United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 27, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/26/2012 - 03/27/2012

** EVENT NUMBERS **


47567 47756 47759 47761 47762 47765 47769 47770 47772 47773

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Part 21 Event Number: 47567
Rep Org: ATC NUCLEAR
Licensee: ATC NUCLEAR
Region: 1
City: OAK RIDGE State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R.A.CHALIFOUX
HQ OPS Officer: JOE O'HARA
Notification Date: 01/03/2012
Notification Time: 16:19 [ET]
Event Date: 01/02/2012
Event Time: 07:00 [EST]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DANIEL HOLODY (R1DO)
DAVID AYRES (R2DO)
PART 21 GRP EMAIL ()

Event Text

PART 21 REPORT - DEFECTIVE 48 VOLT DC SAFETY RELATED POWER SUPPLIES

The following was received via fax:

"ATC Nuclear has identified a design defect associated with power supplies provided through ATC Nuclear, Schenectady, NY. The defect was identified during Failure Mode Analysis following return of one of the units from the customer. The 48 VDC Power Supplies, PIN DA265A1879P00/ST were provided as safety related components to Entergy's Pilgrim Station under Purchase Orders 10240621, 10282296 and 10308991. Entergy's Pilgrim Station is currently the only station in possession of these items. The failures are exhibited as a spurious overvoltage shutdown condition when power is applied or a spurious overvoltage shutdown condition if the overvoltage circuit becomes contaminated with particulate or other material. The design defect is related to the specific silicon control rectifier used in the over voltage protection circuit. An extent of condition review is ongoing to determine if other power supplies provided under these three purchase orders are affected. Currently none of the other power supplies provided have exhibited this condition.

"The affected serial numbers are: 90922-1, 90922-2, 90922-3, 91013-1, 91013-2, 91013-3 under purchase orders 10240621 and 10282296.

"The affected serial numbers are: 110512-1, 110512-2, 110512-3, 110512-4, 110512-5 under purchase orders 10308991.

"ATC does not have sufficient information to evaluate the safety significance of the defect because the quantities and locations of the power supplies currently in use is not known.

"Information Contact: Ray Chalifoux ATC Nuclear (865) 384-0124."

* * * UPDATE FROM CHALIFOUX TO KLCO ON 3/26/12 AT 0841 EDT VIA FAX * * *

"ATC Nuclear has identified an additional defective lot of power supplies provided through ATC Nuclear, Schenectady, NY to Xcel Energy's Monticello Station under Purchase Order #00037345. The defects were identified during Failure Mode Analysis following return of twelve units from the customer. The additional affected 115 VDC Power Supplies, P/N DA265A1313P001/ST, Serial Numbers 110713-1 through 110713-12 also were found to contain design flaws in the overvoltage protection circuitry similar to the 48 VDC power supplies. A design change was implemented to resolve the defective overvoltage protection circuit and the defects were resolved. No other additional customers are affected. The customer had not placed the power supplies into service."

Notified the R3DO (Stone) and the Part 21 Reactor Group via email.

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Non-Agreement State Event Number: 47756
Rep Org: MIDDLESEX CARDIOLOGY ASSOCIATES
Licensee: MIDDLESEX CARDIOLOGY ASSOCIATES
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 062355901
Agreement: N
Docket:
NRC Notified By: JOSEPH CORNING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/20/2012
Notification Time: 13:25 [ET]
Event Date: 03/20/2012
Event Time: 12:30 [EDT]
Last Update Date: 03/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WAYNE SCHMIDT (R1DO)

