United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for December 27, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/23/2010 - 12/27/2010

** EVENT NUMBERS **


46462 46497 46498 46500 46501 46506 46507 46508 46509 46511

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General Information Event Number: 46462
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: EXCELLIMS COPORATION
Region: 1
City: ACTON State: MA
County: MIDDLESEX
License #: 55-0588
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/07/2010
Notification Time: 15:01 [ET]
Event Date: 12/07/2010
Event Time: 13:30 [EST]
Last Update Date: 12/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
DIANA DIAZ-TORO (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING ECKERT & ZIEGLER MODEL NER-004 NI-63 SOURCE

"Excellims Corporation in Acton, MA, (license # 55-0588) telephoned to inform the Agency [Commonwealth of Massachusetts, Radiation Control Program] that a 6 month wipe test of a stored Ni-63 source foil yielded 0.0061 uCi. The Eckert & Ziegler model NER-004 source is stored in the container in which the manufacturer sent the source. The RSO stated that a previous wipe test of the same Ni-63 source yielded higher results and he concluded that he had wiped the 'hot' side. This wipe test (0.0061 uCi) was a wipe of the 'inactive' side, however, he thought that he may have spread contamination to the inactive side during the previous inadvertent wipe test of the 'hot' side.

"ACTION REQUESTED: The RSO will send to the Agency an initial written notification of this wipe test result and the technical data sheet of the NER-004 source that he received from the manufacturer. He stated that he could complete this request in a few days.

"ACTION TAKEN: Document this telephone notification; inform Agency supervision; submit a report to US NRC."

The source has been secured in the original container and stored in a secure location. A Eckert & Ziegler model NER-004 is used in a Gas Chromatograph and has a Ni-63 source of less that 50 milliCuries.

* * * UPDATE FROM JOHN SUMARES TO VINCE KLCO ON 12/24/10 AT 1004 EST * * *

The following information was received by facsimile:

"Analysis results of a Ni-63 source foil wipe test indicated 0.0061 uCi, which is above 0.005 uCi limit.

"The original wipe test sample registered a high reading because the swab test was accidentally performed incorrectly when the active side and inactive side were swabbed. The leak test procedure was reviewed and the test was repeated using the correct procedure. The repeat test indicated 0.0061 uCi and the licensee concluded that some of the Ni-63 from the active side had been transferred to the inactive side during the initial wipe test. The licensee reported this wipe test result to the Agency. The source foil was kept in storage. To address the issue, the leak test procedures for the Ni-63 foil provided by the manufacturer and testing facility was reviewed again, and the leak test instructions were incorporated into the licensee's radiation safety manual. The foil was decontaminated using appropriate safety and control measures and all decontamination materials were placed in waste storage. After decontamination of the inactive side of the foil, the wipe test was repeated using the correct procedure, and the results were <0.00005 uCi. The Ni-63 source was considered ready for use.

"The Agency was provided written notification of this event, initial wipe test results, the technical data sheet for the source involved, and the final wipe test results after foil decontamination.

"The Agency considers this event to be closed."

Notified R1DO (Perry) and FSME (Lewis).

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General Information Event Number: 46497
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LANTHEUS MEDICAL IMAGING
Region: 1
City: NORTH BILLERICA State: MA
County: MIDDLESEX
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: ANTHONY CARPENITO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/20/2010
Notification Time: 10:34 [ET]
Event Date: 12/19/2010
Event Time: [EST]
Last Update Date: 12/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
JIM WHITNEY (ILTA)
GLENDA VILLAMAR (FSME)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - DELAYED MEDICAL SHIPMENT

The following was received via email from the Commonwealth of Massachusetts:

"Licensee reported not receiving 400 Ci Mo-99/Tc-99m shipment from supplier on schedule (arrival originally expected for 12/18/10). Licensee is in communication with supplier and carrier(s) in ongoing effort to locate missing package.

