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Event Notification Report for March 9, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/08/2007 - 03/09/2007

** EVENT NUMBERS **


43211 43213 43215 43220 43221 43223

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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 #: GENERAL
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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General Information or Other Event Number: 43220
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CENTURA HEALTH: PENROSE- ST. FRANCES HEALTH SERVICES
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 197-02
Agreement: Y
Docket:
NRC Notified By: THOMAS PENTECOST
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2007
Notification Time: 18:35 [ET]
Event Date: 03/07/2007
Event Time: [MST]
Last Update Date: 02/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
EDWIN HACKETT (FSME)

Event Text

AGREEMENT STATE REPORT- MEDICAL EVENT - UNDERDOSE TO PATIENT

During a series of fractional medical treatments given to the patient on 2/13/07 through 2/20/07, a dose of 24000 centigray was administered to the dose area of the patient instead of the 31092 centigray prescribed dose. The isotope used was Iridium-192. The source strength was unknown at the time of the report.

"The HDR misadministration was the result of a failure to correct for the proper length of the type of connector used in the procedure. The error resulted in a dose more than 20% below the prescribed dose. The error in the procedure was identified during the review process following the conclusion of the last dose fraction."

The length of the connector differed from the correct length by 1.4 centimeters. The prescribing physician said that the patient will likely have a skin reaction to the treatment that will heal with time.

"The [Colorado Health] Department's inspector is scheduled to conduct an inspection at the Penrose Hospital on Monday, March 12, 2007. He was briefed with the known details of the misadministration at this date and will look further into this matter."

The state expects to provide additional information at a later date.

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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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.

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Power Reactor Event Number: 43223
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ROY GREEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/08/2007
Notification Time: 16:15 [ET]
Event Date: 03/08/2007
Event Time: 14:50 [EST]
Last Update Date: 03/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JOHN CARUSO (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 50 Power Operation

Event Text

TECHNICAL SPECIFICATION SHUTDOWN DUE TO A DEGRADED SEAL IN THE "A" REACTOR RECIRCULATION PUMP


"Reactor Recirculation Pump 'A' removed from service due to a degraded seal. TS 3.4.1 entered to meet requirement for single loop operation at 1050. When the pump was secured, the 3D monicore system failed preventing verification of thermal limits. TS 3.4.1 action D entered at 1450 required to be in mode 3 (Hot Shutdown) within 12 hours."


The NRC Resident Inspector was notified of this event by the licensee.


Reactor Recirculation Pump 'A' seal is degraded, no increase in leakage. Licensee is in contact with General Electric in trying to restore the 3D monicore system. All Emergency Core Cooling Systems and the Emergency Diesel Generators (all 3 divisions) are fully operable if needed and the electrical grid is stable. Nine Mile Point Unit 1 is in coastdown for a scheduled refueling outage. Nine Mile Point Unit 2 should be in Mode 3 (Hot Shutdown) by 0100 hours on 03/09/07.

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