Event Text

INCORRECT PATIENT ADMINISTERED NUCLEAR STRESS TEST

"This will serve as the incident report on a patient who inadvertently received an injection of technetium 99m in the Middletown office of Middlesex Cardiology Associates. [The gentleman] is a 68-year-old patient. He has underlying dementia and, at times, poor understanding of his medical care. He arrived at the office over 30 minutes late for his appointment. He identified himself to the front office staff [by his first name]. Because of HlPPA laws, the front office staff did not announce his full name. It turns out that a separate patient, [with the same first name] was scheduled for a 12:30 PM nuclear stress test. [The patient] was brought to the nuclear cardiology imaging department which is separate from the usual patient waiting room. He was told that he was going to have a pharmacologic stress test performed. Before the medical assistant could ask his date of birth, the patient indicated to the nuclear staff that he had had coffee earlier in the day which raised some confusion as to whether he could undergo pharmacologic stress testing. [The patient] never indicated that he was simply there for an office visit. He was subsequently told that he could only have resting imaging performed and would have to return on a separate day for the pharmacologic stress test. He agreed. He had undergone previous nuclear testing and therefore did not protest having an injection of technetium performed. He subsequently received 32.8 mCi of technetium 99 sestamibi. At that point, the correct nuclear stress test patient, checked in with the front office staff. Immediately, it became evident that there were 2 gentleman [with the same first name] scheduled for separate visits on 3/20/12. License photo identification was then performed. It was then discovered that [the first patient] had inadvertently received the technetium injection inappropriately. Given the fact that this dose of technetium would only produce a total body dose of 0.55 rads or approximately 5.3 mGy, there was not felt to be any concern for long-term medical sequelae.

"The patient's physician had a discussion with the patient and subsequently called his daughter to discuss the incident. A detailed letter was also sent to the patient's primary care physician.

"Based on NRC regulations, I contacted the [NRC] Operations Center at 1:25 PM on 3/20/12. I spoke to [the Headquarters Operations Officer] to explain the situation. This afternoon, we had a meeting with all front office staff and nuclear staff to review the importance of patient identification so that this type of incident will never occur again. Patients for nuclear testing will be identified by first and last names as well as birthdates to eliminate confusion."

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: 47759
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: WOOD RIVER REFINERY
Region: 3
City: ROXANA State: IL
County:
License #: IL-01282-01
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/22/2012
Notification Time: 11:03 [ET]
Event Date: 03/21/2012
Event Time: [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - PROCESS GAUGE SHUTTER STUCK IN OPEN POSITION

The State of Illinois reported the following information via email:

"The Wood River Refinery reported that a shutter mechanism on a fixed gauge (Ohmart Model SH-F1B, S.N. 2508CN) was found stuck in the open position during a routine survey and maintenance check. The gauge contained a 3.7 GBq (100 mCi) Cs-137 source. Staff were unable to return it to the shielded position. The gauge is in an unoccupied area.

"The device/area has been posted. Surveys indicate normal radiation levels in the vicinity of the device compared to the SSD registry. There is product in the vessel and 2 other gauges are in the vicinity.

"Personnel and shift managers have been informed of the situation. A service vendor has been on scene and so far has been unable to close the shutter after lubrication. Additional service measures are being pursed by the vendor."

IL Item No. IL12005

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Agreement State Event Number: 47761
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROBE TECHNOLOGY SERVICES
Region: 4
City: FORT WORTH State: TX
County:
License #: 05112
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/22/2012
Notification Time: 17:29 [ET]
Event Date: 03/14/2012
Event Time: [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
CHRISTIAN EINBERG (FSME)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - SOURCE LOST DURING TRANSPORT

The State of Texas provided the following information via email:

"On March 22, 2012, the Agency was notified by a licensee that a 350 millicurie (13 GBq) Americium 241-Beryllium source was lost during shipment. The source was picked up in Fort Worth, Texas by a common carrier for delivery to Houston, TX on March 14, 2012. When the source arrived in Houston, TX it was discovered that the source should have been delivered to the company's Corpus Christi, TX location. The common carrier contacted the licensee in Fort Worth and they agreed to have the source sent to the Corpus Christi location. On March 20, 2012, the licensee in Corpus Christi contacted the licensee in Fort Worth and stated that they had not received the source. The licensee in Fort Worth contacted the common carrier and was informed by them that they could not locate the source, but they were looking for it. On March 22, 2012, at 1420 hours the Fort Worth licensee contacted this Agency to report that they had decided to report the source as lost.

