United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2009 > January 28

Event Notification Report for January 28, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/27/2009 - 01/28/2009

** EVENT NUMBERS **


44799 44801 44802 44803 44804 44807 44808 44809 44810

To top of page
General Information or Other Event Number: 44799
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: ECS CAROLINAS, LLP
Region: 1
City: GREENSBORO State: NC
County:
License #: 041-0253-4
Agreement: Y
Docket:
NRC Notified By: CLIFF HARRIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 16:06 [ET]
Event Date: 01/19/2009
Event Time: 17:15 [EST]
Last Update Date: 01/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LOST, THEN FOUND, MOISTURE DENSITY GAUGE

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

"N.C. Radiation Protection Section was notified on 19 Jan 2009 by the State EOC of the loss of a Troxler Model 3430 portable moisture density gauge (Serial No. 20385) possessed by ECS Carolinas under a specific license. The gauge contained two sealed sources: (1) Cesium-137, 8 mCi, source serial no. 75-1733 and (2) Americium-241:Beryllium, 40 mCi, source serial no. 47-15863.

"The device was lost while being transported between job sites. While in transit, the device was on the tailgate of the transport vehicle; the device was not secured in its transport box nor was it blocked and braced. The Greensboro Police and Fire Departments were notified by the company's RSO at 17:35 [hrs.] and arrived at the scene. Efforts to find the device were not successful. NC Emergency Management was notified by the company's RSO. Instrotek [a local vendor] notified the RSO that a citizen passer-by had observed the device being struck by an SUV on Merritt Drive in Greensboro, NC. The citizen stopped and placed the device in the bed of his pickup truck and transported it to his home in Burlington, NC. The citizen notified Instrotek (telephone number on calibration label on device) of his discovery. A Health Physicist from the NC Radiation Protection Section was dispatched to the citizen's residence and arrived at 19:45 [hrs.]. The device was located on the back, screened porch of the residence, well away from any occupants of the residence. The plastic housing of device was broken, but was otherwise in good condition. Radiation surveys indicated that the sources were in the shielded position, the source rod was in good condition and in the fully retracted position. The source handle/ rod assembly was not locked. The citizen reported that no one had extended the source rod while the device was in his possession. The RSO and an Authorized User from ECS Carolinas, LLP arrived at the residence, packaged the device in an appropriate transport box, blocked and braced the box in a company pickup truck, and transported the device to the authorized storage site at their home office in Greensboro, NC. There were no exposures to radiation from these sources during this event. The Health Physicist was notified on 20 January 2008 by Troxler Electronics that it took possession of the device for damage assessment and repair.

"The investigation of this event by the NC Radiation Protection Section is ongoing."

NC Event Report ID No.: NC-09-08

To top of page
General Information or Other Event Number: 44801
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: APPLIED TESTING & GEOSCIENCES LLC
Region: 1
City: BRIDGEPORT State: PA
County:
License #: PA-1036
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 17:29 [ET]
Event Date: 01/07/2009
Event Time: [EST]
Last Update Date: 01/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LOST, THEN FOUND, MOISTURE DENSITY GAUGE

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

An Applied Testing & Geosciences employee had possession of a vehicle containing a moisture density gauge. After an evening on the town, the employee had a taxi return him to his hotel as he had forgotten where he left the vehicle. The next day, the employee called in sick and then reported the vehicle stolen to local law enforcement. Later in the day, the vehicle was recovered with the gauge intact. The licensee took possession of the gauge.

PA Reference Number: PA090005

To top of page
General Information or Other Event Number: 44802
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: QSL INSPECTIONS
Region: 1
City: MONROE State: NC
County:
License #: 0901058-1
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/23/2009
Notification Time: 13:03 [ET]
Event Date: 01/13/2009
Event Time: 15:00 [EST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

"Licensee performing a routine radiography source exchange. New source (100 Ci) would not come out of source exchanger. Licensee Asst RSO attempted to withdraw old source (22 Ci), and old source came out of source exchanger and had to be recovered.

"WB [Whole Body] Dosimetry From Landauer (confirmed)
"317 [mR] WB for Asst RSO
"366 [mR] WB for Radiographer who retrieved source

"Dose Estimates to Extremity
"7.5 Rem to left hand for Asst RSO
"1.73 Rem to right hand for Radiographer who retrieved source
"REACTS has received blood tube for testing for Asst RSO."

The licensee is shipping both sources back to the manufacturer.

