United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 13, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/09/2012 - 11/13/2012

** EVENT NUMBERS **


48329 48429 48451 48468 48469 48470 48472 48473 48474 48480 48496 48497
48500 48501 48502 48503

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Agreement State Event Number: 48329
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: BURLINGTON HOUSE MILL
Region: 4
City: MONTICELLO State: AR
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/21/2012
Notification Time: 16:09 [ET]
Event Date: 09/20/2012
Event Time: 18:00 [CDT]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENT RESOURCE (EMAI)
DARYL JOHNSON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING OHMART BETA GAUGE

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

"While conducting an investigation of a citizen's allegation on September 20, 2012, the Department [Arkansas Department of Health] recovered a generally licensed device in a scrap yard in Dermott, Arkansas. The device is:

"Ohmart Beta Gauge: Model BAL
Gauge Serial Number: 3780BC
Isotope: SR-90
Activity: 25 millicuries

"This device was retrieved and transported to the Department's [Arkansas Department of Health] storage location in Little Rock at approximately 1800 CDT on September 20, 2012.

"Ohmart provided information concerning the shipment date (12/1994) and the location. The device was shipped to Burlington House Mill in Monticello, Arkansas. Ohmart also informed the Department [Arkansas Department of Health] that a second device had also been shipped with this source. The source holder serial number for this device is 3779BC.

"Health Physicists visited the old Burlington site after finding the device in the scrap yard in Dermott, Arkansas.

"Health Physicists returned on September 21, 2012 to the Monticello and Dermott areas to search in locations where the second device may have been disposed. At the time of this notification, the Department [Arkansas Department of Health] considers the second device to be missing.

"The Department [Arkansas Department of Health] has notified the Mississippi Department of Health.

"The Department [Arkansas Department of Health] is still investigating and searching for the missing device. An investigation is on-going to identify the possible owner of the devices.

"The Department [Arkansas Department of Health] considers this event open at this time pending the completion of the investigation."

Arkansas Incident Number AR-2012-009.

* * * UPDATE AT 1014 EDT ON 10/02/12 FROM ROBERT PEMBERTON TO S. SANDIN * * *

The following update was received from the State of Arkansas via email:

"On October 1, 2012, while conducting a follow-up investigation of allegation ARK-2012-009, the Department recovered the second generally licensed device originally shipped to the Burlington House Mill in Monticello, Arkansas. The device is described as follows:

Manufacturer: Ohmart
S.O. : AR940603068A
Source Holder: BAL
Source Serial Number: 3779BC
Isotope: Sr-90
Activity: 25 mCi
Date 12/94

"The device was retrieved from property on East Calhoun Street, Monticello, Arkansas and transported to the Department's storage vault in Little Rock.

"The device housing was not damaged and preliminary wipes of the device showed no removable contamination.

"An investigation is on-going to identify the possible owner of the devices.

"The Department considers this event open at this time pending the completion of the investigation."

Notified R4DO (Powers), FSME RESOURCE and ILTAB via email.

* * * UPDATE FROM THE ARKANSAS DEPT. OF HEALTH VIA FAX ON 11/9/12 AT 1530 EST * * *

"On November 9, 2012, both recovered sources were picked up for disposal from the Department's storage vault in Little Rock Arkansas. Neither source has been found to be leaking.

"The Department has completed its investigation and considers this event closed."

Notified R4DO (Farnholtz) and FSME Resources email.


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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48429
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/22/2012
Notification Time: 03:49 [ET]
Event Date: 10/22/2012
Event Time: 00:10 [CDT]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
GREG PICK (R4DO)

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

Event Text

POTENTIAL CONDITION COULD BYPASS FLOODING BARRIERS AND AFFECT RESIDUAL HEAT REMOVAL EQUIPMENT

"During a walkdown evaluating potential for adverse consequences of site flooding, per 10CFR50.54(f) request, a condition was identified which had the potential to adversely impact the ability to address external flooding conditions. The old Emergency Offsite Facility (which currently houses information technology offices) has a drain pipe which connects to Sump AA in the Augmented Radwaste (ARW) building and bypasses the flooding barriers erected per maintenance procedure 7.0.11 in the event of site flooding.

