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Event Notification Report for March 14, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/13/2008 - 03/14/2008

** EVENT NUMBERS **


43947 44045 44052 44053 44059 44060 44062

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43947
Rep Org: BRIDGEPORT HOSPITAL
Licensee: VARIAN CORPORATION
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-01060-01
Agreement: N
Docket:
NRC Notified By: DAVID S WISHKO
HQ OPS Officer: JASON KOZAL
Notification Date: 01/31/2008
Notification Time: 10:46 [ET]
Event Date: 01/30/2008
Event Time: [EST]
Last Update Date: 03/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
NEIL PERRY (R1)
MICHELE BURGESS (FSME)
PART 21 GROUP E-MAIL ()

Event Text

POTENTIAL INOPERABLE SAFETY FUNCTION

"In regard to Part 21.21 Notification of failure to comply or existence of a defect and its evaluation, [the licensee notified] the NRC of a defect that was detected on the Varian, Mammosource unit, Gammamed Plus (M1), ID#H64E168.

"The defect noted was the following:

"A daily check is performed to verify when the source guide tube is disconnected from the unit head, the source will not extend. This test is performed as recommended on p. 73 of the ESTRO Booklet No.8, ' A Practical Guide to Quality Control of Brachytherapy Equipment'. Disconnecting the tube (i.e. the lock that connects the source guide tube to the turret of the Mammosource) the dummy wire or the source wire should have been prevented from extending out. If the disconnect is within 2 mm of being connected the wire does extend out. This was documented on a check film using the Mick PerinaDoc phantom. As recommended in the Varian GammaMed HDR User Manual, P. 6-20, Varian BrachTherapy service was called.

"Notification:

"Varian Corp. was notified of this problem on 1/30/08 and a service engineer will be sent to the site to adjust the light sensor that communicates whether the source guide tube is connected. We are continuing treatment with two independent physicists verifying before treatment that the source guide tube is connected properly and securely."

* * * RETRACTION FROM WISHKO TO HUFFMAN VIA E-MAIL AT 1431 EDT ON 3/13/08 * * *

"Verbal communication with an engineer from Varian Corporation stated that when the source guide tube is disconnected within 2 mm from the turret of the Mammosource, the source can extend. Since this is a design feature and accepted by Varian Corporation, I wish to withdraw my report of notification on a discovered defect."

R1DO (Lorson) and FSME (Wastler) notified.

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General Information or Other Event Number: 44045
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: APPLETON MEDICAL CENTER
Region: 3
City: APPLETON State: WI
County:
License #: 087-1014-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2008
Notification Time: 16:32 [ET]
Event Date: 03/06/2008
Event Time: [CST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3)
SCOTT FLANDERS (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE PATIENT UNDERDOSES

"The Department of Health and Family Services (DHFS) was notified on March 6, 2008, of possible underdoses to up to eight patients treated with Samarium-153 since late 2006.

"When the licensee was preparing a recent dose of Samarium-153, the activity measured in the dose calibrator did not read as expected. After review, the licensee determined that the dose calibrator was calibrated to measure Samarium-153 in a vial, but the nuclear medicine technologist had measured the activity of Samarium-153 in a syringe instead. For this particular case, the dosage was remeasured properly prior to administration, but further review of cases identified up to eight additional instances when the nuclear medicine technologists may have measured the activity of Sarnarium-153 in a syringe instead of in a vial. Samarium-153 has a combined beta and gamma decay spectrum, and when the activity is measured in a syringe, the attenuation and volume geometry is estimated to lead to administered activities of approximately 30% less than prescribed in the written directives.

"DHPS will investigate this incident next week."

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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General Information or Other Event Number: 44052
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: TEAM INDUSTRIAL SERVICES, INC.
Region: 4
City: NEBRASKA CITY State: NE
County:
License #: IL-011396-01
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/11/2008
Notification Time: 14:21 [ET]
Event Date: 03/10/2008
Event Time: [CDT]
Last Update Date: 03/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
MARK RING (R3)
MICHELE BURGESS (FSME)

Event Text

NEBRASKA AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The State of Nebraska Department of Health & Human Services, Radiation Control Program, Radioactive Materials Branch reported that a radiographer employed by Team Industrial Services, Inc. was potentially overexposed while performing radiography at a Nebraska City, NE facility. Team Industrial Services, Inc. is performing work in Nebraska under reciprocity of their Illinois license.

