United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for January 19, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/18/2012 - 01/19/2012

** EVENT NUMBERS **


47476 47579 47589 47591 47592 47593 47604 47606 47609

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47476
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MIKE TERRY
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/24/2011
Notification Time: 11:17 [ET]
Event Date: 11/24/2011
Event Time: 03:15 [CST]
Last Update Date: 01/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JULIO LARA (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

Event Text

EMERGENCY 4160 VOLT AC BUSSES DECLARED INOPERABLE

"On Thursday, November 24, 2011, at 0315 CST, with the reactor at 100% steady state thermal power, Kewaunee Power Station declared both emergency 4160 Volt AC busses inoperable due to voltages being high outside of the procedurally directed voltage band. As a result, in accordance with Technical Specification 3.8.9, Distribution Sources - Operating, Kewaunee entered Technical Specification LCO 3.0.3 to, within 1 hour, initiate shutdown of the unit. At 0410 [CST], per management direction, the load tap changers for the supply transformers were adjusted to reduce the emergency bus voltages to within their procedural operating band. At this time, both emergency busses were declared Operable and LCO 3.0.3 was exited. Minimum required accident voltages were met at all times.

"The NRC Resident Inspector has been notified."

* * * RETRACTED AT 1515 EST ON 01/18/12 FROM RICHARD REPSHAS TO S. SANDIN * * *

"On November 24, 2011, EN # 47476 provided notification that both emergency 4160 Volt AC busses were inoperable based on voltages being high outside of a procedurally directed voltage band.

"Subsequent investigation and analysis determined that unnecessary conservatisms were used in the development of the voltage values used in procedure, OSP-MISC-002, Electrical Power System Weekly Surveillance Test. Review of the actual voltages present during the event determined that the voltages did not exceed the required values to support bus operability.

"Therefore, the busses remained operable and this condition did not meet the reportability criteria identified in 10 CFR 50.72. As a result, the notification made on 11/24/2011 is hereby retracted."

The licensee informed the NRC Resident Inspector.

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Non-Agreement State Event Number: 47579
Rep Org: BENEFIS HEALTH CARE
Licensee: BENEFIS HEALTH CARE
Region: 4
City: GREAT FALLS State: MT
County:
License #: 25-12710-01
Agreement: N
Docket:
NRC Notified By: KARI CANN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/09/2012
Notification Time: 16:00 [ET]
Event Date: 01/05/2012
Event Time: [MST]
Last Update Date: 01/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RYAN LANTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

MEDICAL UNDEREXPOSURE TO TARGET AREA USING HIGH DOSE RATE AFTERLOADER DEVICE

The licensee reported that a patient received only about 10% of the required dose to the target area during a treatment for esophageal cancer. The prescribed dose for the esophageal region was 700 centigray. The area was being treated with a Varian High Dose Rate Brachytherapy Afterloader device using a 6.344 Curie Ir-192 source. The location of the source is normally tracked by a radiographically opaque image near the source. In this case, the end of the catheter also appeared somewhat radiographically opaque and was mistaken for the source location. Consequently, the source was mispositioned about 4 cm back from the intended target area resulting in the underexposure.

The physician and patient have been notified and no health effects are anticipated from the area that was unintentionally exposed due to the mispositioning of the source.

* * * UPDATE AT 1345 EST ON 01/18/12 FROM KARI CANN TO S. SANDIN * * *

The licensee is continuing their review of this incident and have determined that the source may have been mispositioned by as much as 29 cm back from the intended target area. This may have resulted in excessive exposure to portions of the upper neck and back of the patient. A physician has scheduled an anatomical examination of the patient tomorrow to assess if there are any adverse effects related to the treatment. NRC Region IV Inspectors are currently on-site.

Notified R4DO (Pick) and FSME (McIntosh).

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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Agreement State Event Number: 47589
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS GAMMA RAY LLC
Region: 4
City: KATY State: TX
County:
License #: 05561
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/13/2012
Notification Time: 08:48 [ET]
Event Date: 01/10/2012
Event Time: [CST]
Last Update Date: 01/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY SOURCE TO RETRACT

The following information was received via E-mail:

"On January 13, 2012, the Agency [Texas Department of State Health Services, Radiation Branch] was notified by the licensee that a source disconnect had occurred on January 10, 2012 at one of their job sites. The radiographer was using a Spec model 300 radiography camera containing a 116 curies cobalt-60 source. They had completed 20 exposures. After their last exposure, they approached the radiography camera and noted that their dose rate instrument was indicating that the source was not shielded. The radiographer returned to the end of the crank out device to make sure that he had retracted the source. The radiographer found that while the drive cable was completely retracted, the lock was not operating, and the source was still exposed. The radiographer contacted the company's Radiation Safety Officer (RSO). The radiographers set new boundaries at two millirem per hour and waited for the RSO. The RSO arrived at the location and determined that the source was located in the collimator. The RSO retrieved the source without incident.

