United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 17, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/16/2012 - 10/17/2012

** EVENT NUMBERS **


48389 48390 48392 48408 48410 48413

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Agreement State Event Number: 48389
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNADINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/09/2012
Notification Time: 15:15 [ET]
Event Date: 05/23/2012
Event Time: [PDT]
Last Update Date: 10/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

The following was received from the State of California:

"During a routine inspection on Oct. 8, 2012, RHB inspectors discovered a potential medical event had occurred on May 23, 2012. A patient was admitted to the hospital for carcinoma treatment of the endometrium near both ovaries on May 22, 2012 and treatment began at 1800 PDT. The treatment plan called for 3000 cGy to each ovary, using two [Redacted] sources and an ovoid applicator. [The] dosimetrist placed one source at a time into an insert, which was to be verified by the physician, a second year medical resident, who then placed the insert into the applicator and patient. The source inserts are individually screwed into the ovoid applicator, which prevents the source from movement. The patient treatment was to take 26.5 hrs. On May 23, 2012 at 2030, [the doctor] and the dosimetrist were removing the implant from the patient, starting with the right side. That source was verified to be in the insert and then placed into the pig. The doctor then proceeded to remove the left side insert, which was handed to the dosimetrist, who found the insert to be empty. The radiation survey meter was used immediately around the patient, rolling her back and forth as it appeared the source may be on the bed somewhere. The source was found on an IV monitor stand, which was approx. 2 foot from the patients head partially blocked by a portable lead shield that had been placed the day before. The source recovery was completed around 2045. Hospital staff (supervising MD, lead dosimetrist and RSO) were notified of the event and the patient treatment of the left side was completed on May 29, 2012, after revising the original patient treatment plan. The investigation did not discover how the source ended up on the IV stand. The licensee's RSO evaluated the event and did not feel that it qualified as a medical event per 10CFR35.3045 and therefore did not inform RHB within the 24 hour timeframe."

5010 #: 052312

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: 48390
Rep Org: CONTINENTAL CEMENT
Licensee: CONTINENTAL CEMENT
Region: 3
City: HANNIBAL State: MO
County:
License #: 24-20263-01
Agreement: N
Docket:
NRC Notified By: JOE HEIBEL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/09/2012
Notification Time: 15:25 [ET]
Event Date: 10/09/2012
Event Time: 11:00 [CDT]
Last Update Date: 10/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

SHUTTER STUCK OPEN ON FIXED VEGA AMERICAS, INC. NUCLEAR GAUGE

The licensee hired VEGA Americas (formerly Ohmart/VEGA) to remove a fixed industrial gauge from their Green America Recycling facility. During removal, it was determined that the shutter was stuck in its normal operating open position. The vendor placed a temporary shutter over the source and will be shipping the gauge back to their facility for disposal. There were no personnel overexposures reported as a result of this incident.

The gauge was a VEGA Americas model SHF2-0, S/N M-6997, containing 120 mCi of Cs-137.

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Agreement State Event Number: 48392
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: APPLIED INSPECTION SYSTEMS, INC.
Region: 4
City: FAYETTEVILLE State: AR
County:
License #: ARK-0572-0332
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/09/2012
Notification Time: 16:13 [ET]
Event Date: 10/08/2012
Event Time: [CDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECTED

The following information was obtained from the State of Arkansas via email:

"The Arkansas Department of Health [the Department] was notified on October 8, 2012 at 1345 [hrs. CDT], by the licensee, of a source disconnect. The radiography crew had completed a radiograph of a pipe weld and was unable to retract the source into the shielded position. The licensee's RSO was notified, the boundaries were verified and the radiography crew made several attempts to retract the source. The crank-out device was disassembled and the crew manually pulled the cable and discovered that the drive cable had separated.

"The licensee contacted Source Production & Equipment Company (SPEC) for source retrieval. Licensee representatives remained on-site and maintained direct surveillance awaiting the arrival of the source retrieval team. SPEC personnel arrived on site on October 9, 2012 and were able to retrieve the source into the radiography camera.

"The Department sent two Health Physicists to observe the source retrieval.

"Equipment involved: Radiography Camera is a SPEC 150, SN # 1357, radiography source is a SPEC G-60, SN # TH0302 containing [redacted] Iridium-192.

"The camera was inspected by SPEC personnel and the source leak tested. After the associated equipment (crank-out and guide tube) were replaced, the camera was returned to service.

"The Department is awaiting a report from SPEC and from the licensee.

