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Event Notification Report for April 23, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/22/2008 - 04/23/2008

** EVENT NUMBERS **


44050 44143 44145 44146 44150 44154 44155

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44050
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MARK IHLENFELDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/10/2008
Notification Time: 23:59 [ET]
Event Date: 03/10/2008
Event Time: 18:13 [CDT]
Last Update Date: 04/22/2008
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
1 N Y 100 Power Operation 100 Power Operation

Event Text

HPCI INOPERABLE

"During performance of the quarterly high pressure coolant injection (HPCI) Surveillance Test, a technical specification step could not be completed due to observed system water flow and discharge pressure oscillations. These oscillations are presently under investigation. The tech spec step involved establishing flow conditions at a certain discharge pressure. The problem is either with the test return system or the control system. A formal troubleshooting plan is being developed to determine the root cause and corrective action required to re-establish operability of the HPCI system. The system remains inoperable due to the problem found during testing. If the problem is found to be caused by the control system, then it could have potentially impacted the ability of the HPCI system to mitigate the consequences of an accident."

HPCI is currently in a 14 day Tech Spec 3.5.1.h LCO.

The licensee notified the NRC Resident Inspector. The licensee will be notifying the Minnesota Duty Officer.

* * * UPDATE FROM MARK KRUSE TO JASON KOZAL ON 4/22/08 AT 1631 * * *

"Monticello is retracting the event reported based on further reviews of the event which found that the issue did not impact HPCI operability. A problem was identified with the test return valve CV-3503 which is not a safety-related component. The stations formal troubleshooting team has identified the cause for the degradation and corrective actions will be tracked in the station's corrective action program."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Cameron).

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General Information or Other Event Number: 44143
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
Region: 4
City: TULSA State: OK
County:
License #: OK-05860-01
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/16/2008
Notification Time: 16:35 [ET]
Event Date: 04/16/2008
Event Time: 14:00 [CDT]
Last Update Date: 04/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
BILL VON TILL (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

A patient at the Oklahoma State University Medical Center in Tulsa, Oklahoma was undergoing prostate treatment. The treatment was to implant 187 Pd-103 seeds (1.5 microCuries each) into the patient. The seeds were injected using a MIC gun which was manufactured by TheraGenics in Buford, Georgia. During the procedure it was observed that one of the seeds was sheared off with only 5% of the seed showing. The patient is believed to have the other 95% of the open seed inside his body. The radiation oncologist was present when this event happened. The patient was surveyed and his radiation levels were 0.46 mr/hr, which is within normal levels. The patient was not informed as yet, but should be by the attending physician. The half life of Pd-103 is 17 days, and most likely will be defused throughout the body.

* * * UPDATE ON 4/17/2008 AT 1036 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *

The State provided the following information via email:

"At about 2:00 PM on April 16, a patient was receiving 187 Pd-103 seeds for prostate therapy. The seeds were Theragen Model 200 of 1.5 microCuries each, manufactured by Theragenics, in Buford, Georgia, and purchased from Bard in Georgia. After injecting the seeds, the facility discovered one end of a Pd-103 seed in the 'mic' cartridge that had been used to hold the seeds. Only about 5% of the seed was present, and it is assumed the other 95% was injected into the patient. The piece found was leaking radioactivity. Surveys with a calibrated meter showed that the patient met the criteria for unrestricted release. The licensee plans to ask the referring physician to notify the patient. The licensee speculates that a malfunction in the mic gun caused the seed to be out of alignment when the cartridge was inserted or removed, leading to the clipping of the end, but this is highly preliminary, and the result of speculation rather than definite findings. The licensee will do an investigation. The licensee has temporarily stopped doing prostate implants. DEQ will send investigators to the site."

Notified FSME (Burgess) and the R4DO (Clark).

* * * UPDATE ON 4/17/2008 AT 1536 FROM MIKE BRODERICK TO JASON KOZAL * * *

The State provided the following information via email:

"There was a miscommunication between the state and the facilities, average strength for the Pd-103 sources involved in this event is 1.5 milliCuries, rather than 1.5 microCuries. The licensee has informed the patient of the event. The mic gun involved has been taken out of service. It is also considered possible the cartridge holding the sources was flawed, but the cartridges were disposed of as biomedical waste immediately after the surgery and will not be available to be checked. The licensee informs [the state] that the cartridges are generally covered in blood after one of these procedures, and such cartridge disposal is typical. The licensees are holding the mic gun until a state inspector arrives for an investigation, after which it will be returned to the manufacturer for evaluation."

Notified FSME (Von Till) and R4DO (Miller).

