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Event Notification Report for September 15, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/14/2011 - 09/15/2011

** EVENT NUMBERS **


47248 47254 47265 47268

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Fuel Cycle Facility Event Number: 47248
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: JOHN CARTER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/07/2011
Notification Time: 13:12 [ET]
Event Date: 09/07/2011
Event Time: [EDT]
Last Update Date: 09/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DANIEL RICH (R2DO)
FUELS OUO GROUP ()
ABY MOHSENI (NMSS)

Event Text

FITNESS FOR DUTY REPORT RELATED TO INTRODUCTION OF ALCOHOL INTO PROTECTED AREA

The licensee reported a fitness-for-duty violation due to an employee who inadvertently brought alcohol into the protected area. The violation was self-reported by the individual involved. The employee is being tested under the FFD program and his access has been denied pending outcome of an investigation. Contact the HOO for additional details

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Agreement State Event Number: 47254
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS REGIONAL CANCER CENTER
Region: 3
City: WASAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: MARK PAULSON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2011
Notification Time: 16:26 [ET]
Event Date: 09/07/2011
Event Time: 12:00 [CDT]
Last Update Date: 09/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN UNDERDOSAGE

"Wisconsin Department of Health Services (DHS) received notification by phone call from the licensee on September 8, 2011 about a medical event involving I-125 permanent prostate seed implants. During a standard review conducted September 7, 2011 of a post seed implant report the Authorized Medical Physicist determined that the dose delivered differed from the prescribed dose by 20% or more. Specifically it was found that only 76% (110 Gy) of the prescribed dose was delivered to 90% of the CTV for an implant completed on July 22, 2011. The licensee had established the dose based criteria that by post-operation CT, prostate D90 values are < 80% or >130% for classifying medical events. The licensee has notified the Authorized User, referring physician and will notify the patient during a scheduled examine the week of September 11, 2011. There is no expected immediate harm to the patient and the Authorized User and referring physician will discuss with the patient to determine if supplemental radiation (implant or external beam) will be done. DHS conducted an investigating of this medical event on September 9, 2011 by sending a special inspection team. The preliminarily conclusion after reviewing the licensee's procedures and discussion with the Authorized User and Authorized Medical Physicist is that the under dose was directly caused by edema of the prostate, i.e. post implant procedure swelling."

Wisconsin Event Number: WI110014

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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Fuel Cycle Facility Event Number: 47265
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 P. MURRAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/14/2011
Notification Time: 13:32 [ET]
Event Date: 09/13/2011
Event Time: 14:45 [EDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
EUGENE GUTHRIE (R2DO)
TIM MCCARTIN (NMSS)

Event Text

24-HOUR REPORT INVOLVING POTENTIAL FAILURE TO MAINTAIN DOUBLE CONTINGENCY CRITERIA

"As part of the ongoing GNF-A Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA) project, reviews of documentation for scrap accumulation hoods were performed that identified procedural actions that were different than described in the criticality safety analysis. It was determined at approximately 2:45 PM on September 13, 2011 that uranium mixed with small amounts of moderator were not prevented from movement into these hoods. This resulted in a condition where the moderation criticality control documented as being necessary to meet double contingency may not have been maintained. The other criticality control on geometry was maintained at all times.

"At no time was an unsafe condition present, however the accumulation hoods were shut down until necessary controls were available. Additional corrective actions and extent of condition are being evaluated.

"This event is being conservatively reported pursuant to GNF-A internal procedure reporting requirements within 24 hours of discovery."

The licensee will inform state and local agencies and the NRC Region II Office of this incident.

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Power Reactor Event Number: 47268
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DANIEL HAUTALA
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/14/2011
Notification Time: 18:15 [ET]
Event Date: 09/14/2011
Event Time: 10:23 [MST]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG PICK (R4DO)

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
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF TWO PUBLIC WARNING SYSTEM SIRENS

"On September 12, 2011, the Palo Verde Emergency Preparedness Department discovered that public warning system siren 1 was not responding and was out of service. The loss of this siren did not constitute a loss of capability to alert a large segment of the population for greater than one hour and was therefore, not reported. Troubleshooting had commenced but was not completed. On September 14, 2011, at 1023 Mountain Standard Time, the Palo Verde Emergency Preparedness Department was notified by Maricopa County Sheriff's Office (MCSO) that siren 6 had failed. Since siren 1 remains out of service pending repairs, and siren 6 is now out of service, the loss of the two sirens constitutes a loss of capability to alert a large segment of the population for greater than one hour and is reportable. This is a reportable event as a loss of communication and assessment capability that could potentially impact a population of greater than 10 percent of the people in the 10-mile emergency planning zone (approximately 750 people affected). Therefore, this notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii).

"If an event occurs while the sirens are out of service, the Palo Verde Emergency Plan has a contingency for dispatching MCSO vehicles with loudspeakers to alert persons within the affected area. The MCSO is prepared to implement this contingency should it become necessary.

"Troubleshooting to determine the cause of the failure of siren 6 has also commenced.

"The NRC Resident Inspector has been notified of the out of service sirens and this ENS call."

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