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Event Notification Report for September 19, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/18/2007 - 09/19/2007

** EVENT NUMBERS **


43639 43640 43643 43644 43648 43649 43651

General Information or Other Event Number: 43639
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037152AAB
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: JASON KOZAL
Notification Date: 09/13/2007
Notification Time: 15:04 [ET]
Event Date: 02/01/2005
Event Time: [CDT]
Last Update Date: 09/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE DIFFERS BY GREATER THAN 50% OF PRESCRIBED

The State provided the following information via email:

"A teletherapy patient received a dose greater than 50% of the prescribed fractionated dose due to an improperly calculated dose delivery time. The medical physicist used a fractionated dose of 200 cGy instead of the prescribed dose of 100 cGy. This overexposure occurred during the first fraction to the patient. Before the second scheduled treatment, a different therapist questioned the long treatment time and brought the matter to the medical physicist. The physicist checked the calculations, discovered the error and cancelled the treatment for the day. The radiation oncologist anticipates no unusual acute or late effects from the delivered dose. The University of Iowa no longer is in possession of this device. It was de-sourced on November 16, 2005."

The device was a sealed Co-60 teletherapy source. The therapy was targeting the bone marrow.

Iowa report number: IA070003

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General Information or Other Event Number: 43640
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ASSET MANAGEMENT
Region: 3
City: HUGO State: MN
County:
License #: 1008-200-82
Agreement: Y
Docket:
NRC Notified By: GEORGE F. JOHNS, JR.
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/13/2007
Notification Time: 17:11 [ET]
Event Date: 09/13/2007
Event Time: 14:00 [CDT]
Last Update Date: 09/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
PATRICE BUBAR (FSME)
ILTAB (via email) ()
CNSC (via fax) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via email:

"The Minnesota Department of Health (MDH) has been notified that on September 13, 2007 at approximately 2:00 PM, a moisture-density gauge containing sealed sources of radioactive material was stolen from a pick-up truck owned by Asset Management. The truck was parked at a residence in Forest Lake, Minnesota, and the gauge was believed to have been stolen sometime during the previous night.

"The MDH, which regulates the use of these types of radioactive materials in Wisconsin, is working with the Forest Lake Police Department and officials of Asset Management to recover the stolen gauge.

"The moisture density gauge is used to measure the moisture content and density of soils and building materials. The gauge is a yellow box measuring approximately 30 inches in length, 14 inches in width and 17 inches in height (see attached picture). The gauge and the case weigh a total of 90 pounds. The gauge itself weighs 29 lbs. The case and the gauge are clearly marked as containing radioactive materials. . ."

The gauge is a Troxler Model 3430 (S/N 33277) containing two (2) sources; 9 millicuries Cs-137 and 44 millicuries Am-241:Be. The State of Minnesota issued a press release with contact information for the return of the gauge.

MN Report No.: MN070006.

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: 43643
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONSOLIDATED ENGINEERING LABS
Region: 4
City: SAN ROMONE State: CA
County:
License #: 3250-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JASON KOZAL
Notification Date: 09/14/2007
Notification Time: 18:48 [ET]
Event Date: 09/13/2007
Event Time: 18:00 [PDT]
Last Update Date: 09/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
ILTAB VIA E-MAIL ()
PATRICE BUBAR (FSME)
MEXICO (VIA FAX) ()

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The licensee completed testing at jobsite and thought he had stowed his moisture density gauge (Troxler model 3340, SN 25752, 8 - 10 mCi Cs-137/ 40 mCi Am-241/Be). He left the jobsite in Shingle Springs, CA, and while in-transit to Elk Grove, CA (via highway 50) the technician heard a thud from outside of the vehicle but did not think anything of it. When the technician arrived at his residence he noticed the truck's tailgate was down and realized the gauge was missing. He backtracked to the jobsite and was unable to locate the gauge on the highway or at the jobsite. The technician notified the RSO, the Elk Grove Police Department and the California Highway Patrol. The State will provide more information as it becomes available.

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: 43644
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: METCO
Region: 4
City: HOUSTON State: TX
County:
License #: TX-L030181926
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/15/2007
Notification Time: 19:26 [ET]
Event Date: 09/14/2007
Event Time: 22:00 [CDT]
Last Update Date: 09/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
PATRICE BUBAR (FSME)
THOMAS BLOUNT (IRD)

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL OVEREXPOSURES DURING INDUSTRIAL RADIOGRAPHY

At approximately 2200 hrs. on 9/14/07 during radiography work at a jobsite in Vidor, TX (30 miles north of Beaumont), two radiographers noticed that their pocket dosimeters read off-scale high (range 0- 200 m R). They were using a 94 curie Co-60 camera (QSA model 943, A424-14, S/N36391B) to take radiographic shots of a 6 inch thickness steel ladle and had just changed the film in the holder which was located about 7 inches from the exposed source behind the steel ladle. It appeared that the source had not retracted into its shielded volume. A specialist in source retrieval was brought to the jobsite and the source successfully returned to its stowed position. During retrieval the specialist's pocket dosimeter also went off-scale high (range 0-5 R) at which time he switched to a higher reading dosimeter (range 0-20 R) completing the task with an indicated dose of 13 R.

The State of Texas was notified of the incident at 1804 hrs. on 9/15/07 and confirmed that the licensee was sending the individuals dosimetry off for emergency reading. Further, the State contacted REAC/TS (Radiation Emergency Assistance Center/Training Site) who recommended that these individuals be immediately medically examined with followup blood chemistry tests, i.e., CBC (complete blood cell), performed the following day to document any cytogenic changes. The State will conduct an investigation to determine the cause of the overexposures.

