| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/12/2007 - 07/13/2007 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 43447 | Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: STARMET NMI
Region: 1
City: CONCORD State: MA
County:
License #: SM-0179, SU-1
Agreement: Y
Docket:
NRC Notified By: BOB GALLAGHAR
HQ OPS Officer: JOHN KNOKE | Notification Date: 06/27/2007
Notification Time: 09:05 [ET]
Event Date: 06/26/2007
Event Time: 20:00 [EDT]
Last Update Date: 07/12/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)
| Event Text AGREEMENT STATE REPORT - SMALL FIRE AT LICENSEE'S FACILITY
"On Wednesday, June 26, 2007, at approximately 8:00 PM EST a fire was reported at the Starmet NMI facility in Concord, Massachusetts [2229 Main Street]. Starmet NMI possesses two materials licenses with Massachusetts, License No. SM-0179 and License No. SU-1453. The fire occurred in the foundry area within the facility, formerly used for the manufacture of depleted uranium munitions. The fire appeared to be contained to a small area within the building, in the vicinity of a 55-gal drum, a 5-gal bucket and a small pile of metal shavings.
"Radiological surveys performed once the fire was extinguished resulted in no elevated readings from any of these containers or the material. The investigation is ongoing and more information will be provided as it is obtained."
* * * UPDATE FROM ROBERT GALLAGHAR TO SNYDER AT 1416 ON 7/12/07 * * *
"The Concord Fire Department has determined the cause of the fire to have been the auto-ignition of metal filings and therefore non-suspicious in nature. The official fire investigation has been closed. No off-site radiological consequences resulted from this fire.
Notified FSME (Holonich), R1DO (Lorson) via e-mail. |
| General Information or Other | Event Number: 43476 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ENGEN CORPORATION
Region: 4
City: RIVERSIDE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: D. AQUINO
HQ OPS Officer: JOHN KNOKE | Notification Date: 07/09/2007
Notification Time: 14:07 [ET]
Event Date: 07/31/2002
Event Time: [PDT]
Last Update Date: 07/09/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
REBECCA NEASE (R4)
| Event Text AGREEMENT STATE REPORT - DAMAGED NUCLEAR GAUGE
The licensee provided the following information via facsimile:
"During the routine license inspection on 5/15/07, the inspector learned that one of the licensee's nuclear gauges (Humboldt, SM 486) was run over by a water truck at a jobsite in Menifee, Riverside on 7/31/02. The licensee did not report the incident to the Department [California Department of Public Health]. An incident report was generated by the licensee, dated 7/31/02, and filed. According to the incident report, the gauge was immediately inspected for damage by the ARSO. The sources and shielding were found to be undamaged and completely intact. The casing and electronic parts were badly damaged. The gauge was transported to their office for further evaluation and a leak test was performed. The results of the leak test were received August 12, 2002, and the gauge was not leaking.
