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Event Notification Report for March 8, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/07/2007 - 03/08/2007

** EVENT NUMBERS **


43147 43206 43208 43211 43213 43215 43217 43218 43221

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 43147
Rep Org: ST. FRANCIS HOSPITAL, HARTFORD, CT
Licensee: ST. FRANCIS HOSPTIAL, HARTFORD, CT
Region: 1
City: HARTFORD State: CT
County: HARTFORD
License #: 06-00854-03
Agreement: N
Docket:
NRC Notified By: E. WILCOX
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/06/2007
Notification Time: 13:49 [ET]
Event Date: 02/06/2007
Event Time: 07:00 [EST]
Last Update Date: 03/07/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT

A patient was being treated for cancer of the cervix. The planned total dose to the cervix was to be 2046.5 cGy, over a 39 hour time period. The licensee was using an LDR Selectron Afterloader. Nine cesium-137 sources, activity of each source 16.7 millicuries, were used in the afterloader. The patient started treatment on 02/05/07 at 1235 EST. Today, 02/06/07, between the hours of 0630 - 0717 EST the patient pulled the applicator out approximately 4 centimeters.

The patient was given the correct dose to the cervix for 16.09 hours for a total dose of 844.5 cGy. The patient was given an incorrect dose to the vaginal area for between 30 - 60 minutes. The total dose to the incorrect area is between 50 - 200 (Max) cGy. This incident was not harmful to the patient. The patient's doctor was notified of this incident. The patient will not be retreated.

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.

* * * RETRACTION AT 11:50 ON 3/7/2007 BY DR E. WILCOX TO M. ABRAMOVITZ * * *

This event is not reportable because of patient intervention. The patient refused continuing treatment.

Notified the R1DO (Caruso) and FSME (Morell).

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General Information or Other Event Number: 43206
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: TO BE DETERMINED
Region: 3
City: MILWAUKEE State: WI
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: MIKE MACK
HQ OPS Officer: JASON KOZAL
Notification Date: 03/02/2007
Notification Time: 14:27 [ET]
Event Date: 03/02/2007
Event Time: 11:00 [CST]
Last Update Date: 03/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
SANDRA WASTLER (FSME)

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

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE FOUND IN SCRAP HEAP

The following was provided by the State via facsimile:

"Event Location: Miller Compressing, Milwaukee, WI

"Event Type: Found Radioactive Material-Portable Moisture Density Gauge

"Notifications: Miller Compressing called [the] Department of Health and Family Services (DHFS)

"Event description: A Troxler moisture density gauge was found at Miller Compressing on 2/22/07. It was in a load of scrap and was separated by the staff at Miller Compressing.

"Additional Information: Miller Compressing is scrap metal recycler in Milwaukee.

"The DHFS staff in Wisconsin has been in contact with the state of Illinois Emergency Management Agency and Troxler Electronic Labs to try and identify an owner or former licensee. The gauge was initially distributed to an Illinois licensee in 1977. The portable gauge is a Troxler Model 3411. The plate on the device indicates the device serial number is 4942. The back plate identifies the nuclides as 8.9 mCi of Cs-137 on 9/5/77 ([serial number] CC-1968) and 40 mCi of Am241:Be on 9/14/77 ([serial number] CAA-1031). The serial no. does not match any gauges currently reported as lost or stolen.

"The shipping container is damaged. The gauge is intact. Miller Compressing is storing the gauge in a locked location on site. DHFS staff will follow up with a site visit."

WI report number: W070005

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.

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General Information or Other Event Number: 43208
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SMITH-EMERY COMPANY
Region: 4
City: GLENDALE State: CA
County:
License #: 2878-30
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: JASON KOZAL
Notification Date: 03/02/2007
Notification Time: 18:17 [ET]
Event Date: 03/02/2007
Event Time: 10:30 [PST]
Last Update Date: 03/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
JACK DAVIS (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED CPN GAUGE

The following was provided by the State via facsimile:

"A moisture density gauge was being used at a construction site in Glendale, CA (near the Water Department and the Los Angeles River). (CPN, model MC3, serial number M36097108). The gauge user had placed the gauge into a box (plastic milk carton) which was then going to be passed down into a trench where it would be used. There was a delay and the box with the gauge inside were placed on the edge of the property waiting to be used. According to [the licensee], the gauge user went to the bathroom, but the other workers were aware of the location of the gauge. At the same time a front loader truck was moving several large pieces of metal. The pieces vibrated off and dropped onto and crushed the gauge.

