United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 27, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/24/2012 - 08/27/2012

** EVENT NUMBERS **


48195 48196 48201 48203 48205 48230 48231 48232 48233

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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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Non-Agreement State Event Number: 48201
Rep Org: WEST VIRGINIA UNIVERSITY HOSPITAL
Licensee: WEST VIRGINIA UNIVERSITY HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-23066-02
Agreement: N
Docket: 03020233
NRC Notified By: NASSER RAZMIANFAR
HQ OPS Officer: VINCE KLCO
Notification Date: 08/17/2012
Notification Time: 11:38 [ET]
Event Date: 10/08/2005
Event Time: [EDT]
Last Update Date: 08/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

MISSING SEALED AMERICIUM-241 SOURCE

"Subject: Official Notification

"This is to inform the NRC Operations Center that West Virginia University [WVU] Hospitals License # 47-23066-02 is not in possession of Item 6.I. Am-241 sealed sources (Amersham Model Dwg. ARC 10048B and 10040B) with an activity of 9.825 millicuries.

"NRC Region 1 is aware of this situation and has been working with us to resolve it. In August of 2005, a request was made to remove the item from our license. At that time NRC Region 1, via an October 8, 2005 email control # 137502, requested documentation of the shipment/disposal of the source. Based on NRC Region1 recommendations, on November 1, 2005 West Virginia University Hospitals withdrew the request to remove the item from the license. Control # 137502.

"In a search of the WVU Radiation Safety Department and Vendor records, no evidence of a shipment of the source was found. It was last listed on our physical inventory on May 7, 1991. The former RSO informed us via phone conversation that he believed it was shipped in the early 1990's.

"All of the search results were documented in writing to NRC Region 1 on May 23, 2012 during our license renewal process. Control # 576453.

"There is a current license amendment request to remove the source from our license. Control # 577671.

"West Virginia University Hospitals is officially notifying the NRC Operations Center at this time to document the situation in an effort to bring the situation to a close, and ultimately remove the source from our license."

The licensee has been working with Janice Nguyen in Region 1 to resolve this issue.

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: 48203
Rep Org: NEBRASKA DEPARTMENT OF HEALTH
Licensee: BED BATH & BEYOND
Region: 4
City: OMAHA State: NE
County:
License #: GL0654
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/17/2012
Notification Time: 13:57 [ET]
Event Date: 06/11/2012
Event Time: [CDT]
Last Update Date: 08/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT INVOLVING 28 MISSING TRITIUM EXIT SIGNS

The following report was received from the State of Nebraska via email:

"This is a preliminary report. We [Nebraska Department of Health and Human Services] will amend when we receive more information.

"On June 9, 2012, about 28 tritium exit signs (SLX 60 model, 11.5 Ci in 2005) were removed and new electrical exit signs were installed in the store by electricians. New lighting fixtures were also installed. The old fluorescent lighting was packaged to be picked up by a recycling facility. On June 11, 2012, the fluorescent lights were picked up. On August 12, 2012, Shaw Industries came to package the tritium exit signs and put labels on them. UPS would then pick them up to ship them to a facility licensed to receive the tritium signs. Shaw Industries could not find the exit signs on August 12, 2012. The store thinks that the tritium exit signs were picked up by the fluorescent lighting recycling company on June 11, 2012. The store is trying to find where the fluorescent lights were taken.

"[The State] has called all Bed and Bath stores that have had signs removed to make sure that only Shaw Industries can pick up the signs. Attempting to determine where the exit signs were taken and retrieve them for proper disposal."

Cause of this event is inattention to detail.

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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Non-Agreement State Event Number: 48205
Rep Org: PSC ENVIRONMENTAL SERVICES LLC
Licensee: PSC ENVIRONMENTAL SERVICES LLC
Region: 3
City: DETROIT State: MI
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: GREG INK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/17/2012
Notification Time: 16:50 [ET]
Event Date: 08/17/2012
Event Time: [EDT]
Last Update Date: 08/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN GIESSNER (R3DO)
FSME EVENTS RESOURCE (FSME)

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

Event Text

TEN TRITIUM EXIT SIGNS DAMAGED

Ten tritium exit signs belonging to Bed Bath and Beyond were inadvertently placed into a compactor and damaged. The signs originally contained 7.5 Ci of tritium when they were purchased 7-10 years ago. Shaw Environmental will take smears of the site next week to determine if there is residual contamination or cleanup required. The signs have been placed in drums and the area quarantined.

