Event Notification Report for February 16, 2012

AGREEMENT STATE REPORT - GAS EXPLOSION OF X-RAY INSPECTION TRAILER - STORED SOURCE UNAFFECTED

The following report is an edited version of information was provided by the North Carolina Radiation Protection Section via e-mail:

"On February 16, 2012 the agency [NC Radiation Protection Section] was notified of a propane tank explosion near Gastonia, NC by the corporate RSO of JANX [NDT/NDE]. This morning when workers at the job site started a generator, an explosion [occurred and] damaged an x-ray trailer at the site. The source of the explosion seems to be a leaking valve on a propane tank. The explosion 'blew off' a wall [of the trailer] and resulted in some burning. On board this trailer was a 1 Ci Ir-192 stopping source contained in a SPEC check model housing. The corporate RSO indicated that the trailer had three compartments and, from what he understood, the back-up x-ray unit onboard the trailer was damaged (Panasonic XIT) [but] the compartment in which the [Ir-192] source was stored was not damaged during the explosion. The housing of the source itself did not show any damage and all radiation levels were normal. The 1 Ci source was moved to a secured Industrial Radiography truck containing a SPEC 150 camera with 110 Ci of Ir-192 that was also on site but not damaged during the explosion. This truck has increased controls on it and was not damaged.

"Two employees have been taken to the emergency room for injuries and the local RSO is on his way to the incident (~10:30am). A NC Rad Mat Inspector was in the area and he will go and verify the report of the corporate RSO.

"The corporate RSO that will be expected [to provide] a written report within 30 days and to leak test the source to ensure that there was no damage. [The NC State x-ray staff] has been notified about the industrial radiography unit [and] they have since contacted the licensee. Since they were working under reciprocity of an NRC license, [NC will also] notify NRC Region I agreement state officer, Monica Oreindi.

"There are no radiation concerns to public health and safety at this time. The inspector was sent just for verification of the report.

"The North Carolina License Number of JANX is 085-1117-2 and physical location address is 1073 Kentland Drive in King, NC 27021. The licensee had issued a reciprocity notification using their NRC license NRC: 21-16560-01 (Reciprocal License NO. 122-0361-R) for their work at the location of the explosion. The notification listed 1441 Delta Drive, Gastonia, NC as the location for work.

"Local media is on site."

LOSS OF SPDS GREATER THAN EIGHT (8) HOURS DUE TO HARD DRIVE FAILURE

"At approximately 0542 hours [EST], the Safety Parameter Display System (SPDS) became non-functional, and therefore was not available in the Control Room or in the emergency response facilities. Efforts are underway to restore the system, but as of 1342 hours [EST] these efforts have not been successful. The loss of SPDS for more than 8 hours is being reported in accordance with 10 CFR 50.72(b)(3)(xiii). Troubleshooting efforts continue to restore the SPDS. The Emergency Response Data System (ERDS) remains functional, and the station remains capable of performing dose assessment using manual inputs per site procedures. The Control Room also continues to have the capability to retrieve plant data inputs to assess plant conditions and perform core damage assessments."

"The NRC Senior Resident Inspector has been notified, and the State of Ohio Emergency Management Agency will be notified."

* * * UPDATE AT 2315 EST ON 02/16/12 FROM TOM COBBLEDICK TO S. SANDIN * * *

As of 2100 EST on 02/16/12 the SPDS has been restored to service and is functioning properly.

The licensee will inform the NRC Resident Inspector. Notified R3DO (Passehl).

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON A METAL THICKNESS GAUGE

The following report was received via e-mail:

"On February 16, 2012, during leak testing by a consultant vendor a radioactive materials gauge shutter was discovered to be stuck open. No radiation exposure to personnel occurred.

"The device is identified as:

Manufacturer: LFE
Model: SS-3A
Serial #: 02311
Isotope: Am-241
Activity: 37 GBq (1 Ci)

"The gauge manufacturer was notified and repairs are scheduled to be conducted today.

"Event Report ID No.: PA120007"

PART 21 REPORT - ROSEMONT PRESSURE TRANSMITTERS OUT OF TOLERANCE CONDITION

The following information was received by facsimile:

"During the course of qualification testing to replace certain diodes identified for obsolescence, an out of tolerance condition during steam pressure/temperature testing was observed on a test pressure transmitter in the qualification program. Through investigation into the out of tolerance condition, it was determined that the condition was not related to the replacement diode, but rather the result of the magnitude of a resistance change made to the transmitter temperature compensation circuitry during a final factory acceptance test. A brief description of the final acceptance test follows.

