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Event Notification Report for October 23, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/22/2008 - 10/23/2008

** EVENT NUMBERS **


44574 44575 44576 44577 44578 44584 44588 44590 44592 44593 44594

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General Information or Other Event Number: 44574
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: WAL-MART
Region: 3
City: MASON CITY State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NANCY FARRINGTON
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/17/2008
Notification Time: 09:33 [ET]
Event Date: 10/17/2008
Event Time: 08:00 [CDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

Wal-Mart Corporate Office reported a total of 2 tritium exit signs missing from one store in Iowa. Store management and maintenance personnel have conducted a search and have determined that the signs are not on the premises. Wal-Mart is declaring these signs to be missing.

Wal-Mart Corporate office notified the Iowa Department of Public Health

The device information is as follows:

1. Location: Mason City, Iowa. Manufacturer - SRB Technology, Serial number - 263251, Curie content - 20.

2. Location: Mason City, Iowa. Manufacturer - SRB Technology, Serial number - 263223, Curie content - 20.


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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General Information or Other Event Number: 44575
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: WAL-MART
Region: 1
City: QUINCY State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/17/2008
Notification Time: 11:29 [ET]
Event Date: 10/16/2008
Event Time: [EDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF SIX TRITIUM EXIT SIGNS

"On 10/16/08 the Agency received 2 telephone calls from Rich Dailey, RSO of Wal-Mart. During the first call Rich Dailey reported the loss of 2 tritium exit signs, S/N 249447 & 249454, from the Wal-Mart store in Quincy [MA]. During the second call Rich Dailey reported the loss of 4 tritium exit signs from the Wal-Mart store in Halifax [MA]. Rich Dailey stated that Wal-Mart is conducting a replacement of all tritium signs. In the Spring of 2008 these exit signs were inventoried. In October 2008, prior to replacement, the signs could not be located. All of the exit signs were manufactured by `SRB Lite' and contain 20 curies of H-3. Rich Dailey will send a written report to the Agency at a later date."

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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General Information or Other Event Number: 44576
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WAL-MART
Region: 1
City: SWAINSBORO State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEITH ST. CYR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2008
Notification Time: 13:39 [ET]
Event Date: 10/16/2008
Event Time: [EDT]
Last Update Date: 10/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

A Wal-Mart store at 14 S. Main Street in Swainsboro GA notified the State of Georgia that a tritium exit sign that had been held in storage was missing. The store had previously removed its tritium signs and was storing them for eventual return to the manufacturer. During an inventory of the signs, one was discovered to be missing. The sign is generally licensed by the State. The sign was manufactured by Isolite with 11.5 curies of tritium. The State of Georgia did not have the serial number of the sign.

* * * UPDATE FROM ERIC JAMESON TO JOE O'HARA AT 1353 ON 10/21/08 * * *

A Wal-Mart store at 6065 Joneboro Road in Morrow, GA notified the State of Georgia that two tritium exit signs were missing. The signs were manufactured by SRB with 20 Curies each S/N 279368 and S/N 282787. Additionally, a Wal-Mart store at 3886 Highway 17 in Toccoa, GA. had one tritium exit sign missing. The sign was manufactured by Isolite with 11.5 curies of tritium. The State of Georgia did not have the serial number of the sign. The signs are generally licensed by the State.

Notified R1DO(Cahill) ,FSME(Burgess), and ILTAB via E-mail

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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General Information or Other Event Number: 44577
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/17/2008
Notification Time: 15:35 [ET]
Event Date: 10/09/2008
Event Time: [CDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - 50 PERCENT UNDERADMINISTRATION OF YTTRIUM-90

The state provided in the following information via e-mail:

