| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
01/23/2012 - 01/24/2012 ** EVENT NUMBERS ** |
 | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Part 21 | Event Number: 47521 | Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: EMERSON PROCESS MANAGEMENT
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE BAITLINGER
HQ OPS Officer: VINCE KLCO | Notification Date: 12/13/2011
Notification Time: 16:55 [ET]
Event Date: 10/13/2011
Event Time: 12:00 [CST]
Last Update Date: 01/23/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
| Person (Organization):
BILLY DICKSON (R3DO)
PART 21 via email ()
| Event Text FISHER CONTROLS PART 21 NOTIFICATION INTERIM REPORT - POSSIBLE DISC PIN ISSUE ON A TYPE A11 BUTTERFLY VALVE
The following information was received by facsimile:
"Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International, LLC (Fisher) is providing the required written interim notification of a possible deviation or failure to comply. On October 13, 2011, Fisher became aware of a possible issue with the disc pin engagement of a 20" type A11 butterfly Valve, serial number 19102243. The affected valve was returned to Fisher for evaluation and correction and, upon correction, was returned to the customer [Clinton Power Station] on November 21, 2011.
"Fisher expects to complete its evaluation by January 31, 2012. At that time, if the evaluation reveals that a potential issue exists with the disc pin engagement, Fisher will issue a notification per the requirements of 10 CFR 21.21(b)."
* * * UPDATE AT 1539 EST ON 01/23/121 FROM GEORGE BAITINGER TO S. SANDIN * * *
This report is retracted based on the following:
"Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International LLC (Fisher) is providing the required written final notification of a possible deviation or failure to comply.
"On December 13, 2011, Fisher provided an interim notification of a possible deviation or failure to comply concerning a possible issue with the disc pin engagement of a 20 inch Type A 11 butterfly valve, serial number 19102243. The affected valve was returned to Fisher for evaluation and correction and, upon correction, was returned to the customer on November 21, 2011.
"Fisher has completed the review of the valve design and has determined that this potential issue would not have negatively affected the subject valve or its performance. Therefore, Fisher will not be issuing a notification per the requirements of 10 CFR 21 21.21(b)."
Notified R3DO (Kozak) and Part 21 Group via email. |
| Non-Agreement State | Event Number: 47599 | Rep Org: AVERA MCKENNAN HOSPITAL
Licensee: AVERA MCKENNAN HOSPITAL
Region: 4
City: SIOUX FALLS State: SD
County: MINNEHAHA
License #: 4016571-01
Agreement: N
Docket:
NRC Notified By: RICHARD MASSOTH
HQ OPS Officer: VINCE KLCO | Notification Date: 01/17/2012
Notification Time: 13:04 [ET]
Event Date: 01/16/2012
Event Time: 16:00 [MST]
Last Update Date: 01/17/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
GREG PICK (R4DO)
ANGELA MCINTOSH (FSME)
| Event Text MEDICAL EVENT DUE TO POTENTIAL DIFFERENT FRACTIONAL DOSE DELIVERED THAN PRESCRIBED
The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.
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: 47601 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL WELL SERVICES
Region: 1
City: MT. BRADDOCK State: PA
County:
License #: PA-G0042
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/18/2012
Notification Time: 10:29 [ET]
Event Date: 12/16/2011
Event Time: 08:00 [EST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - SHUTTER FAILURE ON BERTHOLD TECHNOLOGIES DETECTOR
The following report was received via facsimile from the PA Department of Radiation Protection.
"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business, to the central office about an event that took place on March 18, 2011. This email was received by central office on Tuesday January 17, 2012. It is reportable within 24 hours under 10 CFR 30.50(b)(2).
"Event Description: On March 18, 2011, a service vendor was at Universal Well Services to perform a change of the iron piping. At that time, they noticed an improper functioning shutter mechanism and it was temporarily fixed. On December 16, 2011, the licensee was inspected by Pennsylvania DEP (Dept. of Environmental Protection). It was found that the shutter on the Berthold Technologies Detector, Serial Number 10072 had been replaced on December 15, 2011 with a new shutter Serial Number 10275, permanently fixing the shutter failure.