"Per the USAR, the basis for site flooding is a flood with concurrent surge effects on exposed safety related structures reaching an elevation of 905 feet. This elevation is 2.0 feet above the grade elevation of 903 feet. Flooding protection for important site facilities is provided by installing temporary barriers protecting to elevation 906 feet. Primary and Secondary Flood Barriers are installed at the ARW building external entrances on the 903 feet elevation to protect the Reactor Building from external flood water. The drain piping from the old EOF floor drain and shower is piped directly to Sump AA in the ARW building basement. This is a 3 inch pipe which drains by gravity. There are no isolation features on the pipe, and no barriers to flooding are provided for this facility, thus the potential exists to bypass the flood barriers which would be erected around the ARW Building. Flooding of the building basement could result, disabling processing equipment. If the basement fills up, flood waters could enter the Reactor Building through the internal entrance, which has no additional protection installed. Floodwaters could then affect equipment which is required to remove residual heat.

"This condition has been determined to be reportable per 50.72(b)(3)(v) - Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of SSCs that are needed to remove residual heat. The potential condition was identified on 10/20/2012. Evaluation of the condition and the potential impact was completed and reportability determined on 10/22/2012. The condition has been entered into the Corrective Action Program."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 2211 EDT ON 10/22/12 FROM KYLE SAYLER TO S. SANDIN * * *

"During a walk down evaluating the potential for adverse consequences of site flooding per 10CFR50.54(f) request, a condition was identified which had the potential to adversely impact the ability to address external flooding conditions. The Optimum Water Chemistry (OWC) building has 5 floor drains, at ground level elevation 903 ft, which connect to a common 3 inch drain pipe which connects to a sanitary sump located in the Turbine building, at an elevation of 882 ft, and bypasses all flooding barriers erected per maintenance procedure 7.0.11 in the event of site flooding.

"Per the USAR, the basis for site flooding is a flood with a concurrent surge effect on exposed safely related structures reaching an elevation of 905 ft. This elevation is 2 ft above the grade of the floor drains. Flooding protection for important site facilities is provided by installing temporary barriers which provide protection to an elevation of 906 ft. Primary and secondary barriers are installed at the Turbine building external entrances to protect the Reactor building from external flood waters. Additional secondary barriers are erected inside the Turbine building to provide additional protection to the Diesel Generator rooms. The drain piping from the OWC building floor drains is piped directly to the sanitary sump located in the Turbine building. There are no isolation features on the piping and no barriers to flooding are erected between the Turbine building and Reactor building thus the potential exists to bypass the flood barriers erected around the Turbine building. Flooding of the Turbine building could result in the accumulation of water in sufficient quantities to fill the Turbine building 882.5ft elevation to the height of the external floodwaters which would then be allowed to flow unimpeded by flooding barriers to the Reactor building through the internal entrance which has no additional barriers installed. These floodwaters could then affect equipment, located within the Reactor building, which is required to remove residual heat.

"This condition has been determined to be reportable per 50.72(b)(3)(v) - Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of SSC's. that needed to remove residual heat. This condition was identified at 1550 [CDT on] 10/22/2012 and has been entered into the Corrective Action Program."

The licensee informed the NRC Resident Inspector. Notified R4DO (Hagar).

* * * RETRACTION FROM DAVID MADSEN TO HOWIE CROUCH AT 1228 EST ON 11/9/12 * * *

"This notification is being made to retract Event Notification EN #48429 which reported a loss of safety function due to the discovery of two flow paths (one from the old Emergency Operating Facility and one from the Optimum Water Chemistry building) where an external event flood event at 905 feet would result in flooding of the Turbine and Radwaste basement and eventually the Reactor building basement.

