United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 26, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/25/2012 - 10/26/2012

** EVENT NUMBERS **


48389 48417 48420 48435 48442 48443 48446

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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: 10/25/2012
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 18.5 mg Ra eq. CS-137 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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Agreement State Event Number: 48417
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: ALVIN State: TX
County:
License #: 00087
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2012
Notification Time: 15:55 [ET]
Event Date: 10/16/2012
Event Time: [CDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following report was received from the State of Texas Radiation Branch via facsimile:

"On October 17, 2012, the Agency [Texas Radiation Branch] was notified by the licensee that on October 16, 2012, a radiography source had disconnected from the drive cable during radiography at a field location. The radiographers were using a SPEC 150 exposure device [redacted]. The radiographers had completed an exposure and as they were surveying the exposure device, the radiographer noted that the dose rates at the front of the device were higher than expected. The radiographers contacted their Radiation Safety Officer. A source recovery team was sent to the location and the source was recovered without incident. The licensee read the Instadose dosimeters for the individuals involved in the event and no over exposures occurred. No additional exposure to a member of the general public occurred due to this event. The licensee was not able to determine the cause for the disconnect. The exposure device and the crank-out device the radiographers were using are being sent to the manufacturer for inspection."

Texas Incident #: I-8994

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Agreement State Event Number: 48420
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: METCO
Region: 4
City: HOUSTON State: TX
County:
License #: 03018
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/18/2012
Notification Time: 16:56 [ET]
Event Date: 10/17/2012
Event Time: [CDT]
Last Update Date: 10/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT- UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was received by email:

"On October 18, 2012, the Agency [Texas Radiation Branch] was notified by the licensee that on October 17, 2012, a radiographer was unable to retract a [source] into the QSA 880F exposure device. The guide tube for the device was damaged during radiography operation in the fixed facility when a part fell on it, crimping the guide tube to a point where the source could not pass through it. The licensee stated that they were able to repair the guide tube enough to retract the source and lock it in the exposure device. The licensee stated that no over exposure occurred from the event and no member of the general public received any exposure from the event. Additional information will be provided as it is received in accordance with SA 300.

Texas Incident: I-8998

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Power Reactor Event Number: 48435
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: BRUCE THOMPSON
HQ OPS Officer: VINCE KLCO
Notification Date: 10/23/2012
Notification Time: 20:59 [ET]
Event Date: 10/23/2012
Event Time: 19:22 [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RANDY MUSSER (R2DO)

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

Event Text

DEGRADED CONDITION DUE TO REACTOR HEAD VESSEL PENETRATION INDICATIONS

"On October 23, 2012, V. C. Summer Station Unit 1 (VCSNS) identified two reactor vessel head penetrations (19 and 52) that did not meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1. The station is in a refueling outage (RF20) and the plant is currently shutdown and in Mode 6. The reactor vessel head (RVH) contains a total of 66 penetrations and inspection efforts are approximately 50% percent complete. There have been no previous repairs to the reactor vessel head penetrations and/or j-groove welds. The indications are not through wall as indicated by volumetric and bare metal visual inspections. The penetrations will be repaired to meet the requirements of 10CFR50.55a prior to returning the vessel head to service.

"The inspection results are reportable pursuant to 10CFR50.72(b)(3)(ii)(A). The NRC Resident Inspector has been notified."

The licensee will notify the State of South Carolina and local counties.

* * * UPDATE FROM BETH QUATTLEBAUM TO PETE SNYDER AT 1800 ON 10/25/12 * * *

"On October 25, 2012, V. C. Summer Station Unit 1 (VCSNS) finalized our inspections of the reactor vessel head, which has identified a total of four reactor vessel head penetrations (19, 52, 31, and 37) that did not meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1. The station is in a refueling outage (RF20) and the plant is currently shutdown and defueled. The indications are not through wall as indicated from volumetric and bare metal visual inspections. The penetrations will be repaired to meet the requirements of 10CFR50.55a prior to returning the vessel head to service.

"The inspection results are reportable pursuant to 10CFR50.72(b)(3)(ii)(A). The NRC Resident Inspector has been notified."

Notified R2DO (Musser).

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Power Reactor Event Number: 48442
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: ROB STOUGH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/25/2012
Notification Time: 10:22 [ET]
Event Date: 10/25/2012
Event Time: 09:30 [CDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BOB HAGAR (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 EMERGENCY ASSESSMENT DURING PLANNED MODIFICATIONS

"On October 25, 2012, Callaway Plant will begin implementation of a modification to the plant computer system. The Emergency Response Data System (ERDS) and plant computer stations in the Technical Support Center (TSC) and Emergency Operations Facility (EOF) will be unavailable during the modification. Plant computer stations will remain available in the Control Room. The period of unavailability is anticipated to be approximately 12 hours on October 25, 2012, with an additional 8 hours for system testing on October 26, 2012.

"During the modification process, the TSC and EOF will remain functional and available for use. Plant procedures provide guidance for manual data collection and sending ERDS data to the NRC.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM SHANNON GAYDOS TO PETE SNYDER AT 2123 ON 10/25/12 * * *

"Based on the current work progress on the plant computer system, the Emergency Response Data System (ERDS) and the plant computer stations in the Technical Support Center (TSC) and Emergency Operations Facility (EOF) will not be available until early evening on October 26, 2012."

The NRC Resident Inspector will be notified. Notified R4DO (Hagar).

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Power Reactor Event Number: 48443
Facility: MCGUIRE
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC G. BLOUGH
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/25/2012
Notification Time: 14:17 [ET]
Event Date: 09/29/2012
Event Time: 23:37 [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RANDY MUSSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

INADVERTENT ALIGNMENT OF NUCLEAR SERVICE WATER TO STANDBY NUCLEAR SERVICE WATER POND

"On September 29, 2012, McGuire Nuclear Station experienced an inadvertent alignment of the Nuclear Service Water (RN) system suction and discharge to the Standby Nuclear Service Water Pond (SNSWP). This event occurred when a Unit 2 'B' Train blackout signal was inadvertently generated as a result of a tagging restoration/coordination error. This error resulted in the Unit 2 Train 'B' load sequencer sensing an under-voltage condition on 4160V Essential Switchgear 2ETB, which was de-energized at the time for maintenance activities. Further evaluation determined that the blackout signal which automatically aligned RN to the SNSWP was not in response to actual plant conditions or parameters satisfying the requirements for initiation of a blackout signal or the SNSWP safety function. Since alignment of RN to the SNSWP was not in response to a valid signal, this represented an invalid actuation reportable per the requirements of 10 CFR 50.73(a)(2)(iv)(A).

"As allowed by 10 CFR 50.73(a)(1), McGuire is providing a telephone notification of this invalid actuation in lieu of submitting a written LER. The following additional information is being provided as part of the telephone notification of this event: 'B' Train of RN actuated to align Unit 1 and Unit 2 RN to the SNSWP. 'B' Train actuation of Unit 1 and Unit 2 RN to the SNSWP functioned successfully and was complete. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48446
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: AMY CORDNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/25/2012
Notification Time: 17:13 [ET]
Event Date: 10/25/2012
Event Time: 10:31 [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JOHN CARUSO (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

CONFIRMED POSITIVE FITNESS FOR DUTY

A non-licensed employee supervisor had a confirmed positive for alcohol during a random 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 Friday, October 26, 2012
Friday, October 26, 2012