United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 22, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/21/2008 - 10/22/2008

** EVENT NUMBERS **


44535 44547 44552 44574 44575 44576 44577 44578 44579 44585 44586 44587
44588

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General Information or Other Event Number: 44535
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: METCO
Region: 4
City: HOUSTON State: TX
County:
License #: L-03018
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/03/2008
Notification Time: 10:58 [ET]
Event Date: 09/29/2008
Event Time: 13:00 [CDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
ANNA BRADFORD (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO EXTREMITIES

A radiographer working for METCO was performing radiography operations at CB & I Fabricators in Houston TX. He was moving the radiography camera (a SPEC 150 with a 85 curie Ir-192 source) from one location to another. He removed the nipple off the front of the camera to test the guide tube and his dosimetry started alarming. He observed that the source had come out of the camera about 1/2 inch. At the same time, he inadvertently dropped the camera plug. He picked up the plug and unsuccessfully made two attempts to push the source back in with the plug. He then left the front of the camera and went around and turned the crank and got the source back into the shielded position and then inserted the plug. He then notified appropriate personnel.

METCO sent his dosimetry off and the results came back with a whole body exposure of 946 millirem on October 1. The RSO discussed the details of the event with the radiographer and reenacted the event to attempt to estimate the radiographer's hand exposure because to the close proximity of the source to the hand during the event. Based on the time and distance of the source to the hand, it was estimated that the exposure to the radiographer's right hand may be somewhere between 66 and 282 rem. METCO has called in a consultant to get a more accurate assessment of the exposure to the hand.

The radiographer's work for the rest of the year has been suspended. His hand does not exhibit any eurythemia. No information is available on whether blood work or medical study will be obtained.

Texas will wait for the licensee's final report before it completes and independent investigation of the event.

Texas Report I-8569

* * * UPDATE PROVIDED AT 1210 EDT ON 10/21/08 FROM ART TUCKER VIA EMAIL TO JEFF ROTTON * * *

The following information was received from the State of Texas via email:

"The licensee provided the final dose estimate for the individual involved in this event. The licensee used conservative times established in several reenactments of the event, NCRP publications, and the source manufacturers information to calculate the dose estimate. The estimate to the individual's right hand is 233.71 Rem SDE. The State of Texas calculated the dose to be 235.65 Rem SDE. This individual's TEDE dose was measured at 2.762 Rem for the 2008 calendar year.

Notified FSME (Burgess) and R4DO (Deese).

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Other Nuclear Material Event Number: 44547
Rep Org: WAL-MART
Licensee: WAL-MART
Region: 4
City: BENTONVILLE State: AR
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RICH DAILEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/07/2008
Notification Time: 16:54 [ET]
Event Date: 10/07/2008
Event Time: [CDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DALE POWERS (R4)
MARK DELLIGATTI (FSME)
ILTAB (e-mail) ()

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

Event Text

LOST TRITIUM EXIT SIGNS

Wal-Mart is conducting a worldwide audit of their tritium exit signs. This morning they discovered three missing signs.

The first missing sign was located at the store in Noblesville, Indiana. The serial number is 301651, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.

The second sign was located at the store in Charlotte, Michigan. The serial number and manufacturer were unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.

The third sign was located at the store in Yankton, South Dakota. The serial number is 293214, manufacturer unknown. Curie content unknown. The sign was last inventoried in the spring of 2008.

All three stores were searched for the signs without success.

* * * UPDATE PROVIDED BY RICHARD DALEY TO JASON KOZAL ON 10/09/08 AT 1308 * * *

Three additional signs were discovered missing in the state of Michigan:

1. At a store located at 995 Razorback Dr., Houghton, MI 49931. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).

2. At a store located at 10772 West Carson City Rd., Greenville, MI 48838. The serial number is unknown, the manufacturer is Isolite (11.5 Ci of tritium).

3. At a store located at 7021 SW Nedge Ave, Portage, MI 49002. The serial number is 357889, the manufacturer is Isolite (11.5 Ci of tritium).

All three stores were searched for the signs without success.

Notified R3DO (Lara), and FSME (Burgess) and ILTAB via email.

* * * UPDATE AT 1400 EDT ON 10/10/08 FROM RICH DAILEY TO S. SANDIN * * *

An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 280802. It was last inventoried in Spring 2008 at Wal-Mart Store #5039 which is located in Camden, DE.