Location of the event: 1721 William Road, Monroe, NC 28110

NC Incident: 09-06

To top of page
General Information or Other Event Number: 44803
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE MECKLENBERG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2009
Notification Time: 13:42 [ET]
Event Date: 01/21/2009
Event Time: 11:30 [EST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING I-125 BRACHYTHERAPY SEEDS

The following information was obtained from the State of North Carolina by fax:

"[The] Licensee stores unused I-125 Brachytherapy seeds in bulk with other unused I-125 sources. A routine leak test of the bulked I-125 seeds in October yielded no removable contamination. A routine leak test of the bulked I-125 seeds in January 2009 showed removable contamination: 2.3-2.8 microCuries.

"The licensee has 223 total iodine brachytherapy seeds stored in the storage container and cannot determine which seeds are leaking. 164 seeds were added to the storage container since the October leak test.

"[The] Licensee has contacted [the] manufacturer (Core Oncology) to return seeds and perform assay on seeds to determine which seeds are indeed leaking.

"The licensee cannot ascertain if the I-125 seeds were damaged at patient loading (by licensee physicians) or at the manufacturer."

It is unknown if any patients have been contaminated. All patients are being contacted for bioassays.

Total activity for all the seeds to be returned is 78.71mCi (@0.3 mCi per seed).

NC Incident No. 09-10

To top of page
General Information or Other Event Number: 44804
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: DANA-FARBER CANCER INSTITUTE
Region: 1
City: BOSTON State: MA
County:
License #: 60-0037
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2009
Notification Time: 17:53 [ET]
Event Date: 01/16/2009
Event Time: [EST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL

The following information was received from the Commonwealth of Massachusetts via facsimile:

"A package containing 250 ÁCi P-32 was lost at Dana Farber. The package was delivered and the RP (Radiopharmaceutical) department performed a receipt survey. The package was then carried to laboratory 714. The deliverer claimed he gave it to someone in the lab. Laboratory personnel claimed not to have received it. The RP department has conducted an unsuccessful search to locate the package."

Massachusetts No. MA-09

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.

To top of page
Power Reactor Event Number: 44807
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: JOHN TAYLOR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/27/2009
Notification Time: 12:41 [ET]
Event Date: 01/27/2009
Event Time: 10:17 [EST]
Last Update Date: 01/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GERALD MCCOY (R2)

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

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF 4160V BUS

"Calibrations of the 'A' Unit 4160V Switchgear metering were in progress when the 'A' Unit 4160V Bus tripped. This resulted in the loss of the 'A' Feedwater Booster Pump (FWBP) and 'A' Condensate Pump (CDP). The Operating crew identified the loss of the 'A' FWBP with increasing RCS pressure and manually tripped the reactor. There were no other safety system actuations and the plant is stable at normal post-trip temperature and pressure."

All rods inserted during the trip. Decay heat is being removed via steam dumps to the condenser. The electrical grid is stable with plant loads being supplied by offsite power via the startup transformer. Both vital busses are being powered from offsite. During the transient, main steam relief valves did lift but have been reseated.

The NRC Resident Inspector has been notified.

To top of page
General Information or Other Event Number: 44808
Rep Org: FISHER CONTROLS INTERNATIONAL
Licensee: FISHER CONTROLS INTERNATIONAL
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MATTHEW FARRELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/27/2009
Notification Time: 17:11 [ET]
Event Date: 01/27/2009
Event Time: [CST]
Last Update Date: 01/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
WAYNE SCHMIDT (R1)
GERALD MCCOY (R2)
PATTY PELKE (R3)
CHUCK CAIN (R4)
TOM HERRITY (NRR)
OMID TABATABAI (NRO)

Event Text

PART 21 REPORT - WATER QUALITY DEFICIENCY

The following information was obtained from Fisher Controls International via facsimile:

Fisher Controls International issued a Fisher Information Notice: FIN 2009-02, that notified customers of an issue discovered during an internal audit of manufacturing procedures followed by Fisher Controls International LLC. Specifically, on orders processed by Fisher Controls that invoked demineralized water cleaning requirements, Fisher Controls erroneously certified that all orders met demineralized water requirements when all requirements could not be proven to be met.

To meet the certification requirements, demineralized water must meet the quality requirements of NQA-1. Fisher Controls uses FMP [Fisher Manufacturing Procedure] 12B3 to verify that demineralized water used to clean parts meets NQA-1. Fisher determined that water quality testing using FMP 12B3 performed from January 1, 2001 to May 1, 2008 did not meet the test protocols.