"Upon further review, the design basis Probable Maximum Flood for CNS is 903 feet. The two water entry points discussed in the Event Notification are above the 903 foot elevation. Wave energy would be dissipated before reaching any of the main buildings so there would be a minimal influx of water into the structures. As such, there is no loss of safety function for equipment in the Reactor building basement. NPPD therefore retracts Event Notification EN #48429."

The NRC Resident Inspector has been notified. Notified R4DO (Farnholtz).

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Power Reactor Event Number: 48451
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 10/29/2012
Notification Time: 18:15 [ET]
Event Date: 10/29/2012
Event Time: 17:00 [EDT]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

ERDS LOST DUE TO PROCESS COMPUTER SYSTEM DATA SERVER FAILURE

"At 1700 EDT on October 29, 2012, Fermi 2 discovered a failure occurred with a data server within the Process Computer system at 0115 EDT on October 28, 2012. The failure of the data server affects data input to the server providing information to the Emergency Response Data System (ERDS). ERDS is currently not receiving updated information from Fermi data systems. This loss in capability is being reported as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

"Indications of related plant variables are available in the Main Control Room. The Visual Annunciator System (VAS) and other portions of the Process Computer system remain functional. Meteorological and process effluent radiological monitor indications are available and dose assessment capability is available. Fermi 2 personnel will use normal phone communications to update NRC Operations Center in the case of an event declaration. Information normally provided by ERDS can be transmitted via the notification system as described in the Radiological Emergency Response Preparedness Plan. Fermi 2 will notify the NRC when ERDS is returned to service."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 11/9/12 AT 2056 EST FROM BRETT JEBBIA TO DONG PARK * * *

"This is a follow up to EN #48468 & EN #48451.

"On October 29, 2012, Fermi experienced a failure of a data server within the process computer system which feeds data to Emergency Response Data System (ERDS), and EN #48451 was made to the NRC.

"On November 1, 2012, planned maintenance for Cyber Security Modification began which removed ERDS, SPDS, and IPCS from service, and EN #48468 was made to the NRC.

"On November 9, 2012, planned maintenance on ERDS, SPDS, and IPCS is complete, restoring full emergency assessment capabilities to all onsite emergency response facilities (EN #48468). The maintenance also repaired the data server within the process computer system which feeds data to ERDS (EN #48451)."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Lipa).

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Power Reactor Event Number: 48468
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/01/2012
Notification Time: 08:20 [ET]
Event Date: 11/01/2012
Event Time: 08:00 [EDT]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

INTEGRATED PLANT COMPUTER SYSTEM OUT-OF-SERVICE OUTSIDE THE CONTROL ROOM FOR PLANNED MAINTENANCE

"Beginning November 01, 2012, at approximately 1000 [EDT], the Fermi 2 Integrated Plant Computer System (IPCS) will be removed from service outside of the Control Room to support installation of a Cyber Security Modification. The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and will be out of service when the IPCS is removed from Emergency Response Facilities (ERFs). These systems will be unavailable to all Emergency Response Facilities (ERFs) for approximately 196 hours.

"By 1600 [EDT] on November 9, 2012 it is planned to restore IPCS, including SPDS and ERDS, to the Operational Support Center, the Technical Support Center, and alternate facilities. During this time dose assessment (Raddose) capability will only be available in the manual data input mode. The SPDS indications and Raddose remain available to the plant staff in the Control Room, and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored.

"This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability. ERDS previously reported out of service under event number EN 48451 ."

The licensee informed the NRC Resident Inspector.

* * * UPDATE ON 11/9/12 AT 2056 EST FROM BRETT JEBBIA TO DONG PARK * * *

"This is a follow up to EN #48468 & EN #48451.

"On October 29, 2012, Fermi experienced a failure of a data server within the process computer system which feeds data to Emergency Response Data System (ERDS), and EN #48451 was made to the NRC.