"The Agency contacted the carrier and they confirmed that the package was loaded on the truck going from Houston to Corpus Christi. They stated that the truck stopped in San Antonio, TX prior to going to Houston. The common carrier is still looking for the source. They stated that all of their transportation centers have been notified of the lost package. Additional information will be provided as it is received in accordance with SA-300.

Texas Incident #: I-8941.

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: 47762
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: SHARED MEDICAL TECHNOLOGY
Region: 3
City: NEW RICHMOND State: WI
County:
License #: 005-1271-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/22/2012
Notification Time: 17:35 [ET]
Event Date: 03/22/2012
Event Time: 11:45 [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION DURING TREATMENT

The State of Wisconsin provided the following information via e-mail:

"On March 22, 2012 at 2:30pm the Wisconsin Radiation Protection Section received a telephone notification that a fire had occurred at the licensee's location while performing a lung perfusion study at 11:45am, utilizing a 60 mCi dose of Tc-99m DTPA. The lung perfusion kit being used was a Biodex Medical Systems model Aerotech 1, lot #: 07811324. Per a discussion with the RSO, a patient was receiving a lung perfusion study when the perfusion kit 'burst into flames.' The Nuclear Medicine Technician (NMT) removed the face mask from the patient and the patient's hair caught on fire and the NMT put the fire out with their hands. The patient was immediately taken to the Emergency Room and the first degree burns on their face and neck have been treated.

"The area has been secured and surveys are in progress. The licensee will not be conducting any nuclear medicine procedures until the Radiation Protection Section has completed our investigation."

WI Event Report ID: WI120002.

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Power Reactor Event Number: 47765
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: HOWARD MAHAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2012
Notification Time: 14:33 [ET]
Event Date: 03/22/2012
Event Time: 21:01 [EDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
26.417(b)(1) - FFD PROGRAMATIC FAILURE
Person (Organization):
ROBERT HAAG (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS FOR DUTY [FFD] REPORT INVOLVING PROGRAMMATIC VULNERABILITY

"On March 9, 2012, Shaw's Vogtle 3&4 Construction Contractor FFD program manager notified SNC [Southern Nuclear Operating Company] FFD program manager of his discovery of anomalies in their random pool while preparing to perform the weekly random pool generation. At that time, approximately 20 people were identified as not being in the pool that had active badges. Corrective actions were implemented to update the pool and provide additional verification of any changes made to the pool. Subsequently discussions with licensing resulted in the conclusion that there was not an indication that there was a programmatic issue and thus was reportable under a 30 day report to the NRC. The NRC was informed of this decision and has been at Vogtle collecting data regarding this event.

"Since that time, Shaw has been checking past months to determine the extent of condition. On March 22, at 21:01, Shaw notified SNC that the October - December results of personnel who had active badges but was not in the pool was significantly higher than the January through March results, developed earlier. On the basis of this information, SNC has determined that this now rises to the level of a programmatic vulnerability and is subject to a 24-hour report to the NRC.

"SNC is providing this notification under the provisions of 10 CFR 26.719(b)(4) and 26.417(b)(1) as a discovered vulnerability of the FFD program."

The licensee informed the NRC Resident Inspectors.

* * * UPDATE FROM MAHAN TO HUFFMAN AT 1700 EDT ON 3/26/12 * * *

The licensee noted that this event is also being reported under 10 CFR 26.417(b)(1).

R2DO (Haag) has been notified.

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Power Reactor Event Number: 47769
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TED WEBNER
HQ OPS Officer: VINCE KLCO
Notification Date: 03/25/2012
Notification Time: 23:58 [ET]
Event Date: 03/25/2012
Event Time: 23:36 [EDT]
Last Update Date: 03/26/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
VICTOR MCCREE (R2RA)
ERIC LEEDS (NRR)
ROBERT HAAG (R2DO)
JEFF GRANT (IRD)
FREDERICK BROWN (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO SEISMIC ACTIVITY

On March 25, 2012 at 2336 EDT, an Unusual Event was declared due to an earthquake felt on site. The site entered EAL HU1.1. No plant systems were affected. The National Earthquake Information Center reported a magnitude 3.1 seismic event 6 miles south-south west of Mineral, Virginia. A plant inspection is on-going to determine any plant issues related to the seismic event. Unit 1 is in a refueling outage and containment integrity was maintained. Unit 2 continues in full power operation.

