United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for January 27, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2012 - 01/27/2012

** EVENT NUMBERS **


46380 47423 47522 47612 47617 47619 47622

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General Information Event Number: 46380
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: QUALITY INSPECTION AND TESTING INC.
Region: 4
City: DUTCH JOHN State: UT
County: DAGGET
License #: LA-11238-LO1
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2010
Notification Time: 13:17 [ET]
Event Date: 10/30/2010
Event Time: 07:00 [MDT]
Last Update Date: 01/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
RAYMOND LORSON (NMSS)
MICHELE BURGESS (FSME)
DENNIS ALLSTON (ILTA)

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

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY CAMERA INVOLVED IN A TRANSPORTATION ACCIDENT

A previously terminated Quality Inspection and Testing employee gained unauthorized access to keys of a company vehicle loaded with a radiography camera. The individual appeared intent to drive the vehicle to the Rock Springs Airport located in Wyoming when the truck experienced an accident on Highway 191 about 4 miles south of Dutch John, Utah. When the Utah highway patrol drove up to the accident scene, the patrol found the radiography camera outside of the truck. The SPEC Model 150 radiography camera S/N 1195 containing 40 Curies of Ir-192 was undamaged and placed into the custody of a representative of Quality Inspection and Testing Inc. The individual driving the truck was transported to a medical facility. A survey of the site indicated no spread of contamination or radiation levels above background. A survey of the radiography camera revealed no leakage.

The radiography company was a Louisiana licensee with reciprocity in the State of Utah.

Utah Incident Number: 100006

* * * UPDATE FROM GWYN GALLOWAY TO JOE O'HARA AT 1940 EST ON 1/26/12 * * *

"During the investigation, DRC [Division of Radiation Control] personnel obtained conflicting statements from QIT [Quality Inspection and Testing Inc] management personnel regarding the employee's termination prior to the incident. Additionally, the driver worked two shifts after QIT management stated he had been terminated. The driver claimed he was not terminated until a number of days after his release from the hospital. Other QIT personnel were not aware the driver had been 'terminated' prior to the incident; therefore, the driver was allowed unescorted access to vehicles and devices containing sources from the day QIT management indicated the driver was terminated until the day the accident occurred (approximately 2 to 3 days). Although initially reported as 'stolen' to DRC personnel, to date, the driver has not been charged with the theft of the vehicle or the source and the DRC does not believe that the employee had been terminated."

The state believes that this event does not meet the abnormal occurrence criteria as determined by the Utah Division of Radiation Control.

Utah Incident Number: 100006

Notified R4DO(Drake), NMSS(McCartin), FSME EO(Hsueh), and ILTAB(Hahn)

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

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Agreement State Event Number: 47423
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: HALEY AND ALDRICH, INC.
Region: 1
City: BOSTON State: MA
County:
License #: 20-8251
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/09/2011
Notification Time: 14:16 [ET]
Event Date: 11/09/2011
Event Time: [EST]
Last Update Date: 01/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED SOURCE ROD ON MOISTURE DENSITY GAUGE

The following information was provided by the state via email:

"On 11/9/11 [EST], the licensee reported to the Agency [Massachusetts Radiation Control Program] that a portable moisture density gauge had been damaged by a construction vehicle at a temporary job site. The source rod was bent and extended outside of the shielded gauge body so that it could not be returned to the closed position. The extended rod was left within the measuring hole so that the surrounding soil could provide shielding. A 15-plus-foot radius area was segregated around the damaged gauge. The licensee's radiation safety officer and radiation safety consultant were en route to the site to conduct and oversee the source recovery operation at the time of this report.

"The Agency [Massachusetts Radiation Control Program] considers this event to be open and ongoing.

"Manufacturer: Humboldt Scientific Inc, 5001 Series; Isotopes: Cs-137/ .011 Ci; Am-241/ .044 Ci."


* * * UPDATE ON 1/26/2012 AT 1307 EST FROM TONY CARPENITO TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"The consultant and licensee submitted follow-up reports. An authorized gauge user was attending to the gauge and could not get the attention of the driver of the vehicle being driven in reverse just before gauge damage occurred. The source rod retracted into the gauge body successfully and the gauge was returned in its transport case to the licensee's facility on 11/9/11. A post-retrieval survey determined no residual contamination in the area. Personnel dosimeters worn during retrieval indicated minimal personnel exposure. The licensee presented employees retraining related to construction site safety on 11/10/11. Leak test results indicated no sealed source leakage. The gauge was returned to manufacturer for repairs.

"The Agency considers this event to be CLOSED."

Notified the R1DO (Dentel) and FSME (McIntosh).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47522
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPCINSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 12/13/2011
Notification Time: 19:43 [ET]
Event Date: 12/09/2011
Event Time: 11:59 [CST]
Last Update Date: 01/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BILLY DICKSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION- DEGRADED FIRE BARRIER BETWEEN FIRE AREAS

"A degraded fire barrier between Fire Area (FA) 118 (Bus 26 Room) and FA 128 (Bus 27 Room) has existed during the last three years. The top of the wall between the Bus 26 and Bus 27 room had a missing/degraded fire barrier. At the time of discovery on December 9, 2011 a fire watch was in place. However, it was determined that at various times during the last three years a fire watch was not established.

"Bus 27 has been conservatively aligned to Bus 26 to provide the required degree of separation for redundant safe shutdown trains (between Bus 26 and Bus 25). The fire watch will remain in place as a compensatory measure until the fire barrier is repaired.

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

* * * RETRACTION FROM BRIAN JOHNSON TO JOE O'HARA AT 1555 EST ON 1/26/12 * * *

"An eight hour report per 10 CFR 50.72(b)(3)(ii)(B) was reported on December 13, 2011 for a degraded fire barrier between Fire Area (FA) 118 (Bus 26 Room) and FA 128 (Bus 27 Room.)

'Subsequent engineering analysis determined that the degraded fire barrier maintained the required degree of separation for redundant safe shutdown trains and plant safety was not significantly degraded. The 10 CFR 50.72(b)(3)(ii)(B) report is retracted.

"The NRC Resident Inspector has been informed."

Notified R3DO (L. Kozak)

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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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 01/26/2012
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.

* * * RETRACTION ON 1/26/2012 AT 1339 EST FROM ROBERT MARTIN TO MARK ABRAMOVITZ * * *

"Engineering performed an evaluation to address the impact of the degraded condition on the barrier's design functions. The evaluation concluded that the barrier remained capable of performing its design function with the degraded seal present. Therefore, this condition does not represent an unanalyzed condition that significantly degrades plant safety. The NRC Resident Inspector has been notified."

Notified the R1DO (Dentel).

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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: 01/26/2012
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.

* * * UPDATE AT 1107 EST ON 01/26/12 FROM RICHARD ROWE TO S. SANDIN * * *

"Braidwood Nuclear Station TSC ventilation was restored to available status at 0635 CST on January 26, 2012.

"The previously reported system preventative maintenance has been completed."

The licensee notified the NRC Resident Inspector.

Notified R3DO (L. Kozak).

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