United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 9, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/08/2012 - 02/09/2012

** EVENT NUMBERS **


47633 47642 47645 47649 47651

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Agreement State Event Number: 47633
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT1800494
Agreement: Y
Docket:
NRC Notified By: PHILLIP GRIFFIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/03/2012
Notification Time: 11:10 [ET]
Event Date: 02/02/2012
Event Time: [MST]
Last Update Date: 02/03/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG PATIENT

The following report was received from the State of Utah via email:

"Two patients were scheduled to receive TheraSphere infusions containing microspheres of Yttrium-90 on the same day [02/02/12]. Patient #1 was to receive 5.32 GBq for a treatment dose of 120 Gy. Patient #2 was to receive 1.77 GBq for a treatment dose of 120 Gy. Patient #1 received the dosage for Patient #2 (i.e., 1.77 GBq). The error was detected prior to Patient #2 receiving a dosage. The licensee determined that Patient #1 received a dose that was 33% lower than the prescribed dose in the written directive. The licensee determined this to be a medical event. However, the licensee did not provide enough information to determine if this event is or is not an Abnormal Occurrence. An on-site investigation is planned by the Utah Division of Radiation Control to occur within the next several days."

Utah Event Report ID Number: UT120001.

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: 47642
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GENERAL NUCLEONICS, INC
Region: 4
City: POMONA State: CA
County:
License #: 1288-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/06/2012
Notification Time: 14:54 [ET]
Event Date: 01/11/2012
Event Time: [PST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4DO)
GREG SUBER (FSME)

Event Text

AGREEMENT STATE REPORT - PACKAGE RECEIVED CONTAINING LEAKING SOURCES

The following was received from the State of California via email:

"On Jan. 26, 2012, [the] NRC sent an e-mail to RHB [Radiation Health Branch] management stating that General Nucleonics, Inc. had 22 boxes containing Inflight Blade Inspection (IBIS) devices containing Sr-90 sources (500 microcuries each, Generally Licensed devices) returned to them from the Dept. of the Navy. When the packages were opened, it was discovered that 11 devices were damaged and 5 had removable contamination above 0.005 microcuries. The source manufacturer is QSA Global (formerly AEA Tech), model was Amersham/ now GNI PN # 12205-5 and were installed into GNI PN 12210-1 IBIS Pressure Indicators. Leak testing was performed on 1/11/2012. Source # 3482 / IBIS # 1798, leak test results: 0.13 microcuries of contamination; Source # 1673/ IBIS # 095, leak test results: 0.38 microcuries of contamination; Source # 235 / IBIS # 288, leak test results: 0.30 microcuries of contamination; Source # 2926/ IBIS # 371, leak test results: 0.15 microcuries of contamination; Source # 2843/ IBIS # 378, leak test results: 0.22 microcuries of contamination.

"All indicators were placed into sealed bags and placed into a glove box. The source receiving and testing areas were checked for contamination and none was found. Each IBIS was installed on a U.S.N. CH-53 Sikorsky helicopter for 'warning' of incipient blade failure. Damage had occurred to the top of the indicators, source capsules had been damaged and the source retaining rods were bent from their normal vertical positions. General Nucleonics will be eventually disposing of these devices through a radioactive waste broker."

CA 5010 #: 012612

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Non-Agreement State Event Number: 47645
Rep Org: CHASE ENVIRONMENTAL GROUP
Licensee: NUCOR STEEL COMPANY
Region: 3
City: CRAWFORDSVILLE State: IN
County:
License #: R01108E19
Agreement: N
Docket:
NRC Notified By: CHRIS ECHTERLING
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/08/2012
Notification Time: 10:13 [ET]
Event Date: 02/08/2012
Event Time: 08:30 [EST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN GIESSNER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

SHUTTER ON THICKNESS GAUGE STUCK OPEN

"Chase Environmental Group employees discovered an abnormally high radiation reading on contact with a sealed source gauge at approximately 8:30am EST. Contact readings were 150 mR/hr with the window of the gauge. The shutter indicator light on the C-Frame indicated that the shutter was closed. Cycling the shutter controls did not change the radiation measurements on contact with the window, however the indicator lights cycled from closed to open to closed again.