"Twenty two orders have been identified, from 500+ orders reviewed, which require either the use of demineralized water and/or NQA-1 high quality water for which Fisher cannot prove full compliance. It is important to note that this review was limited to nuclear assembly orders only. Safety-related parts orders were not included because final cleaning was done either with alcohol or acetone."

The affected plants are:

Indian Point 2
Seabrook
Millstone (two valves)
D.C. Cook
North Anna (two valves)
Catawba (seven valves)
Oconee (five valves)
McGuire (three valves)

To top of page
General Information or Other Event Number: 44809
Rep Org: FISHER CONTROLS INTERNATIONAL
Licensee: FISHER CONTROLS INTERNATIONAL
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MATTHEW FARRELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/27/2009
Notification Time: 17:11 [ET]
Event Date: 01/27/2009
Event Time: [CST]
Last Update Date: 01/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
WAYNE SCHMIDT (R1)
GERALD MCCOY (R2)
PATTY PELKE (R3)
CHUCK CAIN (R4)
TOM HERRITY (NRR)
OMID TABATABAI (NRO)

Event Text

PART 21 REPORT - PART NOT EVALUATED FOR ALL CRITICAL CHARACTERISTICS

The following information was obtained from Fisher Controls International via facsimile:

The equipment supplied included a 20 inch Fisher valve coupled to a Bettis actuator.

"The purpose of this Fisher Information Notice (FIN 2009-03) is to alert Alabama Power that as of January 16, 2009, Fisher Controls International LLC became aware of the possibility of a situation which may affect the performance of the applicable equipment.

"This notice applies only to the subject equipment supplied by Fisher Controls International LLC, identified above, that was provided to Alabama Power - Farley.

"Fisher Controls has determined that the subject items were provided with parts that were not properly processed per active valve requirements specified by the Alabama Power Order.

"Specifically, Fisher provided a coupler between the actuator drive lever and valve shaft that was not evaluated for all the critical characteristics deemed necessary for a commercial grade dedicated item per EPRI 5652 and Fisher Manufacturing Procedure FMP 2K27, 'Control of Commercial Grade Items to be Dedicated for Use in Nuclear Safety-Related Systems,' (Fisher Processing Level C).

"We [Fisher Controls] are reviewing the situation and will pursue a corrective action investigation to prevent problems like this in the future.

"Arrangements have been made with Alabama Power to retrofit a correctly processed part on the subject serial number.

"This is a formal notification; Alabama Power was notified of this situation on January 16, 2008."

The coupling provided to Alabama Power did not meet the hardness requirements specified in the order. The coupler provided was annealed versus quench-hardened.

To top of page
Power Reactor Event Number: 44810
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: JOE O'HARA
Notification Date: 01/28/2009
Notification Time: 03:12 [ET]
Event Date: 01/27/2009
Event Time: 20:07 [EST]
Last Update Date: 01/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GERALD MCCOY (R2)

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

UNIT 2 HPCI SYSTEM INOPERABLE FOR TWO HOURS DUE TO CONDENSATE IN EXHAUST LINE

"On January 27, 2009 at approximately 2007, the Unit 2 High Pressure Coolant Injection (HPCI) System was declared inoperable due to a sustained high level in the HPCI Exhaust Line Drain Pot. This sustained high level was caused by a failure of the HPCI Barometric Condenser Condensate Pump, which prevented the removal of the accumulated condensate. An alternate drain path was established and the exhaust line drain pot high level condition was cleared at 2202. However, due to this condition existing for approximately two hours, it cannot be assured that HPCI would have been able to perform its designed function under all conditions. The potential of HPCI system component damage or isolation from an exhaust line failure due to water hammer during a system initiation could not be positively eliminated.

"Initial safety significance: Minimal. The Reactor Core Isolation Cooling (RCIC) System, Automatic Depressurization (ADS) System, and Low Pressure Emergency Core Cooling Systems (ECCS) - two Loops of Core Spray and two Loops of Low Pressure Coolant Injection (LPCI) - remain operable.

"Manual actions have been taken to drain the HPCI Exhaust Line Drain pot and have been successful. Determination of the cause of the failure of the HPCI Barometric Condenser Condensate Pump and restoration to service are in progress."

The NRC Resident Inspector has been notified.

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