"[The licensee] said the sources appeared to be intact, however the plastic gauge housing was destroyed and the lead shielding leaves that normally surround and shield the end of the source rod (where the Cs-137 source would normally reside in a shielded position) were not in position anymore and were therefore not shielding the Cs-137 source now. [A] Los Angeles County Radiation Management Health Physicist, responded to the site to do an evaluation and to survey the source. The sources were intact and undamaged. There was no contamination. The dose rate at 1 foot was 20 milliRoentgen per hour (mR/hr). The end of the source rod was shielded and the remains of the gauge were placed into the transportation case. The gauge was transported by the RSO to Maurer Technical Services (the CPN manufacturer representative) [Deleted] so it can be shipped back to the manufacturer for disposal. The highest dose to any individual from this event was probably less than 5 millirem total. Corrective actions: The RSO will give refresher training to all gauge users to review their existing policies and procedures - gauge users are to have control over the gauge at all times."

CA report number: 030207

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General Information or Other Event Number: 43211
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: DIAGEO
Region: 1
City: BALTIMORE State: MD
County:
License #: GENEREAL
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/05/2007
Notification Time: 08:00 [ET]
Event Date: 07/01/2006
Event Time: [EST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
GREG MORELL (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE - MISSING AMERICIUM-241 SOURCE

The following information was provided by the State of Maryland via facsimile:

Diageo is a State of Maryland general licensee for a 100 millicurie Am-241 radioactive material gauge used to measure the fill height of beverages bottled at the facility. Diageo provided a report in writing to the State on 1/8/07 that the source was missing.

"The source and its source holder were discovered missing from an Industrial Dynamics Company (IDC) Model FT-50 device by the company around June 2006. Diageo and IDC conducted an extensive search of the facility and did not locate the source. The State conducted an investigation of the incident on 2/16/07 and no root cause of the loss/theft could be identified. Visual search and surveys were conducted in facility inventory areas. Interviews with IDC confirmed that only IDC or other qualified specific licensees are allowed to remove the source holder from the unit. IDC states that they did not remove the source from the device. Diageo states that their personnel did not remove the source. Potential waste stream routes from the facility are being investigated. Diageo states that they cannot identify any mechanism whereby the source could have gotten into the company waste stream. Diageo failed to report the incident to local law enforcement."

During the State investigation the following issues were identified: "failure to maintain inventory records; failure to conduct leak tests; failure to perform operational test at required frequencies; and non-operational source indicators lights. Maryland has reported the case to local FBI."

The State has notified Region 1 (White and Janda) about this event.

The State Report number is MD070004

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.

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General Information or Other Event Number: 43213
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNKNOWN
Region: 1
City: GASTONIA State: NC
County:
License #: UNKNOWN
Agreement: Y
Docket:
NRC Notified By: GRANT MULLS
HQ OPS Officer: JASON KOZAL
Notification Date: 03/05/2007
Notification Time: 13:27 [ET]
Event Date: 02/20/2007
Event Time: 08:30 [EST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
GREG MORELL (FSME)
ILTAB (E-MAIL) ()

Event Text

AGREEMENT STATE REPORT - ABANDONED INDUSTRIAL GAUGE FOUND IN SCRAP YARD

The following was provided by the State via facsimile:

"On the morning of 03/02/07 NCRPS became aware of a potential unknown radioactive source discovered [on 2/20/07] by a scrap yard [State Line Scrap Metal]. NCRPS dispatched a health physicist in an effort to gain reliable information. The health physicist was at the scrap yard by early afternoon and had collected technical information to be used in fully analyzing the unknown source. The source is potentially an abandoned industrial gauge (licensed radioactive material) and NCRPS is following protocol to determine a responsible party. The source was packaged in a 55 gallon drum and isolated in a safe and controlled manner (exposure rates less than 2 mR/hr) prior to site departure on 03/02/07.

"NCRPS is continuing event evaluation and determining necessary follow-up actions."

The State has not determined the source or the strength of the source at this time.

NC report ID number: NC-07-07

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General Information or Other Event Number: 43215
Rep Org: ALABAMA RADIATION CONTROL
Licensee: QUALITY ASSURANCE TESTING LABORATORIES
Region: 1
City: MONTGOMERY State: AL
County:
License #: 819
Agreement: Y
Docket:
NRC Notified By: DAVID TUBERVILLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/05/2007
Notification Time: 16:42 [ET]
Event Date: 03/05/2007
Event Time: 14:00 [CST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
JACK DAVIS (FSME)
DUNCAN WHITE (R1)
ILTAB (EMAIL) ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN CPN MOISTURE DENSITY GAUGE