"Last known location, per IRE (shipper), was Frankfurt, Germany. At 12/20/10, 8:30 AM ET, licensee received verbal confirmation confirming the shipment is still on the ground in Germany. Licensee has requested more definitive confirmation from its source(s).

"The Agency [Commonwealth] considers this event still OPEN."


* * * UPDATE AT 1330 EST ON 12/21/2010 FROM THE COMMONWEALTH OF MASSACHUSETTS TO JOHN SHOEMAKER * * *

"The licensee stated that photographic evidence has been received confirming the shipment is still on the ground in Germany. The shipment will be returned to the supplier.

"The Commonwealth of Massachusetts considers the event to be closed."

Notified R1DO (Perry), FSME (Burgess), and ILTAB (Whitney)


* * * UPDATE AT 1137 EST ON 12/23/2010 FROM ANTHONY CARPENITO TO DONALD NORWOOD * * *

The Massachusetts Event Docket Number for this event is 12-9422.

Notified R1DO (Perry), FSME (Villamar), FSME (Lewis) and ILTAB (Johnson) all via E-mail.


THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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 Event Number: 46498
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: WESTERN TECHNOLOGIES, INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ-07-080
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/20/2010
Notification Time: 15:10 [ET]
Event Date: 12/20/2010
Event Time: [MST]
Last Update Date: 12/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN O'SULLIVAN (FSME)
JIM WHITNEY (ILTA)
MEXICO EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The State of Arizona emailed the following information:

"This First Notice constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received WITHOUT verification or evaluation, and is basically all that is known by the Agency Staff [Arizona Radiation Regulatory Agency] at this time.

"At approximately 8:00 AM December 20, 2010, the licensee phoned the Agency [state] to report of a stolen Troxler Laboratories Model # 3430, serial # 36977. The truck from which the gauge was stolen was located at 3330 West Greenway Road Bld. #7, Phoenix, AZ. The gauge contained 8 milliCuries of Cesium-137 and [40 milliCuries (typical) Americium-241: Beryllium]. Phoenix Police were notified at 6:00 AM by the employee. The employee stated that his keys were stolen out of his apartment. The thief then took the gauge out of its agency required lockbox from the bed of a company truck. Phoenix PD is also investigating this event.

"The Agency continues to investigate the actions of the licensee and timeliness of reporting the theft. Mexico, the States of CA, CO, NE, NM, UT, and TX as well as the U.S. NRC and the Arizona Governor's office have been notified of this event. Press coverage is not anticipated."

First Notice: 10-014

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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 Event Number: 46500
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST ELIZABETH HOSPITAL
Region: 3
City: APPLETON State: WI
County:
License #: 087-1284-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 11/30/2010
Event Time: [CST]
Last Update Date: 12/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSES

This information was emailed by the state as follows:

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. During a recent routine inspection, DHS determined that in response to the Information Notice, this licensee was reviewing medical records of several patients who may have received doses during prostate brachytherapy that were less than intended. On November 30, 2010, the licensee's Radiation Safety Officer reported the preliminary identification of one medical event. On December 20, 2010, the licensee's 15-day written report included information on this event, plus an additional two medical events. The doses delivered are D90 values based on CT scans performed thirty days post-surgery.

Treatment Date Isotope Prescription Dose Delivered Percentage
6/17/2008 Pd-103 125 Gy to prostate 97.4 Gy to prostate 77.9%
8/24/2009 I-125 145 Gy to prostate 107.9 Gy to prostate 74.4%
9/02/2009 I-125 145 Gy t0 prostate 93.05 Gy to prostate 64.2%


"The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patients and referring physicians. The licensee stated that the events occurred due to clinical limitations of the interstitial prostate brachytherapy implant technique. The licensee made process improvements (i.e. planning to D90 of 115% of the prescribed dose) which have resulted in unproved dosimetric coverage. DHS inspectors performed a reactive inspection and will follow up on the next inspection."

