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Event Notification Report for January 21, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/20/2010 - 01/21/2010

** EVENT NUMBERS **


45630 45633 45634 45638 45641

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Hospital Event Number: 45630
Rep Org: QHG OF INDIANA
Licensee: QHG OF INDIANA
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01535-01
Agreement: N
Docket:
NRC Notified By: THOMAS M. KUMPURIS
HQ OPS Officer: JOE O'HARA
Notification Date: 01/14/2010
Notification Time: 16:00 [ET]
Event Date: 01/14/2010
Event Time: 14:00 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
ROBERT LEWIS (FSME)

Event Text

INCORRECT DOSE ADMINISTERED TO PATIENT

Two patients were to receive hyper thyroid therapy on 1/14/10, and the hospital prepared written directives for each patient. One patient was prescribed 25 milliCurie of I-131. The second patient was prescribed 30 milliCurie of I-131. The first patient arrived and the technician assayed and administered the 30 milliCurie dose for the patient who was to receive 25 milliCurie. The tech administered 31.4 milliCurie to the patient. This is a 25.6% difference than prescribed in the written directive for the patient. The patient and prescribing physician have not been informed. The hospital does not believe there is any long term medical consequence to the patient. The hospital management team is reviewing protocols to prevent recurrence of this event.

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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Power Reactor Event Number: 45633
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/18/2010
Notification Time: 23:03 [ET]
Event Date: 01/18/2010
Event Time: 15:00 [CST]
Last Update Date: 01/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTINE LIPA (R3DO)
CANADA VIA FAX ()
WILLIAM RULAND (NRR)
ROBERT LEWIS (FSME)
This material event contains a "Less than Cat 3" level of radioactive material.

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

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

Event Text

MISSING RADIOACTIVE SOURCES GREATER THAN 10 TIMES THE LIMIT

"In 2009, a radioactive source inventory was conducted by a Prairie Island Radiation Protection Specialist. During the inventory, it was determined that two sources were missing that are greater than 10 times the quantity specified in 10CFR20 Appendix C. These two sources include a 0.07 [micro]Ci U-234 radiation monitor detector and a 0.2 [micro]Ci mixed gamma standard that contains 0.09 [micro]Ci of Am-241 (a 60 ml vial used for HPGe calibration.) The U-234 source is normally stored in the Hot I&C Shop and the mixed gamma standard with Am-241 is normally stored in the Hot Chemistry Lab. The inventory, that concluded on December 18, 2009, listed these sources as lost. Four other sources, that do not exceed 10 times any quantity specified in 10CFR20 Appendix C, were also unaccounted for during this inventory. Radiation Protection is still in the process of locating the missing sources that were identified during this inventory."

The licensee will provide information on the four other sources to the Operations Center on 1/19/2010.

The licensee has informed the NRC Resident Inspector.

* * * UPDATE FROM STEVE INGALLS TO DONG PARK @ 1547 EST ON 01/19/10 * * *

"The four sources that do not exceed 10 times any quantity specified in 10CFR20 Appendix C:

"Isotope Ci Content
"C-14 TLD check source 0.5 [micro]Ci
"Cs-137 check source 8.8 [nano]Ci
"mixed gamma calibration source 1.9 [micro]Ci
"mixed gamma calibration source 2.0 [micro]Ci

"The 2.0 [micro]Ci mixed gamma source (previously reported as 0.2 [micro]Ci) that contains 0.09 [micro]Ci of Am-241(60 ml vial used for HPGe calibration) has been located in the Hot Chemistry Lab. Investigation into the five remaining sources continues."

The licensee has informed the NRC Resident Inspector.

Notified R3DO (Pelke), NRR EO (Cunningham), FSME EO (Camper), and Canada via fax.

* * * UPDATE FROM JOHN KEMPKES TO VINCE KLCO @ 2039 EST ON 01/20/10 * * *

"Current status update on the sources that exceed 10 times any quantity specified in 10CFR20 Appendix C:

"The 2.0 [micro]Ci mixed gamma source - located and properly stored. The source was within the controlled area. (Previously reported)

"The 0.07 [micro]Ci U-234 radiation monitor detector - installed in Containment (located by maintenance documentation review). (Previously reported)

"While conducting a verification of all sources, a different 0.07 [micro] Ci U-234 radiation monitor detector was discovered to be missing. This detector is the same design as the originally reported U-234 detector but a different serial number. (New item)

"The station has completed a verification of all sources; the results are undergoing management review. Search for the missing sources continues.

"The Resident Inspector has been notified."

Notified R3DO (Pelke), NRR EO (Cunningham), FSME (Camper), and Canada via fax.

