| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
11/19/2010 - 11/22/2010 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 46245 | Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: JELD-WEN WOOD FIBER OF OREGON
Region: 4
City: KLAMATH FALLS State: OR
County: KLAMATH
License #:
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DONALD NORWOOD | Notification Date: 09/10/2010
Notification Time: 17:29 [ET]
Event Date: 02/22/2010
Event Time: [PDT]
Last Update Date: 11/19/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAIR SPITZBERG (R4DO)
JACK FOSTER (FSME)
| Event Text AGREEMENT STATE REPORT - BROKEN FIXED GAUGE SHUTTER
The following information was received via facsimile:
"Jeld-Wen Wood Fiber of Oregon located in Klamath Falls possesses 5 fixed gauges at their wood door manufacturing facility.
"In late December 2009, the Radiation Protection Services [RPS] office [State of Oregon] received a phone call from [the Jeld-Wen] Maintenance Manager, who talked to [the] RPS Licensing Manager and stated that he wished to report that there were two gauges at their facility that were having shutter mechanism problems. [The Maintenance Manager] stated he would elaborate on the issue in an email.
"On February 22, 2010, [the Maintenance Manager] emailed [the RPS Licensing Manager] and stated that the gauge with the broken shutter mechanism (Ronan, model SA-8, serial M2119, 20 mCi Cs-137, high level indicator gauge, installed 12-15-88) was operating in the open shutter position and unable to close. [The Maintenance Manager] stated that the licensee had manufactured a 1.5" thick shutter (by approximately 8 inches wide by approximately 1 meter long) that fits between the gauge and the vessel it is attached to. He also stated that this gauge is in a restricted access area that is roped off and the closest area of worker frequency is 20 feet away. [The Maintenance Manager] stated that the other gauge with the 'sticking' shutter (Ronan, model GS-200, serial 3401, 50 mCi Cs-137, digester level indicator, installed 12-15-88) is closable and is also operating. He stated that he would be scheduling a repair for the 50 mCi gauge and would be evaluating whether a replacement will be needed for the 20 mCi gauge.
"On March 15, 2010, [the Maintenance Manager's] email to [the RPS Licensing Manager] was given to [an RPS employee] in radioactive materials licensing. From [the RPS Licensing Manager's] email, another staff member may be working on this incident. [The RPS employee] phoned [the Maintenance Manager] and found that this was an event possibly not entered into the system but he would check with materials inspectors to see if that was the case. [The Maintenance Manager] stated that he was scheduling for repair of the 50 mCi gauge and possibly the 20 mCi gauge but not sure of the latter. [The Maintenance Manager] also stated that he would be submitting an amendment request naming him as Radiation Safety Officer.
"On May 21, 2010, [the RPS employee] requested an update on the repairs/actions by the licensee for the two gauges. No response was received.
"On June 9, 2010, [the Maintenance Manager] phoned [the RPS employee]. He stated that the company did not have the fiscal ability to replace the 20 mCi gauge and asked if the company could continue operating the gauge for approximately 2 more years. [The RPS employee] stated that the SS&D sheet would have to be reviewed as well as an onsite inspection of the gauge.
"On June 23, 2010, [the RPS employee] reviewed the SS&D for the 20 mCi device. For a 500 mCi Cs-137 source, exposure rates with the shutter open were listed as 43 mR per hr at 2 inches, 4.3 mR per hr at 1 foot, and 0.6 mR per hr at 1 meter. At 4 percent of maximum activity allowed, the 20 mCi source located in a restricted access area using 1 meter distance should give an exposure rate of approximately 300 microR per hr maximum. It was also determined that an inspection would be made of the facility in Klamath Falls in late July [in order] to verify exposure rates around the gauge with the shutter open.
