United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for May 10, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/09/2012 - 05/10/2012

** EVENT NUMBERS **


47883 47886 47890 47891 47906 47911

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Agreement State Event Number: 47883
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: BP - COOPER RIVER PLANT
Region: 1
City: WANDO State: SC
County:
License #: 252
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/01/2012
Notification Time: 14:11 [ET]
Event Date: 01/25/2012
Event Time: [EDT]
Last Update Date: 05/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER FAILED IN CLOSED POSITION

The following report was received via fax:

"The SC [South Carolina] Department of Health and Environmental Control was notified in writing on January 25, 2012, that during a routine shutter check, a Vega Americas Corporation Model SHRD gauging device containing 20 Ci of Cs-137, had a shutter mechanism that was harder to operate than normal. Vega Americas Corporation was contacted and on January 24, 2012, a Vega Americas Corporation technician arrived and was evaluating the operation of the shutter when it failed in the closed position. The metal operating handle broke off and the shutter cannot be moved. The source holder was surveyed and [it was] verified that the shutter is in the closed and safe position.

"Following further correspondence with the licensee on May 1, 2012, the licensee stated that Vega Americas Corporation will not repair the source holder. Vega Americas Corporation will be handling the proper disposal of the SHRD fixed gauge.

"Even though this event is being reported, the Department of Health and Environmental Control does not feel that this is a reportable event since the shutter is closed and radiation exposure in excess of regulatory limits is not possible."

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Agreement State Event Number: 47886
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FORMOSA PLASTICS CORP
Region: 4
City: POINT COMFORT State: TX
County:
License #: 03893
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/02/2012
Notification Time: 11:00 [ET]
Event Date: 04/19/2012
Event Time: [CDT]
Last Update Date: 05/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER STUCK IN OPEN POSITION

The following report was received from the State of Texas Department of Health Radiation Branch (via e-mail):

"On May 1, 2012, the Agency (Texas Radiation Branch) was notified by a licensee that the shutter on a Ronan SA-1 nuclear gauge containing 50 millicuries of cesium-137 was stuck in the open position. This is the normal position for the gauge shutter.

"The licensee contacted the gauge manufacture and the gauge shutter was repaired by the manufacturer on May 1, 2012. The shutter failure did not create an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA - 300."

Texas Report I-8950

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Agreement State Event Number: 47890
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SUPERIOR WELL SERVICES, INC
Region: 1
City: NORTH EASTERN State: PA
County:
License #: PA-1168A
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/02/2012
Notification Time: 15:08 [ET]
Event Date: 04/30/2012
Event Time: [EDT]
Last Update Date: 05/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DENSITOMETER DISLODGED

The following report was received via fax:

"On April 30, 2012, while on location in North Eastern, PA, an incident occurred which indirectly involved a nuclear density device. While pumping at a well site at 7200 psi, a large section of 4 inch pipe became dislodged at a joint, sending the pipe in the direction of the gauge. This caused a piece of iron to collide with the densitometer which in turn, knocked the in-line densitometer off of the 4 foot, 4 inch piece of iron it was attached to.

Gauge Information:
Material: Cs-137
Manufacturer: Thermo MeasureTech
Sealed Source Model: 57157C
Activity: 250mCi

"The density gauge showed no signs of damage. The device was immediately secured and a trained employee was dispatched to retrieve and properly package and transport the device back to the Blacklick, PA facility. The device was leak tested in the field and surveyed with a Ludlum Model 3. The densitometer is currently in secure storage at the Blacklick facility and is awaiting repair from a licensed service provider. The Department [PA Bureau of Radiation Protection] plans to conduct a reactive inspection on Tuesday, May 8, 2012."