"On November 1, 2012, planned maintenance for Cyber Security Modification began which removed ERDS, SPDS, and IPCS from service, and EN #48468 was made to the NRC.

"On November 9, 2012, planned maintenance on ERDS, SPDS, and IPCS is complete, restoring full emergency assessment capabilities to all onsite emergency response facilities (EN #48468). The maintenance also repaired the data server within the process computer system which feeds data to ERDS (EN #48451)."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Lipa).

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Agreement State Event Number: 48469
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/03/2009
Event Time: [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

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

"Licensee contacted the Department [Georgia Radioactive Materials Program] via telephone on 8/12/09 reporting that a patient who underwent a nuclear cardiology treadmill stress test on 8/3/09 resulted in an embryo/fetus exposure greater than 500 mRem. The Department received a report from the licensee on 8/14/12 describing that prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/10/09. Isotopes and activity administered to the patient were as follows: Tc-99m 28.2 mCi & Tl-201 3.62 mCi with a Total Activity of 31.82 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

Report: GA-2009-12i

NMED# 090811

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Agreement State Event Number: 48470
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/17/2009
Event Time: [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

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

"Licensee informed the Department [Georgia Radioactive Materials Program] via written correspondence dated 8/28/09 that a patient who underwent a nuclear cardiology treadmill stress test on 8/17/09 resulted in an embryo/fetus exposure greater than 500 mRem. Prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/27/09. Isotopes and activity administered to the patient were as follows: Tc-99m 26.9 mCi & Tl-201 5.38 mCi with a Total Activity of 32.28 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

Report: GA-2009-18i

NMED# 090812

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Agreement State Event Number: 48472
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TOWN OF LYONS
Region: 4
City: LYONS State: CO
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 16:55 [ET]
Event Date: 10/22/2012
Event Time: [MDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TRITIUM EXIT SIGN

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

"The Colorado Department of Public Health and Environment received notification on 10-23-12 from Town of Lyons, Town Hall, 432 Fifth Avenue, Lyons, CO 80540, that a tritium exit sign was found on the floor when an employee entered the building on 10-22-2012. This exit sign was installed on 10-19-12. It is presumed the installation was incorrectly completed causing the sign to fall. An employee who entered the building picked the sign up and reported the damaged sign to the Public Works Director who contacted the Radioactive Materials Unit on 10-23-12 at 1330 PDT to report the damaged exit sign. The tube containing the Tritium is reported as damaged.

"The sign was reported installed on 10-19-12. The sign fell from the ceiling during the weekend, and was found on Monday, 10-22-12 just inside the front entrance to the building. The licensee was provided documentation regarding how to package and ship the sign back to the manufacturer. The documentation emailed to him included the NRC NUREG -1556, Vol. 16 Appendix L.

"Maker of the sign is Best Lighting Products. The model number is SLXTU1RB10 and serial number is 232970. The date it was reported shipped to the licensee was 12/28/10.

"The activity of H-3 is 7.03 Curies."

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Agreement State Event Number: 48473
Rep Org: COLORADO DEPT OF HEALTH
Licensee: WESTIN HOTEL -WESTMINSTER
Region: 4
City: WESTMINSTER State: CO
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 16:55 [ET]
Event Date: 10/02/2012
Event Time: [MDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

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

"The Colorado Department of Public Health and Environment received notification on 10-2-12 from Westin Hotel - Westminster, 10600 Westminster Blvd., Westminster, CO 80030. Phillip McDonald, Engineering Manager, reported a contractor removed and disposed of one exit sign during a remodel project when a new front entrance was completed, (no date given on project).

"Maker of Sign: Isolite
Model Number: SLX60
Serial Number: 12-02897
Activity (Curies of H-3): 6.2 Curies
Date Manufacture Shipped: 1/31/2012
Date of Loss: No Date Reported for project.
Location of Sign When Lost: Front entrance

"Other Details: Per the letter submitted by Phillip McDonald, he states 'I do remember this device being installed, but I was unaware it had radioactive material inside or the responsibility of tracking this device. Our restaurant was remodeled this year and the contractor removed the device and disposed of it'."