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: 44145
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: TEAM INDUSTRIAL SERVICES
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-2005-01
Agreement: Y
Docket:
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: PETE SNYDER
Notification Date: 04/17/2008
Notification Time: 17:27 [ET]
Event Date: 04/17/2008
Event Time: [CDT]
Last Update Date: 04/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3)
BILL VON TILL (FSME)

Event Text

RADIOGRAPHY CAMERA MALFUNCTION

This "incident occurred on April 15, 2008 at about 8:20 PM at a new [non-nuclear] power plant under construction. Team Industrial Services was performing industrial radiography on Unit 1. The radiography was being performed on elevation 807 on a header approximately 4 foot off of the roof of the boiler.

"According to statements from the crew, they had exposed the source on their first shot of the pipe weld, and approximately 15 seconds into the shot they heard what they thought was the guide tube and collimator faillng off the pipe to the roof of the boiler. They then went to retract the source back into the exposure device and encountered an obstruction preventing the source from being retracted into a secured position in the exposure device. They attempted [to retract the source] three times with no success.

"The industrial radiographer contacted the facility radiation safety officer and advised him that he had a source he could not retract back into the exposure device. The industrial radiographer extended the radiation safety boundaries above and below the area. The Radiation Safety Officer (RSO) advised [the radiographer] that he was on his way to the site.

"The RSO arrived at the site at approximately 9:00 PM. At this time an initial assessment was made and a decision was made to bring in two more trained technicians to assist with boundary control and retrieval of the sealed source. After arrival of the extra technicians, a plan for retrieval was discussed with all technicians, including the Corporate Radiation Safety Officer.

"The industrial radiographer stated that his pocket dosimeter had gone 'off scale.' This means that he could have received a dose of at least 200 millirems of radiation. At this time he was advised that he would not be assisting with the retrieval but he continued to assist with boundary control. The licensee has estimated that the industrial radiographer received 630 mR.

"At approximately 11:35 PM, the shielding of the source and attempt to repair the guide tube commenced. Four lead shot bags were placed over the end of the guide tube where the sealed source was known to be. The radiation levels were reduced to 15 millirems per hour at five feet from the source under the lead shot bags. The RSO then approached the guide tube with a pair of pliers, located the distortion in the guide tube and rounded it with the pliers. He then returned to the crank assembly and retracted the source successfully back into the exposure device. The RSO is estimated to have received 32 mR from conducting the repair.

"A determination was made that there was not an equipment failure, it was a result of the guide tube falling from the pipe to the roof of the boiler that damaged the guide tube resulting in the obstruction. Boundaries were maintained throughout the incident to ensure that at no time any member of the general public could enter the incident area.

"DHFS plans to investigate this incident on the next inspection (to be conducted in the near future)."

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General Information or Other Event Number: 44146
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ARDAMAN & ASSOCIATES, INC.
Region: 1
City: HIALEAH State: FL
County:
License #: 3456-2
Agreement: Y
Docket:
NRC Notified By: CHARLES E. ADAMS
HQ OPS Officer: JASON KOZAL
Notification Date: 04/17/2008
Notification Time: 17:49 [ET]
Event Date: 04/17/2008
Event Time: [EDT]
Last Update Date: 04/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
BILL VON TILL (FSME)
ILTAB (VIA E-MAIL) ()

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

Event Text

AGREEMENT STATE - LOST TROXLER GAUGE

The licensee provided the following information via email:

After completing a job a Troxler Moisture Density Gauge (Model number 3430, Serial Number 34618) was loaded into the back of the licensee's truck and not secured. The unsecured gauge fell out of the truck in transit from the job site. The licensee discovered the gauge missing and notified supervision.

The licensee notified the local police department and is actively searching for the gauge. The licensee plans to offer a reward for return of the missing gauge. The State of Florida is further investigating the incident.

* * * UPDATE FROM ADAMS TO CROUCH (VIA EMAIL) ON 04/21/08 @ 1334 EDT * * *

"Florida incident FL08-060 which was reported and occurred on April 17, 2008 involved a lost Troxler gauge. It was recovered today. A gentleman found it at the intersection of 40th St. and 38th Ave. in Coral Gables on Thursday, the day it was lost. He finally called the licensee today and the licensee took possession of it about 10:30 this morning. It is undamaged."

Notified R1DO (White) and FSME EO (Burgess).


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: 44150
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: WALMART
Region: 4
City: CYPRESS State: TX
County:
License #: GLA
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JASON KOZAL
Notification Date: 04/18/2008
Notification Time: 11:50 [ET]
Event Date: 03/13/2008
Event Time: [CDT]
Last Update Date: 04/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
MICHELLE BURGESS (FSME)

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

Event Text

AGREEMENT STATE - BROKEN TRITIUM EXIT SIGN

The licensee provided the following information via email:

"On April 17, 2008, the agency received written notification from the Radiation Safety Officer (RSO), reporting that during their routine inventory check they, accompanied by two of their health physics consultants, found the one tritium (H-3) exit signs in a non-public receiving area in their Cypress, Texas store, had a missing face plate, frame and label, red 'EXIT' cover and several H-3 tubes. The RSO reported that the remaining H-3 tubes were intact.

