Event Notification Report for January 30, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/29/2014 - 01/30/2014
Power Reactor
Event Number: 49778
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMAN
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/30/2014
Notification Time: 19:03 [ET]
Event Date: 01/30/2014
Event Time: 13:20 [CST]
Last Update Date: 01/31/2014
Notification Time: 19:03 [ET]
Event Date: 01/30/2014
Event Time: 13:20 [CST]
Last Update Date: 01/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STUART SHELDON (R3DO)
STUART SHELDON (R3DO)
| 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 |
OFFSITE NOTIFICATION DUE TO INADVERTENT ACTIVATION OF ONE EMERGENCY SIREN
"One siren false actuation. At approximately 1415 CST on January 30, 2014, the licensee was notified of a false activation of emergency siren (G-14). The site contacted the siren vendor. It was determined that the siren had falsely actuated 5 to 6 times and has since been deactivated. The Goodhue County Sheriff's department received calls from some area residents. The siren remains out of service and is the only siren out of service within the 10 mile Emergency Planning Zone (EPZ). NRC Resident Inspector has been informed.''
* * * UPDATE FROM MARK LOOSBROCK TO HOWIE CROUCH AT 1743 EST ON 1/31/14 * * *
"Based upon further review, the event time of the false siren actuation was approximately 1320 CST. The previously reported event time of 1415 CST was the confirmation time of the siren vendor responding to the siren actuation. This does not represent a significant loss in emergency notification. The siren system has significant overlap between sirens. For any failed siren, backup methods are implemented per our emergency plan to ensure timely public notification."
The licensee notified the NRC Resident Inspector of this update. Notified R3DO (Sheldon).
"One siren false actuation. At approximately 1415 CST on January 30, 2014, the licensee was notified of a false activation of emergency siren (G-14). The site contacted the siren vendor. It was determined that the siren had falsely actuated 5 to 6 times and has since been deactivated. The Goodhue County Sheriff's department received calls from some area residents. The siren remains out of service and is the only siren out of service within the 10 mile Emergency Planning Zone (EPZ). NRC Resident Inspector has been informed.''
* * * UPDATE FROM MARK LOOSBROCK TO HOWIE CROUCH AT 1743 EST ON 1/31/14 * * *
"Based upon further review, the event time of the false siren actuation was approximately 1320 CST. The previously reported event time of 1415 CST was the confirmation time of the siren vendor responding to the siren actuation. This does not represent a significant loss in emergency notification. The siren system has significant overlap between sirens. For any failed siren, backup methods are implemented per our emergency plan to ensure timely public notification."
The licensee notified the NRC Resident Inspector of this update. Notified R3DO (Sheldon).
Agreement State
Event Number: 50150
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: CHARMA WARING
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: CHARMA WARING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/30/2014
Notification Time: 12:03 [ET]
Event Date: 01/30/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2014
Notification Time: 12:03 [ET]
Event Date: 01/30/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN ROGGE (R1DO)
FSME EVENT RESOURCE (FSME)
JOHN ROGGE (R1DO)
FSME EVENT RESOURCE (FSME)
AGREEMENT STATE REPORT - RADIATION SOURCE STORED IN UNAPPROVED LOCATION
"On January 30, 2014, two physicists within the Department of Radiation Oncology were emailed regarding the imminent shipment of a new Iridium-192 High Dose Rate (HDR) brachytherapy source. This notification was forwarded to the RSO. The source in its original shipping package was delivered by [the transport company] directly to the department on February 3, 2014. Upon arrival of the source, a front desk staff member tried unsuccessfully to notify two physics staff members while the transporter waited. When neither of physics staff members responded to the overhead page, front desk staff signed for the package at 9:43 a.m. The front desk staff member moved the package from the front desk area to the mold room floor (Room # 039.12), which is an unsecured location.
"On February 14th, it was discovered that the source was not in the Radiation Oncology Hot Lab - the appropriate secured location. Upon investigation and questioning of the staff who signed for the package, the location of the source was determined at 2:15p.m. on February 14th. The source was then taken to the HDR suite by the HDR service engineer (on-site to perform the source exchange) before Radiation Safety personnel were able to perform a wipe test and survey the original shipping package. Upon arrival, Radiation Safety personnel performed a wipe test and survey of the inner shielding cask housing the source.
"ADDITIONAL INFORMATION ASSOCIATED WITH THE EVENT:
-The source in its original shipping package was inappropriately stored in the mold room for approximately 11 days, 5 hours.
-Only one female in the department has a declared pregnancy. At no point in time during this period (February 3rd- February 14th) did she enter the mold room.
- The mold room is used only for the preparation of electron cutouts or blocks used in Linac-based treatments. This room is used infrequently (~5 visits per week - about 10 to 15 minutes per visit) by radiation oncology staff (physicists and dosimetrists) wearing radiation dosimeters.
- Adjacent areas to the mold room are a clerical area on one side and hallways on the three other sides.
- Exposure information obtained from the Radiation Safety personnel who surveyed the package on Friday, February 14th were 34 mR/hr at the surface and 0.5 mR/hr at 1 meter.
