United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for May 31, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/30/2012 - 05/31/2012

** EVENT NUMBERS **


47943 47946 47952 47976 47977

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Agreement State Event Number: 47943
Rep Org: COLORADO DEPT OF HEALTH
Licensee: PUBLIC SERVICE COMPANY OF COLORADO
Region: 4
City: HAYDEN State: CO
County:
License #: 032-01
Agreement: Y
Docket:
NRC Notified By: MEGAN BROWN
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/22/2012
Notification Time: 13:02 [ET]
Event Date: 03/23/2012
Event Time: [MDT]
Last Update Date: 05/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE DURING GAUGE REMOVAL

The following information was received via email from the State of Colorado:

"On May 21, 2012, the Colorado Department of Public Health and Environment was notified of an incident which occurred at Public Service Company of Colorado, Colorado License 032-01. The event occurred at the Hayden Station located in Hayden, CO on March 23, 2012. During boiler repairs, two contract workers removed six radiation level detector fixed gauges from an ash hopper without authorization. The gauges were discovered the following day by plant personnel, and it was noted that the shutters were in the open position. Each gauge, Texas Nuclear Model 5197, contained 100 mCi of Cesium-137. Based on dose reconstruction estimates provided by the licensee, it is likely that at least one of the contract workers received an exposure in excess of 2.0 mrem in one hour and up to 6.0 mrem in one hour. No other details are available at this time.

"Event Report ID No.: CO12-I12-09"

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

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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Non-Agreement State Event Number: 47946
Rep Org: UNIVERSITY OF MICHIGAN HOSPITAL
Licensee: UNIVERSITY OF MICHIGAN HOSPITAL
Region: 3
City: ANN ARBOR State: MI
County:
License #: 21-00215-04
Agreement: N
Docket:
NRC Notified By: MARK DRISCOLL
HQ OPS Officer: JOE O'HARA
Notification Date: 05/22/2012
Notification Time: 16:35 [ET]
Event Date: 05/17/2012
Event Time: 08:00 [EDT]
Last Update Date: 05/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
BRIAN McDERMOTT (FSME)

Event Text

MEDICAL EVENT - PATIENT INJECTED WITH WRONG RADIOPHARMACEUTICAL AND QUANTITY

A patient scheduled for a lymphoscintigraphy procedure was incorrectly injected with 25 milliCuries of Tc-99M Medronate instead of the prescribed 3 milliCuries of Tc-99 Sulphur Colloid. The cause of the event was human error. The patient and physician have been notified. The physician believes there will be no long term adverse effects due to this error. In order to prevent reoccurrence, the nuclear medicine staff will add this event to staff training to ensure that staff double check the label and the dosage and drug. Other options are still being assessed.

The licensee also notified NRC Region 3 (Bob Gattone).

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: 47952
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: 00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 05/23/2012
Notification Time: 16:38 [ET]
Event Date: 04/10/2012
Event Time: [CDT]
Last Update Date: 05/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
DEBORAH JACKSON (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE IN CATHETER

The following the received via e-mail:

"On May 23, 2012, the Agency [State of Texas] was notified by the licensee that on April 10, 2012, while the licensee was performing a routine quality assurance test using a beta catheter system device, the 50.2 milliCurie Strontium-90 source train jammed as it began to move from the transfer device to the test catheter. The source train was lodged near the transfer device exit port and could not be returned to the home position. After a few failed attempts to retract the source train, the applicator and phantom were covered with a lead apron, and the manufacturer's Radiation Safety Officer was notified. A manufacturer's technician arrived at the licensee's Hot Lab the morning of April 11, 2012. The technician was not able to return the source to the shielded position. The device was returned to the manufacturer's facility for analysis. Since this fault occurred during routine quality assurance testing, no patient was involved in the procedure. The manufacturer inspected the catheter and found a deformation in the catheter that would have interfered with the source movement. The source was leak tested, and the results indicated that the source was not leaking. The source train has been removed from service.

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

TX Incident # I-8956

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Part 21 Event Number: 47976
Rep Org: RSCC WIRE & CABLE LLC
Licensee: RSCC WIRE & CABLE LLC
Region: 1
City: EAST GRANBY State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: ROBERT GEHM
HQ OPS Officer: JOE O'HARA
Notification Date: 05/30/2012
Notification Time: 16:26 [ET]
Event Date: 05/30/2012
Event Time: [EDT]
Last Update Date: 05/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
HIRONORI PETERSON (R3DO)
GREG PICK (R4DO)
PART-21 GRP EMAIL ()

Event Text

PART 21 NOTIFICATION - FIREZONE 3HR 600V CABLE MAY NOT FUNCTION AS TESTED AND QUALIFIED

The following information was received via fax:

"Nature of Defect: RSCC Wire & Cable LLC's Firezone 3HR 600V cables may have been installed in a configuration not tested by RSCC. RSCC has only tested the Firezone 3HR 600V cable while installed in a tray with no additional cables. The actual installation at the Comanche Peak Nuclear Power Plant of the Firezone 3HR 600V cable was in a tray with other non-fire rated cables. The guidelines given by UL in FHIT.Guide Info and FHIT.31 are not specific enough to cover this case. RSCC Wire & Cable LLC conservatively concludes this may be a potential defect.

"Potential Hazard: Under fire conditions in a tray with other non-fire rated cables, Firezone 3HR 600V cables may not function as tested and qualified in accordance with UL 2196.

"The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action: RSCC has issued a Corrective Action Report (CAR 12-19) to address requirements that include documented installation procedures for Firezone 3HR 600V cables. Robert Gehm, Applications Engineering Manager for RSCC Wire & Cable LLC, has been designated as the responsible individual for action(s) to be taken. Completion of the corrective action is expected by June 29, 2012.

"Notification will be made to Comanche Peak Nuclear Power Plant and the Dresden Nuclear Power Plant for their evaluation regarding the condition as described. Notification will be made by May 31, 2012."

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Power Reactor Event Number: 47977
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPCINSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/31/2012
Notification Time: 04:47 [ET]
Event Date: 05/31/2012
Event Time: 03:04 [CDT]
Last Update Date: 05/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
HIRONORI PETERSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION CONCERNING LOSS OF AMERTAP BALLS

"At 0304 CDT, Prairie Island Nuclear Generating Plant notified the Minnesota State Duty Officer that 1000 Amertap balls were lost from the Unit 1 condenser tube cleaning system. Since the Minnesota State Duty Officer was contacted, this constitutes an 4 hour non-emergency notification per 10 CFR 50.72(b)(2)(xi).

"The licensee has notified the NRC Resident Inspector."

The licensee will notify local and other government agencies.

Page Last Reviewed/Updated Thursday, May 31, 2012
Thursday, May 31, 2012