United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 28, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/27/2012 - 08/28/2012

** EVENT NUMBERS **


48201 48203 48205 48207 48208 48228 48234 48236 48237

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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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Agreement State Event Number: 48207
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket: 12-0677
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/20/2012
Notification Time: 13:26 [ET]
Event Date: 08/13/2012
Event Time: [PDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - MEDICAL EVENT INVOLVING DELIVERY OF UNDERDOSAGE

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

"[The licensee reported] a misadministration on Monday, August 13, 2012, during a treatment with [Y-90] TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University.

"This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly.

"The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container.

"The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly.

"The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today.

"The Y-90 TheraSphere treatment consisted of:

Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray
Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray
Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray"

Oregon Incident # - 12-0031

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: 48208
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: QUALITY INSPECTION & TESTING, INC
Region: 4
City:  State: LA
County:
License #: LA-11238-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 14:52 [ET]
Event Date: 05/12/2012
Event Time: [CDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO RADIOGRAPHER

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

"On approximately May 14, 2012, a radiographer was performing industrial radiography. He dropped his badge approximately 7 feet from the industrial radiography camera for one to two welds. On approximately May 12, 2012 he was performing Mag inspections and had left his dosimetry in his parked car. He noticed some industrial radiography crews performing work near his vehicle. His badge read 7028 DDE [Deep Dose Equivalent] and 6972 SDE [Shallow Dose Equivalent].

"He stated that his pocket ion chamber never went off scale. None of his crew members badges and pocket ion chambers showed any exposure during the time they worked together. Louisiana Department of Environmental Quality is sending an inspector to investigate the dosimetry over exposure."

LA Event Report ID No.: LA120003

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Fuel Cycle Facility Event Number: 48228
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/24/2012
Notification Time: 14:20 [ET]
Event Date: 08/23/2012
Event Time: 19:45 [EDT]
Last Update Date: 08/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
ROBERT HAAG (R2DO)
GORDON BJORKMAN (NMSS)
FUELS OUO GROUP (EMAI)

Event Text

MATERIAL CONTROL AND ACCOUNTABILITY ALARM RESOLUTION

"10 CFR 74.57 (f)(2) requires notification within 24 hours that a Material Control & Accountability (MC&A) alarm resolution procedure has been initiated. In the Solvent Extraction Area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There was no material loss and the issue was resolved on 8/24/2012.

"MC&A process monitoring tests for material balance were run as specified by applicable procedures and requirements. Based on the test results for Building 333 solvent extraction area, the test limit was exceeded. The investigation was completed and the alarm was resolved on 8/24/2012.

"There was no actual or potential safety consequences to workers, the public, or the environment."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 48234
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: GILBERT RICHARDSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/27/2012
Notification Time: 11:10 [ET]
Event Date: 08/27/2012
Event Time: [EDT]
Last Update Date: 08/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT HAAG (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby
4 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION MAINTENANCE

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the work activity affects the functionality of an emergency response facility.

"Planned maintenance activities are being performed today (August 27, 2012) to the Technical Support Center (TSC) HVAC. The work entails removing power to system dampers rendering the TSC non-functional during the performance of this work activity. This work activity is planned to be performed and completed expeditiously within about 24 hours including establishing and removing the clearances and performing post maintenance testing.

"If an emergency condition occurs that requires activation of the TSC, plans are to utilize the TSC during the time this work activity is being performed as long as habitability conditions allow. The Emergency Response Organization duty team members will be relocated to alternate locations if required by habitability conditions in accordance with emergency implementing procedures."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 2014 EDT ON 8/27/12 FROM STRUSINSKI TO HUFFMAN * * *

The TSC ventilation maintenance has been completed and the TSC was returned to service at 2005 EDT on 8/27/12.

R2DO (Haag) has been notified.

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Power Reactor Event Number: 48236
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: LELAND BLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/27/2012
Notification Time: 18:36 [ET]
Event Date: 08/27/2012
Event Time: 15:26 [CDT]
Last Update Date: 08/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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

OFFSITE NOTIFICATION DUE TO HAZARDOUS MATERIAL SPILL

"Notification was made to Missouri Department of Natural Resources and the EPA National Spill Response Center of a Neutralization Tank discharge piping leak on 8/27/12 at 1526 hrs. (CDT). Subsequent testing of the leaking fluid at 1430 hrs. revealed the pH of the leaking fluid was 13, which is a characteristic hazard waste. Reportable quantity is 100 lbs. The estimated total volume released was less than 100 gallons, but greater than 100 lbs. This spill was reported to offsite organizations. Therefore, this event is reportable to the NRC per 10CFR50.72(b)(2)(xi). Mitigating strategy is to neutralize the contents of the tank, and the leaking fluid is being absorbed by absorbent materials."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48237
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/27/2012
Notification Time: 20:48 [ET]
Event Date: 08/27/2012
Event Time: 12:00 [CDT]
Last Update Date: 08/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

BOTH EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE

"At 12:00 CDT maintenance personnel identified a pinhole leak from the Division 1 Service Water System piping in the Service Water Pump Room. Division 1 Service Water [SW] was declared inoperable and LCO 3.7.2 Condition A was entered due to a potential loss of structural integrity. This directs entry into LCO 3.8.1 for Diesel Generator #1 made inoperable by SW. DG 2 was previously made inoperable at 05:39 CDT on 8/25/2012 due to an unrelated issue regarding rain water inleakage into the DG 2 Room. Control Room Emergency Filtration system [CREFs] is aligned to Div 1 power. LCO 3.7.4 Condition A is applicable, requiring restoration of CREFs to operable status within 7 days. TRM LCO 3.6.1 condition A and B also apply, requiring (A) Restoration of containment spray subsystem A to OPERABLE status within 7 days and (B) Restore one RHR containment spray subsystem to operable status within 8 hours.

"DG 1 and DG 2 comprise the onsite emergency power systems. Both DGs inoperable is reportable per 10CFR50.72(b)(3)(v)(D) as a condition that could prevent fulfillment of the safety function of structures or systems needed to mitigate the consequences of an accident.

"Actions were taken to expedite repairs of the DG 2 roof leak and to further characterize the Division 1 SW piping leak. LCO 3.8.1 Condition E allows 2 hours to restore one DG to operable status or enter Condition F, to be in Mode 3 in 12 hours, which was entered at 14:00. Repairs to the roof leak on the DG 2 room were completed, after which DG 2 was declared Operable at 18:30. LCO 3.8.1 Conditions E and F required shutdown were exited at this time. LCO 3.8.1 Condition B for DG 1, and 3.7.2 for SW Loop A, continue to be active. Planning to repair the SW piping pinhole leak is continuing. There were no adverse grid conditions during the period both DGs were inoperable.

"The NRC Resident has been informed of the condition. No media or press release is planned at this time."

Page Last Reviewed/Updated Tuesday, August 28, 2012
Tuesday, August 28, 2012