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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/07/2011 - 04/08/2011
** EVENT NUMBERS **
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| Agreement State |
Event Number: 46718 |
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-001-02110
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONG HWA PARK |
Notification Date: 04/01/2011
Notification Time: 16:03 [ET]
Event Date: 03/16/2011
Event Time: [CDT]
Last Update Date: 04/01/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
RYAN LANTZ (R4DO)
PAUL MICHALAK (FSME) |
Event Text
AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE
The following was received from the State of Arkansas via email:
"On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient.
"The facility has contacted the manufacturer of the administration device.
"On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event.
"Conditions requiring reporting of this event:
"The dose differs from the prescribed dose by more than 50 rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy.
"Arkansas Event Number: 03-11-03"
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. |
| Agreement State |
Event Number: 46719 |
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 33136
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: DONG HWA PARK |
Notification Date: 04/01/2011
Notification Time: 16:24 [ET]
Event Date: 04/01/2011
Event Time: [EDT]
Last Update Date: 04/01/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
RAY POWELL (R1DO)
PAUL MICHALAK (FSME) |
Event Text
AGREEMENT STATE REPORT - I-131 ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE
The following was received from the State of Florida via email:
"A patient was scheduled to receive a 150 mCi dose of I-131 for thyroid cancer therapy treatment on 3/31/11. The dose was two 75 mCi capsules. Only one pill was taken. The other pill was discovered sticking on the bottom of the vial on 4/1/11 (capsules are sticky and the label around the vial prevented direct observation of the capsule from the side). Patient was under dosed by 50%. The tech failed to ensure that both pills were taken. The physician has been notified and he will notify the patient. The patient will be redosed to bring the dose up to prescription. The dosing procedure will be changed to require the tech to verify that the vial is empty. Licensee will submit a written report. Any further action on this incident is referred to Radioactive Materials. This office will take no further action on this incident."
Florida Incident Number: FL 11-028
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. |
| Agreement State |
Event Number: 46726 |
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: TOWNSEND
Region: 1
City: MONCURE State: NC
County:
License #: 019-1564-0G
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: JOHN SHOEMAKER |
Notification Date: 04/05/2011
Notification Time: 12:03 [ET]
Event Date: 03/30/2011
Event Time: [EDT]
Last Update Date: 04/05/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
BRIAN BONSER (R2DO)
ANGELA MCINTOSH (FSME)
JOHN CARUSO (R1DO) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
AGREEMENT STATE - FIVE TRITIUM EXIT SIGNS DESTROYED
The following information was received via facsimile:
On February 4, 2011, the NC Radiation Protection Section (NCRPS) received notice of a bankruptcy sale for Townsend in Pittsboro, NC. On March 15, 2011, the Radiation Safety Officer (RSO) for Townsend was contacted to check the status of 5 exit light signs they had registered. The Townsend RSO informed NCRPS that Townsend had paperwork for the signs, however, in October 2003 the facility had been changed from a chicken slaughter facility to a chicken process facility. During this construction, the 5 exit signs were destroyed. On March 30, 2011, NCRPS performed an inspection at the facility and no exit signs or evidence of signs containing tritium were found. A total of 71.9 Curies of tritium were destroyed at the facility and NCRPS considers the incident closed. NC Report #11-22.
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 |
| !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! |
| Power Reactor |
Event Number: 46735 |
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MIKE SLABY
HQ OPS Officer: PETE SNYDER |
Notification Date: 04/06/2011
Notification Time: 21:20 [ET]
Event Date: 04/06/2011
Event Time: 15:30 [EDT]
Last Update Date: 04/07/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION |
Person (Organization):
JOHN CARUSO (R1DO) |
| 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
DEGRADED FIRE BARRIER
"During walk downs for a planned site modification on April 6, 2011 at 1530 EDT, two degraded fire barrier seals were identified in the wall between the Auxiliary Building Basement and the Charging Pump Room. The wall is listed as an Appendix R wall between Fire Area (FA) ABBM and FA CHG. The wall separates redundant safe shutdown equipment.
"Two cylindrical six inch penetrations through the wall did not contain the required material to conform to a 3-hour fire rated barrier. This has been identified as a missing fire barrier such that the required degree of separation for redundant safe shutdown trains is lacking.
"A fire watch was established as a compensatory measure on 4/6/11. The discovery of this non-compliance is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii)(B).
"The NRC Resident Inspector has been notified of this event."
* * * RETRACTION FROM ALAN MODZELEWSKI TO JOE O'HARA AT 1628 EDT ON 4/7/11 * * *
"The purpose of this report is to retract the event discussed in Emergency Notification System report #46735 submitted on April 6th, 2011. The ENS notification reported an inadequate fire barrier penetration seal discovered on April 6th, 2011 when maintenance inspected the penetration in preparation for a modification. Initial investigation concluded that the fire barrier penetration seal between the Charging Pump room and Auxiliary Building Basement was inoperable because there was inadequate seal material to provide the required three hour barrier rating. It appeared that when looking in the penetration sleeve that a fire board from the opposite room was visible and no foam material was present.
