United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for July 19, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/18/2012 - 07/19/2012

** EVENT NUMBERS **


47956 48081 48085 48086 48088 48090 48112 48117

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 47956
Facility: PORTSMOUTH LEAD CASCADE
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817
Region: 2
City: PIKETON State: OH
County: PIKE
License #: SNM-7003
Agreement: Y
Docket: 70-7003
NRC Notified By: CHARLES SEIDEL
HQ OPS Officer: JOE O'HARA
Notification Date: 05/24/2012
Notification Time: 13:14 [ET]
Event Date: 05/24/2012
Event Time: 08:33 [EDT]
Last Update Date: 07/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
STEVEN VIAS (R2DO)

Event Text

UNAUTHORIZED INDIVIDUAL GAINED ACCESS TO FACILITY

"At 0833 on 05/24/2012, an uncleared vendor employee was piggybacked by a cleared vendor employee through a security gate into the x3012 Security Area. The uncleared employee was removed from the area. There is no known compromise of classified information.

"This incident is reportable to the Nuclear Regulatory Commission as an 8 hour Security Event in accordance with American Centrifuge Administrative Procedure ACD2-RG-044, Nuclear Regulatory Event Reporting, Appendix B, Section K2, IMI-3#14, which states, 'Circumvention of established access control procedures into a security area (excluding Property Protection Area)."

The licensee notified NRC Region 2 (Hartland).

* * * RETRACTION AT 1100 EDT ON 07/18/12 FROM CHARLES SEIDEL TO S. SANDIN * * *

"Update: On 07-18-12 at 1017 the NRC Event has been retracted on the guidance of the Regulatory Organization for the following reason:

"It has been determined that the two previously reported DOE IMI-3 events for 2012 did not meet the requirements for an NRC reportable event and should have been entered into the written log in accordance with 10 CFR 95.57. While they did meet the criteria for an 8-hr reportable event to the DOE they did not meet the NRC requirements for reporting to the NRC Operations Office. We hereby request that both NRC Events 48084 and 47956 be retracted."

Notified R2DO (Desai).

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Agreement State Event Number: 48081
Rep Org: ALABAMA RADIATION CONTROL
Licensee: EASTERN TECHNOLOGICS, INC
Region: 1
City: ASHFORD State: AL
County:
License #: 947
Agreement: Y
Docket:
NRC Notified By: JAMES L. MCNEES
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/10/2012
Notification Time: 11:03 [ET]
Event Date: 06/28/2012
Event Time: [CDT]
Last Update Date: 07/10/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAK FROM NUCLEAR LAUNDRY FACILITY DISCHARGE LINE

The following information is provided by the State of Alabama via facsimile:

"On Thursday, June 28, 2012, representatives of Eastern Technologics, Inc. (ETI) notified the Alabama Office of Radiation Control of the discovery of a leak in the sewer drain that handles the waste water discharge from ETI's nuclear laundry facility in Ashford, Alabama. At that time, ETI was determining the extent of contamination caused by the leak. ETI is authorized to possess and use the radioactive material as part of their operations under Alabama Radioactive Material License No. 947. Under the conditions of this license, ETI is required to restrict effluent releases to sewers to ten percent of the maximum permissible concentrations specified in Appendix B, Table III of Agency [Alabama Office of Radiation Control] Rule 420-3-26-.03 for all radioisotopes (except Co-60). For Co-60, the licensee is required to restrict releases to 20 milliCuries each calendar year.

"ETI excavated the area and determined that the source of the leak was an elbow in the drain pipe. Access to the area identified as contaminated was restricted and controlled. Samples were taken by Alabama Office of Radiation Control personnel on July 1, 2012. The results of the analysis of those samples were made available on July 9, 2012 and identified contamination in the soil at levels greater than five times the lowest annual limit of intake (ALI) as specified in the Agency [Alabama Office of Radiation Control] rules.

"ETI is currently decontaminating the site by excavating the contaminated soil. Personnel from the Alabama Office of Radiation Control are monitoring activities and taking confirmatory samples to verify clean up standards. The cause of the incident and the corrective measures by the licensee are pending at this time. The information is accurate as of 0900 CDT, July 10, 2012."

Alabama Incident # 12-51

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Non-Agreement State Event Number: 48085
Rep Org: ST JOHNS MACOMB OAKLAND HOSPITAL
Licensee: ST JOHNS MACOMB OAKLAND HOSPITAL
Region: 3
City: WARREN State: MI
County:
License #: 21-01190.05
Agreement: N
Docket:
NRC Notified By: LAURA SMITH
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/10/2012
Notification Time: 16:16 [ET]
Event Date: 07/10/2012
Event Time: [EDT]
Last Update Date: 07/10/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

WRONG APPLICATOR USED IN PROCEDURE PREVENTING PATIENT FROM RECEIVING PROPER DOSE

"The RSO received a phone call from the physicist who explained she incorrectly connected the HDR unit during a patient treatment. She explained how she connected a transfer tube to the endobronch catheter, when she should have connected the endobronch catheter directly to the HDR unit. This would add about 1 meter of distance between the intended treatment site and the HDR unit source.