"An inspection of the connector on the source pig tail indicated that it had spread allowing it to disconnect. The licensee is sending the source to the manufacturer for inspection. No exposure limits were exceeded during this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-8919.

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Agreement State Event Number: 47591
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: VINCE KLCO
Notification Date: 01/13/2012
Notification Time: 15:34 [ET]
Event Date: 01/04/2012
Event Time: 09:30 [CST]
Last Update Date: 01/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA NOT PROPERLY SECURED

The following information was received by facsimile:

"This is a report of a transportation incident where an Industrial Radiography Camera was not properly secured. The RSO stated that two radiographers, one an instructor, conducted a radiography job in Bay St. Louis, Mississippi. On January 4, 2012, while returning to the Baton Rouge, LA office, they decided to meet with another radiographer who is an instructor on the radioactive materials license for Mistras and one of the other radiographer's father. The father offered to take the radiography camera to the office in Baton Rouge, LA. The instructor from the radiography job in Bay St. Louis agreed, but did not realize that the father did not have his radiography truck. The father put the camera in the trunk of his personal vehicle unsecured and unbraced. After noticing that the father and son did not have some of the required paperwork, the instructor pursued them. Approximately 2 miles down the road, the father and son in the same vehicle were pulled over for speeding. After they were pulled over, the son, who was driving, was suspected of intoxication and tested. The RSO received a call from the father regarding the impending arrest of the son for DUI at [2130 CST]. The son was arrested for DUI and the instructor from the radiography job secured the radiography camera. The father was arrested for outstanding warrants. Both the father and son were suspected of being under the influence, but the father refused to be tested by law enforcement. The RSO arrived to the site at [2200 CST]. The camera was placed in the Mistras storage vault around [0030 CST on January 5, 2012].

"Mistras is conducting an internal investigation. Louisiana Department of Environmental Quality is investigating. So far, the son's employment has been terminated. The father's Trustworthy and Reliability status has been suspended. All radiographers will be drug tested. Additional information will be forthcoming."

Louisiana Incident Number: LA120001

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Agreement State Event Number: 47592
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: LOUISIANA SCRAP METAL RECYCLING
Region: 4
City: Lafayette State: LA
County:
License #: LA-10073-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: VINCE KLCO
Notification Date: 01/13/2012
Notification Time: 15:35 [ET]
Event Date: 01/06/2012
Event Time: 10:48 [CST]
Last Update Date: 01/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
RICHARD TURTIL (FSME)
MATTHEW HAHN - email ()

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

Event Text

AGREEMENT STATE REPORT - LOST ANALYZER

The following information was received via facsimile:

"[The] Environmental Safety Manager of Louisiana Scrap Metal Recycling notified the [Louisiana] Department of Environmental Quality of a lost Niton XLI 818 Q/serial number 6066 analyzer with 30 mCi of Am-241 on January 6, 2012.

"FINDINGS: The investigation was conducted at Louisiana Scrap Metal Recycling in Lafayette. Contact was made with the Environmental Safety Manager and the [Non-Ferrous Manager], who provided the following information of their internal investigation.

"The facility's investigation revealed that on January 5, 2012, [Employee #1] was scanning a customer's trailer to identify the type metal in the load, with a Niton XLI 818Q/serial number 6066 analyzer with 30 mCi of Am-241. The analyzer was discovered missing the next morning, January 6, 2012 by [Employee #2] at approximately [0900 CST and notified the department at 1048 CST on January 6, 2012 of the missing source. [Employee #2] called [Employee #1] to try to reconstruct his actions of the previous day since he had signed out the analyzer on the utilization log. [Employee #1] stated that he believed that he must have left the analyzer on the trailer of a customer. [Employee #2] called the customer to ask if he had found the analyzer and also the route he took to go home. The customer stated that he had not found the analyzer. [Employee #2] then retraced the route to search for the missing analyzer for approximately eight hours but was not successful. The analyzer is still missing to date, however does not pose a health hazard to the general public.

"In conclusion the licensee did not secure licensed radioactive material from unauthorized removal or access. The above area is contrary to LAC 33:XV.445.A. The licensee failed to maintain constant surveillance to prevent unauthorized use of licensed radioactive material that is in a controlled or unrestrictive area. The above area is contrary to LAC 33:XV.445.B. The licensee also failed to have the minimum of two independent physical controls that form a tangible barrier to secure portable gauges from unauthorized removal, whenever portable gauges are not under the control and constant surveillance of the licensee. The above area is contrary to LAC 33:XV.326.B."