Notified R3DO (Lara), FSME (Einberg) and ILTAB via email.

* * * UPDATE AT 1422 EDT ON 10/14/08 FROM RICH DAILEY TO JOE O'HARA * * *

An additional missing exit sign was identified during the on-going inventory. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 277880. It was last inventoried in Spring 2008 at Wal-Mart Store #1833 which is located in Fredericksburg, VA.

Notified R1DO (Jackson), R3DO (Phillips), FSME (Vontill) and ILTAB via email.

* * * UPDATE AT 1305 EDT ON 10/21/08 FROM RICH DAILEY TO JEFF ROTTON * * *

Two additional missing exit signs were identified during the on-going inventory.

1. 1 sign at store #566, 1115 American Way, Booneville, IN 75237. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 306432.

2. 1 sign at store #3548, 910 Walcott Street, Waterbury, CT 06705. The exit sign was manufactured by SRB and contained 20 Ci of tritium, S/N 266092.

Notified FSME (Burgess), R3DO (Hironori Peterson), R1DO (Cahill), and ILTAB via email.



THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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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General Information or Other Event Number: 44552
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: NORTHWEST INSPECTION
Region: 4
City: KENNEWICK State: WA
County:
License #: IR065
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/08/2008
Notification Time: 11:30 [ET]
Event Date: 09/30/2008
Event Time: 07:00 [PDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECTED FROM CONTROL CABLE

Washington state submitted the following report via e-mail:

"A licensee reported to the Department of Health (DOH) that an industrial radiography (IR) source had become disconnected from the control cable that prevented the retrieval of the source back into its safe shielded position. The exposure device is a QSA Global Sigma 880 with a 97 Curie Iridium-192 source. The source disconnect occurred at 7:00 AM 9/30/08 at a construction site three miles northeast of Moses Lake, Washington. The President and Radiation Safety Officer (RSO) of the licensed IR company are on scene with 12 company employees to correct the situation. The radiographer had previously made several exposures on pipe welds earlier in the day before the disconnect occurred. The source remained at the end of the guide tube, in the collimator, when the radiographer tried to retract it into the device. The radiographer tried this several times. A large area at the construction site has been secured by barricades and the IR personnel are guarding the radiation area. At present, it appears that personnel have not received any elevated or unusual exposure as a result of the disconnect. The IR company is working with the Office of Radiation Protection and the radiography device manufacturer to develop a plan to retrieve the source. DOH staff were sent to the location to assure radiation safety procedures are followed and independent measurements are made."

Washington Report: WA080073

* * * UPDATE PROVIDED AT 1415 EDT ON 10/21/08 VIA EMAIL FROM ARDEN SCROGGS TO JEFF ROTTON * * *

The following information was obtained from the State of Washington via email:

"DOH staff went to the incident site at 1:30 p.m. on the day of the event. They assisted the IR company RSO establish the planned special exposure recovery plan. About 2:30 p.m. the construction-site safety officers were briefed on the recovery plan. Materials and equipment needed for the plan were assembled and at 3:35 they began the recovery operation. The plan included using a site crane and operator to extricate the camera, guide tube, collimator with source from the work scaffolding. The IR equipment was moved to a better location in an area away from the construction site. At 4:26 p.m. the camera and source were placed into a lead lined steel skiff-box and lifted to an area between a high dirt bank and tall concrete retaining wall. The new location was roped off and secured by the IR personnel. The actual recovery began at about 6:30. The IR drive cable was modified as the manufacturer recommended by filing two sides of the attachment fitting. Several attempts were made to hook onto the source pigtail. At around 9:30 the source was successfully pulled back into and locked in the camera. Surveys indicated the source was successfully placed into the shielded position. Pocket dosimeter readings for the four IR employees that were directly involved with the recovery indicated 10, 45, and 52 mRem. None of the construction workers received an exposure above background. The camera, with the source and associated equipment involved with the disconnect, was sent to the manufacturer for evaluation to determine why the equipment failed to operate as designed.

"On October 1, 2008, the DOH Radioactive Materials' supervisor and the IR program lead staff went to the site to follow-up with the investigation and to close the event. While on site, they addressed an assembly of 800 craft construction workers. Several asked questions about the incident and voiced their concerns for the potential exposure they may have received. DOH staff also talked directly to several individuals before and after the briefing. A large majority of the construction workers seemed to understand that their health and safety had not been affected as a result of the incident.