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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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Power Reactor Event Number: 45634
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: GEOFF COOK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/18/2010
Notification Time: 23:43 [ET]
Event Date: 01/18/2010
Event Time: 19:50 [PST]
Last Update Date: 01/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (R4DO)
ROBERT KAHLER (NSIR)

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

Event Text

EMERGENCY OPERATIONS FACILITY INACCESSIBLE DUE TO ROAD FLOODING

"On January 18, 2010, at about 1950 PST, the access road to the SONGS MESA facilities became flooded after a day of rain. The San Onofre Emergency Operations Facility (EOF) is located at the MESA and because of the flooding, is inaccessible to passenger vehicles. While the EOF itself is operable, in the event of an emergency at San Onofre, SCE [Southern California Edison] would direct EOF emergency responders to the alternate EOF located in Irvine, California. SCE is reporting this occurrence to the NRC in accordance with 10CFR50.72(b)(3)(xiii).

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement outage and Unit 3 was operating at about 100% power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

* * * UPDATE FROM GEOFF COOK TO DONG PARK @ 1208 EST ON 01/19/10 * * *

"On January 18, 2010 at about 2101 PST, the MESA road flooding had dissipated sufficiently for car traffic to be passable. In the event of an emergency at San Onofre, there is no longer a need to redirect emergency responders to the alternate EOF located in Irvine, California. This report is to advise the NRC of this change in EOF access status. Also note that it is expected that rain will continue in the SONGS area during the week of January 17, 2010 and this status is subject to change.

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement Outage and Unit 3 was operating at about 100% power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

Notified R4DO (Werner) and NSIR (Kahler).

* * * UPDATE FROM GEOFF COOK TO PETE SNYDER @ 1232 EST ON 01/21/10 * * *

"On January 20, 2009, at about 2107 PST, the access road to the SONGS MESA facilities again became flooded after a day of rain (reference NRC Operations Log Number 45634). The San Onofre Emergency Operations Facility (EOF) is located at the MESA and because of the flooding, is inaccessible to passenger vehicles. While the EOF itself is operable, in the event of an Emergency at San Onofre, SCE would direct EOF emergency responders to the alternate EOF located in Irvine California. SCE is reporting this occurrence to the NRC in accordance with 10CFR50.72(b)(3)(xiii).

"At the time of this occurrence, Unit 2 was in a Steam Generator Replacement Outage and Unit 3 was operating at about 100% power. SCE will notify the NRC resident inspectors about this occurrence and will provide them with a copy of this report."

Notified R4DO (Werner) and NSIR/EP.

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Power Reactor Event Number: 45638
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN PACIOTTI
HQ OPS Officer: VINCE KLCO
Notification Date: 01/20/2010
Notification Time: 12:20 [ET]
Event Date: 12/16/2009
Event Time: 09:00 [EST]
Last Update Date: 01/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RONALD BELLAMY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation
2 N Y 94 Power Operation 94 Power Operation

Event Text

POSSESSION OF ALCOHOLIC BEVERAGE IN PROTECTED AREA

"At approximately 0900 on December 16, 2009, a PPL employee, located within the Susquehanna protected area, received a gift package from a vendor that contained a bottle of an alcoholic beverage. The individual immediately notified his supervision and Susquehanna Security personnel who took possession of the bottle. The bottle was still sealed with the original seal. The NRC [Resident Inspector] and Regional Security Inspectors were informed on the day of the event.

"The individual who received the package was a non-licensed employee.

"This event was originally not recognized as being reportable as a 24 hour call."

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Power Reactor Event Number: 45641
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/20/2010
Notification Time: 17:10 [ET]
Event Date: 01/20/2010
Event Time: 13:17 [CST]
Last Update Date: 01/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PATTY PELKE (R3DO)
MARK CUNNINGHAM (NRR)
WILLIAM GOTT (IRD)

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 Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE FIREFIGHTING ASSISTANCE FOR FIRE IN A NON-SAFEGUARDS DIESEL GENERATOR

"While testing, a fire occurred in the D3 Non-Safeguards Diesel Generator at 1317 [CST]. CO2 was applied and at 1337 [CST], the fire was extinguished. A re-flash occurred at 1413 [CST] requiring further fire brigade and fire department action and was extinguished at 1455 [CST].

"No injuries resulted from this fire and it was contained to the D3 Building. The D3 Building is not adjacent or contiguous to any vital areas, and therefore, entry into Emergency Action Levels was not required. This fire did not pose a threat to the safe operation of the plant.

"The Red Wing Fire Department was called and arrived on site to assist the plant fire brigade. This resulted in declaring a media sensitive event requiring government agency notifications, and therefore, the need for this report.

"The investigation of the cause and extent of damage is ongoing. The [NRC] Resident Inspector has been informed."

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