"Subsequently, an engineering review of the penetration has been completed. The review determined that a minimum of 8 inches of foam is required to maintain a 3-hour rating. Engineering identified that the design also requires a fire board on each side of the foam. Upon measurement it was confirmed that at least 11 inches of the penetration was filled, with a fire board on each side. Based on these measurements, the fire barrier met design requirements and was operable. The individuals performing the initial investigation did not recognize the thickness of the wall. On April 7th, Maintenance proceeded to penetrate the fire barrier for the modification and it was confirmed that foam was behind the fire board. With a 24 inch thick wall, a large portion at the penetration sleeve can be void of material and still meet the 3 hour rating. As such, the April 6th, 2011 event is being retracted.
"The licensee notified the NRC Resident Inspector."
Notified the R1DO (Caruso) |
| Fuel Cycle Facility |
Event Number: 46736 |
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: MICHAEL GREENO
HQ OPS Officer: JOE O'HARA |
Notification Date: 04/07/2011
Notification Time: 11:26 [ET]
Event Date: 04/06/2011
Event Time: 12:05 [CDT]
Last Update Date: 04/07/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM |
Person (Organization):
BRIAN BONSER (R2DO)
ABY MOHSENI (NMSS) |
Event Text
CONTAMINATED WORKER TREATED AT DISPENSARY
"A Honeywell employee (Senior Process Control Engineer) entered the Dispensary at 1205 on 04/06/11 and reported he had foreign material in his right eye. He was on the 1st floor of the FMB (Feeds Material Building) by the glycol heat exchanger closing a valve with a wrench (lazy rod). The wrench struck another pipe and knocked rust off and into his eye. The rust was removed with simple irrigation and a swab. The employee was sent back to work with no additional issues. He was monitored by HP (Health Physics) in the Dispensary and was found to have 5300 dpm/100cm2 (beta, gamma) on his boots and 280 dpm/100cm2 on his coveralls. The individual was not transported offsite. Reported IAW 10CFR40.60 b(3).
"NRC Region II (Richard Gibson) was also informed of this occurrence" |
| Part 21 |
Event Number: 46737 |
Rep Org: ROTORK CONTROLS, INC
Licensee: ROTORK CONTROLS, INC
Region: 1
City: ROCHESTER State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT H. ARNOLD
HQ OPS Officer: CHARLES TEAL |
Notification Date: 04/07/2011
Notification Time: 15:22 [ET]
Event Date: 04/07/2011
Event Time: [EDT]
Last Update Date: 04/07/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH |
Person (Organization):
JOHN CARUSO (R1DO)
BRIAN BONSER (R2DO)
ANN MARIE STONE (R3DO)
NEIL OKEEFE (R4DO)
PART 21 GROUP () |
Event Text
DEFECT IN ROTORK'S 30NA1 MOTOR COVER CASTING
A manufacturing defect was discovered in Rotork's 30NA1 motor cover casting part number 4748. When stroking the valve, the motor cover supports the loads developed from the stator torque and the rotor thrust reactions. The failure occurred at the rotor end bearing support. Investigation has shown that the casting was not manufactured to the drawing specification.
The manufacturer is searching their spares database to determine where it has supplied the motors and will inform the utilities once this list is complete. |
| Research Reactor |
Event Number: 46738 |
Facility: OREGON STATE UNIVERSITY
RX Type: 1000 KW TRIGA MARK II
Comments:
Region: 4
City: CORVALLIS State: OR
County: BENTON
License #: R-106
Agreement: Y
Docket: 05000243
NRC Notified By: STEVE REESE
HQ OPS Officer: STEVE SANDIN |
Notification Date: 04/07/2011
Notification Time: 15:25 [ET]
Event Date: 04/06/2011
Event Time: [PDT]
Last Update Date: 04/07/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT |
Person (Organization):
NEIL OKEEFE (R4DO)
AL ADAMS (NRR) |
Event Text
VIOLATION OF LIMITING CONDITION OF OPERATION 3.8.1, REACTIVITY LIMITS
"Summary of Events:
"The Oregon State University TRIGA Reactor (OSTR) staff is designing a new experiment which will utilize reactivity oscillation to measure reactor parameters. During attempts to measure the maximum worth of the oscillating absorber on Wednesday, April 6, it was determined that the worth of the preliminary test absorber is $0.60 at the mid-plane of the core. Technical Specification 3.8.1, Reactivity Limits states in part that 'The absolute value of the reactivity worth of any single unsecured experiment shall be less than $0.50.' Measurements were taken in a manner such that the apparatus qualifies as a movable experiment, and moveable experiments are taken to be a subcategory of unsecured experiments.
"A neutron absorber was fabricated by crushing an existing inch segment of B4C absorber and placing 29.8 grams of the material in a sealed aluminum TRIGA tube. The reactivity of the absorber was not formally calculated, but it was believed that the worth of the absorber would be less than $0.20. This was based on the fact that a full length control rod absorber (15 inch) is worth about $2.00, depending on position in the core. Past experience has also shown that several grams of Cadmium, a very strong thermal neutron absorber, have a reactivity worth of ~$0.20 in the B-1 position where the absorber was being tested.