"During pressure transmitter final processing, a test is conducted on Model 1154 Series H pressure transmitters to assess the effects of ambient temperature changes on the 4mA to 20mA analog output. The temperature test is performed on each transmitter to verify the transmitter accuracy performance over normal operating temperatures from 40 F to 200 F. If the transmitter does not meet the acceptance criteria for the test, changes can be made to the compensating resistor values to optimize performance in the normal operating temperature range. If the resistance adjustment is too large, it has been determined that the accuracy of the pressure transmitter relative to the published steam pressure/temperature profile and accuracy specification may be exceeded during a steam pressure/temperature event.

"The magnitude of output shift during steam pressure/temperature conditions, that is attributable to the resistance changes made in final processing, is predictable based on the specific amount of resistance added or subtracted during the compensation process for each transmitter. Accordingly, RNII [Rosemount Nuclear Instruments, Inc] has reviewed the production records for the potentially affected transmitters and a revised steam pressure/temperature accuracy specification has been established for each shipped pressure transmitter. The revised steam pressure/temperature accuracy specification has been listed by serial number.

"This revised specification supersedes the published steam pressure/temperature accuracy specification for all Model 1154 Series H pressure transmitters affected by this notification. Also note that for certain calibrations with large zero elevation and suppressions as defined in RNII's Part 21 Notification, dated February 23, 2012, an alternate steam pressure/temperature accuracy specification is also provided for pressure transmitters that are affected by both notifications. All other 1154 Series H published specifications remain unchanged.

"On February 23, 2012, it was concluded that a substantial safety hazard may exist. RNII does not have sufficient information to determine the potential safety impact in plant applications. As a result, a notification about the potential substantial safety hazard is being made in accordance with 10 CFR Part 21 to customers who purchased affected 1154 Series H pressure transmitters.

"The manufacturing rework procedure 01153-3000 has been updated to limit the amount of acceptable resistance that may be added or subtracted during final testing. A revised steam pressure/temperature accuracy specification for each pressure transmitter impacted by this notification has been determined.

"RNII recommends that users review the application where 1154 Series H pressure transmitters are used to determine if there are safety considerations related to the revised steam pressure/temperature accuracy specification."

The United States nuclear sites associated with this Part 21 are: Farley, D.C. Cook, Palo Verde, ANO-1, Calvert Cliffs, Point Beach, Oconee, Catawba, Waterford 3, Braidwood, La Salle, Davis Besse, Crystal River 3, Vogtle, Millstone, Diablo Canyon, Salem, Hope Creek, San Onofre, South Texas, Watts Bar, Comanche Peak, Wolf Creek, St. Lucie, Dominion Energy - Unspecified, and Northeast Nuclear Energy - Unspecified.


* * * UPDATE FROM DUYEN PHAM TO PETE SNYDER ON 4/3/12 AT 1531 EDT * * *

The following information was received by facsimile:

This revision potentially affects the following commercial nuclear power plant sites in the United States:
1. Calvert Cliffs, 2. Millstone, 3. Hope Creek, 4. Salem, 5. Catawba, 6. Crystal River, 7. Farley, 8. Oconee, 9. St. Lucie, 10. Vogtle, 11. Watts bar, 12. Braidwood, 13. Davis Besse, 14. D.C. Cook, 15. LaSalle, 16. Point Beach, 17. Arkansas Nuclear One, 18. Comanche Peak, 19. Diablo Canyon, 20. Palo Verde, 21. San Onofre, 22. South Texas Project, 23. Waterford 3, and 24. Wolf Creek.

"Note: Notification #1 [EN #47693], dated 23 February 2012 (and revised on 2 April 2012) impacts ALL 1154 Series H pressure transmitters range codes 4 to 8 shipped since 1988. This does NOT impact the 1154SH9 since the 1154SH9 has a wider steam pressure/temperature specification. The revised specification is the same for all affected transmitters.