"The device is identified as: Manufacturer: Berthold Technologies USA, LLC; Serial #: 10072 (becoming 10275); Isotope: Cs-137; Activity: 20 mCi.
"CAUSE OF THE EVENT: Excessive build-up of debris
"ACTIONS: The licensee was directed to make the required notification immediately after receiving an NOV (Notice of Violation) from Pennsylvania DEP dated January 13, 2012 about the shutter failure discovered during an inspection on December 16, 2011."
PA Report ID No.: PA110041. |
| Agreement State | Event Number: 47602 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL WELL SERVICES
Region: 1
City: WILLIAMSPORT State: PA
County:
License #: PA-G0043
Agreement: Y
Docket:
NRC Notified By: DAVID J ALLARD
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/18/2012
Notification Time: 10:29 [ET]
Event Date: 11/21/2011
Event Time: 08:00 [EST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - SHUTTER HANDLE FAILURE ON BERTHOLD TECHNOLOGIES DENSITY GAUGE
The following report was received via facsimile from the PA Department of Radiation Protection.
"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business to the central office about an event that took place on approximately November 21, 2011. This email was received by central office on Tuesday, January 17, 2012. It is reportable within 24 hours under 10 CFR 30.50(b)(2).
"Event Description: It was noticed during a job on approximately November 21, 2011, the shutter handle of Berthold Technologies density gauge, Serial Number 10049, had fallen off due to constant vibration and cavitation of the iron piping on the truck. This caused the roll pin that secures the rotary shutter handle to the shutter shaft to wear and eventually fall off. The gauge was temporarily repaired in the field, and reported on November 29, 2011 to the company's safety officer. The gauge was immediately taken out of service and scheduled for repair.
"The device is identified as: Manufacturer: Berthold Technologies USA, LLC; Model: LB8010; Serial #: 10049; Isotope: Cs-137; Activity: 20 mCi.
"CAUSE OF THE EVENT: Excessive vibration of the equipment.
"ACTIONS: On December 1, 2011 repairs were made to Serial Number 10049. For preventative maintenance, the roll pin was replaced on Serial Number 10055 as well."
Event Report ID No.: PA110042 |
| Agreement State | Event Number: 47603 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL WELL SYSTEMS
Region: 1
City: WILLIAMSPORT State: PA
County:
License #: PA-G0043
Agreement: Y
Docket:
NRC Notified By: DAVID J ALLARD
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/18/2012
Notification Time: 10:29 [ET]
Event Date: 09/29/2011
Event Time: 08:00 [EST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - SHUTTER FAILURE DUE TO DROPPING OF A BERTHOLD TECHNOLOGIES DENSITY GAUGE
The following report was received via facsimile from the PA Department of Radiation Protection.
"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business to the central office about an event that took place on September 29, 2011. This email was received by central office on Tuesday, January 17, 2012. It is reportable within 24 hours under 10 CFR 30.50(b)(2).
"Event Description: On September 29, 2011, a gauge with Serial Number 10153 was dropped, bending the shutter control handle, leaving the shutter stuck closed. The workers did not notify anyone of the incident and the gauge was put in storage. When the gauge was to be put back in service on November 10, 2011, it was then observed to be in the damaged condition. The gauge was then put back into a secured storage until the repair could be made. The gauge was repaired by replacing the shutter with a new Serial Number 10306 on December 1, 2011.
"The device is identified as - Manufacturer: Berthold Technologies USA, LLC; Model: LB8010; Serial #: 10153 (replaced by 10306); Isotope: Cs-137; Activity: 20 mCi.
"CAUSE OF THE EVENT: Human error.
"ACTIONS: On December 1, 2011 repairs were made. This was discovered on an inspection by the Department on December 16, 2011."
