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Event Notification Report for September 4, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/03/2009 - 09/04/2009

** EVENT NUMBERS **


45308 45318 45321 45324 45326 45327 45328

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General Information or Other Event Number: 45308
Rep Org: KARMANOS CANCER CENTER
Licensee: KARMANOS CANCER CENTER
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/28/2009
Notification Time: 17:05 [ET]
Event Date: 08/27/2009
Event Time: 18:00 [EDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

MEDICAL EVENT - PATIENT RECEIVED 60% LESS DOSE THAN PRESCRIBED

The licensee was performing reviews on past procedures when they discovered the following reportable event:

On March 3, 2009, a patient received a permanent prostate implant with a prescribed D90 dose of 144 Gy. The implant used fifty-eight I-125 seeds.

On April 3, 2009, the patient returned to the facility for a post-implant CT/dose reconstruction and it was determined that the D90 dose received by the patient was 85 Gy which is 60% of the prescribed dose.

The patient and prescribing physician were notified and the patient underwent an external radiation treatment to compensate.

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: 45318
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: NTH CONSULTANTS, LTD.
Region: 3
City: CLEVELAND State: OH
County:
License #: 31210180007
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/01/2009
Notification Time: 14:38 [ET]
Event Date: 08/31/2009
Event Time: [EDT]
Last Update Date: 09/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following notification was received via email:

"Received call from licensee at 4:58 PM on 8/31/09, regarding a Troxler Model 3400 portable gauge containing 44 mCi of Am-241 and 9 mCi of Cs-137 which was damaged at a job site in Olmstead Falls, Ohio. Serial numbers and manufacturer of sources not currently available. Serial number of gauge not currently available.

"The gauge user completed work with the gauge, locked the gauge, and then placed it on the ground under the tailgate of his truck. The user then went to the cab of the truck to perform some other tasks. While in the cab of the truck, the user noticed that heavy equipment operating at the job site was moving closer to his location, so he decided to move his truck. Forgetting that the gauge had been left outside the vehicle under the tailgate, the user backed over the gauge, causing damage to the case and shearing off the source rod at the case top. The portion of the rod containing the radioactive material remained inside the shielded body of the gauge.

"The licensee's RSO immediately responded to the event and took readings to verify that the source was in the shielded case and that there was no contamination on the ground where the gauge was run over. The damaged gauge has been moved to the licensee's facility in Cleveland where it is in secure storage. The licensee intends to transport the damaged gauge to their licensed repair contractor's facility in Michigan.

"ODH will be inspecting the licensee"

Ohio Report No.: OH090009

Notified R3DO (Lipa) and FSME (McIntosh).

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General Information or Other Event Number: 45321
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENNSYLVANIA STATE UNIVERSITY
Region: 1
City: STATE COLLEGE State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/01/2009
Notification Time: 22:28 [ET]
Event Date: 08/25/2009
Event Time: 14:30 [EDT]
Last Update Date: 09/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE - SURFACE CONTAMINATION LEVELS IN EXCESS OF LIMITS

The following was received via facsimile:

"An empty Type B, 30 gallon drum container was shipped on August 20, 2009 via public carrier from NSSI Sources and Services Inc. from Houston, Texas. It was delivered on August 25, 2009 to a Los Alamos National Laboratory (LANL) job site within a building at Penn State University in State College, PA. The shipping container was found to have external removable alpha contamination in excess of the US DOT limits noted in 49 CFR 173. LANL personnel informed their management and the carrier. Steps were also taken to verify that the contamination did not originate at Penn State. The individual truck that delivered the package to Penn State was surveyed by LANL personnel at about 2100 on 8/25/09. No contamination was found in the truck or the driver's area. There was no risk to any personnel at this facility due to this event. The first wipe found removable alpha contamination well in excess of the 2.2 dpm/centimeter squared DOT limit. After hours of decon, the removable contamination on the shipping containers was still over the limit. Onsite measurements noted little or no associated gamma radiation, and a sample was sent to LANL for alpha spectrum analysis. The material has been tentatively identified as curium-244 (Cm-244).

"PA DEP (Department of Radiation Protection) Bureau of Radiation Protection (BRP) was initially notified August 26, 2009 and has continued to receive more complete information through September 1st. LANL will put a new lid on the drum, package up the waste, and get things ready for shipping on September 2, 2009.

"The Commonwealth of PA has provided email notices of preliminary information related to this event to the NRC Region 1 State Liaison, and will continue to keep NRC informed of the status of our investigation."

See also EN #45309 for the Texas report on the same event.

State Event #: PA090028

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Power Reactor Event Number: 45324
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ADAM MILLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/03/2009
Notification Time: 09:04 [ET]
Event Date: 07/10/2009
Event Time: 02:38 [EDT]
Last Update Date: 09/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES DWYER (R1DO)

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

ELECTRICAL SHORT CIRCUIT RESULTED IN PARTIAL HIGH PRESSURE INJECTION

"This event is being reported via a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER. In this case, the telephone report is not considered an LER. This report is being made under 10 CFR 50.73(a)(2)(iv)(A).

"During a maintenance activity to replace an Engineered Safeguards Actuation System (ESAS) relay, one of the two High Pressure Injection (HPI) valves (MU-V-16C) in the 'B' train partially opened. The HPI system consists of the 'A' and 'B' trains, with each train containing two HPI valves. The cause of the partial opening of the HPI valve was inadvertent contact with adjacent energized circuits during the replacement of the ESAS relay. This resulted in a momentary short circuit, which bypassed the normal actuation logic, causing the HPI valve to open approximately 0.17 inches before blowing the control power fuse that stopped the valve movement. The event resulted in the inadvertent transfer of approximately 1000 gallons of water from the Make-up Tank into the Reactor Coolant System (RCS), before the valve could be restored to the closed position. No other valves or components actuated as a result of the inadvertent short circuit. RCS volume and pressure were stabilized and returned to normal.

