United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for January 26, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/25/2012 - 01/26/2012

** EVENT NUMBERS **


47610 47612 47617 47622

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Agreement State Event Number: 47610
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SUNBURY GENERATION
Region: 1
City: SHAMOKIN DAM State: PA
County:
License #: PA-G0283
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2012
Notification Time: 13:59 [ET]
Event Date: 01/19/2012
Event Time: 13:15 [EST]
Last Update Date: 01/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - FOUR NUCLEAR GAUGES FAILED SEMIANNUAL SHUTTER CHECK

The following information was provided by the Commonwealth of Pennsylvania via email:

"The Department's [PA Bureau of Radiation Protection] central office received an email on January 19, 2012. This event is reportable within 24-hours under 10CFR 30.50(b)(2).

"EVENT DESCRIPTION: It was determined on January 19, 2012 during the six month shutter check that the remote actuator cables and one handle on four devices are inoperable.

"The devices are identified as:
Manufacturer Model Serial Isotope Activity
Texas Nuclear 5197 81624 Cs-137 100 mCi
Texas Nuclear 5197 81631 Cs-137 100 mCi
Texas Nuclear 5197 81634 Cs-137 100 mCi
Texas Nuclear 5197 81635 Cs-137 100 mCi

"CAUSE OF THE EVENT: Normal wear and tear (30+ year old gauges)

"ACTIONS: The shutters are in the locked and closed position and shall remain so until qualified repairs can be made. The gauges are planned to be removed and returned to the manufacturer. No employees were exposed to excess levels of radiation as a result of these failures. The Department plans to conduct a reactive inspection."

Event Report ID No: PA120003

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Agreement State Event Number: 47612
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2012
Notification Time: 19:12 [ET]
Event Date: 01/20/2012
Event Time: 14:09 [EST]
Last Update Date: 01/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF DOSE TO PATIENT

The following information was provided by the Commonwealth of Pennsylvania via facsimile:

"On January 20, 2012, at 1409 EST, the Department's [PA Bureau of Radiation Protection] southeast regional office received notification via phone call about this ME [Medical Event].

"On January 19, 2012, a worksheet was prepared for two patients who were to be treated on the same day, close in time. The worksheets were switched and each patient received the other patient's dose. The first patient reached stasis before receiving the full amount and received a dose 35% above the planned dose. The second patient received 55% less than what was planned.

"CAUSE OF THE EVENT: Human error.

"ACTIONS: No adverse effects are expected from the overdose to the first patient. The second patient will receive a higher dose than planned at their next schedule treatment. The licensee plans on modifying their current procedures to prevent this event from occurring again. The Department plans to do a reactive inspection."

Event Report 10 No: PA120005

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: 47617
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: NUKOTE
Region: 1
City: CONNELLSVILLE State: PA
County:
License #: PA-G0247
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/23/2012
Notification Time: 18:11 [ET]
Event Date: 08/01/2009
Event Time: [EST]
Last Update Date: 01/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
BRUCE WATSON (FSME)

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

Event Text

AGREEMENT STATE REPORT - ABANDONED GENERALLY LICENSED SOURCES

The following report was received from the Commonwealth of Pennsylvania via fax:

"Event Description: International Communication Materials, Inc., (lCMI), a subsidiary of Nukote International, Inc., is a defunct manufacturer of toner and ink cartridges, which had operated a facility that closed in August 2009. This event wasn't discovered until the Department's [PA Bureau of Radiation Protection] Southwest Region inspected ICMI's factory in September 2010. The [ICMI] building was found unsecured, and [gauges were found with] the gauge shutters open and unlocked. The Department located two former ICMI employees, who secured the building and allowed the DEP to close and lock the shutters with padlocks. In August 2011, the SW Region again discovered the ICMI factory unsecure. The Department, with the Pennsylvania State Police, then conducted a joint inspection and discovered evidence that trespassers had entered the building and may have stolen copper pipes. After several unsuccessful attempts to contact Nukote International or ICMI, the Department then communicated with Nukote's largest creditor, CIT Group, and obtained their cooperation in securing both the building and the GL gauges.

"Sources: Three (3) Kay-Ray / Sensail, Inc., Cs-137 GL sources, each 25 mCi
"Serial Nos.: S96M1001, S96M1009, S96M1010

"CAUSE OF THE EVENT: Human Error - failure of ICMI to secure licensed material.

"ACTIONS: As of January 18, 2012, the purchaser / transferee intends to dispose of the generally licensed unit's all together. The transferee has already received quotes from various licensed vendors and will be selecting a vendor as soon as possible.

"Media attention: None at this time

"PA Event Report ID No: PA090045"

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

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Power Reactor Event Number: 47622
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RYAN SZCZESNIAK
HQ OPS Officer: VINCE KLCO
Notification Date: 01/25/2012
Notification Time: 21:39 [ET]
Event Date: 01/25/2012
Event Time: 21:00 [CST]
Last Update Date: 01/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (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

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"Planned preventive maintenance activities are being performed on the Braidwood Nuclear Station Technical Support Center (TSC) Ventilation System. These work activities are planned to be performed and completed expeditiously within 8 hours. This maintenance activity includes the performance of preventive maintenance on the TSC outside air supply fan unit which affects the TSC emergency filter train and air handling unit. During a portion of the time these activities are being performed, this equipment will not be available for operation. As such, the TSC Ventilation will be rendered non-functional during the performance of portions of the work activity.

"If an emergency condition occurs that requires activation of the Technical Support Center, during the time this work activity is being performed, it will take no more than 4 hours to return the equipment back to functional status, dependent on the stage of the work activity at the time an emergency occurs. Plans are to utilize the TSC for any declared emergency during the time this work activity is being performed as long as radiological conditions allow.

"This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the maintenance."

The licensee notified the NRC Resident Inspector.

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