United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 16, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/15/2012 - 03/16/2012

** EVENT NUMBERS **


47727 47731 47734 47738 47740 47742 47743 47744 47745 47746

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Agreement State Event Number: 47727
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Region: 1
City: CHAPEL HILL State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/09/2012
Notification Time: 15:57 [ET]
Event Date: 03/08/2012
Event Time: [EST]
Last Update Date: 03/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING HEPATIC TREATMENT USING YTTRIUM-90 THERASPHERES

The following information was received via e-mail from the State of North Carolina Radiation Protection Section:

"The agency [NC Radiation Protection Section] was notified of a medical event at UNC - Chapel Hill by the RSO. The event occurred yesterday. The patient was administered a Y-90 therasphere dose. Three flushes were done and proper surveys were made to ensure none of the dose was left in the IV lines. As per protocol, dose delivered is calculated via measurement of the administration vial and the waste collection vial. At this point it was noted that the patient only received 78% of the prescribed dose. The surveys indicate that the dose was left in the administration vial.

"Exact prescription dose was not provided at this time. No cause has been determined yet. There was no spilling, but the physician did note that it was harder to push the plunger for the flush to go through than he usually experiences. A second dose was delivered to a different patient using the same lot today, and the administration was successful (95% delivered).

"The patient who received the underdose has not yet been notified due to other health complications not caused by the underdosage. The patient's physician is aware and waiting for an appropriate opportunity to inform the patient. It has been determined that a second dose will not be administered since the physician has deemed the dose received adequate."

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: 47731
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: SAINT THOMAS HOSPITAL
Region: 1
City: NASHVILLE State: TN
County:
License #: R-19190-H14
Agreement: Y
Docket:
NRC Notified By: ROBIN HERIGES
HQ OPS Officer: PETE SNYDER
Notification Date: 03/12/2012
Notification Time: 08:06 [ET]
Event Date: 03/12/2012
Event Time: [EDT]
Last Update Date: 03/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SURFACE CONTAMINATION IDENTIFIED ON LAB FLOOR

The following information was received from the State of Tennessee via e-mail:

"During the routine lab cleanup/surveys, the RSO found 50-70 spots of contamination throughout the lab on the floor. It was determined that the contamination had occurred when a pharmacist working with I-131 capsules under the hood, had removed his glove within the hood. Subsequently, the glove had fallen to the floor depositing an unknown quantity of I-131. The pharmacist then walked through the lab and spread the contamination throughout. The pharmacist failed to survey the area or himself upon exiting the lab. The RSO found no contamination outside the restricted area. The RSO proceeded to cover the floor with cardboard, covering all areas of contamination. Areas were surveyed and the dose rates were very low even at 1 ft. from the I-131 contamination. There were no dose readings at 1 meter. All staff bioassays were below detectable limits."

TN Report ID: TN-10-082

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Agreement State Event Number: 47734
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONSOLIDATED ENGINEERING LABORATORIES
Region: 4
City: OAKLAND State: CA
County:
License #: 3250-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/12/2012
Notification Time: 20:18 [ET]
Event Date: 03/10/2012
Event Time: [PDT]
Last Update Date: 03/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
BRUCE WATSON (FSME)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - TWO MISSING MOISTURE DENSITY NUCLEAR GAUGES

The following information was provided by the State of California via email:

"On March 12, 2012, the RSO at Consolidated Engineering called the RHB [State of California - Radiological Health Branch] to report two missing moisture density nuclear gauges from their Oakland, CA storage facility, followed by an email (see below) detailing the events:

"On January 4 and January 5, 2012, as part of our bi-annual inventory, personnel performed an audit on a number of our nuclear gauges as required by our license. The inventory report was submitted to the RSO for review. Additional information was requested by the RSO on some of the gauges as is normal and customary. All of the gauges at that time were present and accounted for and were found to be satisfactory.

"On January 26, gauge # 0840 was signed in and out of our Oakland laboratory by one of our senior technicians. He subsequently used a different gauge in the days that followed. As part of my continuing duty to monitor locations and conditions of gauges, it became apparent to me last week that one of our gauges, #0840 was not in its designated storage location. In the course of calling all of our technicians and evaluating all of our storage locations, we called all gauges to be brought into our San Ramon office on Saturday March 10th. A second inventory was performed at that time on all of the gauges on our license. It was noted that gauge #0840 was missing as was gauge #5027, which was also stored in the Oakland location.

"We continued to exhaust all records, including sign-in and sign-out logs, report forms and checking with our license repair personnel and have concluded today that these gauges were more than likely stolen out of our Oakland office in January.

Manufacturer Model # Serial No Last documented use of gauge

Troxler 3411B T341 5027 06 January 2012
CPN MC3 M320400840 26 January 2012

"The [source] quantities are as follows:

CPN, 10 millicuries of Cesium 137 and 50 millicuries of Americium 241
Troxler, 09 millicuries of Cesium 137 and 44 millicuries of Americium 241."

