United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 2, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/30/2012 - 04/02/2012

** EVENT NUMBERS **


47768 47771 47779 47788 47789 47791 47793 47794

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Agreement State Event Number: 47768
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NON-DESTRUCTIVE INSPECTION CORPORATION
Region: 4
City: LAKE JACKSON State: TX
County:
License #:
Agreement: Y
Docket: L02712
NRC Notified By: ROBERT FREE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/25/2012
Notification Time: 09:20 [ET]
Event Date: 03/24/2012
Event Time: 16:00 [CDT]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE TO RADIOGRAPHER WHEN CAMERA SOURCE BECAME DISCONNECTED

The following information was received by facsimile:

"On March 24, 2012, the licensee notified the Agency that it one of its radiography teams had experienced a disconnect of a 65 curie iridium-192 on a QSA Delta 880 radiography camera at a temporary work site in Pasadena, Texas. The crank out drive cable had broken and the source had completely disconnected. After an authorized individual performed the source retrieval, the licensee's RSO learned that the radiographer trainer disconnected the source tube from the camera and had carried the source tube around his neck while he climbed down the ladder of the scaffold. The source was in the tube at this time, but it is uncertain at this time the source's location within the tube. When the radiographer trainer reached the platform he removed the source tube from his neck. The licensee's initial dose estimates for the radiographer trainer are a whole body dose of at least 56 rem and an extremity limit that may exceed 100 rem. The radiographer's film badge is being sent for immediate reading. The licensee is conducting an investigation.

"NOTE: During the licensee's initial phone call to the Agency, the Agency understood the whole body dose estimate to be 6 rem and considered the event to be a 24-hour report (the Agency did report to the NRC HOO within 24 hours). However, when the Agency received the written initial report this morning, March 26, 2012, it was discovered that the estimate is 56 rem, which requires immediate notification. This report is being submitted to update and upgrade the event. More information will be provided as it is obtained.

The State also corrected the source strength to 65 curie Ir-192 source. REAC/TS was notified on 03/26/12 and the licensee has made contact with them.

Texas Incident: I-8942

* * * UPDATE FROM KAREN BLANCHARD TO CHARLES TEAL ON 3/29/12 AT 1712 EDT * * *

"The radiographer's badge was processed on March 28, 2012. The badge reading was 812 mrem whole body (deep dose equivalent). Dose reconstruction continues as the investigation continues. More information will be provided as it is obtained."

Notified R4DO (Farnholtz) and FSME (McKenney).

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Agreement State Event Number: 47771
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: JOSEPH MELNIC
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/26/2012
Notification Time: 14:49 [ET]
Event Date: 03/22/2012
Event Time: [EDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN INTENDED DOSE

The following information was received via facsimile:

"On March 23, 2012 the Southeast Regional Office [of the Pennsylvania Department of Environmental Protection - Bureau of Radiation Protection (Department)] received notice from the hospital of a medical event involving yittrium-90 TheraSpheres.

"The patient was being treated for disease of the liver and received 76% of the intended dose in the first delivery and 56% of the intended dose in the second delivery.

"The cause of the event is currently under investigation. More information will be provided when received.

"No harm to the patient is expected. The oncologist was satisfied with the treatment and no additional delivery is anticipated. The Department will conduct a reactive inspection."

Pennsylvania Event Report ID No: PA120010

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: 47779
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: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/28/2012
Notification Time: 10:57 [ET]
Event Date: 03/26/2012
Event Time: [CDT]
Last Update Date: 03/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

ILLINOIS AGREEMENT STATE REPORT - SHUTTER MECHANISM FAILURE

The following information was obtained from the State of Illinois via email:

"The Radiation Safety Office for the licensee reported a second device at their facility had a shutter mechanism failure. The shutter was found stuck in the open position on March 26, 2012 during continuation of their routine maintenance check and survey. The gauge is near the top floor of a coker drum away from any routinely occupied work station. The device/area has been posted with appropriate warning notices. Measured radiation levels appear normal for this type of device with the shutter open. There are two other gauges on this vessel which are operating normally. Operators in the area have been informed of the situation and vessel access is prohibited. The area is subject to high humidity and rust build up is the suspected cause of the shutter failure. In the past, the manufacturer has recommended covers for these devices but none are available. The licensee's consultant and the vendor have been called. Both will be on-site again on March 30, 2012 as previously arranged to service a similar other device that failed last week. They will investigate this recent failure at that time."