"On July 27, 2010, an inspection of the facility was performed by [another employee of RPS]. [This other RPS employee] determined exposure rates around the 20 mCi gauge to be approximately 100 microR per hr at 1 meter. [This other RPS employee] also noted that the gauge is located at or below the catwalk that accesses that area. The licensee was allowed to continue operation with the shutter. [The other RPS employee] also discovered that the 50 mCi gauge with the sticking shutter was not actually sticking but merely hard to open and close due to residue/resin buildup. The licensee cleaned the residue off and covered the shutter mechanism and gauge with a metal canopy to prevent future buildup. Vendor work on this gauge was not performed as the licensee corrected the issue internally. Management approval for the modified shutter of the 20 mCi gauge will be sought at this time. [The Maintenance Manager] noted also during the inspection that the issues with the two gauges had been known by the licensee for approximately 2 years and was only then being reported because he was to become the new RSO and thought it should be.
"On September 10, 2010, a review of this incident was performed and it was found that the NRC HOO had not been notified. A copy of open NMED events for Oregon was also reviewed and no mention of this incident was found. NRC was notified of the incident at this time. Oregon RPS management has not made a final decision on the 20 mCi gauge with the broken shutter mechanism."
* * * UPDATE FROM DARYL LEON TO HOWIE CROUCH VIA FAX ON 11/19/10 @ 1450 EST * * *
"On October 1,2010, [the owner of] an Oregon-licensed fixed gauge service vendor company (RS&S Calibration LLC), Oregon license ORE-91083) contacted the Oregon Radiation Protection Services (RPS) office by email stating that he had cleaned and oiled the shutter mechanism on the gauge with the shutter stuck open (Ronan model SA-8, s/n M2119) and the unit is working properly. The handle is broken yet and [the vendor owner] stated that the customer is going to order a new handle.
"On October 25, 2010, Daryl Leon of RPS emailed the site RSO, Rob Reifel to determine status of handle repair. Mr. Reifel emailed that he was still trying to get a quote on the part and asked if his site maintenance personnel can manufacture a new handle. He also added that [the repair vendor] indicated he (Reifel) should use one provided by the manufacturer. Mr. Leon responded by email stating that the part should be obtained from the manufacturer since safety evaluation of the device was performed with parts originally from the manufacturer and a locally-manufactured part would not suffice. Mr. Reifel indicated that he would 'push harder' to get this done.
"On November 8, 2010, Mr. Reifel emailed Mr. Leon stating that the handle was fixed and that the fix was performed November 4,2010.
"This event is ready for closure for the HOO and NMED (incident 100458)"
Notified R4DO (Pick) and FSME EO (Villamar). |
| General Information | Event Number: 46422 | Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY AND MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: PAUL HUGGINS
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 11/16/2010
Notification Time: 11:01 [ET]
Event Date: 11/13/2010
Event Time: [EST]
Last Update Date: 12/02/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HAROLD GRAY (R1DO)
GLENDA VILLAMAR (FSME)
| Event Text AGREEMENT STATE REPORT - PATIENT RECEIVED A THYROID IMAGING DOSE OF I-123 THAT WAS CONTAMINATED WITH I-131
The following report was received from the State of North Carolina via email:
"This is to notify you about a medical event under the regulation .0364, i.e., within 24-hr notification requirement after discovery. The following summarizes the medical event.
"Event: Contamination of I-123 thyroid imaging dose with I-131 (WRONG RADIONUCLIDE).
"Dose: 380 rad (3.8 Gy) to the thyroid gland (EXCEEDS 50-RAD THRESHOLD FOR ORGAN DOSE)
"Notification: Patient's parent and referring physician have been notified.
"A detailed report will follow within 15 days."
This event occurred sometime on Friday 11/13/10 and was discovered on Monday 11/15/10 at 1535 hrs. The patient was a child and potential adverse effects have not been determined at this 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.
* * * UPDATE RECEIVED FROM PAUL HUGGINS TO JOHN SHOEMAKER VIA EMAIL ON 11/22/10 @ 0954 * * *
"DESCRIPTION OF THE EVENT:
A patient was administered 0.389 mCi of iodine-123 orally for a thyroid uptake and scan procedure. Upon imaging at 4 hours, the technologist noted excessive background in the image. The acquisition computer showed an additional peak at 364 keV, consistent with presence of iodine-131 contamination. The iodine-131 thyroid burden at 21 hours was estimated to be about 43 microcuries. Based upon an iodine-123 uptake of 30%, the intake of iodine-131 was estimated to be about 143 microcuries. The absorbed dose to the thyroid, as estimated on 11/15/2010, was about 3.8 Gy (380 rad), or an equivalent dose of 3.8 Sv (380 rem), assuming age-specific reference values for thyroid mass and effective half-life.