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: 48474
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PARADIGM CONSULTANTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 04875
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 17:46 [ET]
Event Date: 11/01/2012
Event Time: [CDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

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

"On November 1, 2012, the licensee notified the Agency that one of its Campbell-Pacific Model MC-3 moisture/density gauges had been run over by a pickup truck at a temporary work site in Houston, Texas. The gauge contained one 10 millicurie cesium-137 source and one 50 millicurie americium-241/beryllium source. The sources were in the safe position when it was run over. The source rod was broken off at the top of the housing. The gauge was taken to a gauge service company where it was checked. There was no leakage of radiation. A determination will be made by the licensee as to whether they will have the gauge repaired or replaced. There was no exposure to any individual as a result of this incident.

"Gauge Information:
Mfg: Campbell-Pacific
Model: MC-3
SN: M38118595

"Source Information:
cesium-137 -- 10 millicuries -- SN: C8595
americium-241/beryllium -- 50 millicuries -- A8595"

Texas Incident Number: I-9005

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Agreement State Event Number: 48480
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Region: 4
City: LA JOLLA State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/05/2012
Notification Time: 12:56 [ET]
Event Date: 11/01/2012
Event Time: [PST]
Last Update Date: 11/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - DOSAGE ADMINISTERED LESS THAN PRESCRIBED

The following was received from the State of California via email:

"Patient was prescribed to receive 30.24 mCi of Y90 in Microsphere form (MDS Nordion, Model TheraSphere) through a catheter. The catheter became plugged during the procedure not allowing approximately 47% of the prescribed spheres to reach the treatment location. Patient received 16.2 mCi of the prescribed 30.24 mCi (53%)

"The dosage to the patient was not available at the time of report, therefore RHB (Radiation Health Branch) was unable to determine whether this met all requirements to be classified as a 'Medical Event.'

"The reporting requirements will be reviewed once the licensee provides RHB with the dose information.

"A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento."

California 5010 #: 110112

* * * UPDATE FROM DONALD OESTERLE TO CHARLES TEAL ON 11/5/12 AT 1428 EDT * * *

"On 11/2/2012, the dosage to the patient was not available at the time of the report, therefore RHB was unable to determine whether this met all requirements to be classified as a Medical Event. The reporting requirements will be reviewed once the licensee provides RHB with the dose information. A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento.

"At 11:00 am, 11/5/2012 RHB received additional information: The physician's written directive prescribed 130 Gy (13,000 rem) to the liver. The patient received 68.9 Gy (6,890 rem) to the intended organ. The remaining activity was contained by the microsphere delivery system.

"The NRC Operation Center was updated on 11/5/2012; 11:25AM confirming this report as meeting the necessary conditions of classifying this as a Medical Event. "

Notified R4DO (Farnholtz) and FSME Event Resource via email.

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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Power Reactor Event Number: 48496
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE WALSH
HQ OPS Officer: VINCE KLCO
Notification Date: 11/09/2012
Notification Time: 03:03 [ET]
Event Date: 11/09/2012
Event Time: 01:18 [EST]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(iv)(A) - ECCS INJECTION
Person (Organization):
GLENN DENTEL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 90 Power Operation 0 Hot Shutdown

Event Text

UNIT 2 MANUAL SCRAM DUE TO LOSS OF THE INTEGRATED CONTROL SYSTEM

"At approximately 0118 hours [EST] on November 9, 2012, Susquehanna Steam Electric Station Unit Two reactor was scrammed by plant operators due to a loss of ICS (Integrated Control System; which controls the reactor feed and reactor recirculation systems). The reactor operator placed the mode switch in shutdown when reactor water level reached +25 inches and lowering. All control rods inserted and both reactor recirculation pumps tripped at -38 inches. Reactor water level lowered to -52 inches causing Level 3 (+13 inches) and level 2 (-38 inches) isolations. HPCI and RCIC both automatically initiated. HPCI was overridden prior to injection and RCIC was utilized to restore reactor water level to the normal band. All isolations and initiations at this level occurred as expected. No steam relief valves opened. Pressure was controlled via turbine bypass valve operation. All safety systems operated as expected.