PA Event: PA-120014

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Agreement State Event Number: 47891
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: McLEOD REGIONAL MEDICAL CENTER
Region: 1
City: FLORENCE State: SC
County:
License #: 139
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/02/2012
Notification Time: 14:15 [ET]
Event Date: 05/01/2012
Event Time: 15:00 [EDT]
Last Update Date: 05/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE SPILL DURING MEDICAL TREATMENT

"The SC Department of Health and Environmental Control was notified on Wednesday, May 2, 2012, at 1400 hrs, that a nurse's aide was attempting to empty a Foley bag containing I-131 at 1500 hrs on May 1, 2012, when she inadvertently spilled 200-300 cc of the contents of the bag on the floor, her shoe and sock. The patient had received 203 mCi of I-131 for in-patient treatment. The Supervisor, Nuclear Med, was notified and the nurse's aide's foot was decontaminated. Surveys after the decontamination did not indicate the presence of any radioactive material on her skin. The nurse's aide had a bioassay on May 2, 2012, and no uptake was indicated. Absorbent paper had been placed on the floor prior to the in-patient procedure and most of the spill was contained on the absorbent paper. A 12 x 100 inch area of the floor under the patient bed may have contamination and the area will be cleaned and surveyed once the patient has been released.

"[The Nuclear Med Supervisor] was advised by [South Carolina] to submit a written report detailing this event to the [South Carolina] Department within 30 days. The event is open and pending the licensee's investigation and report to the [South Carolina] Department. Updates will be made through the national NMED system."

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Fuel Cycle Facility Event Number: 47906
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: BOB STOKES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/08/2012
Notification Time: 08:49 [ET]
Event Date: 05/07/2012
Event Time: 12:12 [CDT]
Last Update Date: 05/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
DEBORAH SEYMOUR (R2DO)
LARRY CAMPBELL (NMSS)

Event Text

CONTAMINATED INJURED PERSON

"An employee received a laceration on the bridge of his nose when removing a respirator. He went into the onsite medical dispensary where the nurse cleaned the wound and applied a bandage. The employee had been working in the Feed Materials Building. He was donning PPE [Protective Personal Equipment] in the cooling shack on the 6th floor. There was approximately 33,000 dpm/100cm? contamination on the bottom of the employee's plant issued shoes. The employee returned to work following the treatment."

The licensee notified the Senior NRC Inspector.

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Fuel Cycle Facility Event Number: 47911
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By:
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/09/2012
Notification Time: 08:42 [ET]
Event Date: 05/08/2012
Event Time: 16:16 [CDT]
Last Update Date: 05/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
RESPONSE-BULLETIN
Person (Organization):
SCOTT FREEMAN (R2DO)
LARRY CAMPBELL (NMSS)

Event Text

AUTOCLAVE HIGH PRESSURE ISOLATION SYSTEM FAILURE

"At 1616 CDT, on 05-08-12 the Plant Shift Superintendent (PSS) was notified that C-360 (Toll Transfer & Sampling Building) Autoclave #2 had a failure in the Autoclave High Pressure Isolation System [AHPIS]. [AHPIS] is designed to: 1) prevent a cylinder failure inside the autoclave as a result of overheating; and 2) mitigate releases to the atmosphere from releases inside the autoclave. Autoclave containment is required to be operable per TSR 2.1.3.1 while the autoclave is in TSR modes 3 (containment), 4 (autoclave closed), and 5 (autoclave heating). On 5/08/12 at 1610 CDT an operator noticed water flowing from the autoclave head to shell sealing surface on the #2 autoclave in C-360 while a cylinder was being heated (TSR mode 5 - autoclave heating). The PSS was notified of the loss of containment at 1616 CDT and the [AHPIS] was declared inoperable. The steam cycle was interrupted and the autoclave was placed in a non-applicable TSR mode at 1657 CDT. No release of UF6 occurred due to the failure of the [AHPIS].

"This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand; and c.) no redundant equipment is available and operable to perform the required safety function.