The gauge is an Ohmart Corp. model number SHLG-2, serial number 2605CN and contains a 5 Ci Cs-137 source.

The previous failure was reported under NRC EN# 47759.

Illinois Item Number: IL12006

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Power Reactor Event Number: 47788
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JAMES VAUGHN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/30/2012
Notification Time: 00:59 [ET]
Event Date: 03/29/2012
Event Time: 22:42 [EDT]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER NEWPORT (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 97 Power Operation 97 Power Operation

Event Text

LOSS OF TONE ALERT SYSTEM

"On Thursday, March 29, 2012, at 2242 EDT, Oswego County notified Nine Mile Point (NMP) via the land line of a loss of the Tone Alert System as of 2105 (EDT). 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 and (James A. FitzPatrick) JAF Nuclear Power Plants. This failure meets NRC 8-Hour reporting criteria 10 CFR 50.72(b)(3)(xiii).

"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.

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

"At 2300 EDT, Nine Mile Point received notification from Oswego County 911 that the Tone Alert System has been restored and is fully functional as of 2245 EDT."

The licensee has notified the NRC Resident Inspector. The cause of the loss is still being investigated.

* * * UPDATE AT 1035 EDT ON 3/30/2012 FROM RYAN HAMILTON TO MARK ABRAMOVITZ * * *

"At 03:33 [EDT] on 3/30/12, Nine Mile Point was notified by the Oswego County Emergency Management Office (OGEMO) that the Tone Alert System had been out of service for greater than one (1) hour. This condition is considered a significant loss of offsite communication capability and is therefore a 50.72 8-hour non-emergency reportable condition per 10 CFR 50.72(b)(3)(xiii).

"The Tone Alert System failed at 0211 on 3/30/12 and was subsequently restored to service at 0328 on 3/30/12. This failure was the second such failure in a 24 hour period. The first failure occurred at 2105 on 3/29/12 and was restored at 2245 on 3/29/12. The first failure was reported to the US Nuclear Regulatory Commission Operations Center at 0059 on 3/30/12.

"The cause of the Tone Alert System loss is being investigated by the OCEMO. Oswego County reported that the National Weather Service had verified the system was broadcasting as designed at 0540 on 3/30/12. During the time the Tone Alert System was unavailable, the county emergency sirens, the Hyper-Reach system which is a reverse 911 feature available from the county 911 center, and 'Route Alerting' where Local Law Enforcement personnel are able to assist in alerting affected areas of the Emergency Planning Zone were available as alternate mechanisms to provide emergency offsite notifications."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Newport).

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Power Reactor Event Number: 47789
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN A WALKOWIAK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/30/2012
Notification Time: 01:11 [ET]
Event Date: 03/29/2012
Event Time: 21:05 [EDT]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER NEWPORT (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

LOSS OF TONE ALERT SYSTEM

"At 2235 (EDT) on 3/29/12, James A. FitzPatrick (Power Station) was notified by the Oswego County Emergency Management Office (OCEMO) that the Tone Alert System had been out-of-service for greater than one (1) hour. This condition is considered a significant loss of offsite communication capability and is therefore a 50.72 8-hour non-emergency reportable condition per 10 CFR 50.72(b)(3)(xiii).

"The Tone Alert System failed at 2105 (EDT) on 3/29/12, and was subsequently restored to service at 2245 (EDT) on 3/29/12. The cause of the system loss is still being investigated by the OCEMO.

"During the time the Tone Alert System was unavailable the county emergency sirens, the Hyper-Reach system which is a reverse 911 feature was available from the county 911 center, and 'Route Alerting' where Local Law Enforcement Personnel are able to assist in alerting affected areas of an (Emergency Planning Zone) EPZ were available as alternate mechanisms to provide emergency offsite notifications."

The licensee has notified the NRC Resident Inspector. This Tone Alert System also services the Nine Mile Point Power Station.