Louisiana Incident Number: LA120002

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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Agreement State Event Number: 47593
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MEMORIAL HERMANN HOUSTON
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB FREE
HQ OPS Officer: VINCE KLCO
Notification Date: 01/13/2012
Notification Time: 18:27 [ET]
Event Date: 01/13/2012
Event Time: [CST]
Last Update Date: 01/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

A patient of Memorial Hermann in Houston received the wrong radioisotope. A dose of Gallium-67 was ordered, but a dose of Thallium-201 was delivered. Because the dose was improperly labeled as Gallium-67, the dose calibration process indicated an acceptable radioisotope and dose. The patient was injected with the wrong radioisotope on January 11, 2012. During patient imaging on January 13, 2012, it was realized that the patient received the wrong radioisotope. The pharmacy was notified of the error and admitted to delivery of the wrong isotope. The physicist at the hospital estimates that the patient received a dose of about 6 REM whole body.

Texas Incident Number: I-8921

* * * UPDATED AT 1434 EST ON 01/17/12 FROM ROBERT FREE TO S. SANDIN * * *

The following information was received as an update:

"The licensee called to report that the wrong isotope was administered to a patient. Thallium 201 had been injected in a patient instead of Gallium 67 that was ordered. Apparently, the pharmacy sent the wrong isotope. 8 mCi of Gallium was ordered and a estimated 4.7 mCi of Thallium was delivered. Dose activities were similar and the dose calibrator didn't pick up the difference in isotope. Patient was injected on 1/11/12 and imaged 1/13/12. The mistake was discovered in imaging. The licensee will file a written report within 15 days."

Notified R4DO (Pick) and FSME (McIntosh).

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: 47604
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: KENT CHAVET
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/18/2012
Notification Time: 12:30 [ET]
Event Date: 01/17/2012
Event Time: 14:49 [MST]
Last Update Date: 01/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GREG PICK (R4DO)

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
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY REPORT INVOLVING A CONTRACT EMPLOYEE SUPERVISOR

A non-licensed contract employee supervisor had a confirmed positive for an illegal substance taken during a pre-access fitness-for-duty test. The contract employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Non-Agreement State Event Number: 47606
Rep Org: U.S.ARMY TACOM LIFE CYCLE COMMAND
Licensee: U.S. ARMY NATIONAL GUARD
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JOE O'HARA
Notification Date: 01/18/2012
Notification Time: 15:41 [ET]
Event Date: 01/18/2012
Event Time: 13:24 [EST]
Last Update Date: 01/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
HIRONORI PETERSON (R3DO)
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)

Event Text

POTENTIALLY DAMAGED RANGE INDICATOR CONTAINING 3.2 CURIES TRITIUM

The U.S. Army Life Cycle Command was informed by the Combined Support Maintenance Shop in Richmond, Virginia that a range indicator containing 4 sources of 0.8 Curies each of Tritium may be damaged. Apparently, the range indicators appear cracked and are not illuminating properly. The range indicator is locked inside a secured area with no access allowed. The U.S. Army is waiting for results of swipe surveys to determine if there is an actual spread of contamination.

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Power Reactor Event Number: 47609
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GREGORY A. WALLACE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/18/2012
Notification Time: 17:12 [ET]
Event Date: 01/17/2012
Event Time: 17:46 [EST]
Last Update Date: 01/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
DEBORAH SEYMOUR (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

24-HOUR REPORT PER SECTION 2.G OF UNIT 1 OPERATING LICENSE

"Surveillance Requirement 3.8.4.14 for LCO 3.8.4, "DC Sources - Operating," was performed on 02/10/11 for the 125 VDC Vital Battery 4 (VB4). The recorded capacity was 80.2% and VB4 was declared OPERABLE at that time.

"On 06/27/11 VB4 failed the service test as required by SR 3.8.4.13. Prior to the test VB5 was aligned to Vital Battery Board IV. VB5 had previously passed its required SRs within the required surveillance frequency. With VB5 re-aligned to Vital Battery Board IV, the plant was in a configuration that would allow it to meet all design bases events including a four hour station blackout. The eight weakest cells in VB4 were replaced and VB4 re-tested in accordance with SR 3.8.4.13. VB4 passed its acceptance criteria and VB4 was returned to service on 07/06/11.

"However, on 01/17/12, an independent analysis of the computer generated test data indicated that the actual battery capacity calculated on 02/10/11 was 79.87% which is less than the acceptance criteria of 80%. Therefore, between 02/10/11 and 06/27/11, VB4 was inoperable and the plant was in a condition prohibited by TS.

"On 01/06/12 a functional test was performed on VB4. The functional test is a service test using a single unit load profile. The single unit load profile consists of Unit 1 loads, common loads, and loads transferred from Unit 2 to Unit 1. VB4 passed the acceptance criterion (105 Vdc) with a terminal voltage of 111.9 Vdc. This test indicates that VB4 was functional from 02/10/11 to 06/27/11.

"VB4 has been replaced with new battery cells and the acceptance criteria for SR 3.8.4.13 and SR 3.8.4.14 were met."

The error in the recorded capacity of 80.2% was discovered during a root cause investigation and attributed to arithmetical rounding errors. The licensee is continuing their investigation to determine extent of condition.

The licensee informed the NRC Resident Inspector.

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