United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 26, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/23/2012 - 11/26/2012

** EVENT NUMBERS **


48509 48513 48515 48516 48532 48533 48534

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Agreement State Event Number: 48509
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLORIDA HOSPITAL, TAMPA
Region: 1
City: TAMPA State: FL
County:
License #: 0549-3
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 11/15/2012
Notification Time: 13:27 [ET]
Event Date: 11/09/2012
Event Time: [EST]
Last Update Date: 11/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED WRONG TREATMENT PLAN

The following report was received from the State of Florida via facsimile:

"On November 9, 2012, two patients with a different treatment plan (HDR Brachytherapy) were scheduled on the same day, patient 2 received patient 1 treatment plan. [The] error [was] found during mid treatment and stopped. Oncologist and patient informed, treatment continued under original plan, expect no adverse effects to patient Primary care physician has not been informed as of 13 November 2012, 0800 hours. A private company Radio Physics Associates (TRP-73) performs procedures involving HDR at this hospital. Investigation assigned to [State of Florida Bureau of Radiation Control] Tampa Office. No further action will be taken on this incident.

"Isotope involved: Ir-192; Activity: 8.3 Ci"

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: 48513
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL
Region: 1
City: BURLINGTON State: MA
County:
License #: MA 12-8361
Agreement: Y
Docket:
NRC Notified By: MICHAEL WHALAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/16/2012
Notification Time: 20:06 [ET]
Event Date: 11/15/2012
Event Time: [EST]
Last Update Date: 11/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE ()
DENNIS ALLSTON (ILTA)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IRIDIUM-192 SOURCE MISSING DURING SHIPMENT

A representative from the Massachusetts Radiation Control Program called to report information he had received concerning a missing Iriduim-192 Category 3 source shipment that was being imported to QSA Global in Burlington, Massachusetts from Australia. The shipment had cleared customs at JFK and was being stored at a warehouse near JFK (Air Menzies Aviation). On the evening of 11/15/12, the package was scheduled to be picked up at the warehouse, however, it could not be found. At this point the shipment is considered missing. QSA currently believes that the package is simply misplaced at this time. QSA and the carrier continue to search for the package.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 48515
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: S&ME ENGINEERING
Region: 3
City: VALLEY VIEW State: OH
County:
License #: 3121025006
Agreement: Y
Docket:
NRC Notified By: CHUCK McCRACKEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/17/2012
Notification Time: 13:45 [ET]
Event Date: 11/16/2012
Event Time: 16:40 [EST]
Last Update Date: 11/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE ()

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER DENSITY GAUGE

The following information is a summary of a report received from the Ohio Bureau of Radiation Protection:

A Troxler nuclear density gauge was being used on an Ohio Earthwork Project in Riley Township, Ohio. The gauge technician set the gauge on the ground and left it unattended while preparing for testing. A bulldozer moved over the location where the gauge had been set down without realizing the gauge was there.

The isotopes in this unit are 8 millicuries of cesium 137 and 40 millicuries of Am-241/Be.

The damaged unit was a Troxler Model Number 3430, Serial Number 21036. The source serial number for the Cs 137 is 75-2465 and the source serial number for the Am-241:Be is 47-16507

The licensee dispatched a contractor (Solutient Technologies) to the jobsite. Solutient identified that no leakage occurred, that the sources are intact and in their protective housing. The sources were placed in a 5 gallon steel drum and the remainder of the gauge was placed in a 30 gal steel drum and deemed suitable for transport. These containers were removed from the site on Saturday, November 17, 2012 and returned to the licensee's Cleveland office.

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Non-Agreement State Event Number: 48516
Rep Org: ACUREN USA
Licensee: ACUREN USA
Region: 4
City: PRUDHOE BAY State: AK
County:
License #: 42-32443-01
Agreement: N
Docket:
NRC Notified By: ROBERT JEFFERSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/17/2012
Notification Time: 14:50 [ET]
Event Date: 11/16/2012
Event Time: 14:00 [YST]
Last Update Date: 11/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE ()

Event Text

RADIOGRAPHY CAMERA SOURCE CONTROL CABLE BREAKAGE

The following is a summary of a report provided by the licensee to the NRC Operations Center:

The licensee could not fully retract a radiography camera source into the shielded position (Sentinel Delta 880D, Serial # 87400B). It was determined that the control assembly cable had broken approximately three inches from the source connector. The source assembly was gravity fed from the guide tube onto the ground and then shielded by reverse placement into another Sentinel exposure device. A serviceable control assembly was then connected to the original exposure device and the control cable routed through the device and guide tube, then connected to the source. The source was then retracted into the original device without incident.

Corrective actions taken and planned to prevent reoccurrence: Remove 100% of control assemblies from service and complete a thorough inspection. Perform a safety stand down with all radiographers and assistants for review of daily equipment inspections.