"It was determined that the source exited the HDR unit, but never made it to the patient. This was confirmed by a repeat test/reproduction with a dummy patient/setup in the exact format the patient treatment was performed. It was clear from observing this set up a mistaken addition of about 1 meter of transfer tube was added and that the source did not make it to the patient treatment site, or to the patient at all, and instead would be within the endobronch catheter potentially exposing a portion of patient skin (confirmed not to be in direct skin contact). We then placed a farmer chamber, a MOSfet and an Ion chamber in locations where we determined would be the highest possible patient skin dose measurements. We determined the highest potential skin dose to be 1.8cGy/1.8rem (significantly below the 50rem medical event definition) to the patient arm/shoulder area, however due to a folded blanket that was placed in that location it prevented direct skin contact.

"The hospital staff has changed policy as of today, to include a time out for the physicist to verbally voice the assurance to the in room nurse of proper connection to the HDR unit. They are planning an education process for their nursing staff so they may visually assist as a secondary visual confirmation. They are also reassessing additional support staff to be present during HDR treatment in a future meeting. The RSO believes the error happened due to human error, and a rushed procedure that occurred at the end of the day.

"The hospital staff is assessing the patient for potential skin burns both now and in the future (2wk, 5wks for reassessment). They do not expect to see skin burns, but will perform this patient skin burn assessment for assurance and to confirm our lower dose skin estimates. They intend on completing the patient treatment and therefore will complete this written directive dose which was scheduled for 500cGy, based upon the medical consult with the Radiation Oncologist. We are in process of follow-up with the patient, and referring physician."

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: 48086
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: MICHELLE GREENWELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/10/2012
Notification Time: 16:19 [ET]
Event Date: 06/04/2012
Event Time: [CDT]
Last Update Date: 07/10/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

KENTUCKY AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING PROSTATE SEED IMPLANTS

The following information was obtained from the Commonwealth of Kentucky via email:

"A prostate seed implant was performed on June 4, 2012. The procedure presented with some complications related to a deficit from a TURP [Transurethral Resection of the Prostate] surgery performed on the patient over 15 years ago. When the procedure was completed cystoscopy identified no seeds in the bladder or urethra.

"The patient returned for the post implant CT on July 9, 2012. During the post implant visit with the Authorized User, the patient identified he had passed what was thought to be two seeds. Further discussion with the Authorized User identified it was two strands of seeds. The patient flushed one strand into his septic system and will bring the second strand back to the licensee for proper disposal.

"The post implant CT determined approximately 15 seeds were missing from the implant. It appears the two strands containing these seeds were in the deficit resulting from the earlier TURP surgery.

"The licensee is preparing a report for submission to the RHB within the next 15 days."

Radiation Oncologist (AU): [Deleted]
Referring Physician: [Deleted]
Implant Date: 6/4/2012
Prescribed dose: 108 Gy to the prostate
Post implant CT dosimetry: D-90 = 54%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.24 mCi
Number of seeds implanted: 85

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: 48088
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BUILDING AND EARTH SCIENCES
Region: 1
City: SERIERVILLE State: TN
County:
License #: R-A1024-B22
Agreement: Y
Docket:
NRC Notified By: BETH SHELTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/11/2012
Notification Time: 10:02 [ET]
Event Date: 06/15/2012
Event Time: [EDT]
Last Update Date: 07/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME EVENTS RESOURCE ()

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

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following information was obtained from the State of Tennessee via Email:

"On June 15, 2012, Building and Earth Sciences contacted the Division of Radiological Health to report that their Troxler Moisture Density Gauge model 3430 (SN#37366) which contains 8 mCi of Cesium-137 and 40 mCi Americium-241:Beryllium had been hit by a bull dozer at a jobsite in Sevierville, TN. The gauge was visually inspected, and it was determined that the source rod was retracted and inside the gauge but the sliding block was not in place. The survey meter indicated an exposure level of 100 mRem/hr within 1 meter of the base of the gauge in its case. After speaking with Troxler, the RSO replaced the sliding door and held it in place with duct tape. This reduced the dose rate to 18 mR/hr. The gauge was secured into a truck bed and was returned to their licensed facility in Birmingham, AL. Upon arrival in Birmingham, a leak test was conducted and sent for analysis. Once the results were returned, they obtained a return authorization to ship the gauge to Troxler."

Tennessee Event: TN-12-164

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: 48090
Rep Org: NV DIV OF RAD HEALTH
Licensee: JAMES HARDIE BUILDING PRODUCTS
Region: 4
City: SPARKS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/11/2012
Notification Time: 11:36 [ET]
Event Date: 01/01/2005
Event Time: [PDT]
Last Update Date: 07/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
DENNIS ALLSTON (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST CS-137 SOURCE USED IN DENSITY METER

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

"The licensee issued a report of a lost radioactive source previously in service at James Hardie's McCarran, NV manufacturing facility. The missing source material in question was a component of a Thermo Measuretech density meter, Model 5201. The radiation source housing has the serial # B4106. The source's serial # is GV-9532. The isotope is Cesium-137, and the activity is 50 mCi.