- The timing of the wipe test and survey was not in accordance with the requirement that a package containing radioactive material be opened and inspected by the recipient as soon as possible (within 3 hours) after receipt.
- There was no notification directly from [the transport company] that the package was delivered.
"CAUSES OF FAILURE:
-Procedure entitled 'Opening and Receiving of Radioactive Materials' was not followed.
-Communication break-down between the front desk personnel and physics staff.
"ACTION TAKEN TO PREVENT RECURRENCE:
1. Establish one primary physicist and one back-up physicist to serve as the coordinator for the receipt of the radioactive package. Additional physicists within the department will be permitted access into the Radiation Oncology Hot Lab. Additionally, two physicists will sign off in the HDR source inventory logbook upon receipt of the source.
2. All physicists will be trained in accordance with departmental procedures and applicable Department of Transportation (DOT) regulations on the process of receiving this type of package into the department and ensuring its proper storage.
3. The shipping company will be contacted to add all physicists and Radiation Safety personnel to be notified that the source has been shipped. The shipping company will also provide a tracking number for every HDR source package shipped to this facility. Another notification will be made from the transport company that the source has arrived (including delivery confirmation, signature, time & date).
4. Training of all department personnel will be performed and documented. This training will include who is authorized to sign for a radioactive package, how to identify a radioactive package, and the process that should be followed to ensure a safe transfer of the package to Rhode Island Hospital custody.
5. The policy governing the receipt of this type of material will be reviewed, revised, and disseminated upon approval.
6. If the package has not been received within 72 hours of the shipping company's notification, the primary physicist will follow up with the shipping company to determine the location of the package."
Rhode Island Event #2014-001
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
"On January 30, 2014, two physicists within the Department of Radiation Oncology were emailed regarding the imminent shipment of a new Iridium-192 High Dose Rate (HDR) brachytherapy source. This notification was forwarded to the RSO. The source in its original shipping package was delivered by [the transport company] directly to the department on February 3, 2014. Upon arrival of the source, a front desk staff member tried unsuccessfully to notify two physics staff members while the transporter waited. When neither of physics staff members responded to the overhead page, front desk staff signed for the package at 9:43 a.m. The front desk staff member moved the package from the front desk area to the mold room floor (Room # 039.12), which is an unsecured location.
"On February 14th, it was discovered that the source was not in the Radiation Oncology Hot Lab - the appropriate secured location. Upon investigation and questioning of the staff who signed for the package, the location of the source was determined at 2:15p.m. on February 14th. The source was then taken to the HDR suite by the HDR service engineer (on-site to perform the source exchange) before Radiation Safety personnel were able to perform a wipe test and survey the original shipping package. Upon arrival, Radiation Safety personnel performed a wipe test and survey of the inner shielding cask housing the source.
"ADDITIONAL INFORMATION ASSOCIATED WITH THE EVENT:
-The source in its original shipping package was inappropriately stored in the mold room for approximately 11 days, 5 hours.
-Only one female in the department has a declared pregnancy. At no point in time during this period (February 3rd- February 14th) did she enter the mold room.
- The mold room is used only for the preparation of electron cutouts or blocks used in Linac-based treatments. This room is used infrequently (~5 visits per week - about 10 to 15 minutes per visit) by radiation oncology staff (physicists and dosimetrists) wearing radiation dosimeters.
- Adjacent areas to the mold room are a clerical area on one side and hallways on the three other sides.
- Exposure information obtained from the Radiation Safety personnel who surveyed the package on Friday, February 14th were 34 mR/hr at the surface and 0.5 mR/hr at 1 meter.
- The timing of the wipe test and survey was not in accordance with the requirement that a package containing radioactive material be opened and inspected by the recipient as soon as possible (within 3 hours) after receipt.
- There was no notification directly from [the transport company] that the package was delivered.
"CAUSES OF FAILURE:
-Procedure entitled 'Opening and Receiving of Radioactive Materials' was not followed.
-Communication break-down between the front desk personnel and physics staff.
"ACTION TAKEN TO PREVENT RECURRENCE:
1. Establish one primary physicist and one back-up physicist to serve as the coordinator for the receipt of the radioactive package. Additional physicists within the department will be permitted access into the Radiation Oncology Hot Lab. Additionally, two physicists will sign off in the HDR source inventory logbook upon receipt of the source.
2. All physicists will be trained in accordance with departmental procedures and applicable Department of Transportation (DOT) regulations on the process of receiving this type of package into the department and ensuring its proper storage.
3. The shipping company will be contacted to add all physicists and Radiation Safety personnel to be notified that the source has been shipped. The shipping company will also provide a tracking number for every HDR source package shipped to this facility. Another notification will be made from the transport company that the source has arrived (including delivery confirmation, signature, time & date).
4. Training of all department personnel will be performed and documented. This training will include who is authorized to sign for a radioactive package, how to identify a radioactive package, and the process that should be followed to ensure a safe transfer of the package to Rhode Island Hospital custody.
5. The policy governing the receipt of this type of material will be reviewed, revised, and disseminated upon approval.
6. If the package has not been received within 72 hours of the shipping company's notification, the primary physicist will follow up with the shipping company to determine the location of the package."
Rhode Island Event #2014-001
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)