Event Notification Report for June 11, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/10/2010 - 06/11/2010

** EVENT NUMBERS **


45713 45978 45983 45984 45990 45998

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General Information or Other Event Number: 45713
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SHELL LUBRICANTS
Region: 4
City: VICKSBURG State: MS
County:
License #: GL-154
Agreement: Y
Docket:
NRC Notified By: BRANDY FRAISER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/19/2010
Notification Time: 14:56 [ET]
Event Date: 02/01/2010
Event Time: [CST]
Last Update Date: 06/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
ILTAB (via email) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING AN UNACCOUNTED FOR GENERAL LICENSE SOURCE

The following information was received from the State of Mississippi Division of Radiological Health (DRH) via email:

"Description of Incident: The licensee contracted with a disposal company to dispose of one (1) Industrial Dynamic Model C1-2C FILTEC source holder, Serial No. 555, source. During the disposal company's visit, it was discovered that the source was not in the source holder and could not be accounted for. The facility has changed ownership in the previous years and the records were not well maintained of receipt/transfer and leak tests. The Industrial Dynamic Model C1-2C FILTEC source holder, contained a 100 millicurie Americium-241 source, Serial No. not known.

"Isotope(s): Americium-241
"Activity: 100 millicuries
"Date of Incident : unknown
"Date Reported To DRH: 02-01-10

"Mississippi Incident No.: MS-10001"

* * * UPDATE FROM JAYSON MOAK TO PETE SNYDER ON 6/10/2010 AT 1109 EDT * * *

The following information was received from the State of Mississippi Division of Radiological Health (DRH) via email:

"The licensee performed an investigation into the missing source after receiving a notice of violation issued 03-03-2010. The licensee determined the following from their investigation:

"(1) Records obtained from Industrial Dynamics, indicated that all sources were removed from the Filtec C1-2C gauges installed at the Vicksburg plant as well as replacement units recently removed. It appears that the source was removed in 1984 from one Filtec C1-2 gauge Ser. No. 00212, and the gauge remained at the plant. The Ser. No. 00212, for the Filtec C1-2C gauge was deciphered only from the inside cover of an instruction manual found at the plant.

"(2) a sticker, SN:555, was found on or near equipment in storage, but the sticker referenced something manufactured by Nuclear Enterprises Incorporated. The licensee believes the sticker may be referencing a serial number to a machine part and not the source holder in question. This may be where the incorrect reference to a serial number came into question. The licensee believes the former RSO started leak testing the empty Filtec C1-2C gauge Ser. No. 00212, in 2004, and placed a radioactive material label on the empty gauge in 2005, due to the type of equipment it was.

"(3) The only piece of equipment, a partially dismantled Industrial Dynamics/Filtec C1-2C gauge remaining at the facility may have at one time contained a sealed source. This equipment was inspected by Adco Services , the source holder was found to be empty, and a report issued to DRH on 1-12-2010.

"(4) The licensee contacted Industrial Dynamics/Filtec and traced the history of source Ser. No. 555. The licensee reported Industrial Dynamics/Filtec claimed the source holder has never been installed in a gauge in Mississippi.

"The licensee submitted their response and investigative report to DRH on 04-21-2010, and claims it no longer possess any sources of radiation in the state. The violation issued on 03-03-2010 has been rescinded along with termination of GL-154."

Notified R4DO (Powers) and FSME (Mauer).


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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General Information or Other Event Number: 45978
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: LOVELACE MEDICAL CENTER
Region: 4
City: ALBUQUERQUE State: NM
County:
License #: MI 210 94
Agreement: Y
Docket:
NRC Notified By: CARL SULLIVAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/04/2010
Notification Time: 15:20 [ET]
Event Date: 05/04/2010
Event Time: [MDT]
Last Update Date: 06/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
ANGELA MCINTOSH (FSME)
CYNDI JONES (NSIR)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

A patient was treated in early May with a vaginal applicator using three doses of High Dose Rate (HDR) brachytherapy. On May 11, 2010, the patient contacted the doctor's office and complained of skin irritation to her leg. On May 18, 2010, the patient again called to report continued skin irritation. On both of these dates, the patient could not come in to see the doctor. On May 26, 2010, the patient was seen by the doctor and radiation irritation was evident on her leg. Initial estimates of the leg dose are greater than 50 REM. Both the patient and doctor have been notified of this event.

The source was Yttrium (unknown strength). [See correction below]

The State is investigating this event.

* * * UPDATE FROM CARL SULLIVAN TO PETE SNYDER ON 6/10/10 AT 1156 EDT * * *

The event date in the header was corrected to 5/4/10. The source was Ir-192 with an activity of 3506.34 mCi on 5/4/10.

The State continues to investigate this event.

Notified R4DO (Shannon) and FSME (Villamar).

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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General Information or Other Event Number: 45983
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: TARGET ENGINEERING GROUP, INC.
Region: 1
City: MIAMI State: FL
County: MIAMI-DADE
License #: 3366-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/07/2010
Notification Time: 14:26 [ET]
Event Date: 06/07/2010
Event Time: [EDT]
Last Update Date: 06/07/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB via email ()

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

Event Text

FLORIDA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was obtained from the State of Florida via facsimile:

"[The State of Florida] received a report from the company's RSO [Radiation Safety Officer] that a soil moisture density gauge and case was stolen. The licensee parked their truck and left the gauge unattended. Owner still has keys to case and gauge. Unknown as of yet if gauge was chained and locked to vehicle. Licensee will offer a reward. Local police have been notified and licensee is currently awaiting their arrival. Incident assigned to Miami Inspection Office for investigation."

