: 1
City: BOCA RATON State: FL
County:
License #: 0550-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/17/2009
Notification Time: 13:50 [ET]
Event Date: 10/26/2009
Event Time: [EST]
Last Update Date: 11/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND MCKINLEY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via facsimile:

"Patient liver is being treated by thera sphere procedure. First dose was intended to be for left lobe but was delivered to right lobe on 10/26/09. The second treatment was going to be for the right lobe. The window for the right lobe dose was 90-115 grays, but what actually delivered was 18-51 % low. Error was discovered 10/30/09. The patient will be retreated to bring dose up to required level. The patient and doctor have been notified. In the future the radiologist will submit a written statement on the treatment to be preformed before it is accomplished. Licensee will submit a written report. No further action will be taken on this incident."

Source: 1.27 GBq Y-90

Florida Incident: FL09-077

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: 45506
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MEADWEST VACO
Region: 4
City: EVADALE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 13:52 [ET]
Event Date: 04/12/2007
Event Time: [CST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE SHUTTER FAILURE

The following report was received via e-mail:

"On April 19, 2007, the Agency was notified of a generally licensed device malfunction. The general licensee reported that the 'on-off' shutter mechanism failed on a frame beta gauge, designed for measuring mass per unit area of thickness of sheet material. The device was removed from operation, repaired, and put back into operation. The failure was determined to be caused by the lack of maintenance on the device.

"The device is a General License device, a Frame Beta Gauge, Model BG-V, serial no. 940331001, with two Krypton-85 sources of 0.2 Ci each, Model KAC.D3, serial no's. KS429 and KS430."

Texas Incident: I-8408

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General Information or Other Event Number: 45507
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: JAMES HARDIE BUILDING PRODUCTS INC
Region: 4
City: CLEBURNE State: TX
County:
License #: 02040
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 14:46 [ET]
Event Date: 10/15/2007
Event Time: [CST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER STUCK IN OPEN POSITION

The following report was received via e-mail:

"On November 26, 2007, the Agency received a letter from the licensee notifying them that while conducting a routine inventory and shutter inspection of a density gauge, the shutter was found stuck in the open position. The licensee contacted a vendor to repair the gauge. The vendor determined that a bolt on the shutter had broken preventing the shutter from closing. The shutter could not be repaired. The shutter is normally open so there was no increased risk of additional radiation exposure to the workers at the facility. A new device was ordered and the old gauge was disposed of when the new one was installed.

"The gauge was an Ohmart/VEGA Corporation model SH-F1, serial number 8622 K containing a 50 milliCurie Cesium (Cs) - 137 source."

Texas Incident: I-8456

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General Information or Other Event Number: 45508
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CRYOVAC INC
Region:
City:  State:
County:
License #: 01736
Agreement: N
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 15:09 [ET]
Event Date: 12/12/2007
Event Time: [EST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - BACKSCATTER PROBE READING ERRATICALLY

The following report was received via e-mail:

"On December 14, 2008, the Agency received notification that while restarting the line production the operator noted that a NDC model 103 backscatter probe was reading erratically. An operator standing on the first leveled looking up at the probe, which was located on the second level thought he saw a piece of tape on the end of the probe. Upon closer inspection, the operator believed that the probe had been damaged and requested assistance. The facility Radiation Safety Officer had the area around the probe evacuated. Further investigation determined that the probe shutter was in the closed position. The probe was removed by the facilities Hazardous Material Team and placed in a locked storage location. A technician from the manufacturer inspected the probe and determined that the shutter mechanism was operating properly. He removed the shutter and installed it on a spare probe. The old probe was sent to the manufacturer for inspection and repair. The manufacturer inspected the probe and performed a leak test of the source. The source did not appear to have been damaged, and the leak test results were satisfactory. The probe was returned to the facility after some routine repairs."

Texas Incident: I-8463

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Power Reactor Event Number: 45512
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREGG MILLER
HQ OPS Officer: VINCE KLCO
Notification Date: 11/21/2009
Notification Time: 05:58 [ET]
Event Date: 11/21/2009
Event Time: 05:00 [EST]
Last Update Date: 11/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)

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

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED ELECTRICAL MAINTENANCE

"On November 21, 2009, Fermi 2 [removed] the Technical Support Center (TSC) from operation to facilitate maintenance on the facilities' 480-volt AC power supply. This work affects TSC lighting, computers, and ventilation. During this work, which is expected to last over 8 hours, the TSC will be unavailable. In the event TSC activation is necessary, the Emergency Operations Facility (EOF) will be used for the TSC function. Activation and use of the EOF as a backup for the TSC is included in Fermi 2's Radiological Emergency Response Preparedness Plan. The Emergency Call Out System (ECOS) is designed to facilitate contacting TSC personnel to respond directly to the EOF in the event of an emergency. Fermi 2 is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). Fermi 2 will notify the NRC upon completion of this work. Fermi 2 will notify the NRC Resident Inspector."