"An intake of 143 mCi of iodine-131 is comparable to activities that were administered in the past for diagnostic thyroid imaging, and no adverse effects are expected.
"WHY THE EVENT OCCURRED:
Interviews with staff and assaying the equipment used for the iodine-123 administration indicate that the screw-cap on the vial was the likely source of the contamination. It is unclear whether the screw-cap removal device, or improper handling of the cap, was the cause of the contamination.
"STEPS BEING TAKEN TO PREVENT A RECURRENCE:
The Authorized User and senior technical staff have educated staff about proper handling of radioiodine. To prevent a recurrence, we have changed our procedure as follows:
1) Only one radioiodine dose will be kept in the 'dosing hood' at any time.
2) The vial will be opened only when the patient and necessary staff are in the hot lab.
3) A separate cap remover will be used for each radionuclide.
4) Only one technologist will be involved with preparing dosing area, dosing the patient, cleaning up the dosing area and surveying post therapy."
North Caroline Incident #: NC 10-50
Notified R1DO - R. Conte and FSME - G. Villamar
* * * UPDATE FROM PAUL HUGGINS TO ERIC SIMPSON AT 0936 EST ON 12/2/10 * * *
The I-131 intake is being corrected to 143 microcuries, instead of 143 millicuries, as reported previously.
Notified the R1DO (Schmidt) and FSME (Villamar). |
| General Information or Other | Event Number: 46423 | Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: WELLMAN OF MISSISSIPPI, INC
Region: 4
City: BAY ST. LOUIS State: MS
County:
License #: MS-871-01
Agreement: Y
Docket:
NRC Notified By: JULIA RALSTON
HQ OPS Officer: DONALD NORWOOD | Notification Date: 11/16/2010
Notification Time: 17:21 [ET]
Event Date: 10/20/2010
Event Time: [CST]
Last Update Date: 11/16/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GREG PICK (R4DO)
MARK THAGGARD (FSME)
| Event Text AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was received via facsimile:
"On October 29, 2010, the licensee's RSO contacted DRH [Mississippi State Department of Health, Division of Radiological Health] about their inlet shutter/lock out device that would not close completely. The licensee had shutdown one of their Polymer lines for maintenance/turn around on October 20, 2010 and proceeded to the Disc Ring Reactor to lock out the rod source devices. The outlet rod source was retracted into the holder and shutter/lock out device was closed and locked. The inlet rod source was retracted into the holder but the shutter/lock out device would not close completely.
"On October 22, 2010, Berthold Technologies USA, LLC was contacted by the licensee to assess the problem and make repairs. On October 27, 2010, Berthold Technologies USA, LLC came to inspect and perform repairs on the insertion rod source. The maintenance technician fully retracted the source which allowed the shutter/gate to turn further, but not to the fully indicated closed position. The maintenance technician then verified the source was fully retracted by knowledge of the device and survey readings (12 inches from device 2.6 mR/hr at one end, average along length of device, 0.5 mR/hr). The device was then removed for further inspection and maintenance. The device was then locked in the off/closed position and remounted in its original location. Installation surveys were performed, but readings were not obtained as plant maintenance was being done in the area.
"The licensee was instructed by DRH to send in a written report describing the incidents leading up to the event that occurred on October 20, 2010, and any corrective actions or follow up performed. The requested report was received by [DRH] on November 5, 2010. DRH will notify NRC Operations and no other action is required by DRH."
This device contains 7.41mCi of Co-60. The source serial number is 1772-10-02. The shield serial number is 005217.
DRH considers the device to have been repaired successfully and fully operational at the present time.
