United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 21, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/20/2012 - 08/21/2012

** EVENT NUMBERS **


48160 48176 48177 48184 48209 48210 48211 48212 48213

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Agreement State Event Number: 48160
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: GRENADA LAKE MEDICAL CENTER
Region: 4
City: GRENADA State: MS
County:
License #: MS-410-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: PETE SNYDER
Notification Date: 08/06/2012
Notification Time: 12:59 [ET]
Event Date: 05/18/2012
Event Time: [CDT]
Last Update Date: 08/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - UNACCOUNTED FOR BARIUM-133 SOURCES

The following information was received from the Mississippi Department of Radiation Health via e-mail:

"Two (2) Ba-133 [3.86 mCi each] attenuation sources were discovered missing from a quarterly health physics audit at Grenada Lake Medical Center by their consultant. It was discovered by the health physics consultant in early July that documentation regarding the receipt of the sources was not available.

"On 5-18-2012, Bayshore Medical, a third party company was contracted by Philips Healthcare to disassemble and remove a Marconi Axis gamma camera from Grenada Lake Medical Center. The sources were encased inside tungsten holders that were installed inside beacon devices attached to each head of the camera. The nuclear medicine technologist at Grenada Lake Medical Center showed the service engineer for de-installation of the camera the location of the camera and explained to him that Grenada Lake Medical Center would need a receipt record for the two (2) sources removed. The technologist left work for a week during the time the gamma camera was being disassembled and removed from the facility. Upon returning back to the facility the technologist forgot to verify receipt of the sources from the service company.

"Bayshore Medical claimed there was no radioactive sources installed on the Marconi camera removed from Grenada Lake Medical Center. Neither Bayshore Medical or the company that de-installed / bought the camera has a radioactive materials license. Grenada Lake Medical Center has been in contact with Bayshore Medical to track the location of the beacon devices and return them to their facility. The licensee has contacted Philips Healthcare for copies of service records to show the sources were previously installed in the camera. DRH [Mississippi Department of Radiation Health] was contacted by Grenada Lake Medical Center's health physics consultant on 8-3-2012 with a scheduled return date of 8-6-2012, for the beacon devices and sources in question.

"DRH [Mississippi Department of Radiation Health] received a written report of the incident on 8-3-2012. Grenada Lake Medical Center's Radiation Safety Committee has discussed the issue and has developed a policy for future source transfers to prevent a reoccurrence of this incident. Grenada Lake Medical Center will have a person physically verify the removal of any radioactive source along with completing a transfer record prior to any source transfer. Also, Grenada Lake Medical Center will verify that a service company has a radioactive material license to possess and transfer radioactive material."

MS Event: 120002

* * * UPDATE ON 8/14/12 AT 1237 EDT FROM JAYSON MOAK TO DONG PARK * * *

The following information was received from the Mississippi Department of Radiation Health via e-mail:

"Between 5-18-2012 and 5-28-2012, a service engineer from IRS disassembled and removed a Marconi Axis gamma camera from Grenada Lake Medical Center. The camera was previously sold to Philips Healthcare by the licensee. Philips Healthcare then sold the camera to Bayshore Medical who then sold the camera to IRS. The camera remained at the licensee's location throughout the multiple transactions.

"On 8-10-2012, IRS, the company who bought the camera from Bayshore Medical and de-installed the camera from the licensee's location on 5-18-2012, was contacted by DRH [Mississippi Department of Radiation Health]. IRS claimed there were no sources present prior to de-installation of the camera from the licensee's facility."

Notified R4DO (Hagar) and FSME Resources Events via email.

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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Agreement State Event Number: 48176
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: STERIS ISOMEDIX SERVICE
Region: 1
City: NORTHBOROUGH State: MA
County:
License #: 28-7911
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHAR
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/10/2012
Notification Time: 11:07 [ET]
Event Date: 07/23/2012
Event Time: [EDT]
Last Update Date: 08/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - SOURCE UNACCOUNTED FOR IN SHIPMENT

The following information was received from the State of Massachusetts Radiation Control Program via e-mail:

"Containers from REVISS Services, Inc were used to ship return Co-60 sources from Steris Isomedix Services, Northborough, MA to REVISS's UK facility. When the container arrived on 8/7/12 and was opened by the REVISS (UK) staff, they identified that the basket contained only 52 sources rather than the 53 that were expected. When the container arrived the tamper proof seals that were installed by engineers at the plant were intact. A review of the documentation for the operations at the plant indicate that only 52 sources were loaded into the basket. A positive check of the serial numbers confirmed that the one source that was unaccounted for was a Nordion model C-188, Co-60 source, serial number 41313.