* * * UPDATE FROM GREG MILLER TO VINCE KLCO ON 11/22/2009 AT 0036 EST * * *

The planned maintenance has been completed and the TSC has been restored as an Emergency Response Facility.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 45513
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: GEOFFREY HILL
HQ OPS Officer: PETE SNYDER
Notification Date: 11/21/2009
Notification Time: 16:02 [ET]
Event Date: 11/21/2009
Event Time: [EST]
Last Update Date: 11/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JONATHAN BARTLEY (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 OF RESCUE SQUAD FOR OFFSITE INJURY OF HUNTERS

"On 11/21/2009 at 14:27, two individuals arrived at the Surry Power Station Security Checkpoint with an accidental gun shot victim. The three individuals were hunting approximately one mile offsite when one individual was accidentally struck by gun fire. The other two individuals transported the injured individual to the Security Checkpoint at the station. Station personnel contacted the local Sheriff's Department, local Volunteer Rescue Squad, Virginia State Police, and Air Ambulance for assistance. Wounds do not appear to be life threatening, and the individual is being transported offsite via Air Ambulance.

"The site NRC Resident has been notified.

"This notification is being transmitted due to notification of other Government Agencies in accordance with 10CFR50.72(b)(2)(xi)."

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Power Reactor Event Number: 45514
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: ROGER BARNES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2009
Notification Time: 01:13 [ET]
Event Date: 11/21/2009
Event Time: 22:45 [EST]
Last Update Date: 11/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAYMOND MCKINLEY (R1DO)
SAMSON LEE (NRR)
SAM COLLINS (R1 R)
JOHN GROBE (NRR)
MICHAEL JOHNSON (EDO)
BRIAN McDERMOTT (IRD)
COMM ASSTS BRIEFING ()

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

Event Text

RADIATION RELEASE IN CONTAINMENT ASSOCIATED WITH STEAM GENERATOR REMOVAL

"This event is being reported via the ENS to the NRC Operations Center within four hours after notifications were made to the Pennsylvania Emergency Management Agency and local counties for an event of potential public interest. This notification was made at 22:45 on November 21, 2009, after the occurrence of an event related to the safety and health of onsite personnel for which a press release has been made. The press release was made following the event of potential public interest notifications. This report is being made under 10 CFR 72.75(b)(2).

"At approximately 16:00 on Saturday November 21, 2009, low levels of radiation activity were measured on radiation monitors installed in the TMI-1 reactor building. Personnel were directed to immediately leave the reactor building until the source of the activity could be identified. Surveys directly outside of the reactor building construction opening indicated a slight increase in activity. Levels have returned to normal. No contamination was identified outside of the reactor building. Approximately 150 workers were monitored for exposure to the radiation activity. No worker approached or exceeded any exposure limits. The sources of the activity are believed to be from maintenance tasks related to cutting lines in preparation for removal of the 'B' Steam Generator."

The licensee is still investigating the cause of the event but indicated that the radiation release is no longer in progress. Containment Ventilation is established to provide an inflow into containment to the extent possible (considering the openings in containment).

The licensee contacted state and local authorities and the Pennsylvania Emergency Management Agency (PEMA). The licensee notified the NRC Resident Inspector. The licensee has also issued a press release.

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Power Reactor Event Number: 45515
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: BOB WILLIAMSON
HQ OPS Officer: PETE SNYDER
Notification Date: 11/22/2009
Notification Time: 16:31 [ET]
Event Date: 11/22/2009
Event Time: 16:00 [EST]
Last Update Date: 11/22/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JONATHAN BARTLEY (R2DO)
LUIS REYES (R2)
ERIC LEEDS (NRR)
BRIAN McDERMOTT (IRD)
BILL ROPER (DHS)
WILLIAM BARDEN (FEMA)

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

Event Text

FIRE IN THE 1A SWITCHGEAR ROOM

The licensee declared a Notice of Unusual Event (NOUE) condition onsite per Emergency Action Level HU2.1 'Fire within the Protected Area not extinguished within 15 min. of detection or explosion within the Protected Area.'

The fire is in the [non-safety] 1A 7.2 kV switchgear room. Both Engineered Safety Features buses are being supplied by offsite power. The plant remains shutdown and stable in mode 5. Offsite assistance was called to fight the fire. The licensee confirmed the fire as extinguished at 1640 EST and is monitoring the area.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM WILLIAMSON TO SNYDER AT 1906 ON 11/22/09 * * *

The licensee terminated the NOUE at 1855 EST. Upon inspection of the area the licensee noted that 3 areas of non-safety switchgear were affected. Offsite assistance was used in fighting the fires and has since been released.

Notified R2DO (Bartley), NRR EO (Lee), IRD (McDermott), DHS (Vestal), and FEMA (Burckhardt).

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