United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 18, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/17/2012 - 10/18/2012

** EVENT NUMBERS **


48389 48390 48392 48414 48415 48416 48418

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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: 48414
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL BOTTORFF
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/17/2012
Notification Time: 05:46 [ET]
Event Date: 10/16/2012
Event Time: 23:30 [EDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DANIEL RICH (R2DO)

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

ALL FOUR EMERGENCY DIESEL GENERATORS AUTO-START ON VALID UNDERVOLTAGE SIGNAL

"On October 16, 2012, Watts Bar Nuclear Plant Unit 1 experienced a momentary loss of power to the 1B 6.9 KV Shutdown board. This resulted in an emergency start of all 4 Emergency Diesel Generators due to actuation of the designed undervoltage EDG start signal. A manual transfer of the shutdown board from the Normal power supply to the Alternate was in progress to support maintenance. The momentary loss of power lasted approximately 2 seconds, which caused load shed and Diesel Generator start to occur.

"Core cooling was maintained throughout the transient.

"This condition is being reported under 10 CFR 50.72 (b)(3) (iv) (A).

"All safety systems responded as designed. The unit remains stable in Mode 5.

"The cause for this failure is not yet known. Investigation is in progress.

"The NRC Senior Resident has been notified."

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Power Reactor Event Number: 48415
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: GLENDON BURNHAM
HQ OPS Officer: PETE SNYDER
Notification Date: 10/17/2012
Notification Time: 07:40 [ET]
Event Date: 10/17/2012
Event Time: 08:00 [EDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (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

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT OF SERVICE

"At approximately 0800 hours EDT on October 17, 2012, computer engineering personnel will be taking the plant integrated computer system (ICS) out-of-service for planned maintenance. During the time ICS is out-of-service, the Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) will be unavailable. The computer outage is scheduled for twelve hours.

"In the event of an emergency, plant parameter data will be communicated to the facilities through the Status Board Ring Down circuit with back-up by the Private Branch Exchange, Off Premise Exchange, and various redundant intra-facility circuits throughout the emergency facilities. The dose assessment function will be maintained during the out-of-service time period by manual input of data into the Meteorological Information and Dose Assessment System (MIDAS). The ability to open and maintain an 'open line' using the Emergency Notification System will not be affected and will be the primary means of transferring plant data to the NRC as a contingency until the ERDS can be returned to service.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii). A follow-up notification will be made when the maintenance activities are complete and the equipment is restored. The [NRC] Resident Inspector has been notified."

* * * UPDATE FROM THOMAS MORSE TO VINCE KLCO ON 10/17/12 AT 2146 EDT * * *

As of 2140 EDT on 10/17/12, the ERDS system was tested and restored to service. The licensee notified the NRC Resident Inspector.

Notified the R3DO (Orth).

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Power Reactor Event Number: 48416
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: THEODORE SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2012
Notification Time: 13:49 [ET]
Event Date: 10/17/2012
Event Time: 11:38 [EDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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

OFFSITE NOTIFICATION OF WASTE WATER PIPE LEAK CONTAINING TRITIUM

"The Harris Nuclear Plant is following the guidance in NEI 07-07 and has initiated this event notification as a result of our voluntary communication to state agencies in accordance with the Groundwater Protection Initiative. The state was notified at 1138 EDT.

"On October 16, 2012 at 5:12 pm, plant personnel identified a leak from a pipe on plant property. The pipe carries secondary plant and water treatment building waste water for chemical processing. The water, containing a low level of tritium (10,760 picocuries per liter), leaked into the surrounding soil. The surrounding soil is being excavated and the leak is being repaired. The EPA Drinking Water Standard is 20,000 picocuries per liter.

"The health and safety of the public are not affected by this event, based on the location of the leak and the low tritium levels.

"The NRC Resident Inspector has been notified."

The licensee also plans to notify local authorities.

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Power Reactor Event Number: 48418
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN KRITZER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2012
Notification Time: 16:05 [ET]
Event Date: 10/17/2012
Event Time: 09:46 [EDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BLAKE WELLING (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

Event Text

CONFIRMED POSITIVE FITNESS FOR DUTY TEST

A non-licensed employee supervisor had a confirmed positive during a for-cause fitness for duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Thursday, October 18, 2012
Thursday, October 18, 2012