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Event Notification Report for October 21, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/20/2009 - 10/21/2009

** EVENT NUMBERS **


45307 45435 45436 45439 45442 45446 45447 45448

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45307
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: PETE SNYDER
Notification Date: 08/28/2009
Notification Time: 01:13 [ET]
Event Date: 08/27/2009
Event Time: 23:10 [EDT]
Last Update Date: 10/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JOHN WHITE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

NON-CONSERVATIVE TECHNICAL SPECIFICATION SETPOINTS DISCOVERED

"Non-conservative Tech Spec setpoints were discovered that affected Steam Leak Detection for Unit 1 and Unit 2 [High Pressure Coolant Injection] HPCI room high differential temperatures. During a steam leak detection system design basis leak, the present temperature setpoint would not isolate the HPCI steam supply piping.

"A calculation has been performed by engineering which demonstrates that, with both room coolers secured, a design basis steam leak will result in the room ventilation differential temperature exceeding the present Tech Spec setpoints. At this time, the room unit coolers have been secured and HPCI and the associated steam leak detection system remain operable. Calculations are in-progress by engineering for changes to the high differential temperature steam leak detection setpoint."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM J. BROILET TO P. SNYDER ON 10/20/09 AT 1154 EDT * * *

"This is a retraction of the event notification made on 8/28/09 at 0113 EDT. This event (#45307) was initially reported as a condition that could have prevented fulfillment of a safety function under the requirement of 10 CFR 50.72 (b)(3)(v)(c).

"A follow-up review of the HPCI equipment room steam leak detection system calculations determined that other HPCI equipment room ambient high temperature instruments would have automatically actuated a HPCI steam line isolation during a 25 gpm design basis HPCI steam line leak event.

"Therefore, a condition did not exist at the time of discovery that could have prevented the fulfillment of the HPCI steam line isolation safety function."

The licensee notified the NRC Resident Inspector. Notified R1DO (Doerflein).

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General Information or Other Event Number: 45435
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HOTWELL US LTD
Region: 4
City: HOUSTON State: TX
County:
License #: 06145
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/15/2009
Notification Time: 15:55 [ET]
Event Date: 10/15/2009
Event Time: 14:15 [CDT]
Last Update Date: 10/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
MARK DELLIGATTI (FSME)

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

Event Text

POTENTIAL LOST SEALED SOURCE CONTAINING 1.8 CURIES TRITIUM

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

"On June 29, 2009 Hotwell US LTD received a new shipment of two tritium well logging tools from their manufacturer in Austria. The tools each contain a 1.8 Curies (Ci) tritium sealed source inside a 15,000 psi pressure housing. These tools were slated for sale and delivery to Competition Wireline (NRC License No. 25-27802-1) out of Billings, Montana. After arriving at the facility in Houston, Texas, the tools were checked and shipped via [common carrier] to Competition Wireline. One tool (No. 33264) arrived at Competition Wireline on July 1, 2009. On July 6, 2009, Competition Wireline verified to Hotwell US LTD that the other tool (No. 33284) had been received. On October 13, 2009 Competition Wireline reported to Hotwell US LTD that after a general inventory of equipment, they could not locate one of the tools (No. 33284). The licensee has alleged that [the common carrier] never delivered the tool and found that it was last tracked to Memphis, Tennessee. [The common carrier] now shows the package as 'In Transit'. Competition Wireline has notified [the common carrier], and [the common carrier] is conducting an investigation into the location of the package.

The missing tool is described as follows:

" Tool No. 33284
Monoblock No.: 99448
Model No.: ING-10-50-120-TBT
Description: 84 x12 x8 Black Crate

"Texas Incident Number I-8677."

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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Hospital Event Number: 45436
Rep Org: UNIVERSITY OF MICHIGAN HOSPITAL
Licensee: UNIVERSITY OF MICHIGAN HOSPITAL
Region: 3
City: ANN ARBOR State: MI
County:
License #: 21-00215-04
Agreement: N
Docket: 030-0198
NRC Notified By: MARK DRISCOLL
HQ OPS Officer: JOE O'HARA
Notification Date: 10/15/2009
Notification Time: 16:42 [ET]
Event Date: 10/14/2009
Event Time: 17:00 [EDT]
Last Update Date: 10/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
MARK DELLIGATTI (FSME)

Event Text

PATIENT RECEIVED APPROXIMATELY 76% OF THE PRESCRIBED DOSE

A three year old boy was undergoing a palliative treatment for a cancer related illness with I-131. The boy was prescribed 180.5 milliCurie of I-131 by his physician. During the treatment, a technician noticed that there were air bubbles in the intravenous tubing leading to the boy and stopped the treatment. Upon subsequent investigation, it was revealed that the patient only received 138 milliCurie of the prescribed 180.5 milliCurie of I-131, which is approximately 76% of the prescribed dose. The patients physician has been notified, and is making a decision whether to inform the boys parents. The licensee is investigating the cause of the incident.