The four individuals involved in this event received exposures of 95 mR; 48 mR; 20 mR; and 20 mR respectively.

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Non-Agreement State Event Number: 48532
Rep Org: BAYOU INSPECTION SERVICES, INC.
Licensee: BAYOU INSPECTION SERVICES, INC.
Region: 4
City: AMELIA State: LA
County:
License #: LA-7112-L01
Agreement: Y
Docket:
NRC Notified By: JOEY RENTROP
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/23/2012
Notification Time: 14:04 [ET]
Event Date: 11/22/2012
Event Time: 01:00 [CST]
Last Update Date: 11/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

RADIOGRAPHY CAMERA SOURCE DISCONNECT DURING OFFSHORE OPERATIONS

At approximately 0100 CST on 11/22/12, the RSO was informed that the Iridium source on a Spec 150 camera, S/N 1228, had disconnected during radiography on Bisso Marine's "Mighty Chief" pipe-laying barge offshore of Louisiana. The area was posted with access controlled until the RSO arrived and retrieved the disconnected source. No personnel received any unmonitored or overexposures as a result of this incident. Rad exposures for personnel involved are as follows:

RSO - 50 mR (WB) [Whole Body]
Assistant Radiographer (1) - 100 mR (WB)
Assistant Radiographer (2) - 95 mR (WB)
Assistant Radiographer (3) - 170 mR (WB)
Radiographer - 85 mR (WB)

The licensee will submit a written report in 30 days.

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Power Reactor Event Number: 48533
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVID WELLS
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/24/2012
Notification Time: 03:18 [ET]
Event Date: 11/23/2012
Event Time: 20:08 [CST]
Last Update Date: 11/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation

Event Text

INADVERTENT LOSS OF INSTRUMENT AIR

"On 11/23/2012 at approximately 1956 CST, it was reported that the Control Room (VC) B Chiller breaker was cycling open and closed. In order to stop the cycling, Control Building Unit Sub B was manually tripped causing the following isolations/actuations: loss of power to instrument air (IA) system containment isolation valves causing the Division 2 valves to isolate; loss of power to the low pressure switch that resulted in an automatic start of Division 2 Shutdown Service Water (SX) system; and loss of power to fuel building (VF) system ventilation Division 2 dampers resulting in a trip of the VF system. High Pressure Core Spray (HPCS) became inoperable based on inoperability of the room cooler for the associated Division 4 inverter and battery charger. Operations entered the Loss of AC Power and Automatic Isolation off-normal procedures. Following the loss of power to the VF system ventilation, at 2008, secondary containment differential pressure became positive. At 2009, power was restored to Control Building Unit Sub B and HPCS was restored to operable. At 2011, the standby gas treatment system (VG) was started and at 2013, secondary containment differential pressure was restored. Following re-energization of Unit Sub B, the IA containment isolation valves were re-opened, VG was secured, VF restarted and the Division 2 SX pump was secured.

"The loss of secondary containment differential pressure is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material

"An unplanned inoperability of HPCS reportable under 10 CFR 50.72(b)(3)(v)(D) as HPCS is a single train safety system

"The cause of the breaker cycling is unknown at this time. The NRC Resident has been informed."

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Power Reactor Event Number: 48534
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN KONOVALCHICK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/25/2012
Notification Time: 15:13 [ET]
Event Date: 11/25/2012
Event Time: 11:30 [EST]
Last Update Date: 11/25/2012
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
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 92 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO STEAM GENERATOR FEEDWATER REGULATOR VALVE NOT RESPONDING TO DEMAND SIGNAL

"This notification is being made to report that Salem Unit 2 has experienced an automatic reactor trip at 1130 EST. The reactor trip was caused by 24BF19, 24 steam generator feedwater regulation valve, not responding to demand signal that resulted in a reactor trip due to 24 steam generator lo-lo level. The cause of the 24BF19 failure to respond to demand is under investigation.

"21, 22 & 23 AFW pumps all auto started as expected on the reactor trip feeding the steam generators. 23 AFW pump has been shutdown by procedure. 21 & 22 AFW pumps are maintaining steam generator levels with decay heat removal via the main steam dump system. All control & shutdown rods fully inserted on the reactor trip.

"Salem Unit 2 is currently in mode 3. Reactor coolant system temperature is 547 degrees F with pressure at 2235 psig. There are no shut down technical specifications action statements in effect.

"All ECCS and ESF systems are available. All safety related equipment responded as expected. There were no personnel injuries associated with this event."

The licensee will inform the Lower Alloways Creek Township, the State of New Jersey, and the State of Delaware. The licensee has informed the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, November 26, 2012
Monday, November 26, 2012