United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 19, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/18/2012 - 04/19/2012

** EVENT NUMBERS **


47814 47830 47831 47832 47835 47839 47846 47847 47848 47849

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47814
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE WALSH
HQ OPS Officer: VINCE KLCO
Notification Date: 04/07/2012
Notification Time: 15:27 [ET]
Event Date: 04/07/2012
Event Time: 13:54 [EDT]
Last Update Date: 04/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
JOHN CARUSO (R1DO)

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

TRANSPORT OF POTENTIALLY CONTAMINATED WORKER

"On 04/07/2012 at 1354 [EDT], Susquehanna Steam Electric Station requested an offsite ambulance via the 911 system for medical assistance. The individual was in the radiologically controlled area and was treated as contaminated. An offsite ambulance arrived on site at 1413 hrs. and the ambulance departed the site at 1424 hrs. enroute to the Berwick Hospital.

"This is considered a transport of a contaminated individual requiring an 8 hour ENS Notification per 10CFR50.72(b)(3)(xii)."

Licensee health physic technicians accompanied the individual to the hospital.

The licensee notified the NRC Resident Inspector and the Pennsylvania Emergency Management Agency.

* * * RETRACTION FROM DARVIN DUTTRY TO JOHN SHOEMAKER ON 04/18/2012 AT 1522 EDT * * *

"On 04/07/2012, PPL Susquehanna reported that a potentially contaminated individual was transported offsite via ambulance for medical assistance. The individual had been in the radiologically controlled area when the event occurred, and for medical reasons could not be completely surveyed for radioactive contamination prior to transport to the hospital. Therefore the event was considered transport of a contaminated individual.

"Health Physics personnel accompanied the individual to the hospital and conducted surveys of the individual, ambulance and hospital equipment and facilities. The results of these surveys indicated that no contamination was detected and the individual, ambulance and all hospital facilities and equipment were non-contaminated.

"Based on the above information, reporting pursuant to 10CFR50.72(b)(3)(xii) described in the referenced Event Notification is retracted."

The licensee has notified the NRC Resident Inspector. Notified R1DO (Joustra).

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Agreement State Event Number: 47830
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ECS MID-ATLANTIC, LLC
Region: 1
City:  State: VA
County: ARLINGTON
License #: 107-314-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2012
Notification Time: 10:07 [ET]
Event Date: 04/11/2012
Event Time: [EDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

"On April 11, 2012, a technician performing compaction tests using a CPN MC portable moisture density gauge (10 millicuries cesium-137; 50 millicuries americium-241), left the gauge during a test to prepare the next test location 20 to 30 feet away. A compaction roller ran over the gauge and shattered the gauge housing. The technician cordoned off the area and contacted the Radiation Safety Officer. The RSO contacted the Virginia Emergency Operations Center and returned the gauge to its storage area after ensuring the sources were inside their shields. Based on an onsite investigation by members of the Virginia Radioactive Materials Program, it was determined that no individual was likely to have received a radiation dose and that the gauge sources were secured in their shields. The licensee has contacted the gauge distributor to return the gauge."

Virginia Report No.: VA-12-001

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Agreement State Event Number: 47831
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: EUREKA State: CA
County:
License #: 1703
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 11:50 [ET]
Event Date: 04/04/2012
Event Time: [PDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - TC-99M GENERATOR INADVERTANTLY SENT TO NON-LICENSED RECIPIENT

The following information was received from the State of California by email:

"The hospital had sent a depleted Tc-99m generator to an incorrect recipient, a non-licensee. They had intended to return it to Mallinckrodt in St. Louis, [Missouri]. He [RSO] thought the generator still contained about 100 mCi. The package was shipped on 4/4/12, and was retrieved on 4/6/12 after the mistake was discovered."

The package was returned to Saint Joseph Hospital and the following week the hospital resent the package to the correct recipient, Mallinckrodt.

