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Event Notification Report for November 28, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2008 - 11/28/2008

** EVENT NUMBERS **


44677 44681 44683 44685 44686

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General Information or Other Event Number: 44677
Rep Org: NEVADA STATE HEALTH DEPARTMENT
Licensee: NEVADA PHYSICIANS IMAGING
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-12-0514-01
Agreement: Y
Docket:
NRC Notified By: ADRIAN HOWE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2008
Notification Time: 17:43 [ET]
Event Date: 11/21/2008
Event Time: [PST]
Last Update Date: 11/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)

Event Text

AGREEMENT STATE REPORT - THYROID SCAN ADMINISTERED TO THE WRONG PATIENT

Nevada Physicians Imaging, the licensee, reported to the Nevada State Department of Health that they inadvertently administered 220 microCi of I-123 to the wrong patient. Patient A (the correct patient) was scheduled to receive a thyroid scan. Patient B (the wrong patient) shared the same name as Patient A and was scheduled to receive treatment at the same time. As a result, Patient B underwent a thyroid scan intended for Patient A. It is unknown what diagnostic procedure Patient B was intended to receive.

The patient has not been notified of the incorrect treatment. The licensee was in the process of notifying the prescribing physician.

The State of Nevada will investigate this incident after receiving the licensee's report.

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General Information or Other Event Number: 44681
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GILES ENGINEERING
Region: 4
City: DALLAS State: TX
County:
License #: 4919
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOE O'HARA
Notification Date: 11/24/2008
Notification Time: 13:20 [ET]
Event Date: 11/23/2008
Event Time: 16:00 [CST]
Last Update Date: 11/24/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
LANCE ENGLISH (ILTA)
MEXICO VIA E-MAIL ()
MICHELE BURGESS (FSME)

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

Event Text

STOLEN TROXLER MOISTURE DENSITY GAUGE

"While at the office, Site002, on Sunday, November 23, 2008, the licensee had a truck with a gauge secured in the bed which was stolen by cutting the chain and lock. The employees had left to go to a jobsite and upon returning to the office noticed that the gauge had been stolen. The Dallas Police Department was notified and a report was filed. The Agency was notified at the start of business on Monday, November 24, 2008. The gauge was a Troxler 3430 (S/N 334330) and had two sources, 8mCi of Cs-137 (S/N 750-8953) and 40mCi of Am-241 (S/N 471455)."

TX Incident #- I-8582

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: 44683
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA AT BERKELEY
Region: 4
City: BERKELEY State: CA
County:
License #: 1333-01
Agreement: Y
Docket:
NRC Notified By: MARK GOTTLIEB
HQ OPS Officer: PETE SNYDER
Notification Date: 11/25/2008
Notification Time: 14:08 [ET]
Event Date: 11/21/2008
Event Time: [PST]
Last Update Date: 11/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING ELECTRON CAPTURE SOURCE

The following information was received from the State of California via email:

"A leak test of a generally licensed 9.78 mCi Nickel-63 Electron Capture Source, Serial Number NH285 28.17, manufactured by QSA Global , Inc., indicated 0.0053 uCi of Nickel-63 contamination. The source was stored in room 20D of the Space Sciences Laboratory at the University of California at Berkeley (UCB). The source was taken out of service and repackaged until the investigation by UCB has been completed. A second wipe of the source was taken and was negative."

California 5010 Number (Date Notified): 112108

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Power Reactor Event Number: 44685
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: JOE O'HARA
Notification Date: 11/26/2008
Notification Time: 15:12 [ET]
Event Date: 11/26/2008
Event Time: 12:00 [EST]
Last Update Date: 11/26/2008
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
Person (Organization):
DANIEL RICH (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 22 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO EHC MALFUNCTION

"At 12:00 hours EST, an apparent Electro-Hydraulic Control (EHC) system malfunction while synchronizing the Main Generator to the grid resulted in a Group 1 Main Steam Isolation Valve (MSIVs) closure on low reactor pressure and a subsequent automatic reactor scram.

"Preliminary investigation of the automatic scram signal indicates that Main Steam Line Low Pressure Instruments (B21-PT-N015 A thru D) sensed low steam line pressure after the Main Generator was paralleled to the grid. This resulted in the closure of all MSIVs. Closure of MSIVs in Mode 1 results in an automatic reactor scram.

"All control rods fully inserted. With the exception of the EHC system, all systems responded as designed. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B) due to the Reactor Protection System (RPS) actuation and 10CFR 50,72(b)(3)(iv)(A) due to the Primary Containment Isolation System (PCIS) Groups 1, 2, and 6 actuations.

"Unit 2 was not affected by this event and remains at 100% power."

Reactor Pressure is 844 psig, reactor temperature is 526 degrees Fahrenheit. MSIV's remain shut. Decay heat was removed via MSIV bypass lines. RCIC actuated for a period of time for level control but has been secured. CRD pumps are providing makeup water. No SRV's or relief valves lifted.


The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 44686
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: DON SHEEHAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/26/2008
Notification Time: 15:52 [ET]
Event Date: 11/26/2008
Event Time: 13:06 [EST]
Last Update Date: 11/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAWRENCE DOERFLEIN (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF EMERGENCY COMMUNICATIONS LINES

"On 11-26-2008, at 13:06 EST, both Control Rooms were notified by Emergency Planning Department that the following phone notification systems are out of service: RECs [Radiological Emergency Communications System] line, ENS line and HPN line. Also, three dedicated '754' prefix lines in the TSC are currently inoperable. Site Information Technology Department personnel are working with communications equipment vendor, Verizon, to resolve the issues. "

State and local authorities and the NRC Resident Inspector have been notified.

* * * UPDATE AT 1612 EST ON 11/26/08 FROM SHEEHAN TO HUFFMAN * * *

The RECs, ENS, and HPN lines have been returned to service with the exception of a line to the State Warning Point in Albany NY. The NRC Resident Inspector has been notified.

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Monday, November 05, 2012