"On the afternoon of March 5, 2007 at approximately 2:00 pm, the Radiation Safety Officer for Quality Assurance Testing Laboratories, Inc. of Montgomery, Alabama notified the State that a CPN model MC-3 moisture density gauge was stolen from its storage location in Montgomery, Alabama. Quality Assurance Testing Laboratories, Inc. is authorized to possess and use radioactive material under their Alabama Radioactive Material License No. 819. The gauge was last seen Thursday, March 1, 2007 when it was placed in storage. The gauge was discovered missing at 10:00 am on the morning of March 5, 2007. The Montgomery Police Department was notified and responded. The stolen gauge was identified as a CPN model MC-3, serial number M300705778, with 10 millicuries of Cs-137 and 50 millicuries of Am-241-Be. The RSO indicated that the gauge was stored in a locked shed that had no windows. The door is equipped with a regular door lock and a deadbolt. There was no sign of forced entry and only the one gauge was stolen. Other gauges containing radioactive material were in the building but not affected. The RSO indicated that the transport case was not locked and the source shutter was not locked. According to the RSO, no other equipment was stolen. The licensee is canvassing the pawn shops within the city providing them pictures for their information."

Alabama Event 07-14.


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.

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Power Reactor Event Number: 43217
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BRIAN SCOTT
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/07/2007
Notification Time: 06:11 [ET]
Event Date: 03/07/2007
Event Time: 03:05 [EST]
Last Update Date: 03/07/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GEORGE HOPPER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation

Event Text

EMERGENCY DIESEL GENERATOR AUTOSTART ON LOSS OF "B" RESERVE STATION SERVICE TRANSFORMER

"The Unit-2 H Emergency Diesel Generator (EDG) automatically started on a Degraded Voltage/Under Voltage (DV/UV) signal due to the loss of the 'B' Reserve Station Service Transformer (RSST). The Unit-2 H Emergency Diesel Generator is supplying the Unit-2 H 4160 Volt Bus. Both Unit 1 and Unit 2 were stabilized using the appropriate abnormal procedures.

"During the event, the Unit 2 'B' Main Feed Water Pump motor, 2-FW-P-1B1, was noted to be running with the other motor, 2-FW-P-1B2, not running. The Unit 2 'B' Main Feed Water Pump was subsequently placed in Pull-to-Lock. Investigation continues as to the cause of the loss of the 'B' Reserve Station Service Transformer and the start of the Unit 2 'B' Main Feed Water Pump motor.

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 43218
Rep Org: TYCO ELECTRONICS
Licensee: TYCO ELECTRONICS
Region: 1
City: FAIRVIEW State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT VILLEGAS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/07/2007
Notification Time: 09:30 [ET]
Event Date: 03/05/2007
Event Time: [EST]
Last Update Date: 03/07/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN CARUSO (R1)
GEORGE HOPPER (R2)
STEVE ORTH (R3)
VINCENT GADDY (R4)
TABATABAI (E-MAIL) (NRR)

Event Text

POTENTIAL DEFECT IN E7000 RELAYS

"Notification of limited E7000 relay recall (CII-010).

"During our normal assembly processing of nuclear E7000 relays, Tyco Electronics experienced an issue with a component. A spring in the base assembly broke during the calibration process. An analysis of the spring revealed non-conforming heat treatment causing the spring to become brittle. Further investigation revealed that this condition was limited to one specific lot of springs."

The cause of the defect was determined to be stress corrosion cracking (SCC). Testing of other springs in this lot did not identify additional defective springs. Tyco's inspection process has been changed to better detect SCC. The defective springs have been purged from inventory and customers notified.

Plant affected by this recall are:
Braidwood
Farley
Fitzpatrick
Indian Point 3
Limerick
Millstone
North Anna
Oyster Creek
Peach Bottom
Perry
Prairie Island
San Onofre
Susquehana
Vogtle
Watts Bar

Other agencies/organizations:
Delphi Controls
Engine Systems Inc
Entergy Oswego Warehousing
Ergy Tech
GE Nuclear Energy
Progress Energy Carolinas
Trentec Inc - Curtiss-Wright Flow Control Group

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Power Reactor Event Number: 43221
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: SCOTT BRITT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/08/2007
Notification Time: 01:07 [ET]
Event Date: 03/07/2007
Event Time: 20:50 [EST]
Last Update Date: 03/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GEORGE HOPPER (R2)

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

HPCI DECLARED INOPERABLE FOLLOWING SURVEILLANCE TESTING

"While Performing HPCI ATTS Panel, 1H11-P927, Functional Test & Calibration Surveillance (57SV-SUV-013-1S) For Ambient Torus Temperature High, The HPCI System Isolated. The Functional Test & Calibration Was Complete. The Isolation Was Reset. Following Return Of The Test Switch To Normal, HPCI Isolation Trip Logic 'A' Initiated & Closed 1E41-F002. HPCI Isolation Valve F002/F003 Alarm Annunciated When The Isolation Valve Started Closing & The HPCI Turbine Trip Solenoid Energized. I&C Investigating Time Delay Relay For Possible Cause."

HPCI has been declared inoperable placing Unit 1 in TS LCO A/S 3.5.1.c - 14 days to restore. The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012