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Agreement State Event Number: 47832
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS MD ANDERSON CANCER
Region: 4
City: HOUSTON State: TX
County:
License #: 00466
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 13:35 [ET]
Event Date: 04/11/2012
Event Time: [CDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT RECEIVING YTTRIUM-90 MICROSPHERES TREATMENT

The following information was sent by the State of Texas via email:

"On April 13, 2012, the Agency [Texas Department of Health] was notified by the licensee that a therapy event had occurred on April 11, 2012. A patient was prescribed 105 grays using Yttrium-90 microspheres. The patient received only 77.4 grays. The licensee stated that the reduced exposure was because a flow clamp was not in the fully opened position allowing microspheres to plate out in the flow tube instead of being administered to the patient. The licensee stated that there were no adverse effects on the patient.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Report No: I-8948

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: 47835
Rep Org: NV DIV OF RAD HEALTH
Licensee: TOP DOLLAR RECYCLING
Region: 4
City: LAS VEGAS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 20:37 [ET]
Event Date: 04/11/2012
Event Time: [PDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL DETECTED IN LOAD OF SCRAP METAL

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

On 4/11/12 a report was received [by Nevada State Health Division] that a truckload of radioactive scrap metal belonging to Top Dollar Recycling was refused in Southern California. This scrap steel originally came from a mine in Utah. On 4/12/12, the 40 foot semi-truck of scrap metal returned to Top Dollar Recycling and a site visit by the State Radiation Control Program (RCP) was conducted.

RCP staff took measurements of the semi-truck's scrap metal. Background reading was <10uR/hr, and the highest readings of 50uR/hr on contact were near the back of the truck on the driver's side. The truck was unloaded using a small bobcat loader, spread out and surveyed. One piece of scaffolding, about 4 foot long and bent roughly in half, had elevated readings of 180 uR/hr on contact and identified as Ra-226. The scaffold, which was tubular steel and hard packed with soil type debris, was the source of radiation.

The remainder of the semi-truck was unloaded, and all scaffolding metal was segregated and surveyed individually. No additional sources of radiation were identified. The other metal on the truck was also surveyed with no elevated readings. The outside of a very large pile (12' x 20') of metal from the same mine was scanned and no elevated reading were found.

Top Dollar Recycling took possession of the item, wrapped it in a plastic garbage bag before moving it to a sturdy container in the storage/control location.

Item Number: NV120011


.

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Agreement State Event Number: 47839
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: CLOSE THE LOOP, INC.
Region: 1
City: HEBRON State: KY
County:
License #: 401-865-430
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER KEFFER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/16/2012
Notification Time: 14:22 [ET]
Event Date: 04/13/2012
Event Time: 07:00 [CDT]
Last Update Date: 04/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

LOST STATIC ELIMINATOR

The licensee notified the Kentucky Department of Public Health and Safety, Radiation Health Branch on April 16, 2012 at 1135 (CDT) of a missing static eliminator. The static eliminator was discovered to be missing by an oncoming operator on April 13, 2012 at 0700 (CDT). An operator on the previous shift reported the device to be in place. The Director of Facility Operations was not in the office on April 13, 2012 and was not made aware of the missing device until April 16, 2012 at 0715 (CDT). The licensee initiated a search for the device on April 16, 2012 at 0715 (CDT) but has been unsuccessful in locating the device. The licensee plans to continue searching for the device. The licensee does not suspect tampering or theft and no exposures to personnel have occurred or are expected at this time. The device is a Model P-2021 Static Eliminator, Serial # A2HU670, with a 10 mCi Po-210 source.

Kentucky Radiation Health Branch Report number KY120007.

No other notifications have been made by the licensee.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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Part 21 Event Number: 47846
Rep Org: FISHER CONTROLS INTERNATIONAL
Licensee: FISHER CONTROLS INTERNATIONAL, LLC
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE BAITINGER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/18/2012
Notification Time: 14:46 [ET]
Event Date: 04/18/2012
Event Time: [CDT]
Last Update Date: 04/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JUDY JOUSTRA (R1DO)
REBECCA NEASE (R2DO)
NEIL OKEEFE (R4DO)
PART 21 GROUP (EMAI)

Event Text

FISHER TYPE 9500 BUTTERFLY VALVES CONTAIN NON DEDICATED PARTS

"While reviewing an incoming order for a Type 9500 Butterfly Valve, it was discovered that two parts, namely the Thrust Plate and Thrust Plate Cap Screws, were not called out for Commercial Grade Dedication per Fisher Manufacturing Procedure (FMP) 2K27. These parts are considered an essential-to-function part in order for the valve to perform an active safety function.

"Upon discovery of this possible failure to comply, an investigation was performed on all Safety-Related Type 9500 Butterfly Valves that have been shipped, are in active service or inventory, and are required contractually to be dedicated and it was determined that the Thrust Plate and Thrust Plate Cap Screws in these valves were supplied commercial grade and had not been dedicated per FMP 2K27.