"Steris Isomedix Services was contacted and at their earliest chance will inspect the pool to ensure that the source was not dropped onto the floor of the pool. There were no abnormal radiation readings that would indicate that the source was removed from the pool during operations. Because the documentation does not indicate that the source was ever removed from the source module, Steris Isomedix Services has a high level of confidence that the source is still in the irradiator pool.

"Steris Isomedix Services, Northborough, MA and REVISS will continue updating as information is acquired.."

* * * UPDATE AT 1047 EDT ON 8/11/12 FROM JOSH DAEHLER TO HUFFMAN * * *

The subject missing Co-60 source, serial # 41313, was discovered this morning (8/11/12) to be located in module 10, position 23, in the Steris (Northborough) pool irradiator. The serial number of the source was visually confirmed by Steris, REVISS, and a State of Massachusetts Inspector. The source is no longer missing. The State is continuing its investigation into the circumstances of this event.

Notified R1DO (Burritt), R3DO (Lipa), FSME (Henderson), and IRD MOC (Marshall).


THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 48177
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: NLMK PENNSYLVANIA
Region: 1
City: FARRELL State: PA
County:
License #: PA-1074
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/10/2012
Notification Time: 13:41 [ET]
Event Date: 08/09/2012
Event Time: [EDT]
Last Update Date: 08/10/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON GAUGE

The following information was provided by the Commonwealth of Pennsylvania via facsimile:

"On Thursday, August 9, 2012, the licensee informed the Department's [Department of Environmental Protection (DEP)] Southwest Regional Office about the discovery of a shutter failure. It is reportable within 24- hours under 10CFR 30.50(b)(2).

"During a semi-annual leak test being performed by a consultant, the shutter was found inoperable and stuck in the open position. No dose is believed to have been received by any personnel.

"The device is identified as: Manufacturer: LFE, Model #: SS-3A, Device Serial #: 300-483L, Sealed Source Model #: SS-3A, Sealed Source SN: 02311, Isotope: Am-241, Activity: (1 Ci).

"The cause of the event was equipment malfunction. Licensee continued running the mill with permission granted by DEP until the consultant arrived later that same day. Repairs were made to the shutter mechanism, followed by a radiation survey, wipe test, and function check of the gauge. The gauge is now operating properly. DEP scheduled a reactive inspection for August 10, 2012."

PA Event Report No. PA120024

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Agreement State Event Number: 48184
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: NON-LICENSEE
Region: 1
City: MEMPHIS State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ALLEN GREWE
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/13/2012
Notification Time: 12:29 [ET]
Event Date: 08/11/2012
Event Time: [EDT]
Last Update Date: 08/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - INDIUM-111 VIAL DAMAGED IN SHIPMENT

The following information was provided by the State of Tennessee via facsimile:

"On August 11, 2012, the shipper contacted the Division of Radiological Health to report that a package containing 31.7 mCi of Indium-111 was run over in the 'courtyard' area. Caps were off all six internal shielding pigs. Vials in four pigs were intact. The fifth vial was found and returned to the pig. The sixth vial was crushed and the contents (5.3 mCi) released. The shipper's fire personnel responded and washed the area (20 to 30 feet in diameter) and released the water to the storm water runoff drain. One area about 4 inches by 4 inches could not be decontaminated. A steel plate was bolted onto the asphalt in that area and dose rates of 0.5 mR/hr at a meter was observed. This area is not an occupied area. The half-life for Indium-111 is 2.8 days. The plate will be removed in 30 days and the area will be reassessed. No injuries, [and] no personnel contamination."

Event Report ID No.: TN-12-207

* * * UPDATE ON 8/14/12 AT 1456 EDT FROM BETH SHELTON TO DONG PARK * * *

The following update was provided by the State of Tennessee via email:

"The sixth vial was crushed and the contents (4.4 mCi) released. One area about 4 cm in diameter could not be decontaminated. A steel plate was bolted onto the asphalt in that area and dose rates of 0.05 mR/hr at a meter were observed."

Notified R1DO (Powell) and FSME Events Resource via email.

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Power Reactor Event Number: 48209
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MIKE TERRY
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 16:26 [ET]
Event Date: 08/20/2012
Event Time: 11:00 [CDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ERIC DUNCAN (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

Event Text

MINOR THRU-WALL LEAK AT WELD IN SAFETY INJECTION SUCTION PIPING

"While working In the vicinity of valve SI-3, the isolation valve between the Boric Acid Storage Tanks and the common Safety Injection (SI) pump suction piping header, plant staff discovered a thru-wall leak at the weld between the SI-3 valve body and the piping upstream of SI-3. Minor leakage (less than 1 drop per minute) was observed at the flaw location. Upon being informed of this condition, plant operators closed SI-3 at 1109 [CDT] to isolate the affected portion of the piping from the SI suction piping. The time period from when the leak was discovered until it was isolated from the SI piping was less than 10 minutes.

