United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 8, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/07/2012 - 11/08/2012

** EVENT NUMBERS **


48458 48459 48465 48485 48487 48491

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Agreement State Event Number: 48458
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GOOLSBY TESTING LABORATORIES INC.
Region: 4
City: HUMBLE State: TX
County:
License #: 03115
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/30/2012
Notification Time: 13:24 [ET]
Event Date: 10/18/2012
Event Time: [CDT]
Last Update Date: 10/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE SOURCE DISCONNECTED

The following information was received by email:

"On October 18, 2012, the Agency [State of Texas Radiation Branch] received a request from an exposure device manufacturer for reciprocity to retrieve a . . . cobalt 60 source into a Spec 300 radiography device. The Agency contacted the Texas licensee and was told that the source had been retracted and that no reportable event had occurred. The licensee stated it needed assistance in disconnecting the drive cable from the source pig tail. On October 23, 2012, the Agency was informed by the manufacturer that the dose rates measured at the front of the exposure device indicated that the source may not be in the fully shielded position. On October 30, 2012, the Agency was informed by the manufacturer that the source was stuck inside the device approximately three inches from the locked and fully shielded position. The licensee has not reported this event to the Agency. The Agency will conduct an on-site investigation at the licensee's facility on November 1, 2012. There does not appear to have been any exposures to members of the general public. There were no overexposures to employees of the manufacturer. Exposures to the licensee's employees have not been determined. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA 300."

Texas Incident: I-9000

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Agreement State Event Number: 48459
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: JONES & DEMILLES ENGINEERING
Region: 4
City:  State: UT
County:
License #: UT-2100140
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/30/2012
Notification Time: 18:59 [ET]
Event Date: 10/15/2012
Event Time: 14:00 [MDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

A Troxler model 3440 portable gauging device (serial number 66163, containing approximately 8 milliCuries of cesium-137, and approximately 40 milliCuries of americium-241/beryllium) was hit by a bull dozer at a temporary jobsite. The source rod containing the Cs-137 source was not extended and remained in the shielded position. The case was cracked but the americium source was not damaged. The RSO arrived at the site and the survey results did not show evidence of contamination. The damaged gauge was placed in the transport case and removed from the jobsite.

Utah Event Number: UT-120004

* * * UPDATE FROM PHILIP GRIFFIN TO JOHN KNOKE AT 1926 EDT ON 11/01/12 * * *

The following information was provided by the State of Utah via email:

"The licensee's RSO reported to the Division that one of the licensee's gauge operators was at a temporary job site to perform soil moisture density measurements on October 15, 2012. As the gauge operator was preparing to make the first measurement, he looked behind him and saw a bulldozer coming towards him. The gauge operator was able to avoid being run over by the bulldozer, but the portable gauge was run over and damaged. The operator informed the licensee's RSO of the incident, and the RSO went to the temporary job site to investigate the incident. According to the RSO, there were other drivers in other vehicles at the job site when the incident occurred. They had honked their horns to get the attention of the bulldozer driver, but they could not.

"After clearing everyone out of the area, the RSO verified that the 8 mCi Cs-137 source was in the safe, shielded position, and that the 40 mCi Am-241:Be source was intact. The top cover of the gauge was cracked, and the source rod and depth gauge were bent approximately 15 - 20 degrees off vertical. The RSO was able to get the damaged gauge into the transportation package, and the RSO performed a survey of the area of the accident to verify that no contamination was present. Finding none, the RSO took the damaged gauge back to the licensee's facility in Richfield, Utah.

"Gauge information: Troxler 3440, s/n 66163

"The portable gauge was recently purchased from Troxler in June 2012, and the sources in the gauge had been leak tested by Troxler and no leakage was found.

"The incident occurred on 10/15/12 at approximately 2:00 PM. The manager got the message late in the day on 10/18/12."

Notified the R4DO (Rick Deese) and FSME Event Resource

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Agreement State Event Number: 48465
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: EUREKA State: CA
County:
License #: 1703-12
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/31/2012
Notification Time: 18:50 [ET]
Event Date: 10/17/2012
Event Time: 15:37 [PDT]
Last Update Date: 10/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT INVOLVING MISADMINISTRATION

"On 10/17/12, the licensee notified RHB (Radiation Health Branch) of an issue related to prostate brachytherapy and questioned if this falls into the category of Medical Event (ME). RHB is currently investigating this matter to evaluate if a ME had occurred.