"The nuclear gauge still has not been repaired, and is not being used by the licensee, although the leak test is being done on the required frequency. As part of the routine inspection, a Notice of Violation was issued on 5/30/07 for failure to report/notify the Department, within 24 hours of the incident and failure to submit a written report within 30 days after the incident." |
| General Information or Other | Event Number: 43477 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROFESSIONAL SERVICES INDUSTRIES, INC
Region: 4
City: DALLAS State: TX
County:
License #: L04940-00
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE | Notification Date: 07/09/2007
Notification Time: 15:38 [ET]
Event Date: 07/07/2007
Event Time: [CDT]
Last Update Date: 07/09/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
REBECCA NEASE (R4)
JOE GIITTER (FSME)
JIM WHITNEY EMAIL (TAB)
MEXICAN GOV'T EMAIL ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - MISSING MOISTURE DENSITY GAUGE
The licensee provided the following information via email:
"On July 9, 2007, Corporate RSO for Professional Service Industries, called to report a moisture density gauge missing during quarterly inventory. The RSO reported that Troxler model 3430 S/N 30189 was missing when inventory was conducted on 07/07/07. The gauge contains two radioactive sources; an 8 mCi Cs-137 source S/N 750-2295, and a 40 mCi Am-241 source S/N 47-27166. The sources were leak tested on 03/14/07. The last known use of the device was on 06/09/07. The employee assigned the moisture density gauge returned the truck and keys to the office and did not return to work. It was assumed the gauge had been placed back into storage. It is possible the employee stole the gauge. The RSO reported that a list of about 20 pawnbrokers in the area were contacted and informed that there was a $500.00 reward offered for the return of the gauge. The RSO reported that the employee was wanted in California for back child support. Company representatives searched his former residence, but didn't find evidence of the gauge there. I [State] told the RSO that we would place a notice to the State Pawnbrokers Association. I [State] also suggested that, if they will accept it, he [RSO] should file a theft report with Dallas Police Department. The RSO asked that we notify the Pawnbrokers' Association of the reward offer and that it is a 'no questions asked' offer."
Texas Incident # I-8424
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. |
| General Information or Other | Event Number: 43478 | Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/10/2007
Notification Time: 13:40 [ET]
Event Date: 05/10/2007
Event Time: [EDT]
Last Update Date: 07/11/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN ROGGE (R1)
MICHELE BURGESS (FSME)
| Event Text MEDICAL AFTERLOADER-APPLICATOR PLACED IN INCORRECT LOCATION
"On 10 May 2007 it was discovered that a patient who was being treated for recurrent endometrial cancer (Paravaginal Tumor) had received a dose which differed from the prescribed dose for the fraction by greater than 50%. The intended dose to the patient was 500 cGy to the tumor. However, the dose was delivered approx 54mm from the tip of the catheter instead of 5 mm from the tip. It was noted in the misadministration report that there were no critical structures that were exposed above any threshold tolerance. Due to a physics catheter measurement error, which was entered into the treatment plan, the catheter did not go in as deeply as intended but stopped short of the target. On audit of the procedure, and remeasurement of the catheter, the chief physicist identified the error in measurement and filed a report with the RI RCA. Corrective actions in addition to re-measurement and subsequent adjustment of treatment plan included adjustment in the dose per remaining fractions to provide the correct dose to the target."
Rhode Island Report: RI-07-001
Actual initial dose was approximately 10% of expected.
Source Ir-192, 8.05 Curies
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.
* * * UPDATE FROM FLANNERY TO O'HARA VIA E-MAIL AT 0949 ON 7/11/07 * * *
"This event (EN43478) has been reviewed and determined to be a reportable medical event." |
| Hospital | Event Number: 43484 | Rep Org: ST LUKES REGIONAL MEDICAL CENTER
Licensee: ST LUKES REGIONAL MEDICAL CENTER
Region: 4
City: TWIN FALLS State: ID
County:
License #: 11-27312-01
Agreement: N
Docket:
NRC Notified By: JEFFERSON FAIRBANKS
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/12/2007
Notification Time: 14:40 [ET]
Event Date: 07/12/2007
Event Time: [MDT]
Last Update Date: 07/12/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
VINCENT GADDY (R4)
RICH LEONARDI (R4)
JOSEPH HOLONICH (FSME)
| Event Text MISSING Ir-192 SOURCE
A 6 Curie source was being shipped by Federal Express from the Twin Falls branch of St Luke's Regional Medical Center to Alpha-Omega in Louisiana. A cardboard box arrived in Louisiana containing what appeared to be aircraft parts.
See also Event Notification #43480
* * * UPDATE ON 7/12/07 AT 1525 FROM JEFFERSON FAIRBANKS TO MARK ABRAMOVITZ * * *
The source was found at Alpha-Omega in Louisiana. It had been at their location and misreported as lost.