Event Report ID No.: WI100018


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 Event Number: 46501
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MERCY MEDICAL CENTER
Region: 3
City: OSHKOSH State: WI
County:
License #: 139-1177-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 08/12/2008
Event Time: [CST]
Last Update Date: 12/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSE

This information was emailed by the state as follows:

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. On December 20, 2010, the licensee's Radiation Safety Officer notified DHS that on August 12, 2008 a patient received only 75.4 % of the prescribed dose during prostate brachytherapy using I-125 seeds. The patient was prescribed 145 Gy to the prostate, and based on a CT scan performed thirty days post-surgery, the licensee determined that the treatment delivered only 109.3 Gy to the prostate.

"The authorized user who treated this patient is no longer at the licensee's facility. The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patient and referring physician. The licensee has already made process improvements (i.e. planning to higher D90 values) which have resulted in improved dosimetric coverage. DHS inspectors will follow up on the next routine inspection."

Event Report ID # WI100019

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: 46506
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: NATHAN SEID
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2010
Notification Time: 12:40 [ET]
Event Date: 12/23/2010
Event Time: 10:50 [CST]
Last Update Date: 12/23/2010
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):
GREG WERNER (R4DO)
ALLEN HOWE (NRR)
WILLIAM GOTT (IRD)

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

Event Text

UNCOMPLICATED REACTOR TRIP FROM 100% POWER

"At 1050 CST on 12/23/2010, Fort Calhoun Station experienced a reactor trip due to an unknown cause. No abnormal indications were present at the time of the trip.

[Procedure] "EOP-00, Standard Post Trip Actions, was performed.

"At 1054 CST, transitioned to [procedure] EOP-01, Reactor Trip Recovery. All Safety Functions of EOP-01 are being satisfied.

"At 1207 CST, 345KV Backfeed was established to all 4160V buses.

"The plant is currently stable in Mode 3, and the station continues efforts to determine the cause of the reactor trip."

All tripable control rods fully inserted during the reactor trip. No PORVs or safety valves lifted. The steam generators are being fed from the Main Feed Pumps and decay heat is being removed to the main condenser. No Emergency Safety Features actuated during the trip except for the reactor trip.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46507
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: ERIC SWAIN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/23/2010
Notification Time: 16:40 [ET]
Event Date: 12/23/2010
Event Time: 14:07 [EST]
Last Update Date: 12/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
NEIL PERRY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 0 Startup 0 Hot Shutdown

Event Text

REACTOR SCRAM DURING STARTUP

"At 1407 EST, during reactor startup at a RCS [Reactor Coolant System] pressure of 570 psig and with the turbine off-line, a Low Condenser Vacuum trip signal from both RPS [Reactor Protection System] channels resulted in an automatic reactor scram. All control rods fully inserted and plant response was as expected. This notification is in accordance with 10CFR50.72(b)(2)(iv)(B). The reactor is currently subcritical."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46508
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPBINSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2010
Notification Time: 18:37 [ET]
Event Date: 10/22/2010
Event Time: 18:49 [CST]
Last Update Date: 12/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ERIC DUNCAN (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

Event Text

UNANALYZED CONDITION - BATTERY CHARGERS MAY LOCKUP DURING A DESIGN BASIS EVENT

"On October 22, 2010, the station confirmed the following:

"On a safety injection (SI) event with no loss of offsite power (LOOP), calculations show that at various points in the load sequence, the voltage at the charger Motor Control Center will dip low enough on the SI unit to lockup both of the chargers. Additionally, when considering out of sequence loads, such as the containment spray pump, starting on the emergency diesel generator during normal load sequencing, the potential exists that the voltage for any of the chargers on an SI event with a LOOP may drop to the point that would cause the chargers to lockup.

"On October 22, 2010, the station completed an operability evaluation of the 11, 12, 21, and 22 battery chargers, implemented compensatory measures to restore battery chargers in the event of an SI to maintain operability (a simple manual action to restart the charger), and determined that the battery chargers were operable but non-conforming.

"The NRC Resident [Inspector] has been informed."

The licensee is planning on correcting this issue during the next refueling outage.