"The manufacturer was notified and the manufacturer advised that air pressure should be disconnected to cause the shutter to close. After removing air, no changes to radiation levels were found. Nucor employees are arranging for the manufacturer to come on site to repair the gauge as soon as possible.

"Because the shutter will not close, Nucor has locked out air and electrical power to the device to prevent inadvertent operation, and cordoned off the area to prevent anyone from accessing the gauge. Measurements at one foot from the window of the gauge were less than 2 mR/hr. The area is posted as a Radiation Area. Chase Environmental Group employees made all radiation measurements and were wearing dosimetry. No overexposures are expected.

"The gauge involved is at the Nucor Steel company in Crawfordsville, IN. The Nucor NRC License number is 13-25975-01 and the RSO is Dave Sulc. The gauge is a DMC Am-5A, serial# BS21645. The source is Am-241, activity of 1 Ci, and serial# 1979LQ. This is a C-frame thickness gauge to measure steel in a pickling process in the Cold Mill facility of Nucor Steel. The previous leak test of the gauge was August of 2011.

"Chase Environmental Group (licensed in the state of TN, R-01108-E19) is a contractor to Nucor for consulting, training, and leak testing."

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Non-Agreement State Event Number: 47649
Rep Org: AMERICAN ELECTRIC POWER
Licensee: AMERICAN ELECTRIC POWER
Region: 1
City: MOUNDSVILLE State: WV
County:
License #:
Agreement: N
Docket:
NRC Notified By: DENISE POWELL
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 15:55 [ET]
Event Date: 02/07/2012
Event Time: [EST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ART BURRITT (R1DO)
PAUL MICHALAK (FSME)

Event Text

BROKEN SHUTTER CABLE ON FIXED PROCESS GAUGE

While closing a the shutter on a Thermo Fisher Model 5197 gauge containing 100 milliCuries of Cs-137, the operating cable broke. There were no personnel exposures. The gauge shutter is currently shut. The licensee is contacting the manufacturer to arrange for repair.

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Power Reactor Event Number: 47651
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOHN RIDINGER
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 19:31 [ET]
Event Date: 02/08/2012
Event Time: 13:35 [CST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
STEVEN VIAS (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
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

SCRAM FUNCTIONALITY MAY BE DEGRADED IN A APPENDIX R FIRE

"During BFNP NFPA 805 transition review, it was determined in the vent of an Appendix-R fire, the Reactor Protection System (RPS) function could be rendered not functional. The current Appendix R Safe Shutdown Analysis states: "The safe shutdown function of the Reactor Protection System (RPS) is to initiate reactor scram through actuation of the control rod drives. The RPS includes the RPS motor-generator power supplies and associated control and indicating devices, sensors, relays, bypass circuitry, and switches that initiate rapid insertion of control rods (scram) to shutdown the reactor. The RPS utilizes a fail-safe design so that device failures or a loss of power will result in control rod insertion. The scram function will remain available despite any fire-induced spurious signals that may be generated due to the effects of a postulated fire in any fire area. This system is expected to perform its function automatically, however credit is taken only for manual scram. No additional analysis is needed to ensure the availability of reactor scram in the even of a fire.

"Due to lack of physical separation with 120 volt AC lighting circuitry, the RPS system potentially could remain energized due to a postulated hot short circuit during a fire which could potentially prevent the control rods from inserting. Therefore, the fail-safe design of the RPS system would not be maintained. Compensatory actions in the form of fire watches to mitigate this condition are in place in accordance with the BFNP Fire Protection Report.

"This event is reportable as an 8-hour notification to the NRC in accordance with 10CFR50.73(a)(2)(ii)(B).

"The NRC Resident Inspector has been notified of this event.

"This event was entered into the licensee's Corrective Action Program as PER 503304."

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