"[The State] has subsequently heard that the manufacturer (QSA Global) had determined that the pigtail connector had an engineering defect that allowed that connection to part from the drive cable causing the disconnect."

Notified FSME (Burgess) and R4DO (Deese)

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General Information or Other Event Number: 44574
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: WAL-MART
Region: 3
City: MASON CITY State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NANCY FARRINGTON
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/17/2008
Notification Time: 09:33 [ET]
Event Date: 10/17/2008
Event Time: 08:00 [CDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Iowa. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart is declaring these signs to be missing.

Wal-Mart Corporate office notified the Iowa Department of Public Health

The device information is as follows:

1. Location: Mason City, Iowa. Manufacturer - SRB Technology, Serial number - 263251, Curie content - 20.

2. Location: Mason City, Iowa. Manufacturer - SRB Technology, Serial number - 263223, Curie content - 20.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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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General Information or Other Event Number: 44575
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: WAL-MART
Region: 1
City: QUINCY State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/17/2008
Notification Time: 11:29 [ET]
Event Date: 10/16/2008
Event Time: [EDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF SIX TRITIUM EXIT SIGNS

"On 10/16/08 the Agency received 2 telephone calls from Rich Dailey, RSO of Wal-Mart. During the first call Rich Dailey reported the loss of 2 tritium exit signs, S/N 249447 & 249454, from the Wal-Mart store in Quincy [MA]. During the second call Rich Dailey reported the loss of 4 tritium exit signs from the Wal-Mart store in Halifax [MA]. Rich Dailey stated that Wal-Mart is conducting a replacement of all tritium signs. In the Spring of 2008 these exit signs were inventoried. In October 2008, prior to replacement, the signs could not be located. All of the exit signs were manufactured by `SRB Lite' and contain 20 curies of H-3. Rich Dailey will send a written report to the Agency at a later date."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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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General Information or Other Event Number: 44576
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WAL-MART
Region: 1
City: SWAINSBORO State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEITH ST. CYR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2008
Notification Time: 13:39 [ET]
Event Date: 10/16/2008
Event Time: [EDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

A Wal-Mart store at 14 S. Main Street in Swainsboro GA notified the State of Georgia that a tritium exit sign that had been held in storage was missing. The store had previously removed its tritium signs and was storing them for eventual return to the manufacturer. During an inventory of the signs, one was discovered to be missing. The sign is generally licensed by the State. The sign was manufactured by Isolite with 11.5 curies of tritium. The State of Georgia did not have the serial number of the sign.

* * * UPDATE FROM ERIC JAMESON TO JOE O'HARA AT 1353 ON 10/21/08 * * *

A Wal-Mart store at 6065 Joneboro Road in Morrow, GA notified the State of Georgia that two tritium exit signs were missing. The signs were manufactured by SRB with 20 Curies each S/N 279368 and S/N 282787. Additionally, a Wal-Mart store at 3886 Highway 17 in Toccoa, GA. had one tritium exit sign missing. The sign was manufactured by Isolite with 11.5 curies of tritium. The State of Georgia did not have the serial number of the sign. The signs are generally licensed by the State.

Notified R1DO(Cahill) ,FSME(Burgess), and ILTAB via E-mail

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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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General Information or Other Event Number: 44577
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/17/2008
Notification Time: 15:35 [ET]
Event Date: 10/09/2008
Event Time: [CDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - 50 PERCENT UNDERADMINISTRATION OF YTTRIUM-90

The state provided in the following information via e-mail:

"On 10/10/08, licensee's RSO notified DRH [Division of Radiological Health] of a Yttrium-90 SIR-Spheres medical event. The reportable event involved the administration of 54 mCi of SIR-Spheres for one patient with approximately 27 mCi instilled into both the right and left hepatic arteries. After instilling approximately 27 mCi of Yttrium-90 SIR Spheres based on radiation readings into the right hepatic artery, a smaller catheter for the left hepatic artery was used due to anatomy and to get to the segment feeding the tumor. While attempting to instill the Yttrium-90 SIR Spheres into the left hepatic artery over-pressurization caused the three (3) way valve in the containment box to give way and resulted in the release of a therapeutic dose of Yttrium-90 SIR Spheres into the delivery system containment box as per design. Due to the release of the second part of the dose into the containment box only approximately 50% of the dose was able to be administered. The procedure was terminated and the delivery box was bagged and held for decay-in-storage. Personnel in the room were monitored for contamination and the room was surveyed and released. The patient was released with no harmful effects foreseeable by the Radiation Oncologist. The patient and referring physician were notified of additional future treatment.