"On 10/10/08, licensee's RSO notified DRH [Division of Radiological Health] of a Yttrium-90 SIR-Spheres medical event. The reportable event involved the administration of 54 mCi of SIR-Spheres for one patient with approximately 27 mCi instilled into both the right and left hepatic arteries. After instilling approximately 27 mCi of Yttrium-90 SIR Spheres based on radiation readings into the right hepatic artery, a smaller catheter for the left hepatic artery was used due to anatomy and to get to the segment feeding the tumor. While attempting to instill the Yttrium-90 SIR Spheres into the left hepatic artery over-pressurization caused the three (3) way valve in the containment box to give way and resulted in the release of a therapeutic dose of Yttrium-90 SIR Spheres into the delivery system containment box as per design. Due to the release of the second part of the dose into the containment box only approximately 50% of the dose was able to be administered. The procedure was terminated and the delivery box was bagged and held for decay-in-storage. Personnel in the room were monitored for contamination and the room was surveyed and released. The patient was released with no harmful effects foreseeable by the Radiation Oncologist. The patient and referring physician were notified of additional future treatment.

"Licensee suggested the incident may have been caused by the size of the catheter, a kink in the catheter, or a smaller syringe being used by the interventional radiologist putting increased pressure on the 3 way valve. As a result of the medical event the licensee's treatment team will review the delivery system setup before pressure is applied to ensure the flow of the SIR-Spheres will not be impeded within the catheter."

License No.: MS-MBL-01

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: 44578
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ST. VINCENT'S HOSPITAL
Region: 1
City: JACKSONVILLE State: FL
County:
License #: FL Lic 14-6
Agreement: Y
Docket:
NRC Notified By: DAVID FERGUSON
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/17/2008
Notification Time: 17:48 [ET]
Event Date: 09/17/2008
Event Time: [EDT]
Last Update Date: 10/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
BILL VONTILL (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO UNINTENDED TISSUES

The Commonwealth of Florida was notified on 10/17/2008 by the licensee's Medical Physicist regarding a dose of 3400 cGy (3400 rad) administered to unintended tissues during several breast cancer therapy treatments over the period of September 10 - 17, 2008. The apparent unintended dose was identified on 10/16/2008, when the patient reported to the licensee symptoms of erythma (skin reddening) to the breast not intended to be treated.

Specifically, the patient was being treated for breast cancer with an Ir-192 High Dose Rate (HDR) Afterloader unit (source strength, manufacturer, and model unknown at the time of this report). When the erythema was reported by the patient, the Medical Physicist reviewed the records and determined that the HDR Afterloader was mis-programmed such that the source stopped 10 centimeters short of the intended tumor bed in the right breast. As a result, the entire dose intended for the tumor bed was administered to the left breast that was not intended to be treated.

The Commonwealth of Florida did not currently have information regarding any potential long term effects for the patient due to this event. The Commonwealth of Florida will dispatch an inspector to the facility early next week to follow-up on this event. A written report of this event will be provide by the State at that time.

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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Fuel Cycle Facility Event Number: 44584
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/21/2008
Notification Time: 17:06 [ET]
Event Date: 10/21/2008
Event Time: 13:02 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
ALAN BLAMEY (R2)
EUGENE PETERS (NMSS)
FUELS OUO GRP-email ()

Event Text

IROFS FAILURE IN AREA 600

"Area 600 uses a flammable gas as part of its operation. IROFS FIRE6-6 is a control that prevents the flammable gas from exiting the main process equipment and being released into an attached glovebox. FIRE6-6 makes use of a dual door system, only one door is allowed to be open at a time and the chamber between the doors is purged. The accident scenario of concern is release of the flammable gas into the glovebox and an explosion in the building. IROFS FIRE6-8, 6-1 and 6-9 ensure an inert gas purge occurs prior to opening the main process equipment to the glovebox and are also credited as IROFS.

"The equipment associated with FIRE6-6 is designated as Safety Related Equipment (SRE) and is functionally tested annually. The test was performed on October 21, 2008. The test failed because when one door was open, the 2nd door opened slightly (approx 1 inch). Though there are mitigating factors such as potential dilution of the flammable gas through the glovebox ventilation system, it was determined that IROFS FIRE6-6 was degraded and that the performance criteria of 10CFR70.61 were not met.