California Incident #5010-031212

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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Agreement State Event Number: 47738
Rep Org: COLORADO DEPT OF HEALTH
Licensee: HIGH MOUNTAIN INSPECTION
Region: 4
City: GREELEY State: CO
County:
License #: 1042-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/13/2012
Notification Time: 17:39 [ET]
Event Date: 03/13/2012
Event Time: [MDT]
Last Update Date: 03/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
JAMES DANNA (FSME)
DENNIS ALLSTON (ILTA)

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

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA WAS LOST AND RECOVERED

A radiographer working for High Mountain Inspection was conducting radiography on a pipeline near De Beque, CO. The radiographer failed to secure the camera in his pickup truck when he drove off to the next location. Arriving at his destination the radiographer realized his camera was missing and retraced his steps. The radiography camera with a 26 Curie, Ir-192 source was not located.

At 1826 EDT the State of Colorado called and said a member of the public had found the missing camera and called the licensee. The licensee is now in possession of the radiography camera and the source has not been tampered with.

The camera is a SPEC, s/n 150. The source s/n is SJ0702.

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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Power Reactor Event Number: 47740
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: ANTHONY FULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/14/2012
Notification Time: 08:00 [ET]
Event Date: 03/14/2012
Event Time: 08:00 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
EUGENE GUTHRIE (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

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"At approximately 0800 EDT on March 14, 2012, preplanned maintenance will be performed on the Technical Support Center (TSC) ventilation system. This maintenance will be performed for door seal replacement, ventilation shaft seal and belt replacement. This maintenance is planned to be performed and completed within 10 hours. If an emergency condition should occur that would require activation of the TSC, the Harris Nuclear Plant (HNP) emergency plan has procedural guidance for use of an alternate location.

"This event is reportable per 10 CFR 50.72(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 FROM RICHARD VANDENBERG TO JOHN KNOKE AT 1735 EDT ON 03/14/2012 * * *

The preplanned maintenance on the Technical Support Center (TSC) ventilation system was completed at 1730 EDT. The TSC is now fully functional.

The licensee has notified the NRC Resident Inspector. Notified the R2DO (Guthrie).


* * * UPDATE FROM RICHARD VANDENBERG TO CHARLES TEAL AT 0840 EDT ON 03/15/2012 * * *

"At approximately 0800 on March 14, 2012 preplanned maintenance will be performed on the TSC ventilation system. This maintenance will be performed for door seal inspections and ventilation fan belt inspections. This maintenance is planned to be performed and completed within 10 hours. If an emergency condition should occur that would require evacuation of the TSC, the Harris Nuclear Plant (HNP) emergency plant has procedural guidance for use of an alternate location.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity reflects an emergency response facility for the duration of the maintenance."

The licensee has notified the NRC Resident Inspector. Notified the R2DO (Guthrie).


* * * UPDATE FROM RICHARD VANDENBERG TO DONALD NORWOOD AT 1650 EDT ON 03/15/2012 * * *

"At approximately 1630 on March 15, 2012, all scheduled maintenance has been completed and the TSC has been restored to a fully functional status."

The licensee notified the NRC Resident Inspector. Notified R2DO (Guthrie).

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Power Reactor Event Number: 47742
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE DE FILLIPPO
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 16:22 [ET]
Event Date: 03/14/2012
Event Time: 13:05 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (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

TONE ALERT RADIOS OUT OF SERVICE

"At 1430 EDT on March 14, 2012, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the Tone Alert Radios had been out of service since 1305 EDT.

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.

"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.

"This loss is believed to have been caused by a problem on a Verizon trunk line, which is currently being investigated.

"The event has been entered into the corrective action program and the NRC Resident Inspector has been briefed."

Licensee also notified the state and local authorities.


* * * UPDATE FROM STEVE DEFILLIPPO TO DONALD NORWOOD AT 1207 EDT ON 3/15/12 * * *

"On 03/15/2012 at 10:22, JAF was notified by Oswego County Emergency Management that the tone alert radio system had been restored to service 03/15/2012 at 09:33. The NRC Resident Inspector has been provided an update on status of the tone alert radio system."

Notified R1DO (Krohn).

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Power Reactor Event Number: 47743
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RYAN HAMILTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2012
Notification Time: 17:32 [ET]
Event Date: 03/14/2012
Event Time: 13:05 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (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

LOSS OF THE TONE ALERT RADIO SYSTEM

"On Monday, March 12, 2012, at 1435 EDT, Oswego County Warning Point notified Nine Mile Point, and NYS [New York State] Warning Point, via the land line, of a loss of the Tone Alert System for greater than one hour from the National Weather Service as of 1305 hrs. Site Emergency Procedures define a loss of Tone Alert System for greater than one hour, as a significant loss of Emergency Communications (EPIP-EPP-30).

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) population for the NMP [Nine Mile Point] and JAF [James A. Fitzpatrick] Nuclear Power Plants. This failure meets NRC 8-Hour reporting criteria 10 CFR 50.72(b)(3)(xiii).

"The County Alert Sirens, which also function as part of the Public Prompt Notification System, remained operable.