"The RSO called RHB for guidance about three permanent prostate seed implants for which post-implant dosimetry showed less than ideal dose coverage of the gland. The RSO reiterated that none of these deviations were a surprise all were expected based on intra-operative experience. In one Iodine-125 case, poor coverage of the lateral base resulted from significant pubic arch interference. In the other two cases, both Palladium-103, poor coverage of the base occurred from vendor failure to disclose an additional unplanned spacer at the end of each seed strand.

"As stated, the D90 value (minimum dose to 90% of the CT-defined prostate one month following the implant) for the I-125 case was 77% and for the two Pd-103 cases was 68% and 53% of the dose prescribed as a minimum peripheral dose to the ultrasound-defined prostate +margin prior to the implant. The RSO requested RHB read this statement carefully, as it compares apples to oranges 'The RSO will make the case that the post-plan D90 is relevant as an assessment of plan and programmatic quality but is irrelevant for definition of a medical event'.

"The RSO indicated that the hospital's physicians do not prescribe by D90. What is prescribed is a minimum peripheral dose (MPD) to the ultrasound-defined prostate gland plus planning margin (PTV). A pre-plan is generated to deliver the intended MPD (145 Gy for I-125 monotherapy and 125 Gy for Pd-103 monotherapy) to the PTV. The resulting planned combination of radionuclide, source strength, and number of sources is what is approved, prescribed, ordered, and implanted.

"Very often, changes are made intra-operatively to account for implantation difficulties and clinical factors (deviation of urethra from predicted path, pubic arch interference, presence of more aggressive disease in a specific part of the gland, etc). In addition, extra seeds are ordered for each case, to be implanted at the discretion of the Authorized User (AU). Extra seeds may be implanted to boost areas of sparse coverage following implantation of planned seeds. Extra seeds may also be implanted to boost areas of known aggressive disease to a dose higher than the initial MPD. It is impossible to mentally arrive at a new dose that might correlate to a D90 on post-implant dosimetry under these conditions. The AU recognizes that this will result in an increase to the D90 on the post-plan but does not alter the dose on the written directive but only the number of sources (in part to of the written directive following implant but prior to release of the patient) to reflect the intra-operative changes. This is because the prescribed dose refers to a MPD for the pre-implant ultrasound prostate volume with margin (as our policy states). It was never meant to correlate with a D90 on a CT-defined prostate volume (which volume may be double the ultrasound-defined pre-implant volume) a month after the implant.

"As a result of the clinically discretional implantation of extra seeds, many of our D90 results in post-implant dosimetry actually exceed 100% of the prescribed dose. Several even exceed 120% of the 'prescribed' dose, and this is intentional. Nevertheless, the radionuclide, source strength, number of seeds, and duration of implant (permanent) indicated on part 2 of each written directive (the part completed following implantation but prior to release of the patient) correctly reflects what was done, as required by 10 CFR 35.41. The RSO called RHB about these three cases because the dose delivered to parts of these prostate glands was less than intended, an anticipated but initially unplanned result due to known but unplanned and uncontrollable outside factors.

"The Authorized Users for these cases are still reviewing the clinical data to determine what, if any, additional medical actions will be taken. Note that none of these cases meet the criteria for a medical event as recommended by the Nuclear Regulatory Commission's Advisory Committee on the Medical Use of Isotopes on October 18, 2011 (see attached). These criteria analyze the spatial distribution of seeds within octants of the gland as well as the overall D90 (threshold for which is lowered to 60% of prescription dose, and only in conjunction with failure of the spatial analysis). In each of these cases (and in contrast to what happened in the VA cases), very few seeds (only a few percent) were implanted outside the planning margin of the prostate CTV. Even by the older document the state reference, the May 18, 2011 Prostate Permanent Implant Brachytherapy and Associated Medical Event Questions and Answers from Clarification of Current Guidance for Prostate Permanent Implant Brachytherapy, the hospital assert (as in Case 2) that ' in accordance with NRC regulations, a ME has not occurred, since the delivered activity is equal to the prescribed activity for the treatment site (as defined by the AU). Even though the D90 values differ by more than 20 percent; the AU does not use D90 to prescribe dose, and is therefore, not required to use D90 to perform the regulatory evaluation of the prescribed dose'."

