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Event Notification Report for June 19, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/18/2009 - 06/19/2009

** EVENT NUMBERS **


44930 45010 45101 45134 45137 45142 45143

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General Information or Other Event Number: 44930
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON DICKINSON INFUSION THERAPY SYSTEMS INC
Region: 4
City: BROKEN BOW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JOE O'HARA
Notification Date: 03/23/2009
Notification Time: 16:28 [ET]
Event Date: 03/22/2009
Event Time: [CDT]
Last Update Date: 06/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - ABNORMAL EXCESS LOSS OF WATER INTO DRAIN SYSTEM FROM DE-IONIZATION SYSTEM

The following information was provided from the State of Nebraska via e-mail:

"The Nebraska DHHS [Department of Health and Human Services] was notified on March 23, 2009 at 0825 by the Radiation Safety Officer (RSO) for Becton Dickinson in Broken Bow, Nebraska. On March 22, 2009 in the evening, the RSO received a call from one of the pool irradiator operators. During the operator's weekly sterilizer checks, he noticed that the pool water make-up meter indicated the pool had used 1,103 gal for the week. Normal usage is about 120 gal/week. Investigation on the next morning revealed a bleed valve on the D.I. [de-ionizing] water system was cracked open, allowing D.I. water to flow to drain. This was not readily apparent because the hose goes down into the drain. The RSO closed the valve, recorded the current meter reading, noting the meter had used about 100 gal overnight. The RSO intends to check the reading Tuesday morning to see if closing the valve solved the problem. This water leaking does not affect the level of the pool water.

"Nebraska DHHS has notified Randy Erickson, NRC, Region IV

"Event report ID No. NMED NE090006"

* * * UPDATED FROM TRUDY HILL (VIA EMAIL) TO HOWIE CROUCH @ 0924 EDT ON 6/18/09 * * *

"The next [meter] reading on 3/29 was also elevated at 336 gallons. The next readings were 201 gallons on 4/5, 244 gallons on 4/12 and 231 gallons on 4/19. Levels had dropped, but were still slightly higher than expected. The licensee's maintenance technicians discovered that the oil pressure safety switch in the compressor unit of the water chiller system was tripping off and shutting down the unit. The safety switch was replaced on May 1.

"In addition, the licensee installed a beacon and an audible alarm to alert an operator when the chiller oil pressure safety switch tripped out. This prevents the chiller from being down for any length of time without anyone's knowledge. The safety switch continued to trip out occasionally but was reset immediately so the water use returned to normal readings of 110 gallons on 5/3, 60 gallons on 5/10 and 63 gallons on 5/17. The licensee continued the investigation and parts were obtained to repair the compressor unit. On 5/18, the licensee replaced the oil pump, pressure sensor and changed the oil in the compressor. The unit ran for the next 24 hours without any further issues. The licensee said they would continue to monitor the situation closely, but they believe the issue has been resolved."

Notified R4DO (Cain) and FSME EO (McIntosh).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45010
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JEFFREY A. MIELL
HQ OPS Officer: VINCE KLCO
Notification Date: 04/23/2009
Notification Time: 02:33 [ET]
Event Date: 04/22/2009
Event Time: 19:45 [CDT]
Last Update Date: 06/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMNES CAMERON (R3DO)

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

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DECLARED INOPERABLE

"On 4/22/2009 during an inspection of the HPCI (High Pressure Coolant Injection) Suppression Pool Suction piping it was identified that the suction piping was in contact with a piping support clamp. Per the design of the support, the clamp ring to pipe clearance should be 1/2 inch. With the identified contact, the integrity of the pipe support cannot be assured during a seismic event. At the time of discovery, the HPCI suction was aligned to the Suppression Pool. Subsequently, the suction has been realigned to the Condensate Storage Tank with both Suppression Pool suction valves deenergized in the closed position. HPCI remains available with suction aligned to the Condensate Storage Tank.

"Due to this, HPCI was declared INOPERABLE on 4/22/2009 at 7:45 PM (local time). This event is reportable per 10 CFR 50.72(b)(3)(v)(D) for a single train safely system potentially unable to perform its safely function of accident mitigation.

The licensee entered a 14 day LCO (Limiting Condition of Operation) associated with the inoperable HPCI system.