"The event occurred due to a degraded IROFS that was discovered during a periodic functional test. Initial investigation indicates that a failed position switch is the cause. [The potential health and safety consequences are] a potential explosion in a glovebox and release of radiological material and exposure to the worker. No actual explosion or radiological exposure occurred.

"Discussed situation with Safety management and with NRC Resident Inspector. Operations has locked out the flammable gas supply on Area 600 until the equipment associated with FIRE6-6 is fixed and the SRE test passes."

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Power Reactor Event Number: 44588
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: JASON KOZAL
Notification Date: 10/22/2008
Notification Time: 01:44 [ET]
Event Date: 10/21/2008
Event Time: 20:51 [PDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICK DEESE (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

UNIT 2 MANUAL REACTOR TRIP DUE TO JELLYFISH INTRUSION

"On October 21, 2008, with both units operating at 100% power, Operators manually actuated the Unit 2 reactor protection system (RPS/reactor trip) due to high differential pressure (DP) across the circulating water pumps' intake traveling screens. The high DP resulted from a rapid influx of jellyfish. All systems responded as designed. All control rods fully inserted. Auxiliary feedwater actuated as designed. The grid is stable with power being supplied by 230 Kv startup power. Diesel generator (DG) 2-2 and 2-3 are operable in standby. DG 2-1 is inoperable due to scheduled maintenance. The traveling screens for the safety-related auxiliary saltwater system (ASW) are not degraded and are managing the influx of jellyfish with no significantly elevated DP. Unit 2 is stable in Mode 3 at normal operating temperature and pressure.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'RPS actuation,' and 50.72(b)(3)(iv)(A), 'Specified System Actuation.'

"Operators reduced power on Unit 1 in response to the potential loss of normal flow to the condenser due to the jellyfish influx on the traveling screens. Currently, the traveling screens are maintaining DP within limits and the unit is stable at 50% power.

"Unit 2 decay heat removal is being performed by Auxiliary Feed Water to four steam generators blowing down via the 10% steam dumps to atmosphere."

No other safety related equipment was out of service at the time of the trip.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY JOHN WHESTLER TO JASON KOZAL ON 10/22/08 AT 0726 * * *

The licensee issued a press release regarding this issue.

Notified R4DO (Deese).

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Fuel Cycle Facility Event Number: 44590
Facility: BWX TECHNOLOGIES, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: CHERYL GOFF
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/22/2008
Notification Time: 13:35 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
ALAN BLAMEY (R2)
EUGENE PETERS (NMSS)
FUELS OUO ()

Event Text

CONCURRENT REPORT CONCERNING NRC NEWS RELEASE

"In response to media inquiries concerning the NRC's news release involving a notice of violation and proposed civil penalty, Babcock & Wilcox Company responded for BWXT with the attached information to media representatives from Lynchburg News & Advance and the Associated Press out of West Virginia. As requested the NRC news release is also attached.

"B&W Response to NRC's Notice of Violation: The incident occurred when an operator responded to a spill of hydrofluoric acid using an incorrect neutralizing chemical. As a result, the operator incurred an injury to his eyes.

"As noted in the Nuclear Regulatory Commission's (NRC) Notice of Violation, the actions of the employee, his coworkers and our onsite emergency team after the hydrofluoric acid exposure occurred ensured that the employee was not seriously injured as a result of this incident. This fact is confirmed by the statements of four independent medical opinions; one of these physicians was independently contracted by the NRC.

"The company [BWXT] acknowledges that this incident identified weaknesses in our spill response procedures and chemical labeling practices. Corrective actions have been developed to address these weaknesses. The company will submit a written response to the NRC within 30 days."

The licensee will be notifying the NRC Resident Inspector.