"This unit was received on site in July, 2004 and put into commission in December of 2004. This particular unit was installed on the agitator feed line (a process line that transfers feed material in a mixing vessel to a production machine). At some time in 2005, the density meter in question was removed from service and replaced with an inline flow meter.

"Thermo Scientific was contacted to determine if the source material in question had ever been sent back to them for recycling or disposal. They have no record of receiving the material in question. In early 2012, the McCarran facility executed a major site clean-up effort. This included taking inventory of all spare parts in the warehouse and cleaning up the 'bone yard'.

"Western Metals Recycling was contacted prior to this clean-up initiative and asked if they had ever found radioactive material in a scrap metal load from James Hardie. They said that they had not. They also stated that all inbound loads are screened for the presence of radioactive material, and that they would have located the lost device had it come into their yard. No scrap metal shipments generated from the 'bone yard' clean-up initiative were found to contain radioactive material.

"At this time James Hardie believes that it has done all that can be done to locate the lost source material. The facility is now easily inspected due to recent clean-up efforts, and effort will continue to be made to locate the lost radiological material. In the event that the lost material is located, the licensee will notify the State of Nevada immediately and initiate action to return the source material to Thermo Scientific for recycling or disposal.

"There is currently one Thermo Measuretech density meter in service at this facility. The device is operated under a General License. In accordance with license requirements, annual training is provided to all site personnel."

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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Power Reactor Event Number: 48112
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TIM HOLLAND
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/17/2012
Notification Time: 15:18 [ET]
Event Date: 07/17/2012
Event Time: 11:40 [CDT]
Last Update Date: 07/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID PROULX (R4DO)

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

TECHNICAL SUPPORT CENTER NON-FUNCTIONAL DUE TO DEGRADED CHARCOAL ADSORBER

"At 1140 [EDT] on Tuesday, July 17, the Callaway Plant Technical Support Center (TSC) was declared non-functional due to a degraded charcoal filter in the building's filter absorber unit. At 1140 [EDT] on July 17, 2012, Callaway was notified of the test results for a charcoal test sample that was taken on July 5, 2012. The results did not meet surveillance procedure acceptance criteria.

"Efforts are underway to replace the charcoal in the unit.

"If an emergency were to be declared requiring activation of the TSC while it is non-functional, TSC emergency response personnel would report to their backup locations in accordance with Callaway Plant emergency planning procedures.

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

"The NRC Resident Inspector has been notified." The licensee indicated the TSC will be functional within 24 hours.

* * * UPDATE AT 1012 EDT ON 07/18/12 FROM TIM HOLLAND TO JOHN KNOKE * * *

"The TSC was restored to functional status at 2200 [CDT] on July 17, 2012."

The licensee informed the NRC Resident Inspector. Notified R4DO (Walker).

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Power Reactor Event Number: 48117
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRIAN DEVINE
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/18/2012
Notification Time: 09:33 [ET]
Event Date: 07/18/2012
Event Time: 08:15 [EDT]
Last Update Date: 07/18/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
DAVE LEW (DRA)
JACK DAVIS (NRR)
WILLIAM GOTT (IRD)
BRUCE BOGER (ET)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

UNUSUAL EVENT DECLARED DUE TO FLASHOVER IN THE LOAD CENTER TRANSFORMER CABINET

"An electrical transformer fault occurred resulting in a loss of both Recirc Pumps. The reactor was manually scrammed from 100% power as required by Plant Procedure OT-112.

"The electrical transformer was walked down by Operations supervisor. Licensee's assessment was that a flashover occurred, and was confined to the load center transformer cabinet. Based on observed damage, EAL declaration of HU3 was made."

HU3 is identified as an explosion within the Protected Area.

The licensee has notified the NRC Resident Inspector. Licensee also notified state, local and other government agencies.

Notified other agencies (DHS SWO, FEMA, DHS NICC)

* * * UPDATE FROM BRIAN DEVINE TO JOHN KNOKE AT 1022 EDT ON 07/18/12 * * *

"Limerick, Unit 1 is terminating from their Unusual Event (HU3) due to the initiating event and conditions no longer being present. The 124A Fault was isolated by the trip of the designed protection features (feeder breaker trip). A walkdown of the area/equipment was completed with no adverse conditions noted. Normal plant shutdown activities are in progress. The area/equipment is quarantined for investigation."

The licensee will be issuing a press release. Notified other agencies (DHS SWO, FEMA, DHS NICC)

The licensee has notified the NRC Resident Inspector. Notified R1DO (Dimitriadis) and NRR EO (Davis)

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