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM BOB MURRELL TO JOE O'HARA AT 1417 ON 6/18/09 * * *

"The purpose of this notification is to retract a previous report made on 4/23/09 at 0233 (ET) (EN 45010). Notification of the event to the NRC was initially made as a result of declaring High Pressure Coolant Injection (HPCI) system inoperable when the Suppression Pool Suction piping was identified as being in contact with a piping support clamp. Per the design of the support, the clamp ring to pipe clearance should have been 1/2 inch. With the identified contact, the integrity of the pipe support could not be assured during a seismic event.

"Since the initial report, NextEra Energy Duane Arnold (NextEra) has determined that the HPCI system was capable of performing its safety function.

"NextEra concluded that the identified configuration, while not meeting design requirements, would not prevent HPCI from performing its intended safety function. This conclusion was based on analysis that demonstrated that the piping would remain intact during a design basis accident.

"This event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73."

The licensee notified the NRC Resident Inspector.

Notified R3DO(Lipa)

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General Information or Other Event Number: 45101
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: DOUGLAS COUNTY HEALTH DEPARTMENT
Region: 4
City: OMAHA State: NE
County: DOUGLAS
License #: 01-45-01
Agreement: Y
Docket:
NRC Notified By: JIM DEFRAIN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/28/2009
Notification Time: 18:10 [ET]
Event Date: 05/26/2009
Event Time: 11:30 [CDT]
Last Update Date: 06/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED X-RAY FLOURESCENCE DEVICE

The following information was obtained from the State of Nebraska via facsimile:

"The Douglas County Health Department, a Nebraska licensee (license no. 01-45-01), reported that a Radiation Monitoring Devices, Inc. (RMD) Model LPA-1 portable x-ray fluorescence [XRF] device had been damaged on May 27, 2009. The XRF contained 12 millicuries of Cobalt-57. An authorized user left the XRF on a window sill and the XRF fell approximately eight feet to the floor. The XRF case was cracked in several pieces, but the integrity of the sealed source shield was not damaged. Radiation dose readings of the damaged XRF were within the expected range [for this device]. No individuals of the public or occupational workers were exposed as a result of this event. The licensee was able to return the XRF to its shipping container [which was placed in the] licensee's secured storage facility. The licensee was instructed to contact the manufacturer, perform a leak test and contact [the State of Nebraska] prior to shipping the XRF back to the manufacturer."

Nebraska Event Report ID: NE-09-0011

* * * UPDATE FROM TRUDY HILL (VIA EMAIL) TO HOWIE CROUCH @ 0924 EDT ON 6/18/09 * * *

"The licensee contacted RMD. RMD was satisfied with the reported low radiation dose readings, and the licensee was instructed to ship the XRF back in its storage container. The Nebraska Office of Radiological Health received written confirmation that RMD received the RMD LPA-1 XRF for decommissioning."

Notified R4DO (Cain) and FSME EO (McIntosh)

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General Information or Other Event Number: 45134
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: BECKMAN COULTER INSTRUMENTS
Region: 4
City: BREA State: CA
County:
License #: 0441-30
Agreement: Y
Docket:
NRC Notified By: KATHLEEN HARKNESS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2009
Notification Time: 15:10 [ET]
Event Date: 06/10/2009
Event Time: [PDT]
Last Update Date: 06/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE - LEAKING LIQUID SCINTILLATION COUNTER SOURCE

The following information was received from the State of California Radiologic Health Branch via e-mail:

"On June 10, 2009, the RSO for Beckman Coulter Instruments reported that a 21.5 year old Cs-137 source removed during decommissioning from a Beckman Coulter LSC (Liquid Scintillation Counter): model LS 5801 counter (s/n 7015110) was found to have 0.013 microcuries removable contamination. The reportable limit is 0.005 microcuries. It was removed from the LS counter by a Beckman Field Service Technician and returned to the Beckman Coulter facility in Fullerton for disposal, where the leak test was performed. No other contamination was found inside the LS device. The source part number is 598860, lot # ST1022018 - reference date was 12/18/87. The most probable cause of the leakage was the source holder was cracked due to age. Beckman Coulter has determined that the useful life is 8 years for these sources. The company is replacing all sources older than 8 years as corrective action."

The State provided additional information indicating that the original source activity was 30 microcuries.

