United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for June 19, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/18/2013 - 06/19/2013

** EVENT NUMBERS **


49102 49104 49129 49130 49131 49132

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Agreement State Event Number: 49102
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF MINNESOTA
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1049-211-27
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/10/2013
Notification Time: 16:53 [ET]
Event Date: 08/22/2012
Event Time: [CDT]
Last Update Date: 06/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
FSME EVENT RESOURCES ()

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL OVERDOSE

The following report was received via e-mail:

"On May 26, 2013 during a transfer of electronic treatment planning records to a new system, the University of Minnesota (license number 1049-211-27) discovered a medical event that occurred on August 20-22, 2012 at the university of Minnesota Medical Center in Minneapolis with the Nucletron HDR. The licensee reported that dosimetry staff were testing the transfer of information from previously treated patients into a brachytherapy check program, and it was discovered that in this particular case the source position data was entered into the HDR planning system incorrectly. The licensee is calculating the exact doses delivered and it appears as though the dose to unintended regions by greater than 50% for several areas. The Minnesota Department of Health was notified of the potential event on May 27, 2013. A final report will be submitted when the report is received from the licensee."

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: 49104
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: CODER X-RAY SERVICES
Region: 4
City: McPHERSON State: KS
County:
License #: 21-B165-01
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 06/11/2013
Notification Time: 10:59 [ET]
Event Date: 06/09/2013
Event Time: [CDT]
Last Update Date: 06/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The State of Kansas was notified by the licensee that on 6/9/2013, personnel dosimetry indicated that one assistant radiographer had received a potential overexposure, and two other assistant radiographers had received potential elevated exposure. The licensee reported that the dosimetry had been stored improperly and in close proximity to a location where a source change out had occurred. Corrective actions taken by the licensee include establishment of a controlled dosimetry storage location and additional training of personnel on the use of dosimetry. The individual with the potential overexposure was removed from radiography duties and given alternate work assignments. All three individuals were notified of the dosimetry readings.

The dosimeter readings were 5.046 rem, 1.133 rem and 0.633 rem.

* * * UPDATE FROM JAMES HARRIS VIA FAX AT 1050 EDT ON 6/17/13 * * *

The following information was obtained from the State of Kansas via fax:

"Based on the last dosimetry report [received by the licensee], several employees have received a high dose. The reported doses are Employee 1 - 5046 mR, Employee 2 - 1133 mR, and Employee 3 - 633 mR.

"The three employees are radiographers assistants acting under one of the 4 licensed radiographers. The three radiographers assistants never worked together on any single job. The only common denominator between the three assistants is that their film badges were stored in the same general area. The licensed radiographers that were assigned to them received no such high dose rates. The three assistants also did not have any off-scale readings from dosimetry nor did they report any unusual incidences. All three also stated they did not believe that they could possibly have received an unusually high dose during that time period based on dosimetry, rate alarm, and survey meter readings.

"Upon further investigation, it was discovered that the three were leaving their film badges in their [work] uniforms in a controlled area within the shop between shifts. During this time period, radiographic operations were conducted at the shop facility. Additionally, there was a source change conducted by two radiographers in the controlled area of the shop during this time. During times these employees were not working, their [work] uniforms would have been located in the controlled area allowing their badges to be exposed during radiographic operations.

"In conclusion, there are two possible explanations for the substantial increases in exposure to the three assistants badges. Conclusion one would be that excessive heat and humidity played a role in the increased readings found with the badges. Conclusion two would involve film badges in close proximity to the area where radiographic operations were being conducted with the individuals assigned to those badges being absent at the time, therefore creating an erroneous reading leading to the obvious assumption that the badges alone were exposed, not the individuals associated with these badges being exposed.

"Corrective action taken at this time: Badges will be stored in the office, [with the proper controls in place] when not being worn. Retraining [was] conducted on the physical properties of the film badge and how badges become exposed through various means.

"Based on the reading of employee 1's badge, he will not be involved in radiographic operations nor be allowed in the controlled areas near radiation in the shop until a full investigation is completed."

The State of Kansas is still investigating this event.

Kansas Case No.: KS130005

Notified R4DO (Walker) and FSME Events Resource via email.

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Power Reactor Event Number: 49129
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOHN HUFF
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/18/2013
Notification Time: 11:24 [ET]
Event Date: 06/18/2013
Event Time: 08:12 [EDT]
Last Update Date: 06/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

STACK RADIATION MONITOR REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

The licensee removed the Stack Radiation Monitor from service for pre-planned maintenance. The radiation monitor was returned to service at 1056 EDT.

The licensee will notify state and local government agencies. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 49130
Facility: MILLSTONE
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOHN HUFF
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/18/2013
Notification Time: 11:24 [ET]
Event Date: 06/18/2013
Event Time: 08:20 [EDT]
Last Update Date: 06/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)

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

Event Text

SPENT FUEL POOL ISLAND RADIATION MONITOR REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

The licensee removed the Spent Fuel Pool Island Radiation Monitor from service for pre-planned maintenance.

The licensee will notify state and local government agencies. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 49131
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JOHN CAVES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2013
Notification Time: 16:42 [ET]
Event Date: 04/27/2012
Event Time: 14:33 [EDT]
Last Update Date: 06/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BINOY DESAI (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

REACTOR HEAD NOZZLE PENETRATION FLAWS IDENTIFIED

"On April 27, 2012, while the Harris Nuclear Plant was shutdown for a scheduled refueling outage, the reactor vessel head penetrations were being examined in accordance with Inservice Inspection Program requirements. Examinations were being performed to identify flaws before they grow to a size that could effect the structural integrity of the reactor vessel. Those examinations identified flaws in four head penetration nozzles that exhibited characteristics of Primary Water Stress Corrosion Cracking. The four nozzles were repaired using the inner diameter temper bead welding process. Examinations performed following the repairs confirmed the repairs were successful.

"This was originally submitted as a voluntary report on May 29, 2012 at 1511 EDT. The condition has since been determined to be reportable per 10CFR50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been informed."

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Part 21 Event Number: 49132
Rep Org: PARKER HANNIFIN CORPORATION
Licensee: PARKER HANNIFIN CORPORATION
Region:
City:  State:
County:
License #:
Agreement: N
Docket:
NRC Notified By: CRAIG BECKWITH
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2013
Notification Time: 17:50 [ET]
Event Date: 06/18/2013
Event Time: [EST]
Last Update Date: 06/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BINOY DESAI (R2DO)
WAYNE WALKER (R4DO)
PART 21 REACTORS (EMAI)

Event Text

PART 21 - 304L STAINLESS STEEL USED INSTEAD OF 316 STAINLESS STEEL

After being notified that tubing fittings which should have been machined from 316 Stainless Steel appeared to have been machined from 304 Stainless Steel instead, Parker Hannifin had chemical and mechanical property testing performed on the fittings. The testing confirmed that the material was actually 304L SS not 316 SS.

Parker Hannifin compiled a list of all potential part numbers and customers affected by this nonconformance. Parker Hannifin reviewed the records related to each of the seventeen safety-related part numbers shipped within the applicable time frame. The only order invoking 10CFR Part 21 that shipped with the corresponding heat code was shipped to South Texas Project. STP received 150 pieces of part number 4-2 FBZ-SS-CNQ.

Parker Hannifin is notifying STP of this nonconformance.

Page Last Reviewed/Updated Wednesday, June 19, 2013
Wednesday, June 19, 2013