"The 'B' HPI train had been declared inoperable and the unit entered a 72 hour LCO at 1:03 AM on 7/10/2009 due to configuration requirements needed for the planned ESAS relay replacement. The inadvertent partial 'B' train HPI did not impact the 'A' HPI train, and the unit remained at full power during this event. Following troubleshooting and replacement of the control power fuse, MU-V-16C was tested and restored to OPERABLE at 4:59 AM on 7/11/2009.

"The licensee notified the NRC Resident Inspector."

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General Information or Other Event Number: 45326
Rep Org: ENGINE SYSTEMS, INC
Licensee: ENGINE SYSTEMS, INC
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PAUL STEPANTSCHENKO
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/03/2009
Notification Time: 16:12 [ET]
Event Date: 08/17/2009
Event Time: [EDT]
Last Update Date: 09/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DANIEL RICH (R2DO)
PART 21 GROUP ()

Event Text

PART 21 - FAULTY EMERGENCY DIESEL GENERATOR START-UP SOLENOID VALVE

The following is excerpted from a fax received from the reporting organization:

"Engine Systems Inc. (ESI) began a 10CFR21 deviation evaluation on 08/17/09 after Brunswick Nuclear Plant (BNP) notified ESI of a failure of one of their air start solenoid valves. The valve failure reportedly occurred on 08/02/09 as indicated by a slow start of the safety-related emergency diesel generator during a surveillance run. This caused the diesel generator to be declared inoperable. Subsequently, ESI opened up an internal work order to receive back the failed valve (S/N 1230588) as well as two more valves believed to be suspect (S/Ns 1230583 and 1230586). Soon after, another internal work order was opened up to receive and evaluate 10 additional air start solenoid valves from BNP inventory. ESI completed the evaluation on 8/31/09 and determined the issue to be reportable in accordance with 10 CFR 21, 'Reporting of Defects and Non-compliance.'"

The solenoid actuated valve in question opens when energized and closes when de-energized. "The valve is installed in-line with the starting air piping via 2" NPT connections in the valve body and is utilized for two applications on the Nordberg diesel engine. Upon receipt of a diesel generator start signal, the valve is energized and directs the starting air supply to either the starting air header of the diesel engine or turbocharger jet assist piping. Failure of the valve in these applications could result in a failure of the diesel engine to start and therefore prevent the diesel generator from performing its safety-related function. A total quantity of four valves are used per engine; one installed in the left bank starting air piping, one in the right bank starting air piping, and two in parallel supplying the turbocharger jet assist.

"ESI's investigation determined that in failed valves, the upper DC sleeve had dislodged from the solenoid housing and slid down the bonnet, contacting the lower DC sleeve. This action disrupts the magnetic field to the extent that the valve will not function properly.

"ESI has supplied a total quantity of 33 [of the affected] solenoid valves and all were supplied to BNP. There are only two utilities that use Nordberg diesel engines for safety-related power supply and BNP is the only nuclear site ESI is aware of that uses the [affected] valve."

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Power Reactor Event Number: 45327
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: SCOTT BRAY
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/03/2009
Notification Time: 16:32 [ET]
Event Date: 09/03/2009
Event Time: 15:25 [EDT]
Last Update Date: 09/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL RICH (R2DO)

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

OFFSITE NOTIFICATION TO VIRGINIA DEQ

"At 12:10 on September 3rd, 2009, the Surry Power Station Chemistry Department received the results from an offsite lab analysis of an Oil and Grease and Total Suspended Solids sample. This sample was taken from the discharge of the Surry Power Station Radiological Waste Facility on 8/11/2009. The results from the offsite lab indicated Oil and Grease results of 37 ppm, which exceeds the VPDES (Virginia Pollutant Discharge Elimination System) limit of 20 ppm.

"This notification is being transmitted due to Notification of Other Government Agencies under 10CFR50.72(b)(2)(xi). The Virginia Department of Environmental Quality (DEQ) has been notified of this event. The Senior NRC Resident has been notified of this event. "

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Power Reactor Event Number: 45328
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: MIKE McBREARTY
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/03/2009
Notification Time: 23:18 [ET]
Event Date: 09/03/2009
Event Time: 17:30 [PDT]
Last Update Date: 09/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION TO LOS ANGELES COUNTY PUBLIC HEALTH RADIATION MANAGEMENT DIVISION

"On September 3, 2009, at approximately 1730 PDT, Southern California Edison was notified by a metal recycling vendor that a metal recycle load that was picked up at SONGS had been rejected at Terminal Island (Long Beach, CA) because it set off a radiation portal monitor as it was being processed through. The vendor (Alpert and Alpert) was requested to immediately ship the material back to SONGS. The County of Los Angeles Public Health, Radiation Management Division (Joji Ortego) called to confirm final destination, and a Special DOT Permit was issued to return the shipment to SONGS.

"The truck is currently returning to San Onofre where SCE Health Physicists will evaluate the load.

"SCE is reporting this event in accordance with 10CFR50.72(b)(2)(xi). SCE will provide an update to this report after the truck has returned to SONGS and the contents evaluated.

"At the time of this report, Unit 2 and Unit 3 were operating at about 99 and 100 percent power respectively."

The NRC Resident Inspectors have been notified of this occurrence and will be provided with a copy of this report.

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