"Licensee suggested the incident may have been caused by the size of the catheter, a kink in the catheter, or a smaller syringe being used by the interventional radiologist putting increased pressure on the 3 way valve. As a result of the medical event the licensee's treatment team will review the delivery system setup before pressure is applied to ensure the flow of the SIR-Spheres will not be impeded within the catheter."

License No.: MS-MBL-01

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: 44578
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ST. VINCENT'S HOSPITAL
Region: 1
City: JACKSONVILLE State: FL
County:
License #: FL Lic 14-6
Agreement: Y
Docket:
NRC Notified By: DAVID FERGUSON
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/17/2008
Notification Time: 17:48 [ET]
Event Date: 09/17/2008
Event Time: [EDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
BILL VONTILL (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO UNINTENDED TISSUES

The Commonwealth of Florida was notified on 10/17/2008 by the licensee's Medical Physicist regarding a dose of 3400 cGy (3400 rad) administered to unintended tissues during several breast cancer therapy treatments over the period of September 10 - 17, 2008. The apparent unintended dose was identified on 10/16/2008, when the patient reported to the licensee symptoms of erythma (skin reddening) to the breast not intended to be treated.

Specifically, the patient was being treated for breast cancer with an Ir-192 High Dose Rate (HDR) Afterloader unit (source strength, manufacturer, and model unknown at the time of this report). When the erythema was reported by the patient, the Medical Physicist reviewed the records and determined that the HDR Afterloader was mis-programmed such that the source stopped 10 centimeters short of the intended tumor bed in the right breast. As a result, the entire dose intended for the tumor bed was administered to the left breast that was not intended to be treated.

The Commonwealth of Florida did not currently have information regarding any potential long term effects for the patient due to this event. The Commonwealth of Florida will dispatch an inspector to the facility early next week to follow-up on this event. A written report of this event will be provide by the State at that time.

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: 44579
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RIK DROKE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/17/2008
Notification Time: 20:45 [ET]
Event Date: 10/17/2008
Event Time: 16:15 [EDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
70.74 APP. A - ADDITIONAL REPORTING REQUIREMENTS
Person (Organization):
STEVEN VIAS (R2)
CHRISTOPHER REGAN (NMSS)
FUELS OUO (email) ()

Event Text

INADVERTENT TRANSFER OF UNSAMPLED DISCARD SOLUTION

"Transfer of low uranium concentration discard solution from Tank WF03 to Waste Water Treatment Facility (WWTF) Tank 29 without final sample and analysis due to inadvertently opening incorrect valve.

"There were no actual or potential safety consequences to workers, the public, or the environment.

"Solution from discard Tank WF04 had been sampled and analyzed and was approved for transfer to WWTF Tank 29. An incorrect valve was opened and low uranium concentration solution was transferred from discard Tank WF03 to WWTF Tank 29 without final sample and analysis. All sources into the discard tanks (WF03 and WF04) are routed through an in-line uranium concentration monitor.

"Remaining SSC's were available and reliable. Solution in discard Tank WF03 had passed through an in-line uranium concentration monitor which would have stopped the transfer if a high uranium concentration was present.

"Solution in discard Tank WF03 and WWTF Tank 29 were sampled. Both uranium concentration results are low. The solution in discard Tank WF03 would have met sample analysis requirements.

"The safety significance is low due to the low mass and concentration of U-235. In-line monitor was also present which would have prevented transfer of high concentration solution into discard Tank WF03.

"The control is to sample and analyze solution prior to transfer to WWTF. The deficiency in this case is the failure to perform those actions prior to discard.

"Event was identified and entered into Problem Identification, Resolution and Correction System (PIRCS) - PIRCS #15829. Investigation is underway. Both the discard Tank WF03 and the WWTF Tank 29 were sampled."