"The [Unit 2] reactor is currently stable in Mode 3. An investigation into the cause of the loss of ICS is underway.

"Unit One continued power operation [at 78% power].

"The NRC Resident Inspectors were notified. A press release will occur."

The licensee will inform the State of Pennsylvania.

Decay heat removal is being maintained through the main condenser. On-site electrical power is in the normal configuration.

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Fuel Cycle Facility Event Number: 48497
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/09/2012
Notification Time: 14:59 [ET]
Event Date: 11/09/2012
Event Time: 11:00 [EST]
Last Update Date: 11/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
MARVIN SYKES (R2DO)
DAVID PSTRAK (NMSS)

Event Text

UNANALYZED CONDITION - SYSTEM AS-FOUND CONDITION NOT FULLY DESCRIBED IN ISA

"As part of the ongoing GNF-A review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), an accident sequence associated with hydrogen piping in the laboratory area was being evaluated. As part of this evaluation, a configuration that had not been properly analyzed was identified. Based on a review of this as-found condition, it was determined at approximately 11 AM [EST] on November 9, 2012 that the system was not fully described in the ISA and resulted in a failure to demonstrate performance requirements were met.

"Hydrogen supply to the affected piping system has been isolated. Additional corrective actions and extent of condition are being evaluated.

"This event is being reported pursuant to the reporting requirements of 10CFR70 Appendix A (b)(1) within 24 hours of discovery."

The licensee determined the as-found condition is of minimal safety significance. The licensee will be notifying NRC Region 2, State, and local authorities.

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Power Reactor Event Number: 48500
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALEX MCLELLAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/10/2012
Notification Time: 16:20 [ET]
Event Date: 11/09/2012
Event Time: 04:20 [EST]
Last Update Date: 11/10/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GLENN DENTEL (R1DO)

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

Event Text

RPS ACTUATION RESULTING FROM LOW REACTOR WATER LEVEL

"At approximately 04:20 hours on November 9, 2012, Susquehanna Steam Electric Station Unit Two reactor received a subsequent scram due to low reactor water level during recovery from the scram (EN# 48496) that occurred at approximately 01:18 hours due to a loss of ICS (Integrated Control System; which controls the reactor feed and reactor recirculation systems). Reactor water level was +15 inches at the time of the trip. All isolations and initiations at this level occurred as expected. No steam relief valves opened. Pressure was controlled via turbine bypass valve operation. All safety systems operated as expected.

"The reactor is currently stable in Mode 3. Unit One continued power operation. The NRC Resident Inspectors were notified."

The licensee will notify the Pennsylvania Emergency Management Agency.

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Power Reactor Event Number: 48501
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN WALKOWIAK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/11/2012
Notification Time: 06:08 [ET]
Event Date: 11/11/2012
Event Time: 03:55 [EST]
Last Update Date: 11/11/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GLENN DENTEL (R1DO)
DAVE LEW (R1)
ERIC LEEDS (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DUE TO TURBINE TRIP FOLLOWED BY UNUSUAL EVENT DECLARED DUE TO MAIN TRANSFORMER AND BUS DUCT FIRE

"An unplanned, automatic reactor scram occurred at 0355 EST due to a Main Turbine trip signal. All safety systems operated and actuated as expected. Both the Main Transformer, T-1A and normal station services transformer T-4 activated their respective deluge systems. On-site fire brigade and offsite fire assistance have successfully extinguished the T-1A transformer fire. There is still an active fire in the T-1A bus ductwork. The plant will be taken to cold shutdown conditions. At 0545 EST the plant entered the emergency plan at the NUE level due to inability to successfully extinguish the fire."