"The loss of the Tone Alert System constitutes a significant loss of Emergency Off-Site Communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper-reach system, which is a reverse 911 feature available from the county 911 center. Local law enforcement personnel are also available for 'Route Alerting' of the affected areas of the EPZ."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM NATHAN LILIENTHAL TO VINCE KLCO AT 1050 EDT ON 3/15/2012 * * *

"The tone alert system was restored Thursday, March 15, 2012 at 0933 EDT."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Krohn).

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Power Reactor Event Number: 47744
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: RYAN TREADWAY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 18:20 [ET]
Event Date: 03/14/2012
Event Time: 11:20 [PDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CHUCK CAIN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNIT 3 STEAM GENERATOR TUBES FAILED IN-SITU PRESSURE TESTING

"On January 31, 2012, Unit 3 was shut down due to detection of a tube leak in one Steam Generator (SG). The shutdown was previously reported on Event Notification # 47628. Southern California Edison (SCE) has been performing in-situ pressure testing with non-radioactive water on tubes with significant wear indications. On March 14, 2012, at approximately 1120 PDT, Unit 3 Steam Generator (SG) E088 Tube R106 C78 did not meet the target performance criteria because leakage exceeded 0.5 gallons per minute at the maximum pressure achieved during the test (2,884 psig). This was the leaking tube that resulted in the Unit 3 shutdown.

"Subsequently, two additional tubes in Unit 3 SG E088 did not meet the target performance criteria as follows: at 1249 PDT, Tube R102 C78 exceeded 0.5 gallons per minute at 3,268 psig and at 1425 PDT, Tube R104 C78 exceeded 0.5 gallons per minute at 3,180 psig. These occurrences are reportable as an 8-hour notification to the NRC in accordance with 10 CFR 50.72(b)(3)(ii)(A). Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. A follow-up notification will be made for additional in-situ pressure test failures. The extent and cause of the condition will be addressed in the follow-up licensee event report that will be submitted in accordance with 10 CFR 50.73(a)(2)(ii)(A). Defective tubes will be removed from service as required prior to Unit 3 plant startup.

"Unit 2 has been shut down since January 9, 2012 for a scheduled refueling outage. SCE previously performed in-situ pressure testing of the tube with the most wear in Unit 2. Results from this test demonstrated that the tube met the target performance criteria.

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


* * * UPDATE FROM LEE KELLY TO DONALD NORWOOD AT 2108 EDT ON 3/15/2012 * * *

"In-situ pressure testing on Unit 3 steam generator tubes was started on March 14, 2012 and is ongoing. On March 15, 2012, four additional tubes in Unit 3 SG E088 did not meet the target performance criteria of three-times normal pressure conditions as follows: (1) At 1109 PDT, Tube R100 C80 failed at 4,739 psig; (2) at 1437 PDT, Tube R107 C77 failed at 5,160 psig; (3) at 1604 PDT, Tube R101 C81 failed at 4,889 psig; and (4) at 1734 PDT, Tube R98 C80 failed at 4,886 psig.

"Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. Follow-up notifications will be made for any additional in-situ pressure test failures."

The licensee notified the NRC Resident Inspector. Notified R4DO (Cain).

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Power Reactor Event Number: 47745
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: KENNETH BRESLIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/15/2012
Notification Time: 04:12 [ET]
Event Date: 03/14/2012
Event Time: 20:34 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAUL KROHN (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

HPCI INOPERABLE DUE TO FAILURE OF TURBINE GOVERNOR VALVE

"On March 14th, 2012 at 2034 EST the High Pressure Coolant Injection System (HPCI) was declared inoperable due to a failure of the turbine governor valve to respond as expected to demanded position. With the HPCI system flow controller output signal at zero percent demand the governor valve traveled to the mid position and did not remain closed as expected when the oil system auxiliary pump was started. With this unexpected response the speed and flow control system for the turbine is inoperable. The failure was discovered as part of a planned evolution for oil sampling.

"All other Emergency Core Cooling Systems and the Reactor Core Isolation Cooling (RCIC) system remain operable.

"The unit remains at 100% power.

"The station has initiated an Event Response Team to identify and correct the cause of the failure.

"No personnel injuries resulted from the event.

"The NRC Resident Inspector and Lower Alloway Creek Township will be notified."

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Power Reactor Event Number: 47746
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOHN CLARK
HQ OPS Officer: VINCE KLCO
Notification Date: 03/15/2012
Notification Time: 08:32 [ET]
Event Date: 03/15/2012
Event Time: 08:30 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (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

"A planned maintenance evolution at the Oyster Creek Nuclear Generating Station will remove the Technical Support Center (TSC) ventilation system from service. Therefore, the TSC ventilation system will be rendered non-functional during the course of the work activities. The TSC ventilation is expected to be out of service for approximately six hours from 0800 [EDT] to 1400 today.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72(b)(3)(xiii) due to potential loss of the TSC. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC resident has been notified."

* * * UPDATE FROM JOHN CLARK TO VINCE KLCO AT 1109 EDT ON 3/15/2012 * * *

The TSC was restored to service on March 15, 2012 at 1107 EDT. The licensee will notify the NRC Resident Inspector.

Notified the R1DO (Krohn)

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