CA 5010 Number: 101712

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Power Reactor Event Number: 48485
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: JOHN FICKLE
HQ OPS Officer: VINCE KLCO
Notification Date: 11/07/2012
Notification Time: 09:39 [ET]
Event Date: 11/07/2012
Event Time: 09:00 [CST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

PLANNED OUTAGE OF EMERGENCY SIRENS

"A planned outage of all FCS [Fort Calhoun Station] sirens is to occur at 0900 CST today to replace required router power supplies. Based on the planned maintenance, all sirens for the Alert Notification System within the Emergency Planning Zone (EPZ) will be nonfunctional. Prior notifications and coordination with Local Law Enforcement have been completed with compensatory measures established to support notification of the public in case of an actual emergency during the scheduled maintenance.

"The planned maintenance is expected to take three hours with a projected completion time of 1200 CST. Also, contingencies have been established with the maintenance to back out if required in support of Law Enforcement activities.

"This is being reported per 10CFR50.72(b)(3)(xiii) for: 'Any event that results in a major loss of emergency assessment capability, off site response capability, or communications capability'."

The licensee notified the NRC Resident Inspector and local counties.

* * * UPDATE FROM JOHN FICKLE TO CHARLES TEAL ON 11/7/12 AT 1246 EST * * *

"At 1129 CST, maintenance was completed with all sirens restored to functional status. Local Law Enforcement has been notified and relaxed required compensatory actions. NRC Resident informed."

Notified R4DO (Farnholtz).

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Power Reactor Event Number: 48487
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF GROFF
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/07/2012
Notification Time: 12:39 [ET]
Event Date: 11/07/2012
Event Time: 09:21 [EST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHRISTINE LIPA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 68 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SHUTDOWN DUE TO HYDROGEN IN-LEAKAGE TO STATOR WATER COOLING SYSTEM

"At 09:21 EST 11/7/12, the reactor mode switch was taken to shutdown and the main turbine generator was manually tripped in response to hydrogen gas in-leakage into the stator water cooling system from the main turbine generator. The scram was uncomplicated, and all control rods, except one, fully inserted into the core. One control rod stopped at position 02 and was manually inserted. The lowest reactor vessel water level reached was 125 inches, and as expected, HPCI & RCIC did not actuate. No safety relief valves (SRV) actuated. Reactor water level is being controlled in the normal band using the control rod drive and reactor feedwater systems. All isolations and actuations for reactor water level 3 occurred as expected.

"The cause of the increased hydrogen gas in-leakage into stator water cooling is under investigation. At the time of the manual scram, all Emergency Diesel Generators were operable. All Emergency Core Cooling Systems were available and no significant safety related equipment was out of service. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), as an event that results in actuation of the reactor protection system (RPS) when the reactor is critical."

The MSIVs are open with decay heat being removed via steam to the main condenser using the bypass valves. The plant is in a normal shutdown electrical lineup.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48491
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: ANDREW ZUCHOWSKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/07/2012
Notification Time: 20:18 [ET]
Event Date: 11/07/2012
Event Time: 12:40 [EST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
GLENN DENTEL (R1DO)

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

Event Text

LIQUID PENETRANT SURFACE INDICATIONS FOUND ON CONTROL ROD DRIVE RETURN NOZZLE SAFE END TO PIPE WELD

"Oyster Creek Nuclear Generating Station is currently in Cold Shutdown executing Refueling Outage 1R24, which includes in-service inspections.

"At 1240 EST, General Electric notified Oyster Creek Management of surface indications that were detected by dye penetrant testing. The indications are in the adjacent base material area of the System Pressure Boundary weld. The indications are located Top Dead Center (TDC) of the 3 inch pipe. Indication #1 is upstream 0.7 inches away from the weld toe, the indication is 1.5" long. Indication #2 is downstream 0.2 inches away from the weld toe, the indication is 2.5" long. The depth of the indications are unknown at this time.

"Initial investigation revealed that there was no moisture or leakage found in the area of the indications. Further investigation is in progress to better characterize the indications. The cause is under investigation and corrective action plans are being developed.

"The surface defects have been evaluated by Exelon and determined to meet the criteria for reporting identified in NUREG-1022: Welding or material defects in the primary coolant system that cannot be found acceptable under ASME Section XI. IWB-3600, 'Analytical Evaluation of Flaws,' or ASME Section XI, Table IWB-3410-1, 'Acceptable Standards'."

The NRC Resident Inspector has been informed.

Page Last Reviewed/Updated Thursday, November 08, 2012
Thursday, November 08, 2012