All control rods fully inserted following the reactor scram. MSIVs remain open with decay heat being removed via steam to the main condenser using the bypass valves. All electrical buses are powered from their normal offsite reserve source.

The licensee notified the NRC Resident and appropriate State and local government agencies.

Notified DHS SWO, FEMA, DHS NICC and NuclearSSA via email.


* * * UPDATE FROM JOHN WALKOWIAK TO DONALD NORWOOD AT 0642 EST ON 11/11/2012 * * *

As of 0639 EST the fire in the T-1A bus ductwork has been extinguished.


* * * UPDATE FROM MARK HAWES TO DONALD NORWOOD AT 0747 EST ON 11/11/2012 * * *

"Local fire department is on-site. No radiological release and no protective actions required. Plant cooldown in progress."


* * * UPDATE FROM MARK HAWES TO DONALD NORWOOD AT 0810 EST ON 11/11/2012 * * *

"The Unusual Event (HU 6.1) has been terminated at 0801 EST. Cooldown in progress to cold condition. Reactor level at 206 inches and pressure is at 530 pounds."

The licensee notified the NRC Resident and appropriate State and local government agencies.

Notified R1DO (Dentel), NRR EO (McGinty), IRD (Gott). Notified DHS SWO, FEMA, DHS NICC and NuclearSSA via email.

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Power Reactor Event Number: 48502
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS GARRISON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/12/2012
Notification Time: 14:13 [ET]
Event Date: 11/12/2012
Event Time: 11:00 [EST]
Last Update Date: 11/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER INOPERABLE NUMEROUS TIMES OVER PREVIOUS THREE YEARS WITHOUT PROPER REPORTING

"This non-emergency event report is being made per 10CFR50.72(a)(1)(ii) which requires reporting events that occurred within three years of the date of discovery.

"Based on operating experience, Engineering personnel reviewed past maintenance activities involving the Technical Support Center (TSC) ventilation system (VH system) and identified 11 occasions between September 2009 and October 2012 (3 years) where the VH system functions could not have been restored within the required facility activation time. The specific instances have been documented in our corrective action program.

"If an emergency had been declared during these periods and TSC ERO activation was required, the TSC would have been staffed and activated unless the TSC became uninhabitable due to ambient temperatures, radiological or other conditions. If relocation of the TSC staff was necessary, the Station Emergency Coordinator would relocate the staff to an alternate TSC location.

"Practices and processes have been revised to improve control of TSC maintenance activities and to improve facility availability going forward. In addition, site reporting guidance has been revised to assure timely reporting of these types of events if required.

"This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2, since the maintenance activities affected an emergency response facility."

The licensee will be notifying the NRC Resident Inspector and state and local authorities in North Carolina and South Carolina.

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Power Reactor Event Number: 48503
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MATTHEW QUICK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/12/2012
Notification Time: 20:52 [ET]
Event Date: 11/12/2012
Event Time: 15:51 [CST]
Last Update Date: 11/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHRISTINE LIPA (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

REACTOR BUILDING ISOLATION WITH STANDBY GAS TREATMENT SYSTEM ACTUATION DURING RADIOACTIVE MATERIAL MOVE

"At 1551 EST on 11/12/12, the 'A' Refuel Floor Process Radiation Monitor reached 62 mR/hr during movement of the old steam dryer in the plant reactor building. This resulted in the isolation of the drywell containment air monitor and the oxygen analyzer primary containment isolation valves. The signal also resulted in a reactor building isolation (Secondary Containment), start of 'A' Standby Gas Treatment, and transfer of the control room ventilation to the High Radiation Mode.

"All automatic isolation valves have been reset. Reactor building and control room ventilation have been reset. Standby gas treatment has been secured. There were no challenges to the health and safety of the general public.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, November 13, 2012
Tuesday, November 13, 2012