On March 7, 2008, while at the job site, the radiographer noticed that his direct-reading pocket dosimeter was off-scale. He reported this to the regional Team Industrial Services RSO and stated that he believed he just bumped the dosimeter to cause the off-scale condition. The RSO directed him to send his TLD to Landauer Laboratories for processing.

On March 10, 2008, Landauer informed the RSO that the TLD indicated that the radiographer received 7.753 REM Deep Dose Equivalent.

The Team Industrial RSO notified his corporate RSO, who then notified the State of Nebraska. The radiographer has been restricted from radiation areas while Team Industrial and the State of Nebraska investigates this incident.

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General Information or Other Event Number: 44053
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: APPLIED TECHNOLOGY SERVICES
Region: 1
City: JESSUP State: GA
County: WAYNE
License #: GA-0896-1
Agreement: Y
Docket:
NRC Notified By: JOEL MIMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/11/2008
Notification Time: 16:16 [ET]
Event Date: 03/11/2008
Event Time: [EDT]
Last Update Date: 03/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
MICHELE BURGESS (FSME)

Event Text

GEORGIA AGREEMENT STATE REPORT

The State of Georgia reported that one of their licensees, Applied Technical Services, was conducting radiography at the Rayonier Paper Mill in Jessup, GA. While filming a tank weld, the radiography camera fell approximately 24 feet to the ground. The licensee was unable to retract the source back into the camera.

The licensee isolated the area and covered the source with temporary lead shielding. Additionally, they established a 2 mR/hr boundary around the source which will be continuously manned until the manufacturer (QSA Global) representative arrives to secure the source and camera.

The licensee reports that no overexposures occurred during this incident.

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Power Reactor Event Number: 44059
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: LAURIE LAHTY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/13/2008
Notification Time: 12:38 [ET]
Event Date: 03/13/2008
Event Time: [EDT]
Last Update Date: 03/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MARK RING (R3)
RAY LORSON (R1)
MARK LESSER (R2)
TROY PRUETT (R4)
VERN HODGE (NRR)
JOHN THORP (NRR)

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

POTENTIAL DEFECT IN FAIRBANKS MORSE EMERGENCY DIESEL GENERATOR SNUBBER VALVE MATERIAL AND HEAT TREATMENT

Abstract:

"Palisades has experienced failures of two snubber valves on an emergency diesel generator since November 2005. These valves were made from AISI E 52100 material. Entergy has determined through destructive metallurgical analysis that the material was incorrectly heat-treated. Not all of the install snubber valves were constructed of this material. The defect in the material of the snubber valves may allow the snubber valves to crack under operation, resulting in fuel oil leakage and loss of fuel oil supply to the affected cylinder on the engine.

Component information:

"Manufacturer: Fairbanks Morse
Model: ALCO Model 251F
ALCO Part Number: 2402466

Description:

"Palisades has experienced failures of two snubber valves on the 1-2 emergency diesel generator since November 2005 due to incorrectly heat treated material of the snubber valves. Both snubber valves failed soon after being initially installed in the engine or after being re-installed in the engine after maintenance. The first snubber valve failed after operating for approximately 10 hours of operation. The second snubber valve was installed in the engine and had approximately 135 hours of run time on it before it was removed, inspected and re-installed in the engine. After reinstallation into the engine, the snubber valve failed after approximately 2 hours of operation. Review of the purchasing history of the snubber valves could not identify when these failed snubber valves were originally purchased.

"On February 27, 2008, Entergy determined, through destructive metallurgical analysis, that the material that was incorrectly heat-treated was AISI E52100 material. Not all snubber valves were constructed of this material. Subsequently, the receipt inspection practices were revised to include testing of the snubber valves for the suspect material. This is accomplished by using a Niton XLT 800 chemical analyzer to identify (non-destructively) the chemical content of the snubber valves. Snubber valves with manganese contents <0.5% are rejected as they are most likely to be constructed of E52100 material.

"In January 2008, five snubber valves were rejected due to not meeting Palisades material requirements. Subsequently, one of the snubber valves was destructively tested and confirmed to have been incorrectly heat treated. These snubber valves were identified to have been purchased in 2004.

"A Part 21 evaluation was performed and it was concluded that this is a substantial safety hazard because the defect may allow the snubber valves to crack under operation, resulting in fuel oil leakage and loss of fuel oil supply to the affected cylinder on the engine. The loss of fuel oil supply to a cylinder may affect the ability of the emergency diesel generator to meet its design basis load rating; the external leakage of fuel may result in the potential for a fire to develop and render the diesel generator inoperable; and the leakage of fuel may affect the ability of the fuel oil system to supply adequate fuel oil to the diesel generator throughout its mission time.