"The RSO reported that they conducted informal interviews with store managers and associates that revealed no additional information as to the date or circumstances of the damage to the sign. The RSO and their consultants stated that because available information does not suggest that the H-3 exit sign (TES) was recently damaged, Wal-Mart believes that no significant contamination currently exists at the site. Additionally, he stated that Wal-Mart reached this conclusion in consultation with consultant Certified Health Physicists (CHPs).

"The RSO stated that their long term corrective actions included: implementing protocols, which have been communicated to employees, for the proper handling of TES to ensure public health and safety and the protection of its employees. They report that they are in the process of inventorying all of the TES at its sites across the country to re-establish the accuracy of its records and to track the current locations of the TES, with the intent of ensuring that all TES are accounted for and handled properly.

"The RSO stated that the damaged TES will be packaged for shipment according to protocols established by their consultants and consistent with Nuclear Regulatory Commission (NRC) guidelines. Wal-Mart anticipates shipping the remnants of the damaged TES to a specific licensee or arranging for a waste broker to ship the TES to a specific licensee authorized to receive it within thirty-days of their report to the agency, which was dated April 10, 2008."

Texas report I-8507

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 44154
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL REED
HQ OPS Officer: JASON KOZAL
Notification Date: 04/22/2008
Notification Time: 12:58 [ET]
Event Date: 04/22/2008
Event Time: 08:41 [EDT]
Last Update Date: 04/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN WHITE (R1)

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

LOSS OF SAFETY FUNCTION DUE TO BLOWN FUSE

"At 0841, the Control Room received an alarm indicating an issue with the CD481 1E inverter. Upon walkdown, it was noted that the main power fuse had failed and the inverter channel was powered from a backup non-1E AC source. IAW HCGS procedures, the C EDG was declared inoperable because it would not start in response to a LOCA signal. Electrical output of the CD 481 inverter was available through the event and no transient or actuations occurred.

"All require Technical Specification surveillance tests for TS 3.8.1 were completed within the required time-frame.

"Additional equipment that was tagged for scheduled maintenance included the D EDG which is currently in an outage window and inoperable. This resulted in 2 of the 4 HCGS EDGs inoperable. With the C and D EDGs inoperable, both Control Room Emergency Filtration Systems (CREF) would be without diesel back-up power supplies in the event of a LOCA and thus inoperable. With no operable CREF systems, Technical specification 3.0.3 applies. A loss of both CREF systems would constitute a loss of function of a safety system designed to mitigate the consequences of an accident (10 CFR50.72(b)(3)(v)(D)).

"Replacement of the CD481 1E inverter main power fuse and assessment of inverter function was completed at 10:36. The inverter was placed back in its normal alignment. All related Technical Specification equipment is operable with the exception of the D EDG, which remains in the scheduled maintenance outage. "

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 44155
Rep Org: NTH CONSULTANTS
Licensee: NTH CONSULTANTS
Region: 1
City: GLASGOW State: DE
County:
License #: 21-14894-01
Agreement: N
Docket:
NRC Notified By: JIM PARSONS
HQ OPS Officer: JASON KOZAL
Notification Date: 04/22/2008
Notification Time: 13:27 [ET]
Event Date: 04/22/2008
Event Time: [EDT]
Last Update Date: 04/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
JOHN WHITE (R1)
JAMNES CAMERON (R3)
RON ZELAC (FSME)

Event Text

LOSS OF CONTROL OF TROXLER MOISTURE DENSITY GAUGE

The licensee employee transporting a Troxler moisture density gauge was transiting on DE 896 along Cobbler Creek Curve at approximately 2030 on 4/21/08 and was involved in a severe car accident. The State Police and emergency medical services responded to the scene. The employee was incapacitated and transported to the hospital. The responders were unaware of the presence of the Troxler and had the vehicle towed to a towing yard for storage.

The licensee RSO learned of the accident at approximately 1145 and immediately contacted the Delaware State Police and local law enforcement (Newcastle County Sheriff). The licensee was given the contact information of the towing yard and proceeded to contact the towing yard staff. The licensee informed the towing yard of the situation and requested that a visual inspection be performed of the external integrity of the container. The results of the inspection were that the gauge remains chained to the bed of the truck and the container appears to remain secure. The licensee requested that the towing yard keep the area around the vehicle clear of personnel. The company local RSO in Pennsylvania is enroute to the vehicle and will perform a field leak test on the gauge upon arrival.

Troxler information (SN 32643 - Source Strength 8 mCi Cs-137 and 40 mCi Am/Be).

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Thursday, March 29, 2012