United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 24, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/23/2012 - 08/24/2012

** EVENT NUMBERS **


48190 48191 48193 48195 48196 48214 48223

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48190
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KIRK DUEA
HQ OPS Officer: VINCE KLCO
Notification Date: 08/15/2012
Notification Time: 04:37 [ET]
Event Date: 08/14/2012
Event Time: 20:45 [CDT]
Last Update Date: 08/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN GIESSNER (R3DO)

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

Event Text

SAFETY SYSTEM OVERPRESSURE PROTECTION FAILURE DUE TO CLOSED VALVES

"At 2045 [CDT] on 8/14/12, MNGP [Monticello Nuclear Generating Plant] Operations determined that valves RHR-82 and RHR-84 had been inappropriately closed as part of an isolation clearance order for work on shutdown cooling suction piping. These valves are required to be open to provide overpressure protection for RHR piping passing through primary containment penetration X-12. Upon discovery of the condition, Primary Containment was declared Inoperable and the Required Actions of Tech Spec 3.6.1.1 were entered. Following discovery, the isolation was restored and the valves opened. At 0001 [CDT] on 8/15/12, Primary Containment was declared Operable.

"This issue is being reported in accordance with 10CFR50.72(b)(3)(v)(C) and 10CFR50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of the safety functions of a system needed to control the release of radioactive material or to mitigate the consequences of an accident.

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

The licensee will contact the Minnesota State Duty Officer.

* * * RETRACTION FROM RANDY SAND TO CHARLES TEAL ON 08/23/12 AT 1545 EDT * * *

"This notification is a retraction of ENS 48190 based on further engineering evaluation. Monticello had previously evaluated penetration X-12 for thermally induced over pressurization. The evaluation qualified the piping components in the penetration for a maximum pressure of 3,306 psig using ASME Section III Appendix F operability criteria. The peak pressure calculated for the penetration was 2,743 psig based on Reactor pressure of 1000 psig with Reactor in Mode 1, and at worse case LOCA conditions for the Drywell. These assumptions and parameters envelop those that were present when valves RHR-82 and RHR-84 were closed on August 14, 2012. Therefore, this event would not have prevented the fulfillment of the safety function reported.

"The NRC Resident Inspector has been notified."

Notified R3DO (Duncan).

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Agreement State Event Number: 48191
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EAGLE X-RAY
Region: 4
City: MONT BELVIEU State: TX
County:
License #: L03246
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 08/15/2012
Notification Time: 10:37 [ET]
Event Date: 08/15/2012
Event Time: [CDT]
Last Update Date: 08/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
WILLIAM GOTT (IRD)
JIM WHITNEY (ILTA)
ANGELA MCINTOSH (FSME)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY CAMERA

The following information was received by email:

"On August 15, 2012, the licensee notified the Agency [Texas Department of State Health Services] that sometime during the evening, a QSA Global 880D radiography camera was stolen out of the dark room of one of their trucks. The camera contained Iridium-192. The truck was parked at the licensee's office, however the Radiographer left the camera in the truck instead of transferring the camera to the vault. The thieves broke into five radiography trucks taking various items including generators and the one camera. A police report was filed with the Chamber County Sheriff's Department. The thieves did not take the crank outs or source tube."

"The State of Texas event number for this event is I- 8979. Additional information will be provided in accordance with SA 300."

Notified DHS, FEMA, USDA, HHS, DOE, DHS NICC and EPA EOC.

* * * UPDATE ON 8/15/12 AT 1330 EDT FROM CHRIS MOORE TO DONG PARK * * *

"On August 15, 2012, around 1130 [CDT], the licensee and Local Law Enforcement recovered the stolen QSA Global 880D Radiography Camera. The camera is stored in the vault at the licensee facility and is in normal working condition. [A person of interest has been identified]. The truck used by the thief was identified on video surveillance tape. The camera was in the back of truck at the residence of the thief. Investigation will continue for the company and radiographers [concerning] Increased Controls (IC) security violations."

Notified R4DO (Hagar), FSME (McIntosh), ILTAB (Whitney), IRD (Gott), Mexico via fax, DHS, FEMA, USDA, HHS, DOE, DHS NICC and EPA EOC.

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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Non-Agreement State Event Number: 48193
Rep Org: UNITED STATES AIR FORCE
Licensee: UNITED STATES AIR FORCE
Region: 1
City: EGG HARBOR TOWNSHIP State: NJ
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: RYAN DANLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2012
Notification Time: 14:31 [ET]
Event Date: 08/15/2012
Event Time: [EDT]
Last Update Date: 08/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RAY POWELL (R1DO)
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE ()

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

Event Text

POTENTIALLY LOST AMERICIUM-241 SOURCE

"The potentially lost source is a M43A1 Chemical Agent Detector Cell (Americium-241, 0.25 mCi). The source exceeds 1000 times the quantity listed in Appendix C to Part 20.

"The source was made ready for shipment to our recycling and disposal office and given to the local traffic management office. Currently, we have no record of the shipment and cannot locate the shipping package. A comprehensive physical and document search is under way.

"Device Serial # Z03-C-30470
"Source Serial # Z03-C-31725"

The licensee notified R4 (Cook).

