United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 10, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/09/2012 - 02/10/2012

** EVENT NUMBERS **


47633 47642 47645 47652 47653 47655 47656

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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 #: 13-25975-01
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: 02/09/2012
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 8:30 a.m. 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."

* * * UPDATE FROM CHRIS ECHTERLING TO JOE O'HARA AT 1608 EST ON 02/09/12 * * *

The following was received via e-mail.

"On February 8th, 2012, a sealed source gauge abnormal event was reported, event# 47645. Today, a representative from Advanced Gauging Technologies, LLC arrived at Nucor Steel Crawfordsville and was able to repair the gauge successfully. The shutter and indicator lights are now operating appropriately."

Notified R3DO(Giessner) and FSME EO(Michalak).

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Power Reactor Event Number: 47652
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: JACK MORRISON
HQ OPS Officer: VINCE KLCO
Notification Date: 02/09/2012
Notification Time: 09:37 [ET]
Event Date: 02/08/2012
Event Time: 10:47 [CST]
Last Update Date: 02/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
VIVIAN CAMPBELL (R4DO)

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

Event Text

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED EMPLOYEE SUPERVISOR

A non-licensed employee supervisor had a confirmed positive for alcohol during random testing. The employee's access to the plant has been terminated and his badge deactivated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 47653
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: LIDIA LITINSKI
HQ OPS Officer: PETE SNYDER
Notification Date: 02/09/2012
Notification Time: 14:01 [ET]
Event Date: 02/08/2012
Event Time: 16:30 [CST]
Last Update Date: 02/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
STEVEN VIAS (R2DO)
PATTI SILVA (NMSS)

Event Text

CONTAMINATED INDIVIDUAL RECEIVES MEDICAL ATTENTION ONSITE

"On February 8, 2012, at 1630 [CDT] Honeywell employee was admitted to the plant's Dispensary for treatment of a thermal burn to the neck from a steam line. The plant's nurse treated this individual at the Dispensary. Health Physics staff performed whole body survey after treatment and discovered that employee's boots contamination exceeded 8000 dpm/100cm2. The employee was not transported off site."

The source of the contamination was uranium and uranium ore concentrate. Contaminated areas of the plant were surveyed for remediation.

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Power Reactor Event Number: 47655
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: TED SMITH
HQ OPS Officer: PETE SNYDER
Notification Date: 02/09/2012
Notification Time: 20:37 [ET]
Event Date: 02/09/2012
Event Time: 17:00 [EST]
Last Update Date: 02/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
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

Event Text

POTENTIAL DEGRADATION OF TECHNICAL SUPPORT CENTER HABITABILITY

"The dose calculation of record documents is that the assumed inleakage to the technical support center (TSC) is 60 cubic feet per minute (CFM), The calculation does not provide a documented validation of why the 60 CFM value is conservative and acceptable. Engineering judgment supports the likely validity of the 60 CFM value. However, if the inleakage value is not valid by a sufficient margin, the TSC would not meet the habitability design basis requirements. This report is submitted based upon a potential loss of emergency assessment capability, offsite response capability, or off site communications capability in accordance 50.72(b)(3)(xiii).

"Existing procedures require monitoring habitability of the TSC and taking action in the event radiological conditions preclude occupancy. The on-duty TSC Site Emergency Coordinator, TSC Radiological Control Director, and Emergency Operations Facility Emergency Response Manager have been informed of the condition and the protocol for utilization of alternate facilities. A walkthrough of the process will be held for others holding those positions in a timely manner.

"The Senior Resident Inspector has been informed."

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Power Reactor Event Number: 47656
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BARRETT NICHOLS
HQ OPS Officer: PETE SNYDER
Notification Date: 02/09/2012
Notification Time: 22:21 [ET]
Event Date: 02/09/2012
Event Time: 17:55 [EST]
Last Update Date: 02/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ART BURRITT (R1DO)

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

Event Text

MAIN STEAM LINE PRESSURE TRANSMITTERS FOUND INOPERABLE

"A condition was discovered on February 9, 2012 that could have prevented fulfillment of the safety function to shutdown the reactor and maintain it in a safe shutdown condition and mitigate the consequences of an accident.

"During maintenance performed on the main steam line pressure transmitters on both trains, the one-time use only EEQ seals were not replaced rendering the transmitters inoperable. These transmitters initiate safety injection and main steam isolation functions in the event of a main steam line break. Since all transmitters were inoperable this condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(A) and (D)."

The condition existed for about a week.

"Subsequently the required number of transmitters have been repaired and are operable.

"The NRC Senior Resident Inspector was notified and was present in the control room during the repair activity."

The licensee also notified the State of Connecticut.

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