Event Report ID No.: PA110043. |
| Agreement State | Event Number: 47605 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-1280
Agreement: Y
Docket:
NRC Notified By: DAVID J ALLARD
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/18/2012
Notification Time: 13:59 [ET]
Event Date: 01/17/2012
Event Time: 08:00 [EST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - BROKEN THERMO MEASURE TECH MODEL 5204 COLLIMATOR
The following report was received via facsimile from the PA Department of Radiation Protection.
"Notifications: The department's western regional office received a phone call on January 17, 2012 and then referred the matter to the central office via email and telephone on January 18, 2012. This event is reportable within 24 hours under 10 CFR 30.50(b)(2)(i).
"Event Description: A collimator failure was discovered during a monthly routine maintenance check on January 17, 2012. The collimator had broken off of the shutter mechanism.
"The device is identified as - Manufacturer: Thermo Measure Tech; Model 5204; Isotope: Cs-137; Activity: 4 Ci.
"CAUSE OF THE EVENT: Equipment Failure
"ACTIONS: Upon discovery, a service provider was contacted and repairs were made by replacing the collimator with a spare one. Surveys were performed to verify appropriate conditions. No employees were exposed to excess levels of radiation as a result of this failure. A 30 day licensee report is expected. The department plans to conduct a reactive inspection."
Event Report ID No.: PA120002 |
| Agreement State | Event Number: 47607 | Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSAL ENGINEERING SCIENCES, INC.
Region: 1
City: ORLANDO State: FL
County:
License #: 1136-1
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: STEVE SANDIN | Notification Date: 01/18/2012
Notification Time: 16:37 [ET]
Event Date: 01/18/2012
Event Time: [EST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)
| Event Text AGREEMENT STATE REPORT INVOLVING A DAMAGED TROXLER GAUGE
The following report was received from the State of Florida via fax:
A Troxler gauge, Model 3440, was run over and the housing cracked. The source was retracted at the time. The incident is currently under investigation.
FL Incident Number: FL12-005 |
| Agreement State | Event Number: 47608 | Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: G.E. HEALTHCARE
Region: 3
City: ARLINGTON HEIGHTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JOE O'HARA | Notification Date: 01/18/2012
Notification Time: 16:50 [ET]
Event Date: 01/14/2012
Event Time: [CST]
Last Update Date: 01/18/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GREG PICK (R4DO)
HIRONORI PETERSON (R3DO)
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)
| Event Text AGREEMENT STATE REPORT - MISSING THEN RECOVERED THALLIUM-201 SOURCE
"On January 17, 2011 the licensee's radiation safety officer called [the state] to advise that a portion of a shipment of radiological material to be used for medical purposes had not arrived at its intended destination. A package containing two doses of Thallium-201 of nominally 20 milliCi each was picked up by the Texas licensee, Pan Handle Nuclear, on January 14, 2012 in Amarillo. However, the package showed signs of repaired damage and when inspected, the third dose of Thallium-201 was missing from the package. The manufacturer was alerted on the morning of January 16th and they subsequently contacted the carrier, regarding the package.
"HazMat Personnel from [the shipping company] conducted a trace of their facilities associated with the transfer which resulted in the missing vial being identified as 'found' in the Memphis 'Over goods' holding area. Apparently, the package had become damaged early in the morning on January 14th during the shipping process such that one of the three vials had escaped the packaging. The damage to the package was noted and repaired, however an accurate count of the contents was not conducted and, contrary to standing instructions from the manufacturer, the package was forwarded to the intended recipient rather than being returned to the manufacturer.
"The 'missing' vial was subsequently found on the same day later that morning, some hours after the package was processed through the Memphis hub. The vial was identified as hazardous based on the trefoil which appeared on the shielded and intact container and the manufacturer's name. It was isolated and placed into an over pack that same day. The slightly damaged, but intact shielded container was then returned to the manufacturer as of January 18, 2012 after it was determined to be the 'missing' third vial. Surveys of the returned vial conducted by the manufacturer showed that there was no external contamination on the shielded vial, there was no damage to the vial and all the expected material remained present."