The gauge was a Troxler Moisture Density gauge, model 3440, serial number 37225. The gauge has a 40 mCi AmBe-141 source and a 8 mCi Cs-137 source.

Florida incident number: FL10-070

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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General Information or Other Event Number: 45984
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WEST SHORE PIPE LINE COMPANY
Region: 3
City: GREEN BAY State: WI
County:
License #: GENERAL709614
Agreement: Y
Docket:
NRC Notified By: MARK PAULSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/07/2010
Notification Time: 15:07 [ET]
Event Date: 06/07/2010
Event Time: [CDT]
Last Update Date: 06/07/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

WISCONSIN AGREEMENT STATE REPORT - STUCK OPEN PROCESS GAUGE SHUTTER

The following information was received from the State via facsimile:

"On June 7, 2010 a representative of West Short Pipe Line Company notified Wisconsin Radiation Protection Section of a stuck shutter. This was discovered during a routine six-month shutter check. The device is a Ronan SA1 containing 500 mCi of Cs-137. The general licensee performed a radiation survey and radiation levels were normal. Licensee also performed routine leak test, results are pending. Normal operation for the device is with the shutter open. The device is located in a restricted area that is fenced off. The nearest personnel access point is 600 ft away from the device. The licensee will contact the manufacturer for service.

"The Radiation Protection Section will continue to monitor the situation and will request information concerning the cause of the stuck shutter."

Wisconsin Report No: WI100007

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Power Reactor Event Number: 45990
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WALTER MILLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/09/2010
Notification Time: 07:58 [ET]
Event Date: 06/09/2010
Event Time: 03:31 [CDT]
Last Update Date: 06/10/2010
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):
REBECCA NEASE (R2DO)

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

Event Text

REACTOR SCRAM DUE TO CLOSURE OF MAIN STEAM ISOLATION VALVES

"At 0331 CDT on 6/9/10, the Unit 2 reactor automatically scrammed due to closure of the Main Steam Isolation Valves (MSIVs). Operating Instruction 2-OI-99 section 8.1, Reactor Protection System (RPS) Bus B Transfer from Motor Generator to Alternate, was in progress for planned maintenance. The MSIVs closed during the RPS power transfer. The cause of the closure of the MSIVs is under investigation.

"All systems responded as expected to the reactor scram. Safety Relief Valves (SRVs) opened automatically as designed to limit the pressure transient. No Emergency Core Cooling System (ECCS) or Reactor Core Isolation Cooling system (RCIC) reactor water level initiation set points were reached and all expected containment isolation and initiation signals were received. Reactor pressure control was established by manually operating one SRV then maintained using the Main Steam Line Drain Valves. RCIC and the High Pressure Coolant Injection system (HPCI) were manually initiated to control reactor water level. The scram was reset, MSIVs were opened, and the Main Condenser was established as a heat sink. Reactor water level control was established with the Reactor Feedwater System and RCIC and HPCI were returned to standby readiness.

"At 0408 CDT on 6/9/10, a full scram signal was received when 2F Intermediate Range Monitor (IRM) spiked momentarily followed by a spike on 2C IRM. The reactor was stable and operating in Mode 3, Hot Shutdown. No ECCS or RCIC initiation set points were reached. No additional containment isolation signals or initiation set points were received. The cause of the 2C and 2F IRM spikes is under investigation.

"The scram event from critical is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B), 'any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A). The scram received at 0408 CST is reportable within 8 hours 10CFR 50.72(b)(3)(iv)(A), 'any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation,' and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector was notified."

All rods fully inserted as a result of the first reactor scram. The plant is currently in a normal, post-trip electrical line-up. All SRVs did reseat. There was no impact to the other two units.

* * * UPDATE FROM BILL BAKER TO PETE SNYDER ON 6/10/10 AT 1749 EDT * * *

"Additional review of available data and inspection results revealed that Safety Relief Valves (SRVs) did not lift automatically during the scram. The only operations of SRVs were performed manually to control reactor pressure until the Main Steam Isolation Valves (MSIVs) were reopened. All other details described in the original event notification remain as stated."

The licensee notified the NRC Resident Inspector.

Notified R2DO (Nease).

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Power Reactor Event Number: 45998
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE LINDEMANN
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 06/10/2010
Notification Time: 10:37 [ET]
Event Date: 06/10/2010
Event Time: 08:30 [CDT]
Last Update Date: 06/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MONTE PHILLIPS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION MAINTENANCE

"On June 10, 2010, at 0830 hours CDT, Byron Station removed part of the Technical Support Center (TSC) ventilation (I.e., OVV25C) filtration system from service to facilitate necessary maintenance on the makeup fan. This work is expected to last approximately 10 hours. This maintenance affects the ability of the TSC ventilation to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, then the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility because of the unavailability of the emergency filtration mode of the ventilation system. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector has been notified."

* * * UPDATE FROM MIKE LINDEMANN TO PETE SNYDER AT 1542 EDT ON 6/10/10 * * *

Maintenance has been completed and the TSC ventilation system was returned to service as of 1430 CDT. The licensee notified the NRC Resident Inspector.

Notified R3DO (Phillips).

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