Causes:

"Snubber valves constructed from AISI E52100 material may be incorrectly heat-treated. The cause of this is not known.

Corrective Actions:

"Palisades experienced two failures, which were reported in Licensee Event Reports 2005-007 and 2007-006. Entergy identified the improper heat treatment following the second failure. Entergy has subsequently replaced all snubber valves on the 1-1 emergency diesel generator. Entergy replaced the defective snubber valve and the remaining snubber valves on the 1-2 emergency diesel generator that had been replaced at the same time the defective snubber was installed. Since the replacement snubber valves on 1-2 emergency diesel generator did not have their material composition verified, eight additional snubber valves were sub replaced after verifying E52100 was not present. Entergy plans to replace the remaining 10 snubber valves on 1-2 emergency diesel generator. Based on the amount of in-service time of these snubber valves and verification of 26 acceptable snubber valves, there is reasonable expectation of operability."

The licensee notified the NRC Resident Inspector.

Palisades has been in contact with Fairbanks Morse concerning this issue.

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Power Reactor Event Number: 44060
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JOHN McCORY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/13/2008
Notification Time: 18:36 [ET]
Event Date: 03/13/2008
Event Time: 16:44 [CDT]
Last Update Date: 03/13/2008
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MARK LESSER (R2)
VICTOR MCCREE (R2)
JIM WIGGINS (NRR)
JEFFREY CRUZ (IRD)
CATHY HANEY (NRR)
ELIOT BRENNER (PAO)

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

ALERT DECLARED DUE TO TOXIC GAS DISCHARGE INTO THE 1B EMERGENCY DIESEL GENERATOR BUILDING

"During the 1B diesel generator surveillance run, the control room received fire alarms for the 1B diesel generator room. The system operator reported the room was full of smoke and the CO2 system had discharged. The control room manually shutdown the 1B diesel generator due to the event. An Alert classification was declared based on EAL #HA3 - Report or Detection of Toxic or Asphyxiant Gas within the Vital Area in Concentration that May Result in an Atmosphere Immediately Dangerous to Life or Health. No Radiological Release has occurred or is in progress."

The licensee stated that all personnel were accounted for and that no injuries had occurred. The 1B emergency diesel generator building is being ventilated to re-establish habitability. The licensee stated that there is no fire.

During discussions between NRC management and the licensee it was noted that the exhaust header on the 1B EDG had been recently replaced and that a failure of this exhaust header introduced smoke and exhaust gas into the building which actuated the CO2.

The licensee notified State and local agencies and the NRC Resident Inspector. A press release will also be issued.

* * * UPDATE FROM McCORY TO HUFFMAN AT 1945 EDT ON 3/13/08 * * *

The Alert was terminated at 1836 CDT based on ventilation of the room and re-establishment of habitability.
The licensee notified State and local agencies and the NRC Resident Inspector. R2 (McCree), R2DO (Lesser), NRR (Wiggins), NRR EO (Haney) and IRD (Cruz) notified.

Notifications to DHS, FEMA, DOE, EPA, USDA, HHS were also made by the NRC Operations Center.

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Power Reactor Event Number: 44062
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: D. DUNCAN / M. HIMEBAUCH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/13/2008
Notification Time: 18:24 [ET]
Event Date: 03/13/2008
Event Time: 14:45 [EDT]
Last Update Date: 03/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK RING (R3)

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

Event Text

REACTOR BUILDING TO TORUS VACUUM BREAKER PRESSURE SWITCHES MAY NOT PERFORM DESIGN FUNCTION

"March 13, 2008 at 1445 hours, engineering analysis identified that the pressure switches that operate to open the Reactor Building (RB) to Suppression Chamber (Torus) vacuum breaker isolation valves would not perform their design function. The condition impacted the function of both RB to Torus vacuum breaker isolation valves. One vacuum breaker isolation valve has been opened to maintain the function of the vacuum breaker in that line. A plan is being implemented to correct the deficiency and is expected to be completed within the required 72 hour Limiting Condition for Operation expiration time for the current condition. This is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of structures or systems needed to mitigate the consequences of an accident."

The licensee informed the NRC Resident Inspector.

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