"The Arkansas Department of Health, Radioactive Materials Program, Event Number is AR-2012-012"

* * * UPDATE AT 1555 EDT ON 10/16/12 FROM KRIESEL TO HUFFMAN * * *

The Arkansas Department of Health, Radioactive Materials Program, reported that the SPEC source retrieval crew received exposures of 12 mR for individual #1 and 10 mR for individual #2 during retrieval of the source back into the radiography camera.

R4DO(Pick) notified and a copy of this update was e-mailed to FSME Events Resource.

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Power Reactor Event Number: 48408
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: ALLISON HARKEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/16/2012
Notification Time: 08:10 [ET]
Event Date: 10/16/2012
Event Time: 08:00 [EDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DANIEL RICH (R2DO)

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

PLANNED TECHNICAL SUPPORT CENTER (TSC) MAINTENANCE

"At approximately 0800 on October 16, 2012 pre-planned maintenance will be performed that will affect the Technical Support Center (TSC) ventilation system. The scope of the maintenance is to inspect and clean all air handler units, fans, and outside air condensing units that support TSC ventilation. This maintenance is expected to be performed and completed within approximately 13 hours. If an emergency condition should occur, the ventilation system will be restored, but potentially not within the time required for activation of the TSC. In addition, the Harris Nuclear Plant (HNP) emergency plan has procedural guidance for use of an alternate location in the event the TSC is not habitable.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the maintenance."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 48410
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARK HAWES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 13:16 [ET]
Event Date: 10/16/2012
Event Time: 07:00 [EDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BLAKE WELLING (R1DO)

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

Event Text

SHUTDOWN COOLING ISOLATION CAPABILITY LOST

"On October 16, 2012, at 0529 EDT, with the reactor in mode 4 and one operable channel for the Residual Heat Removal (RHR) shutdown cooling isolation function, as permitted by TS 3.3.6.1, Operators identified a rising reactor water level indication on instruments associated with the 3A reactor water level reference leg while actual level remained constant. At 0700 EDT, Operators determined this condition rendered the RHR shutdown cooling isolation function inoperable; specifically, an isolation signal for RHR shutdown cooling based on a low reactor water level. In accordance with Tech Spec 3.3.6.1 Required Action J.1, immediate action was initiated to restore isolation capability. RHR shutdown cooling isolation capability was restored at 1040 EDT by changing in-service RHR shutdown cooling systems.

"This event could have prevented the fulfillment of a safety function, 10 CFR 50.72(b)(3)(v), at time of discovery to mitigate the consequences of an accident (D)."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48413
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: RICHARD O'CONNOR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 19:56 [ET]
Event Date: 10/16/2012
Event Time: 19:20 [EDT]
Last Update Date: 10/16/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
BILL DEAN (R1 R)
BRUCE BOGER (NRR)
JEFFERY GRANT (IRD)
BLAKE WELLING (R1DO)
SHER BAHADUR (NRR)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO EARTHQUAKE FELT ON-SITE

"An Unusual Event was declared at 1920 EDT, HU1 - Earthquake felt in the plant (Control Room), and confirmed by calling the Manchester Dispatch Office.

"Post event walkdowns indicate no reports of damage at the station. Walkdowns of station structures and systems continue.

"Plant is stable in Mode 5 planned refueling outage.

"No adverse impacts to shutdown cooling.

"The station seismic monitor is currently out of service for a scheduled calibration."

The licensee is exiting a refueling outage. The earthquake was felt by the site at 1914 EDT. The United States Geological Survey website indicates that an earthquake of magnitude 4.0 centered 3 miles west of Hollis Center, Maine occurred at this time.

The licensee is currently in a Train 'B' system outage. All Train 'A' systems are functioning as required.

The licensee has notified the NRC Resident Inspector and State authorities. No media or press release is anticipated at this time. The Headquarters Operations Officer has notified other FEDS (FEMA, DHS, DHS NICC and Nuclear SSA via email).

* * * UPDATE FROM SEAN RILEY TO PETE SNYDER AT 0212 ON 10/17/12 * * *

"The Unusual Event was terminated at 0149 EDT. Initiating condition was HU-1 due to the earthquake felt at the plant and confirmed by calling Manchester Dispatch Office. Information obtained by seismic monitoring system confirmed no additional escalation warranted. Site walkdown of key systems revealed no damage from the earthquake. All systems required for the current mode of operation were not adversely affected and remain in operation. "

The licensee will notify the NRC Resident Inspector. Notified R1DO (Welling), NRR (Bahadur), IRD (Grant) and other FEDS (FEMA, DHS, DHS NICC and Nuclear SSA via email).

Page Last Reviewed/Updated Wednesday, October 17, 2012
Wednesday, October 17, 2012