CA Report Number 5010-061009

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 45137
Rep Org: RAPID CITY REGIONAL HOSPITAL
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: LOWELL HUSMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2009
Notification Time: 11:48 [ET]
Event Date: 04/24/2009
Event Time: 14:00 [MDT]
Last Update Date: 06/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
CHUCK CAIN (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

REPORT INVOLVING THERAPEUTIC ADMINISTRATION OF I-131 TO PATIENT IN EARLY PREGNANCY

On 4/24/09 at approximately 1400 hours, a female patient undergoing treatment for hyperthyroidism received a 12.1 millicuries dose of I-131. She had completed both a questionnaire and lab test indicating that she was not pregnant prior to receiving treatment. Subsequent to the administration, she learned she had conceived approximately 2-3 days prior to treatment. This information was provided to hospital staff on 6/16 at which time an evaluation for potential adverse consequences was initiated.

The licensee discussed this issue with NRC Region IV staff (Leonardi).

* * * RETRACTION FROM LOWELL HUSMAN TO JOE O'HARA AT 1242 EDT ON 6/18/09 * * *

The licensee is retracting the event report because they believe the dose to the embryo is less than the limit specified in 10CFR35.3047(a).

Notified R4DO(Cain) and FSME(McIntosh)

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Power Reactor Event Number: 45142
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: FRED CORLEY
HQ OPS Officer: VINCE KLCO
Notification Date: 06/18/2009
Notification Time: 19:26 [ET]
Event Date: 06/18/2009
Event Time: 11:15 [EDT]
Last Update Date: 06/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JONATHAN BARTLEY (R2DO)
ANDREW PERSINKO (FSME)

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

INCOMPLETE TESTING OF RADIOACTIVE WASTE SHIPMENT CONTAINERS

"On June 17, 2009, Catawba prepared a radioactive waste shipment cask for transportation to the Barnwell low level waste disposal facility. The shipment consisted of miscellaneous spent filters and the shipment was made on the same day. On June 18, 2009, Catawba discovered that all of the required conditions of approval in the Certificate of Compliance for the shipping container were not observed in making the shipment. Specifically, Catawba failed to conduct all of the required leak rate tests for the container prior to shipment. According to procedure, leak rate tests of the container's primary lid, secondary lid, and vent line are required to be performed. Contrary to this requirement, leak rate tests of the secondary lid and vent line were not performed. This event will require a written report to the NRC within 60 days pursuant to 10 CFR 71.95(c).

"Catawba is making this ENS notification as a courtesy notification. There is no requirement for Catawba to notify any government agency of this event. However, the State of South Carolina Department of Health and Environmental Control (SC DHEC) will ultimately be made aware of this event by Energy Solutions at Barnwell. There is no evidence that the affected shipping container has actually leaked or is leaking. The secondary lid and vent line were successfully leak rate tested at Barnwell following notification and a request by Catawba management on June 18, 2009.

"Catawba has notified the NRC Senior Resident Inspector of this event."

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Power Reactor Event Number: 45143
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: GREG LOOSE
HQ OPS Officer: VINCE KLCO
Notification Date: 06/18/2009
Notification Time: 22:04 [ET]
Event Date: 06/18/2009
Event Time: 21:39 [EDT]
Last Update Date: 06/19/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
ART BURRITT (R1DO)
COLLINS (RAR1)
LEEDS (ET)
FREDERICK BROWN (NRR)
ANTHONY McMURTRAY (IRD)
WIGGINS (NRR)
KETTLES (DHS)
CANUPP (FEMA)

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

EMERGENCY DECLARED DUE TO INDICATED FIRE IN EMERGENCY RESPONSE FACILITY SUBSTATION

At 2139, the licensee declared a Notification of Unusual Event in response to a fire alarm and CO2 activation in the emergency response facility (ERF) substation. The licensee entered emergency action level (EAL) 4.1. The fire brigade responded to assess for damage. No damage was found. The incident was attributed to a spurious activation of the CO2 system. The licensee terminated the unusual event at 2236.

The licensee notified the NRC Resident Inspector. The NRC did not change agency response mode for this event.

* * * UPDATE FROM JAMES DAUGHTERY TO HOWIE CROUCH @ 0135 EDT ON 6/19/08 * * *

The CO2 discharge was isolated to the Emergency Response Facility Substation Building, and the building has been ventilated. Investigation into the cause of the spurious CO2 actuation is ongoing.

Notified the R1DO (Burritt) via email.

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Thursday, March 29, 2012