Mississippi Incident Report Number: MS-10007 |
| General Information or Other | Event Number: 46429 | Rep Org: GE HITACHI NUCLEAR ENERGY
Licensee: GE HITACHI NUCLEAR ENERGY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DALE PORTER
HQ OPS Officer: PETE SNYDER | Notification Date: 11/19/2010
Notification Time: 08:33 [ET]
Event Date: 11/18/2010
Event Time: [EST]
Last Update Date: 11/19/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
| Person (Organization):
HAROLD GRAY (R1DO)
ALAN BLAMEY (R2DO)
NRR PART 21 GROUP (EMAI)
| Event Text POTENTIAL FOR REVERSE POLARITY ON HPCI TURBINE EG-R HYDRAULIC ACTUATORS
"GE Hitachi Nuclear Energy (GEH) has completed an evaluation of the 'Reverse Polarity on HPCI EG-R Hydraulic Actuators,' and has concluded that this is a Reportable Condition in accordance with the requirements of 10 CFR 21.21 (d).
"Discussion:
"GEH provided a refurbished HPCI turbine EG-R Hydraulic Actuator, (GEH Part number DD213A8527P003), as a safety related component, to a domestic BWR/4. When the customer installed the EG-R Hydraulic Actuator at the plant, calibration and post maintenance testing found that the turbine governor valves went to the full open position when the proper response was a fully closed position. Troubleshooting of the newly installed component revealed that the polarity of the component was reversed. An improperly configured EG-R Hydraulic Actuator cannot be utilized in the system because the reversed polarity causes the turbine governor control valves to operate in a manner opposite to the expected response, and calibration of the component by plant personnel cannot be completed.
"GEH contracted Engine Systems Incorporated (ESI) to perform the repair/refurbishment of this EG-R Hydraulic Actuator. This particular EG-R Hydraulic Actuator is identified as GEH part number DD213A8527P003. The specific EG-R Hydraulic Actuator that was identified with this defective condition was identified as serial number 2288717.
"Conclusion:
"This condition would change the operational characteristics of the HPCI system and would create a Substantial Safety Hazard or a violation of a Technical Specification Safety Limit. As such this condition has been determined to be a Reportable Condition within the context of 10 CFR Part 21.21 (d).
"ABWR and ESBWR Design Certification Documentation Applicability:
"The issues described above have been reviewed for applicability to documentation associated with 10CFR 52 and it has been determined that there is no affect on the technical information contained in either the ABWR certified design or the ESBWR design in certification.
"Recommended Action:
"GEH recommends that [the Hatch, Hope Creek and Peach Bottom] sites that have received EG-R Hydraulic Actuator(s) (GEH Part number DD213A8527P003), check warehouse inventory. If the EG-R Hydraulic Actuator remains 'in stock,' the potential exists that incorrect internal wiring could exist resulting in the EG-R Hydraulic Actuator not responding as expected. GEH recommends that if an EG-R Hydraulic Actuator (GEH Part number DD213A8527P003) is in warehouse stock, that the component be returned to GEH for verification of the internal wiring configuration." |
| Power Reactor | Event Number: 46431 | Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: DAVID BARNETT
HQ OPS Officer: DONALD NORWOOD | Notification Date: 11/22/2010
Notification Time: 23:32 [ET]
Event Date: 11/22/2010
Event Time: 17:47 [CST]
Last Update Date: 11/22/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
BILLY DICKSON (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Startup | 0 | Startup | Event Text VALVES IDENTIFIED OPEN IN MODE 2 THAT SHOULD HAVE BEEN CLOSED
"At 1547 CST, November 22, 2010, the reactor mode was changed from Mode 4 to Mode 2 with the main steam drain valves, which are primary containment isolation valves, tagged open with power removed from their respective breakers. The valves were tagged to comply with S/D [Shutdown] operating procedure requirements. The valves should have been restored prior to making the mode change. The main steam line drain isolation valves MO-2373 and MO-2374 were restored at 1747 CST and verified at 1755 CST. Startup was held for determination of further actions needed. Reactor startup recommenced at 2200 CST. Currently the reactor is not critical."
The licensee notified the NRC Resident Inspector. The licensee notified the Minnesota State Duty Officer. | |