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Power Reactor Event Number: 46509
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES EWART
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/25/2010
Notification Time: 19:40 [ET]
Event Date: 12/25/2010
Event Time: 16:25 [PST]
Last Update Date: 12/25/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GREG WERNER (R4DO)
ELMO COLLINS (R4)
ART HOWELL (R4)
WILLIAM GOTT (IRD)
LINDA HOWELL (R4)
ERIC LEEDS (NRR)
ALLEN HOWE (NRR)
MICHAEL PECK (R4)
JOHN KNOX (DHS)
DWIGHT FULLER (FEMA)

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

NOTIFICATION OF UNUSUAL EVENT DECLARED DUE TO HIGH WINDS

Notification of Unusual Event declared due to high winds. EAL HU 1.2 condition of peak wind in excess of 80 miles per hour have been met. Sustained winds at the present time are 53.5 miles per hour. Wind direction (from) 38.8 degrees. There has been no damage on-site. There are no plans to reduce reactor power on either unit at the present time. The Emergency Operations Center has not been activated. The storm front causing the high winds is expected to exit the area within the next three to four hours.

The licensee notified the NRC Resident Inspector. The licensee notified the San Luis Obispo Sheriff and the State of California Office of Emergency Services.


* * * UPDATE FROM JAMES EWART TO DONALD NORWOOD AT 2018 EST ON 12/25/2010 * * *

Current wind speed is 3.7 miles per hour. Wind direction (from) 134.7 degrees. There has been no damage on-site. The access roads to the site are open and passable.


* * * UPDATE FROM JAMES EWART TO DONALD NORWOOD AT 2057 EST ON 12/25/2010 * * *

Current wind speed 9.2 miles per hour. Wind direction (from) 101.6 degrees. The NRC Senior Resident Inspector is on-site.


* * * UPDATE AT 2333 EST ON 12/25/2010 FROM JEFF PORTNEY TO MARK ABRAMOVITZ * * *

The licensee terminated the NOUE at 2021 PST. Winds are less than 2 mph gusting to 2.8 mph from 63.9 degrees. The storm has passed and no damage has been detected. The NRC Resident Inspector will be notified.

Notified the R4DO (Werner), IRD (Gott), NRR EO (Howe), DHS (Knox), and FEMA (Fuller).

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Power Reactor Event Number: 46511
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIMOTHY SCOTT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/26/2010
Notification Time: 20:53 [ET]
Event Date: 12/26/2010
Event Time: 16:20 [CST]
Last Update Date: 12/26/2010
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):
DAVID AYRES (R2DO)

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

Event Text

MANUAL REACTOR SCRAM DUE TO HIGH VIBRATION ON MAIN GENERATOR EXCITER

"On 12/26/2010 at 1620 CST, Browns Ferry Unit 3 initiated a manual reactor SCRAM due to high vibration on the Unit 3 Generator Exciter inboard and outboard journal bearings. All plant systems responded as required to the manual SCRAM signal. No Emergency Core Cooling System (ECCS) initiations occurred as a result of the manual SCRAM signal. Reactor water level lowered below Level 3 (+2") as a result of the SCRAM and was recovered to the normal water level band by the Reactor Feed Pumps (RFPs). The expected Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations were received due to reactor water level lowering below Level 3 (+2") with all systems isolating as required. There were no indications of main steam relief valves (MSRVs) opening.

"The manual scram from critical is reportable within four hours under 10CFR50.72(b)(2)(iv)(B), 'Any event or condition that results in a valid actuation of the Reactor Protection System' and within eight hours under 10CFR50.72(b)(3)(iv)(A), 'Any event that results in an actuation of the specified systems.' The manual scram from critical also requires a 60-day written report in accordance with 10CFR50.73(a)(2)(iv)(A).

"The event was entered into the licensee corrective action program as Problem Evaluation Report 301505.

"The NRC Resident Inspector was informed."

All control rods fully inserted. Plant is in a normal post-scram electrical alignment. Decay heat is being removed through the turbine bypass valves to the main condenser.

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