Illinois Item Number: IL 12004 |
| Power Reactor | Event Number: 47615 | Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KENNETH GRACIA
HQ OPS Officer: STEVE SANDIN | Notification Date: 01/23/2012
Notification Time: 12:43 [ET]
Event Date: 01/23/2012
Event Time: 06:33 [EST]
Last Update Date: 01/23/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
GLENN DENTEL (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 TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED MAINTENANCE
"On January 23, 2012 at 0633 hours, planned routine preventive maintenance was initiated on the Technical Support Center/Operations Support Center (TSC/OSC) diesel generator. The planned maintenance includes fluid and filter replacements, damper inspections and cleaning and is scheduled to be complete on January 26, at 1500 hours. The normal TSC/OSC power supply and all other TSC/OSC functions remain available. During certain periods of the preventive maintenance the diesel generator would not be capable of being restored to service within one hour.
"Under certain accident conditions the TSC/OSC may become unavailable as a result of the diesel generator not being available. Existing Emergency Procedures direct the responsible Emergency Plant Manager to relocate the TSC/OSC staff to the designated alternate location (EOF or main control room) as required. The affected Emergency Response Organization facility leads have been informed.
"The USNRC Resident Inspector Staff has been notified.
"This notification to the USNRC Operations Center is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the potential loss of an Emergency Response Facility (ERF)."
The licensee plans to notify the Commonwealth of Massachusetts. |
| Power Reactor | Event Number: 47618 | Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: JOSEPH TODD
HQ OPS Officer: STEVE SANDIN | Notification Date: 01/23/2012
Notification Time: 18:51 [ET]
Event Date: 01/23/2012
Event Time: 18:04 [EST]
Last Update Date: 01/23/2012 | Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
| Person (Organization):
DEBORAH SEYMOUR (R2DO)
MELANIE GALLOWAY (NRR)
WILLIAM GOTT (IRD)
BRUCE BOGER (ET)
VICTOR McCREE (R2RA)
D. HAYMAN (FEMA)
DANIEL GATES (DHS)
|
| 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 UNSUAL EVENT DECLARED DUE TO FIRE INSIDE CONTAINMENT LASTING > 15 MINUTES
At 1804 EST on 01/23/12, Unit 2 declared an Unusual Event due to an electrical fire in the control cabinet on the Polar Crane. The fire brigade responded, de-energized the equipment and confirmed that the fire was extinguished. There were no injuries as a result of this incident.
At 1837 EST, the license terminated the Unusual Event classification.
Unit 2 is currently in mode 5 (Cold Shutdown) for a Refueling Outage.
The licensee informed state/local agencies and the NRC Resident Inspector. |
| Power Reactor | Event Number: 47619 | Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOE GIOFFRE
HQ OPS Officer: JOHN KNOKE | Notification Date: 01/23/2012
Notification Time: 20:59 [ET]
Event Date: 01/23/2012
Event Time: 13:00 [EST]
Last Update Date: 01/23/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
GLENN DENTEL (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 | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text BREACH IN HIGH ENERGY LINE BREAK BARRIER
"At 1300 EST on 1/23/12, it was determined that an unanalyzed condition existed for the Unit 1 Cable Spreading Room. A high energy line break (HELB) barrier issue was discovered while performing a HELB inspection and the condition is believed to have existed from initial plant construction. A HELB barrier was found to have a breach in it that could allow steam from a high energy line break in the Unit 1 Turbine Building [into the cable spreading room and thus into the control room]. The Control Room is not analyzed for a steam environment. The degree of the impact could not be readily determined, but could likely affect the safety related equipment in the Cable Spreading Room. Therefore, an 8-hour report to the NRC is required under 10 CFR 50.72(b)(3)(ii)(B), 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'"
The licensee will notify the NRC Resident Inspector. | |