"To characterize the worth of the absorber, the reactor was first taken critical with the In-Core-Irradiation-Tube (ICIT) installed in the B-1 position. Critical rod heights were measured and core excess was calculated. The reactor remained critical at 15 watts in automatic mode. The absorber was then manually lowered to the bottom of the ICIT by an operator using a length of nylon line. The regulating rod was observed to behave as anticipated, automatically withdrawing until some maximum worth position near core center was reached by the absorber, and then automatically inserting as the absorber was lowered to the bottom of the core. The worth of the absorber when resting at the bottom of the core was estimated to be less than $0.07.
"When power and reg rod position were stable, the absorber was slowly withdrawn 7.5 inches to the geometric center of the core. The reg rod automatically withdrew to compensate. The difference between reg rod position with no absorber present and reg rod position with the absorber at core center indicated that the worth of the absorber at core center was $0.60. As soon as absorber worth was determined, the reactor was shut down and the absorber was withdrawn from the ICIT. Although oscillatory operation was not planned, the fact that the absorber was moved while the reactor was critical qualified the experiment as a moveable experiment. Since $0.60 is in excess of L.C.O. 3.8.1, reactor operation was secured in accordance with Technical Specification 6.6.2.a." |
| Power Reactor |
Event Number: 46739 |
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: TOM STECKLER
HQ OPS Officer: JOE O'HARA |
Notification Date: 04/07/2011
Notification Time: 19:22 [ET]
Event Date: 04/07/2011
Event Time: 16:07 [PDT]
Last Update Date: 04/08/2011 |
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED |
Person (Organization):
NEIL OKEEFE (R4DO)
BRUCE BOGER (NRR)
ART HOWELL (DRA)
THOMAS BLOUNT (NRR)
MIKE BLANKENSHIP (FEMA)
NINA MCDONALD (DHS)
WILLIAM GOTT (IRD) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
N |
0 |
Cold Shutdown |
0 |
Cold Shutdown |
Event Text
UNUSUAL EVENT DECLARED DUE TO HYDROGEN BURN DURING MAINTENANCE
"[The licensee declared an Unusual Event at 1607 PDT due to a] small hydrogen burn when opening the stator cooling water system for maintenance. There were no injuries or equipment damage."
The licensee entered EAL 93U3 'Toxic Gases inside the Protected Area Boundary.'
The licensee notified state/local agencies and will inform the NRC Resident Inspector. The licensee plans to issue a press release.
* * * UPDATE FROM MATT HUMMER TO DONG PARK AT 0003 EDT ON 04/08/11 * * *
"[At 2053 PDT,] Columbia has terminated the Unusual Event declared at 1607 [PDT] on 04/07/11. Conditions throughout the plant have remained stable. Columbia has confirmed there is no hazard to personnel safety nor a challenge to safe plant operation."
The licensee will notify the NRC Resident Inspector.
Notified R4DO (OKeefe), NRR EO (Blount), IRD (Grant), DHS (Jenkins), and FEMA (O'Connell). |
| Power Reactor |
Event Number: 46740 |
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN MILLER
HQ OPS Officer: DONG HWA PARK |
Notification Date: 04/08/2011
Notification Time: 01:02 [ET]
Event Date: 04/07/2011
Event Time: 17:40 [EDT]
Last Update Date: 04/08/2011 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION |
Person (Organization):
BRIAN BONSER (R2DO) |
| 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
LOSS OF THE CONTROL ROOM EMERGENCY VENTILATION SYSTEM
"At approximately 1740 hours on April 7, 2011, a loss of the Control Room Emergency Ventilation (CREV) system occurred. At the time of the event, the plant was performing 0MST-DG13R. 'DG-3 Loading Test.' During performance of this test, the 480 VAC Emergency Bus E-7 main feeder breaker tripped unexpectedly. As a result, the CREV emergency makeup damper 2-VA-2J-D-CB closed on this loss of power, resulting in two CREV subsystems required by TS 3.7.3, 'CREV System,' being inoperable. As a result, this condition could have prevented the fulfillment of the safety function for this system. Brunswick has a shared control room, but only Unit 1 was required to enter TS 3.7.3 Required Action C.1. for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours). Unit 2 was operating in Mode 4 for a scheduled refueling outage and did not meet any applicability conditions for TS 3.7.3.
"Operability of the CREV subsystems was restored and the related LCO was exited at 1931 hours following the restoration of CREV damper 2-VA-2J-D-CB. Investigation of the E-7 bus trip is ongoing. This report is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.
"The safety significance of this event is considered minimal. The condition existed for approximately 1 hour and 51 minutes. Plant staff took immediate action to return the equipment to service. For the brief time the CREV systems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected."
The licensee notified the NRC Resident Inspector. |
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