Notified the R4DO (Gaddy). |
| Power Reactor | Event Number: 43486 | Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CALVIN FIELD
HQ OPS Officer: PETE SNYDER | Notification Date: 07/12/2007
Notification Time: 17:31 [ET]
Event Date: 07/11/2007
Event Time: 17:04 [EDT]
Last Update Date: 07/12/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
| 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 RAIN CAUSES OVERFLOW OF RWST WATER BASIN
"The following voluntary report is being made as a result of the Industry Ground Water Protection Initiative NEI-07-07. During a heavy rain downfall on 7/11/2007, the U1 Refueling Water Storage Tank (RWST) water basin overflowed. This overflow was slightly contaminated due to prior contamination of insulation which surrounds the RWST. The rainfall is believed to [have leached] the contamination from the insulation to the basin. In accordance with NEI-07-07 guidance, a voluntary communication has been made to the appropriate State/Local officials. Thus the purpose of this notification is to inform NRC of this voluntary notification to State/Local agency. The release was less than regulatory (ODCM or 10 CFR 20 Appendix B) limits. "
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 43487 | Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DEAN RAASCH
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/12/2007
Notification Time: 18:35 [ET]
Event Date: 07/12/2007
Event Time: 10:15 [CDT]
Last Update Date: 07/12/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
DAVID HILLS (R3)
|
| 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 FIRE INSPECTION ANALYSIS OF PRESSURIZER PORVS AND BLOCK VALVES
"During a review of abnormal operating procedure (AOP) 10A, Safe Shutdown-Local Control, by the NRC triennial fire inspection team, it was identified that fire damage to the reactor coolant system (RCS) power-operated relief valve (PORV) and block valve circuits as a result of a fire in the cable spreading room could also result in simultaneous damage to a block valve circuit and spurious actuation of a PORV. While the actions included in abnormal operating procedure (AOP)-10A provide reasonable assurance that positive control of RCS Inventory is maintained, these steps do not ensure that simultaneous failure of the block valve circuit and spurious operation of a PORV will not result in RCS depressurization. Therefore, a postulated fire may potentially remove the ability to fully implement the Safe Shutdown Strategy. Compensatory measures in the form of twice-per-shift fire rounds in the cable spreading room have been implemented."
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 43488 | Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MARK KRUSE
HQ OPS Officer: PETE SNYDER | Notification Date: 07/12/2007
Notification Time: 19:14 [ET]
Event Date: 07/12/2007
Event Time: 16:30 [CDT]
Last Update Date: 07/12/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
DAVID HILLS (R3)
|
| 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 UNALLOWABLE MANUAL ACTIONS CREDITED FOR FIRE SAFE SHUTDOWN
"During performance of NFPA-805, Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined manual operator actions are being credited in IX/12-A Lower 4KV Room and XII/14-A Upper 4KV Room to achieve and maintain hot safe shutdown. The manual actions are to provide temporary ventilation capability to the 4KV rooms to assume continued operability of vital switchgear. The switchgear provides power to equipment needed to achieve and maintain hot shutdown. These manual actions were specified in an Appendix R Section III.G.1/G.2 fire area; however, they do not meet the criteria for allowable manual actions specified in RIS 2006-10, 'Regulatory Expectations with Appendix R paragraph III.G.2 Operator Manual Actions.' No system actuations occurred as part of this event.
"The discovery of these manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii)(B) and has been entered into the site's corrective action program The alternate compensatory measure for these areas is to perform the specified manual actions. An extent of condition review will be initiated that will encompass the remainder of the safe shutdown areas. The results of the extent of condition will be documented in the site's corrective action program with compensatory measures being established as appropriate.
"The 60 day licensee event report, submitted to the Commission in accordance with 10 CFR 50.73(a)(2)(ii), will provide the results of the manual action compliance review and follow-up corrective actions. This is based on preliminary data and further investigation is ongoing."
The licensee will notify the NRC Resident Inspector. | |