"Note: Notification #2 [this report - EN #47716], dated 2 March 2012 (and revised as of today [3 April 2012]) impacts only a subset of 1154 Series H pressure transmitters range codes 4 to 9 shipped from March 1994 to February 2012. This is a smaller affected population and does include the range 9 in the scope. The revised specification for this second issue is serial number dependent and only affects the transmitters listed in Appendix A [of the full part 21 report]."

Notified R1DO(Caruso), R2DO(McCoy), R3DO(Bloomer), R4DO(Haire), and Part 21 Group via email.

AGREEMENT STATE REPORT INVOLVING A FAILED LEAK TEST OF AN ECD SOURCE

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

"On February 16, 2012 Test America at 4955 Yarrow Street in Arvada, Colorado (CO License # 486-03), notified the Colorado Department of Public Health and Environment that one of their Ni-63 electron capture detectors [ECD] failed a leak test. The leak test results for Device HPU0946 exceeded the 0.005 microCurie level. The test wipe measured at 0.0062 microCurie.

"The ECD detector was immediately withdrawn from service and the instrument in which the ECD was located was decontaminated by cleaning with Radiac Wash solution. A direct beta survey was then performed which showed no residual contamination present on the instrument or ECD. ECD No. HPU0946 was sent to the manufacturer for repair."

PART 21 REPORT - ROSEMOUNT PRESSURE TRANSMITTERS WITH NONZERO BASED CALIBRATIONS

The following information was received by facsimile:

"During the course of qualification testing to replace certain diodes identified for obsolescence, RNII [Rosemount Nuclear Instruments, Inc.] has determined that Model 1154 Series H range code 4-8 pressure transmitters with a significantly elevated or suppressed 4 mA point may not meet the published steam pressure/temperature accuracy specification.

"The out of tolerance condition observed during steam pressure/temperature qualification testing is not related to the replacement diode changes. It is an inherent performance characteristic related to large zero elevation or suppression. The steam pressure/temperature accuracy specification will be revised to account for nonzero based calibrations with a significantly elevated or suppressed 4 mA point.

"This revised specification supersedes the published steam pressure/temperature accuracy specification for all Model 1154 Series H pressure transmitters affected by this notification.

"RNII recommends that users review the application where 1154 Series H range code 4-8 pressure transmitters are used to determine if there are safety considerations related to the revised steam pressure/temperature specification."

Rosemount Nuclear has provided instruments to the following list of domestic U.S. customers: Alabama Power; American Electric Power; Arizona Public Service/Pinnacle West; Bechtel Power; Constellation Energy; Dominion Nuclear Connecticut/Dominion Generation; Duke Energy; ECFS MCS; Edison Material Supply; Electro Mechanics; Entergy; Exelon Generation; Florida Power and Light; FPL Energy; Georgia Power; Northern States Power-Minnesota DBA XCEL Energy; Pacific Gas and Electric; Progress Energy Florida; Progress Energy Carolinas; PSEG Nuclear; South Carolina Electric and Gas; Southern California Edison; Southern Nuclear Operating Company; STP Nuclear Operating; Tennessee Valley Authority; TXU/Luminant; Westinghouse Electric.

* * * UPDATE FROM DUYEN PHAM TO PETE SNYDER ON 4/2/12 AT 1224 EDT * * *

The following information was received by facsimile:

"This revision only affects Section 4.0 of the 23 February 2012 notification letter. The pressure values listed in Section 4.0 at 8 hours and 56 hours have been corrected. No other changes have been made."

Notified R1DO(Caruso), R2DO(Lesser), R3DO(Dickson), R4DO(Haire) and Part 21 Group via email.

AGREEMENT STATE REPORT - MISADMINISTRATION OF A RADIOPHARMACEUTICAL

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

"On 2/22/12 the licensee notified the Agency [Texas Department of State Health Services] of a medical event that occurred on 2/16/12. The licensee reported that the wrong radiopharmaceutical had been administered to a patient. Tc-99m MAA was administered rather than the prescribed Tc-99m Pertechnitate. During the administration of the wrong drug, an estimated 1/3-1/2 of the dose infiltrated the skin causing an estimated 400 rad exposure subcutaneously. The referring physician and patient have been notified. No signs or symptoms have been observed in the patient as a result of the incident. The estimated exposure is being reevaluated by the licensee."

Texas Incident: I-8937

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.