* * * UPDATE FROM DANLEY TO KLCO ON 8/16/2012 AT 0956 EDT * * *

The following information was received by email from the licensee:

The licensee received a call from the permit RSO [Radiation Safety Officer] that the Am-241 source has been recovered. It was located in the traffic management office.

Notified the R1DO(Powell), R4DO(Hagar) and FSME 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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Non-Agreement State Event Number: 48195
Rep Org: DEACONESS HOSPITAL
Licensee: DEACONESS HOSPITAL
Region: 3
City: EVANSVILLE State: IN
County:
License #: 13-00142-02
Agreement: N
Docket:
NRC Notified By: JOHN SUTKOWSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 08/16/2012
Notification Time: 10:58 [ET]
Event Date: 08/15/2012
Event Time: 10:00 [EDT]
Last Update Date: 08/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
JOHN GIESSNER (R3DO)
FSME VIA EMAIL ()

Event Text

MEDICAL EVENT DUE TO OFFSET OF THE INTENDED DELIVERY

A HDR (High Dose Rate) treatment was planned for a patient's mammary area, but the delivery of the source position was offset from the intended delivery. The patient and referring physician were informed of the difference between the planned and the delivered dosage. The patient will receive follow-up to discuss potential options.

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: 48196
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SAND LAKE CANCER CENTER, P.A.
Region: 1
City: ORLANDO State: FL
County:
License #: 4162-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/16/2012
Notification Time: 15:02 [ET]
Event Date: 08/02/2012
Event Time: [EDT]
Last Update Date: 08/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

PATIENT RECEIVES UNDER DOSE

The following report was received via fax.

"Received report from the RSO on 2 Aug 2012 at approximately 1430 [EDT] hrs of a medical event that occurred on 1 Aug 2012. Two patients with similar procedures (mammosite) were being treated with an HDR [High Dose Rate]. First patient correctly treated, second patient treated with the same plan as the first. Second patient only under dosed by 0.5%. Their treatment plans were allegedly the same.

"Orlando office investigated licensee and found violation to be caused by operator error. Corrective action consists of a 'Time Out' to verify patient's name, plan, and treatment settings. Further action referred to the Office of Licensing and Materials, this office will take no further action on this incident."

The device is a Nucletron Microselection HDR; S/N 31591.

Florida Incident: FL12-061.

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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Power Reactor Event Number: 48214
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TERRY BRANDT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/21/2012
Notification Time: 06:14 [ET]
Event Date: 08/21/2012
Event Time: 04:07 [CDT]
Last Update Date: 08/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE

"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the emergency power supply to the TSC from service. The TSC would be rendered non-functional with the loss of emergency power. The repair to the power supply is expected to last three days.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore the emergency power supply to service.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC emergency power supply has been restored to normal operation.

"NRC Resident has been notified."

* * * UPDATE FROM STEVE BREWER TO CHARLES TEAL ON 08/23/12 AT 1346 EDT * * *

Maintenance has been completed on the TSC. The TSC has been returned to service.

Notified R3DO (Duncan).

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Part 21 Event Number: 48223
Rep Org: WESTINGHOUSE ELECTRIC COMPANY
Licensee: WESTINGHOUSE ELECTRIC COMPANY
Region: 1
City: CRANBERRY TOWNSHIP State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES GRESHAM
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/23/2012
Notification Time: 09:21 [ET]
Event Date: 08/22/2012
Event Time: [EDT]
Last Update Date: 08/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MICHAEL HAY (R4DO)
PART 21 GROUP (Emai)

Event Text

PART 21 - STRESS CORROSION CRACKING CAUSING RELAY FAILURE IN SAFETY RELATED SYSTEMS

The following is summary of the information received from the licensee:

"The basic component is an Eaton-Cutler Hammer Type ARD660UR DC relay that is commercially dedicated by Westinghouse for use in safety related systems at Palo Verde Units 1, 2 and 3. Except for the Palo Verde plants, Westinghouse is not aware of any other plant that uses this relay as a safety-related component in normally energized applications.

"The relay contacts failed to change state when required to do so during postulated events and/or surveillance testing. Westinghouse has identified the kick-out spring as a possible contributing factor for the relay failure due to stress corrosion cracking. Other anomalies such as relay core barrel tolerance and potential material deficiencies are currently under review. Based upon testing at APS, the relay failure rate is low and non-reproducible. This indicates that a combination of factors could be resulting in the failures with different causes for each failure. Results of testing do not identify a common cause for the failures. For ARD660UR relays used in normally de-energized applications, the kick-out spring will be compressed for only a short period of time and exposure to additional heat generated by intermittent coil energization will be minimal. For relays in normally de-energized applications, it is not expected that the force provided by the kick-out spring will decrease significantly over time and the contacts will change position when the relay coil is de-energized. Westinghouse has not received any reports to date of relay contacts failing to properly change position when the relay goes from a de-energized to an energized state. Because of the kick-out spring's limited exposure to compression and heat generated by the relay coil, it is expected that the springs will perform as intended in normally de-energized applications for the qualified life of the relay.

"Identification of the firm constructing the facility or supplying the basic component which fails to comply or contain a defect.

"Westinghouse Electric Company
"1000 Westinghouse Drive
"Cranberry Township, Pennsylvania 16066"

Page Last Reviewed/Updated Friday, August 24, 2012
Friday, August 24, 2012