* * * UPDATE FROM RICHARD SULLIVAN TO MARK ABRAMOVITZ AT 1023 EDT ON 3/30/2012 * * *

"At 0335 [EDT] on 3/30/12, James A. FitzPatrick was notified by the Oswego County Emergency Management Office (OCEMO) that the Tone Alert System had been out of service for greater than one (1) hour. This condition is considered a significant loss of offsite communication capability and is therefore a 50.72 8-hour non-emergency reportable condition per 10CFR50.72(b)(3)(xiii).

"The Tone Alert System failed at 0211 on 3/30/12 and was subsequently restored to service at 0328 on 3/30/12. This failure was the second such failure in a 24 hour period. The first failure occurred at 2105 on 3/29/12 and was restored at 2245 on 3/29/12. The first failure was reported to the US Nuclear Regulatory Commission Operations Center at 0111 on 3/30/12.

"The cause of the Tone Alert System loss is being investigated by the OCEMO. Oswego County reported that the National Weather Service had verified the system was broadcasting as designed at 0540 on 3/30/12.

"During the time the Tone Alert System was unavailable, the county emergency sirens, the Hyper-Reach system which is a reverse 911 feature available from the county 911 center, and 'Route Alerting' where Local Law Enforcement personnel are able to assist in alerting affected areas of the EPZ were available as alternate mechanisms to provide emergency offsite notifications."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Newport).

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Non-Agreement State Event Number: 47791
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/30/2012
Notification Time: 15:31 [ET]
Event Date: 12/16/2009
Event Time: [EDT]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
ANGELA MCINTOSH (FSME)
BILLY DICKSON (R3DO)

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

Event Text

MISSING CHEMICAL AGENT DETECTOR

When returning from deployment a Virginia National Guard unit discovered that they had lost a M43A1 Chemical Detector containing 250 uCi of Am-241. The unit searched the facility as well as a storage warehouse located in Richmond, VA for the device, but they were unable to locate it.

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 47793
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIM KUDO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/31/2012
Notification Time: 03:42 [ET]
Event Date: 03/31/2012
Event Time: 00:22 [EDT]
Last Update Date: 03/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK LESSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 10 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO UNCONTROLLED COOLDOWN

"At 0022 (EDT) on 03/31/12 while maintaining power stable at 10% for Steam Bypass Control System testing, Unit 1 was manually tripped due to an uncontrolled cooldown caused by PCV-8802 (Steam Bypass Control Valve) unexpectedly opening. Following the trip, PCV-8802 closed and the secondary was isolated by closing the Main Steam Isolation Valves per Standard Post Trip Actions. Following isolation of the steam demand, the trip was uncomplicated with all CEAs fully inserted. No automatic safety system actuations were required and none occurred. The cause of the unexpected opening of the Steam Bypass Control System valve is under investigation.

"The plant is stable in Mode 3 at normal operating temperature and pressure. RCS Heat Removal is being maintained with Auxiliary Feedwater and Atmospheric Dump Valves. The Offsite power grid is available and stable.

"This non-emergency notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) due to manual RPS actuation with the reactor at power."

The RCS cooled down from 532 degree to 515 degrees over a period of approximately 2 minutes and 40 seconds. The reactor was manually tripped when RCS temperature reached 515 degrees and the lowest RCS temperature observed after the trip was 505 degrees.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47794
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BUD HINCKLEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/01/2012
Notification Time: 04:26 [ET]
Event Date: 04/01/2012
Event Time: 04:26 [EDT]
Last Update Date: 04/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BILLY DICKSON (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 N 0 Refueling 0 Refueling

Event Text

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 0445 EDT on Sunday, April 1, 2012, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems will be removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance and post maintenance testing is scheduled to be completed by 1900 EDT on Sunday, April 1, 2012.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DEAN BRUCK TO PETE SNYDER ON 4/1/12 AT 1633 EDT * * *

"The TSC ventilation system maintenance was completed satisfactorily and the system was restored to service at 1620 EDT on 4/1/12."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Dickson).

Page Last Reviewed/Updated Monday, April 02, 2012
Monday, April 02, 2012