The licensee notified the NRC Resident Inspector, State and local agencies.

Notified DHS SWO, FEMA, NICC and Nuclear SSA via email.

* * * UPDATE FROM TED WEBNER TO VINCE KLCO ON 3/26/2012 AT 0417 EDT * * *

On March 26, 2012 at 0410 EDT, the Unusual Event was terminated. The basis for the termination was that all equipment walkdowns are complete with no damage discovered.

The licensee will notify the NRC Resident Inspector.

Notified the R2DO (Haag), NRR EO (Brown), IRD (Grant), DHS SWO, FEMA, NICC and the Nuclear SSA via email.

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Research Reactor Event Number: 47770
Facility: MASSACHUSETTS INSTITUTE OF TECH
RX Type: 6000 KW TANK RESEARCH HW
Comments:
Region: 1
City: CAMBRIDGE State: MA
County: MIDDLESEX
License #: R-37
Agreement: Y
Docket: 05000020
NRC Notified By: TOM NEWTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/26/2012
Notification Time: 10:04 [ET]
Event Date: 03/25/2012
Event Time: 05:15 [EDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
JESSIE QUICHOCHO (NRR)
AL ADAMS (NRR)

Event Text

RESEARCH REACTOR MANUAL SCRAM

At 0356 hrs. EDT, while operating at full power, the reactor automatically scrammed on a high signal on period channel 3. At that time, it was believed that the scram was due to noise on the channel. All channels were checked and at 0449 hrs. it was decided that to restart the reactor.

During the startup, the rods were pulled to the estimated critical position (ECP) without indication on any of the period channels (3 channels installed). It was decided that the xenon could be precluding the reactor so it was decided to bump the rods out. After bumping out the rods, no increase in period was indicated. During the ensuing discussion, the operator observed power increasing and, at approximately 4 Mw, decided to manually scram the reactor.

Investigation into this event is ongoing.

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Power Reactor Event Number: 47772
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN RIEDMULLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/26/2012
Notification Time: 17:28 [ET]
Event Date: 03/26/2012
Event Time: 15:30 [EDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

OFFSITE NOTIFICATION DUE TO SEWAGE LIFT STATION OVERFLOW

"A discharge was reported to the New Jersey Department of Environmental Protection (NJDEP) at 1712 EDT on 3/26/2012, case number 120326171251. The discharge resulted from a sewage lift station that overflowed into a manhole, #8, which is a permitted outfall to the river. Approximately 1500 to 2000 gallons of sewage overflowed into the manhole."

The licensee will notify the Lower Alloways Creek Township. The licensee will also notify the NRC Resident Inspector.

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Power Reactor Event Number: 47773
Facility: BYRON
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES MCBREEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/26/2012
Notification Time: 18:19 [ET]
Event Date: 02/01/2012
Event Time: 21:00 [CDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)

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

Event Text

60-DAY OPTIONAL REPORT - INVALID SYSTEM ACTUATION

"In accordance with 10CFR50.73(a)(2)(iv)(A), this telephone notification reports an invalid actuation of the Unit 2 train B (2B) Emergency Diesel Generator (DG) on February 1, 2012, at 2100 hours. At the time of the event, Unit 2 was in Mode 5, Cold Shutdown. The 2B DG was being prepared for an operability surveillance following a planned work window. As part of this surveillance, a chart recorder is installed to monitor key DG parameters to include the DG start signal. When the second lead was connected across the starting relay contact test point, a DC ground alarm was received and the 2B DG started. The engine functioned successfully and as expected, the 2B DG did not automatically connect to its safety bus, since no bus under-voltage signal was present. The cause is attributed to a faulty chart recorder in that an inadvertent ground resulted in the actuation of the starting relay. This condition was entered into the corrective action program."

The licensee notified the NRC Resident Inspector.

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