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 44585
Rep Org: BALDOR ELECTRIC CO.
Licensee: BALDOR ELECTRIC CO.
Region: 1
City: FLOWERY BRANCH State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES THIGPEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/21/2008
Notification Time: 16:58 [ET]
Event Date: 10/20/2008
Event Time: [EDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
ALAN BLAMEY (R2)
CHRISTOPHER CAHILL (R1)
HIRONORI PETERSON (R3)
RICK DEESE (R4)
C VERNON HODGE (NRR)

Event Text

BALDOR MOTORS WITH ENDRING HEAT DAMAGE

Two motors were discovered to have endring heat damage. These two motors have been returned to Baldor. Six more motors from the same purchase order remain out. These six motors have been recalled by Baldor. Location of these six motors is unknown at the present time. These motors were manufactured for use in Flowserve Limitorque motor operated valve operators.

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Power Reactor Event Number: 44586
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: RICHARD HUBBARD
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/21/2008
Notification Time: 23:27 [ET]
Event Date: 10/21/2008
Event Time: [CDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICK DEESE (R4)

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

Event Text

UNANALYZED CONDITION DURING DESIGN BASIS FIRE IN AREA A-27 OF AUXILIARY BUILDING

"During a design-basis fire in area A-27 (2026' level Auxiliary Building) actions designated in OFN KC-016, FIRE RESPONSE, remove safety-related 125 VDC Power from the B Train Pressurizer PORV, BB PCV-456A, by opening fused disconnects NK0404 and NK0405. The intent of this action is to remove all power from the affected cable tray. This action removes control power to several safety-related components, which are assumed to remain available to the Control Room since the analyzed fire in area A-27 relies on the B Train to maintain safe-shutdown conditions.

"Opening NK0404 and NK0405 and removing control power fm the assumed safe-shutdown train was not fully analyzed as to the impact on Control Room Actions and subsequent affects on availability of the assumed safe-shutdown train.

"Actions taken or planned: 1) Fire detection and suppression in area A-27 are functional. 2) Established an hourly firewatch in area A-27 per the AP 10-104, Breach Authorizations. 3) Changed OFN KC-016, FIRE RESPONSE, to isolate the specific fused disconnect for BB PCV-456A, NK4421, and added a note to the operator to be aware that the PORV could reopen due to a cable-to-cable hot short."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44587
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: BRUCE CHENARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/21/2008
Notification Time: 23:45 [ET]
Event Date: 10/21/2008
Event Time: 19:44 [EDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER CAHILL (R1)

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

Event Text

FAILURE OF 250V DC HPCI INJECTION VALVE UNDERVOLTAGE RELAY

"A 250 Volt DC undervoltage relay for HPCI injection valve MO-2301-8 failed. The reason for the failure is still under investigation. The injection valve is a normally closed valve that opens on an initiation signal. The failure of the under voltage relay would prevent the HPCI injection valve (MO-2301-8) from opening and would prevent HPCI from performing its safety function. Pilgrim Station has entered a 14 day LCO due to Technical Specification 3.5.C.2."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 44588
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: JASON KOZAL
Notification Date: 10/22/2008
Notification Time: 01:44 [ET]
Event Date: 10/21/2008
Event Time: 20:51 [PDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4)

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

Event Text

UNIT 2 MANUAL REACTOR TRIP DUE TO JELLYFISH INTRUSION

"On October 21, 2008, with both units operating at 100% power, Operators manually actuated the Unit 2 reactor protection system (RPS/reactor trip) due to high differential pressure (DP) across the circulating water pumps' intake traveling screens. The high DP resulted from a rapid influx of jellyfish. All systems responded as designed. All control rods fully inserted. Auxiliary feedwater actuated as designed. The grid is stable with power being supplied by 230 Kv startup power. Diesel generator (DG) 2-2 and 2-3 are operable in standby. DG 2-1 is inoperable due to scheduled maintenance. The traveling screens for the safety-related auxiliary saltwater system (ASW) are not degraded and are managing the influx of jellyfish with no significantly elevated DP. Unit 2 is stable in Mode 3 at normal operating temperature and pressure.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'RPS actuation,' and 50.72(b)(3)(iv)(A), 'Specified System Actuation.'

"Operators reduced power on Unit 1 in response to the potential loss of normal flow to the condenser due to the jellyfish influx on the traveling screens. Currently, the traveling screens are maintaining DP within limits and the unit is stable at 50% power.

"Unit 2 decay heat removal is being performed by Auxiliary Feed Water to four steam generators blowing down via the 10% steam dumps to atmosphere."

No other safety related equipment was out of service at the time of the trip.

The licensee notified the NRC Resident Inspector.

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