See report of this same event from the State of Wisconsin EN #48224

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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Power Reactor Event Number: 48230
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: CURTIS MARTIN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/24/2012
Notification Time: 17:33 [ET]
Event Date: 08/24/2012
Event Time: 13:32 [CDT]
Last Update Date: 08/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL HAY (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

PARTIAL LOSS OF REACTOR BUILDING EMERGENCY ASSESSMENT CAPABILITY

"At 1332 CDT on 8/24/12 a failure of power supply RMA-ES-53A was indicated in the Control Room. The power supply was declared Non-Functional. This failure results in the loss of ability to remotely measure and quantify radiological conditions (radiation levels) for multiple areas in the Reactor Building. The power supply provides power to RMA-RA-1 through RMA-RA-10. RMA-RA-11 through RMA-RA-30 remain fully functional and indicating normally.

"The loss of ability to monitor and quantify radiological conditions in multiple areas of the Reactor Building represents a major loss of emergency assessment capability per 10 CFR 50.72(b)(3)(xiii). As specified by station procedures, compensatory measures have been implemented to survey affected areas by installation of portable monitoring devices and trending radiological conditions. RMA-RA-1 through RMA-RA-10 are used for EAL determinations.

"The Work Week Director has been notified to initiate repairs."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48231
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: AMY CORDNER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/26/2012
Notification Time: 02:41 [ET]
Event Date: 08/26/2012
Event Time: 01:10 [EDT]
Last Update Date: 08/26/2012
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

INADVERTENT EMERGENCY SIREN ACTIVATION

"Calvert Cliffs control room was notified at 0110 EDT on 8/26/2012 by the Calvert Control Center (911) that sirens in the Calvert County area were activated. Reports were narrowed down to Lloyd Bowen Rd, Siren C15. At this time the siren is believed to be getting water in the controls due to inclement weather in the area. Maintenance Support is on their way to locally confirm and isolate the suspect siren.

"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 licensee notified the NRC Resident Inspector.

See related EN #48233.

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Power Reactor Event Number: 48232
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: BRETT BAYER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/26/2012
Notification Time: 16:00 [ET]
Event Date: 08/26/2012
Event Time: 12:39 [PDT]
Last Update Date: 08/26/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MICHAEL HAY (R4DO)
ART HOWELL (R4RA)
ERIC LEEDS (NRR)
WILLIAM GOTT (IRD)
JOHN LUBINSKI (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNUSUAL EVENT DECLARED DUE TO EARTHQUAKE FELT ONSITE

A Notice of Unusual Event (NOUE) was declared at San Onofre due to an earthquake felt on site (EAL HU1.1). The US Geological Survey indicates that there was a 5.3 magnitude earthquake near Brawley California, about 125 miles southeast of the plant. There were no indication of any impact to site operations other than being felt by personnel. Equipment inspections and walkdowns are in progress.

The licensee has notified state and local authorities. The NRC Resident Inspector will be notified. Notified other FEDS (FEMA, DHS, DHS NICC and Nuclear SSA via email).

* * * UPDATE FROM BAYER TO HUFFMAN AT 1713 EDT ON 8/26/12 * * *

On August 26, 2012 at 1346 PDT, San Onofre exited the Unusual Event based on an earthquake felt on site. Shortly after exiting the UE, the licensee felt more shaking in the control room. The licensee confirmed with the US Geological Survey that there has been an aftershock. The aftershock was approximately the same magnitude (5.4) and location as the original earthquake (about 125 southeast of the site). The licensee declared another unusual event at 1403 PDT. The licensee will re-perform all equipment walkdowns and inspections.

The NRC Resident Inspector has been notified and is reporting to the site. R4DO (Hay), NRR EO (Lubinski), and IRD (Gott) notified.

* * * UPDATE AT 2352 EDT ON 8/26/2012 FROM ADAM BOW TO MARK ABRAMOVITZ * * *

"Exited the NOUE HU1.1 - Earthquake at 2017 PDT on 8/26/12."

The licensee will notify the NRC Resident Inspector.

Notified the R4DO (Hay), NRR (Lubinski), IRD (Gott), DHS, FEMA, and DHS NICC.

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Power Reactor Event Number: 48233
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MORGAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/26/2012
Notification Time: 17:05 [ET]
Event Date: 08/26/2012
Event Time: 15:30 [EDT]
Last Update Date: 08/26/2012
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

INADVERTENT EMERGENCY SIREN ACTUATION

The Calvert Cliffs control room was notified at 1530 EDT on 8/26/2012 by a site employee that Siren C15 was intermittently alarming. This is a repeat of a similar actuation that had been reported in EN #48231. The licensee has notified the Calvert County Control Center that the siren had actuated. The licensee has deactivated the siren until further investigation and repairs can be accomplished. As was noted in the original event, adverse inclement weather conditions existed at the time the siren was alarming.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, August 27, 2012
Monday, August 27, 2012