* * * UPDATE PROVIDED BY RAY JISHA TO JEFF ROTTON VIA EMAIL AT 0927 ON 09/17/07 * * *

The State provided the following information via email:

"The two workers 200 mR dosimeters were off scale and it appears that they were working with the source not fully retracted as a crimp in the source tube was noted approximately 1.5 feet from the camera. A ladder was used to enter the ladle from one side and the source was positioned on the opposite side with a magnetic hold on device. It has been conveyed that the hold on device fell off at some time and damaged the source tube restricting the full retraction of the source for two shots with a survey being taken on the second shot and thus the source being discovered in the exposed position. The source retrieval was difficult apparently requiring the source to be fully extended so that the source tube could be manually stripped from the drive cable. This took reportedly 12 one minute maneuvers, lead shot bags used when possible."

"Blood was drawn Saturday and twice Sunday for CBC the results of which are to be faxed to REACTS. On Monday blood will be drawn with heparin/lithium for transport to REACTS for cytogenic analysis. Our inspector in the area is to conduct a recreation on the event today and more details will follow in a formal report."

Texas report number I-8444

Notified R4DO (V. Campbell) and FSME EO (Morell), and IRD Manager (Blount)

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General Information or Other Event Number: 43648
Rep Org: TYME ENGINEERING
Licensee: TYME ENGINEERING
Region: 3
City: SOUTHFIELD State: MI
County:
License #: 21-32523-01
Agreement: N
Docket:
NRC Notified By: ANDREW RUDDER
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/18/2007
Notification Time: 10:39 [ET]
Event Date: 09/18/2007
Event Time: 08:00 [EDT]
Last Update Date: 09/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
HIRONORI PETERSON (R3)
GREG MORELL (FSME)
ILTAB Email ()
CANADA Email ()

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

Event Text

STOLEN TROXLER GAUGE

A technician was working at a jobsite on 9/15/07, and when he completed his work about 1800, he drove to the company office in Southfield, MI. He left the Troxler gauge double locked in the back of the company pickup truck. When he reported to work on 09/18/07 at 0700 he noticed that the Troxler gauge was missing from the truck. He reported this to the RSO. The Troxler is a model 3440, s/n 36107, with Am-241/Be (40 mCi), s/n 78-998, and Cs-137 (8 mCi), s/n 77-3236. Licensee reported this to the Southfield police who issued report # 07-58570.

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: 43649
Facility: POINT BEACH
Region: 3 State: WI
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/18/2007
Notification Time: 11:37 [ET]
Event Date: 09/18/2007
Event Time: 08:43 [CDT]
Last Update Date: 09/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
HIRONORI PETERSON (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 53 Power Operation

Event Text

REFUELING WATER STORAGE TANK TEMPERATURE ABOVE OPERATING LIMITS

"At 0043 on 9/18/07, during performance of Technical Specification (TS) Surveillance Requirement (SR) 3.5.4.1, the 2T-13 Refueling Water Storage Tank (RWST) was found to be at 105 degrees F. Limiting Condition for Operation (LCO) 3.5.4 A was therefore not met due to temperature being above the parametric value limit of 97 degrees F (100F technical specification value).

"The cause of the elevated temperatures of 2T-13 is currently under investigation. At 0843 an orderly shutdown of Unit 2 was commenced because of the continued elevated temperature of the Refueling Water Storage Tank. Troubleshooting to identify the cause of the problem and take remedial actions continues."

Unit 1 RWST temperature is 77 F. Licensee is taking action to lower Unit 2 RWST temperature.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY RICK ROBBINS TO JASON KOZAL ON 9/18/07 AT 1901 * * *

"Unit 2 RWST temperature was verified at 97 degrees F at 1421 CDT. The 2T-13 RWST is operable and LCO 3.5.4.is now met. The Unit 2 power reduction was terminated at 20% reactor power. Current plans are to continue to cool down the RWST using station procedures that place the RWST on recirculation through the residual heat removal (RHR) heat exchanger with component cooling water (CCW) to cool the heat exchanger. Plans are in progress to return Unit 2 to full power on 09/18/07.

"A root cause evaluation is in progress to determine the specific cause of the event; however, preliminary investigations have determined that the heaters were on with an improper setpoint. The power supply to the heaters have been turned off and temperatures are being monitored on an hourly basis while the RWST is on recirculation."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Peterson)

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Power Reactor Event Number: 43651
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: TIM BUNKELMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 09/18/2007
Notification Time: 16:29 [ET]
Event Date: 09/18/2007
Event Time: 12:00 [CDT]
Last Update Date: 09/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
HIRONORI PETERSON (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

SHIELD BUILDING VENTILATION SYSTEM INOPERABLE

"At 1200 a condition associated with the Shield Building Ventilation Train A damper controller was identified that rendered the system inoperable. This condition was identified while Shield Building Ventilation Train B was inoperable for routine maintenance. Consequently, both trains of Shield Building Ventilation were simultaneously inoperable. Technical Specification TS 3.6.c requires a reactor shutdown within 12 hours of this condition. The routine maintenance on Shield Building Ventilation Train B was completed and retest performed at 1331. Shield Building Ventilation Train B was returned to operable and Technical Specification requirements to shutdown were exited. The plant remains in a 7 day Action Statement per TS 3.6.c with Shield Building Ventilation Train A inoperable .

"This event is reportable under 10CFR50.72(b)(3)(v)(C), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'"

I&C technician was walking down a different job in the area and noticed a light illuminated on the A control board which should not have been illuminated. Additional investigation revealed an electrical condition would have prevented the modulation of the dampers thereby rendering the A train system inoperable.

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012