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General Information or Other Event Number: 44592
Rep Org: SCIENTECH
Licensee: ENSIGN POWER SYSTEMS
Region: 4
City: IDAHO FALLS State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: TONY GILL
HQ OPS Officer: JOE O'HARA
Notification Date: 10/22/2008
Notification Time: 14:50 [ET]
Event Date: 10/15/2008
Event Time: [MDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
ALAN BLAMEY (R2)
VERN HODGE (NRR)
OMID TABATABAI (NRO)
JOHN THORP (NRR)

Event Text

POWER SUPPLIES MANUFACTURED WITH UNAUTHORIZED CAPACITOR DELIVERED TO H.B. ROBINSON

"On October 15. 2008, Ensign Power Systems. Inc. of Loveland, Colorado informed Scientech of a defect. An internal audit had revealed that some Model 9061-01 power supplies provided to Scientech for use in their safety related line of NUSI modules had been inadvertently manufactured with an unauthorized part.

"The design required the use of two capacitors in the power line filter. When Ensign attempted to purchase the required parts, their supplier made an unauthorized substitution of capacitors. These capacitors are virtually identical, and the packaging was labeled with the correct Ensign Power Systems part number.

"Scientech immediately put a HOLD on all shipments of modules with Ensign power supplies until it could be verified that they were built using the correct parts. (Complete 10/15/08)

"Scientech located all Ensign power supplies in house and isolated them. (Complete 10/16/08)

"Scientech notified H. B. Robinson that some of the twelve modules contain power supplies with unauthorized parts. (Complete 10/16/08)

"Scientech is working with H. B. Robinson to replace the eight Ensign power supplies with [authorized] parts. (in progress)

"Scientech will return all affected power supplies to Ensign for installation of the approved components.

"Scientech will review the revised Ensign receipt inspection procedures to assure that they are robust enough to prevent reoccurrence.

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Power Reactor Event Number: 44593
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MERT PROBASCO
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/22/2008
Notification Time: 17:42 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER CAHILL (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

RCIC DECLARED INOPERABLE DUE TO AGING CONCERN OF SEVERAL FLOW CONTROLLER COMPONENTS

"On October 22,2008, at 1217 hours, with the reactor at 100% core thermal power and steady state conditions, Pilgrim Nuclear Power Station (PNPS) conservatively declared the Reactor Core Isolation Cooling System (RCIC) inoperable in response to concern regarding the reliability of aged capacitors that are installed in the RCIC flow controller.

"As background, the RCIC flow controller was calibrated and successfully tested on October 7th, 2008 as part of normal surveillance activities, however several of the capacitors installed in the controller were noted to be between 21 to 30 years of age. Industry recommended replacement interval for the capacitors is typically between 7 to 10 years of age. PNPS engineering review in conjunction with Entergy fleet consultation concluded today (10/22) that there was no definitive technical bases to provide a reasonable expectation that the RCIC flow controller function can be assured throughout it's mission time due to the capacitor aging concern. Therefore, RCIC was declared inoperable and a 14 day limiting condition for operability action statement was entered in accordance with TS 3.5.D.1. A replacement controller is being prepared for installation, with post maintenance testing projected to be completed by 2100 hours this evening. Ultimately the suspect controller will be the subject of further evaluation and this notification will be updated as appropriate.

"This notification has no impact on the health and safety of the public.

"The NRC Senior Resident Inspector is onsite and has been notified.

"This is an 8 hour notification made in accordance with 50.72(b)(3)(v)(D)."

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Power Reactor Event Number: 44594
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KARL HANTHO
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/22/2008
Notification Time: 21:42 [ET]
Event Date: 10/22/2008
Event Time: 18:50 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
CHRISTOPHER CAHILL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

WORKER TRANSPORTED TO LOCAL HOSPITAL

"A potentially contaminated individual was transported to the Salem County Memorial Hospital by the on-site Fire Protection personnel. The individual had been working in Unit One containment and collapsed. The individual was surveyed en-route to the hospital and was determined to be-not contaminated. The individual remains at the hospital and is undergoing testing and evaluation. Salem Unit One remains defueled with spent fuel cooling in-service."

The NRC Resident Inspector has been notified.

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Thursday, March 29, 2012