"The Thrust Plates retain the Thrust Sleeve Assemblies which provide a bearing surface for the Valve Shaft. The Thrust Sleeve Assemblies also provide adjustment to the Valve Body Liner. The Thrust Plate Cap Screws retain the Thrust Plates. Without the Thrust Plates or the Thrust Plate Cap Screws, there is a risk that the Thrust Sleeve Assemblies will disengage from the Valve Body, preventing the valve from performing its active safety-related function.

"It is Fisher's opinion that while the Thrust plates and Thrust Plate Cap Screws were not dedicated, the failure to dedicate does not pose an inherent safety risk given the materials used.

"Fisher will revise its procedures to ensure that this issue is corrected and does not happen in the future.

"Action Required: Fisher will supply properly dedicated Thrust Plates and Thrust Plate Cap Screws for the affected valves that are in inventory or service, at no cost to the affected customers.

Notification has been made to plants with the Type 9500 Butterfly Valves for; Cooper Plant (NPPD), Vogtle Plant (Georgia Power), Ft. Calhoun Plant (OPPD), and Millstone Plant (Dominion) and specific valve order numbers and serial numbers were provided.

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Power Reactor Event Number: 47847
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JAMES COX
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/18/2012
Notification Time: 18:07 [ET]
Event Date: 04/18/2012
Event Time: 15:11 [CDT]
Last Update Date: 04/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HIRONORI PETERSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 20 Power Operation 0 Hot Shutdown

Event Text

UNIT TWO AUTOMATIC REACTOR SCRAM ON HIGH REACTOR PRESSURE

"On April 18, 2012, at 1511 hours (CDT), an automatic scram occurred on high reactor pressure. The pressure increase occurred during post-modification testing on the main generator automatic voltage regulator, which had been upgraded during the recent refueling outage.

"Following the reactor scram, reactor water level decreased to approximately zero inches, which resulted in automatic Group II and III isolations (Reactor Water Clean Up and Secondary Containment Isolation) as expected. All systems responded properly to the event. The cause of the event is still under investigation.

"Unit 1 was unaffected by the event and remains at 100% power.

"This report is being made in accordance with 10CFR50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A)."

All Control Rods fully inserted, decay heat is being removed through the bypass steam valves to the main condenser, and the plant remains in a normal shutdown electrical alignment.

The high reactor pressure appears to have been caused by a load rejection associated with the main generator voltage regulator testing.

The licensee has informed the NRC Resident Inspector.

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Power Reactor Event Number: 47848
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/18/2012
Notification Time: 18:53 [ET]
Event Date: 10/06/2011
Event Time: 13:44 [CDT]
Last Update Date: 04/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NEIL OKEEFE (R4DO)

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

Event Text

WASTE DISPOSAL SYSTEM CLASS ONE SEISMIC SUPPORT INOPERABLE

"The Waste Disposal System [WDS] Class 1 piping requires operable seismic supports downstream of the isolation valve class break. Currently, eight (8) INC [International Nuclear Safety, Corp.] snubbers have been degraded to [Non Nuclear System] NNS Class 4 ridged struts. The snubbers original design function was to allow thermal motion but restrain seismic motion.

"The snubbers have been identified as potential to create an unanalyzed condition that over stresses the safety class 1 drain pipe upstream of the isolation valve if the snubbers on the drain pipe downstream of the isolation valve were in a locked condition (acting as a strut). Per NRC bulletin 81-01, these snubbers are assumed to be frozen and do not allow movement of the pipe; thus, they have been degraded to rigid struts as they are not in the snubber program and are not tested. They still provide a seismic safety function for [class] II/I issues and act as a strut to provide horizontal restraint to the WDS piping.

"The snubbers were removed from the piping system and tested to determine their performance and if they would have moved to allow thermal growth. Six snubbers failed the test and were either in a locked condition or their movement was dimensionally small relative to the required movement. The [Reactor Coolant System] RCS is within acceptable stress values with the snubbers removed.

"The 8-hour regulatory reporting time has been exceeded."

An initial Reportability Evaluation was completed on March 26, 2012 and had determined the supports were operable. A second Reportability Evaluation later determined the supports have been inoperable since October 6, 2011. The WDS is used to drain the RCS.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 47849
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: LOGAN MILLER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/18/2012
Notification Time: 22:46 [ET]
Event Date: 04/18/2012
Event Time: 19:55 [CDT]
Last Update Date: 04/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
HIRONORI PETERSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

FITNESS FOR DUTY

A non-supervisor licensed operator had a confirmed positive result for alcohol during a random fitness-for-duty test. The operator's access to the plant has been suspended. Contact the Headquarter Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, April 19, 2012
Thursday, April 19, 2012