"As part of the immediate operability determination, plant staff attempted to characterize the flaw to determine the degradation mechanism. Because the flaw could not be readily characterized, the common SI suction piping exposed to the leakage was considered to have been inoperable from the time of discovery until valve SI-3 was closed.

"This condition resulted in both Safety Injection Train A and Safety Injection Train B being inoperable per LCO 3.5.2, ECCS - Operating, Condition A, due to an inoperable common suction line. Since the flaw could not be readily characterized, required ECCS flow was conservatively deemed to not be available and LCO 3.0.3 was conservatively entered per Condition C of LCO 3.5.2 during this brief period (less than 10 minutes) until valve SI-3 was closed. This event is reportable under 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.

"Closing SI-3 restored both Safety Injection Train A and Safety Injection Train B to Operable status and LCO 3.0.3 was exited at 1109 CDT on 8/20/2012.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48210
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 17:30 [ET]
Event Date: 08/20/2012
Event Time: 14:17 [EDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM COOK (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 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT SIREN ACTIVATION

"At 1432 EDT on 08-20-2012, the Beaver Valley Unit 2 Shift Manager was notified by the Beaver County 911 call center that some sirens in the Beaver County area were activated at 1417 EDT. Investigation revealed that approximately 94 of the 120 sirens in the Beaver County area had been inadvertently activated for approximately 20 seconds in a Fire Alert mode during siren maintenance activities. All States and Counties within the Beaver Valley Emergency Planning Zone have been notified.

"This event is reportable as a 4-hour Non-Emergency Notification 10CFR50.72(b)(2)(xi) as 'Any event resulting in notification to other government agencies that has been or will be made.'

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48211
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 18:21 [ET]
Event Date: 08/20/2012
Event Time: 11:06 [EDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
WILLIAM COOK (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 100 Power Operation 100 Power Operation

Event Text

LOSS OF EMERGENCY RESPONSE DATA SYSTEM

"At 1106 EDT, on August 20, 2012 Computer Engineering personnel discovered a computer component failure which would have prevented the transmission of Emergency Response Data (ERDS) to the NRC if the system were to be activated. The actual component failure was determined to have occurred at approximately 2000 EDT on 8/19/12. This resulted in an out of service duration of greater than 8 hours, which was not discovered until after the fact. The system was repaired and returned to service at 1720 EDT on 8/20/12.

"Since Unit 1 and Unit 2 ERDS was unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii)."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48212
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW HESS
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 19:11 [ET]
Event Date: 08/20/2012
Event Time: 15:20 [CDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ERIC DUNCAN (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

Event Text

RWCU SYSTEM ISOLATION DIFFERENTIAL FLOW - HIGH FUNCTION INOPERABLE

"On 8-20-2012 during scheduled surveillance testing, the Reactor Water Cleanup (RWCU) System Isolation Differential Flow - High function was discovered to be inoperable at 1520 CDT. The high differential flow signal is provided to detect a break in the RWCU system when area or differential temperature would not provide detection (i.e. cold leg break). This instrumentation provides isolation signals to both inboard and outboard isolation valves and its loss is being reported pursuant to 10CFR50.72(b)(3)(v)(C).

"The NRC Resident Inspector was notified."

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Power Reactor Event Number: 48213
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WALLACE JUDD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 19:54 [ET]
Event Date: 08/20/2012
Event Time: 16:45 [EDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE GUTHRIE (R2DO)
MIKE CHEOK (NRR)
WILLIAM GOTT (IRD)

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 100 Power Operation 100 Power Operation

Event Text

OSHA NOTIFIED CONCERNING AN ONSITE NON-WORK RELATED FATALITY

"The control room received a 4911 notification [emergency on-site 911 call] regarding an employee illness where the employee was unresponsive. Site Medical Emergency Response Team responded, and requested offsite assistance via ambulance. The employee was transported to Piedmont Medical Center via ambulance where he was pronounced deceased. A notification to OSHA [Occupational Safety and Health Administration] was made at 1645 EDT on 8/20/12 due to the on-site fatality."

The employee had gone to a meeting and feeling ill went to the break room on-site. When the on-site medical team arrived at the break room they were unsuccessful in resuscitating the employee. The licensee will be notifying the state and local agencies.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, August 21, 2012
Tuesday, August 21, 2012