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

"PGDP Assessment and Tracking Report No. ATRC-12-1195; PGDP Event Report No. PAD-2012-02; Responsible Division: Operations"


* * * UPDATE FROM BILLY WALLACE TO DONALD NORWOOD AT 1640 EDT ON 5/9/2012 * * *

After further review the licensee determined that additional reportability criteria were met as described below:

"At 1616 on 05/08/2012, the PSS was notified that C-360 Autoclave #2 had water flowing from the autoclave head to shell sealing surface indicating a potential failure in the Autoclave High Pressure Isolation System (AHPIS) containment, which is relied on as an engineered control in NCSE 042 (SRI 5.5.3). The AHPIS is designed to minimize leaks to atmosphere from the autoclave under maximum pressures resulting from a UF6 release from the cylinder, valve or pigtail in the autoclave. The maximum acceptable leak rate for the autoclaves is 12 SCFM at a minimum test pressure of 90 psig or a 10 psi pressure drop in 1 hour. In order to determine if the AHPIS would have met its safety function, a pressure decay test will be performed. However, the pressure decay test will not be performed within 24 hours of discovery. Therefore, it is conservatively assumed that the leak discovered is greater than 12 SCFM or greater than 10 psi pressure drop in 1 hour; resulting in a 24 hour NCS reportable event. When the leak was noticed, the heat cycle was interrupted and the autoclave placed in a safe configuration. No release of UF6 had occurred in the autoclave when the leak out the autoclave was found.

"This event is reportable as a 24 hour event in accordance with 24-Hr. NRC BL 91-01 Supp. 1. This is a criticality safety event in which violations involving operations that comply with the double contingency principle and do not meet the criteria for a 4-hr report, but still result in a violation of the double contingency principle, such as, events where the double contingency principle is violated but control is immediately reestablished.

"Safety Significance of Events:
--While an NCSA control was not maintained resulting in the potential autoclave leak rate being exceeded, a release of fissile material from a cylinder in the autoclave did not occur and therefore a criticality was not possible.

"Potential Criticality Pathways Involved:
--In order for a criticality to be possible, a cylinder, valve, or pigtail of a fissile cylinder would have to fail and release greater than a safe mass of fissile material into the autoclave and the autoclave containment would have to fail allowing a large release to atmosphere of uranium and settle out in an unfavorable geometry with sufficient moderator present.

"Controlled Parameters:
--The first leg of double contingency is based on mass.

--The first leg of double contingency is based on administrative and design controls to ensure that it is unlikely to have a large release of UF6 from the cylinder, valve or pigtail in the autoclave while healing the cylinder.

--The second leg of double contingency is based on geometry moderation.

"Estimated Amount, Enrichment, Form of Licensed Material:
--No leakage of UF6 occurred.

"Nuclear Criticality Safety Control(s) or Control System(s) and Description of the Failures or Deficiencies:
--The first leg of double contingency is based on mass.

--The first leg of double contingency is based on administrative and design controls to ensure that it is unlikely to have a large release of UF6 from the cylinder, valve or pigtail in the autoclave while heating the cylinder. This control was maintained.

--The second leg of double contingency is based on geometry / moderation.

--Small leaks out of the autoclave to atmosphere are considered normal case and the Autoclave High Pressure Isolation System ensures containment to minimize a significant release to atmosphere if a release occurs in the autoclave during heating. The AHPIS ensures that the maximum leak rate from the autoclave will not exceed 12 SCFM or a maximum acceptable pressure drop of 10 psi in 1 hour. If the containment leak rate is maintained, only a small amount of uranium could leak to atmosphere and the uranium would form in thin layers on surfaces in a geometrically safe configuration. Also there would be insufficient uranium to leak outside of the building; therefore there would not be a sufficient source of moderation. Since this control is assumed to have failed, uranium could leak out of the autoclave to atmosphere if a large release of UF6 occurred in the autoclave and potentially deposit in geometrically unfavorable configurations in areas where sufficient moderators exist. Since the leak rate cannot be confirmed within 24 hours, it is conservatively assumed that the geometry moderation parameter was lost and double contingency was not maintained.

"Corrective Actions To Restore Safety Systems and When Each Was Implemented:
--Perform a pressure decay test on Autoclave #2 according to procedures and if the leak rate is determined to be greater than 12 SCFM or 10 psi in one hour, repair AHPIS prior to heating another cylinder containing uranium.

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

"PGDP Assessment and Tracking Report No. ATRC-12-1195; PGDP Event Report No. PAD-2012-03; Responsible Division: Operations."

Notified R2DO (Freeman) and NMSS EO (Campbell).

Page Last Reviewed/Updated Thursday, May 10, 2012
Thursday, May 10, 2012