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: 45439
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS INC.
Region: 4
City: PASADENA State: TX
County:
License #: 4322
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/15/2009
Notification Time: 18:04 [ET]
Event Date: 10/14/2009
Event Time: [CDT]
Last Update Date: 10/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A RADIOGRAPHY CAMERA SOURCE DISCONNECT

Received a call from State of Texas concerning an incident that occurred 10/14/09 at a temporary jobsite in Texas (location unknown). The company (not identified in the call) is located in Pasadena, TX. The State of Texas representative said that the Radiographer failed to follow procedures and connect the guide tube before cranking out the source. The source subsequently struck the wall and disconnected. The company RSO who is qualified for source retrieval recovered and secured the source. His extremity dosimetry indicated 57 mrem with a whole body dose of about 90 mrem. Details of the incident including licensee name and license number will be provided by update.

* * * UPDATE FROM ART TUCKER TO VINCE KLCO AT 1049 ON 10/16/2009 * * *

The following information was received by e-mail:

"On October 15, 2009, the Agency [State] was notified by the licensee that on October 14, 2009, they experienced a source disconnect while using an Amersham model 660 radiography camera containing a 45.3 curie Iridium (Ir) 192 source. The Radiation Safety Officer (RSO) stated that two radiographers were setting up for their first shot of the day. The guide tube they had was too short, so one of the radiographers connected an additional guide tube to the end of the existing guide tube, while the other radiographer prepared to perform the shot. Neither of the radiographers attached the guide tube to the camera. They then cranked the source out of the camera to perform their first shot. This caused the source to be pushed out of the camera, onto the floor of the shooting bay, and against the wall of a shooting bay. The camera operator felt that he had cranked the source out farther than it should have traveled for the shot and stopped cranking the source. He then tried to return the source to the camera. When the radiographer retracted the drive cable, the source was left loose on the shooting bay floor. The radiographer approached the shooting area with his dose rate meter and found the dose rates were elevated. The radiographer then secured the area and notified the RSO, who is specifically authorized on the license for source retrieval. The RSO developed a strategy to reconnect the source, and then successfully cranked the source back into the camera. No one involved with this event received an exposure exceeding any regulatory limit.

"The RSO stated that their investigation into the event determined that the root cause for the event was the failure of the two radiographers to follow procedure. He also noted a failure of the two radiographers to communicate adequately. The RSO stated that they will retrain all of their radiographers regarding their procedures for the proper connecting and disconnecting of equipment to their exposure devices. He also stated that this training would be repeated in their annual training in 2010."

Texas Incident: I-8678

Notified R4DO(Cain) and FSME (McIntosh).

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General Information or Other Event Number: 45442
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THRUBIT LLC
Region: 4
City: HOUSTON State: TX
County:
License #: 06030
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/16/2009
Notification Time: 14:15 [ET]
Event Date: 10/15/2009
Event Time: [CDT]
Last Update Date: 10/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
MARK DELLIGATTI (FSME)

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

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL LOSS OF RADIOACTIVE MATERIAL DURING SHIPMENT

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

"On October 16, 2009, at 11:35 AM, the licensee notified the Agency [State of Texas] that a 1.78 curie Cesium (Cs)-137 sources, and a 10.8 millicurie California (Cf) -252 source was lost in transport. The sources were picked up by a common carrier on October 14, 2009, for delivery to their facility in Oklahoma City, Oklahoma. At 1600 on October 15, 2009, the licensee was informed that the sources had not arrived in Oklahoma City. The RSO contacted the shipper and was informed that they believed that the sources had been placed on a truck going to Albuquerque, New Mexico. At about 3:00 AM on October 16, 2009, the licensee was notified that the sources were not on the truck going to Albuquerque. The shipper stated that they would contact all of their facilities (290 of them) to look for the packages. The Cs-137 source is in a container that weighs 320 pounds and labeled as Yellow II with a TI of 0.2. The Cf-252 source is in a container that weighs 185 pounds, is labeled as a Yellow II and a TI of 0.6. The RSO went to the shippers facility in Houston and searched for the packages. He did not find them. The shipper will contact the licensee as soon as the sources are located. The license will provide additional information as it is received."

The State of Oklahoma was informed of the missing shipment.

Texas Incident No.: I-8679

* * * UPDATE AT 1951 EDT ON 10/16/09 FROM ART TUCKER TO S. SANDIN * * *

The following update was received from the State of Texas via email:

"On October 16, 2009, at 1715 CT, the licensee contacted the Agency and informed them that at 1657 CT, the licensee was contacted by the shipping company and informed that the two sources had been located at their facility in Kansas City, Mo. The shipping company will deliver the sources to the licensee's facility in Oklahoma City on October 17, 2009."

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

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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Fuel Cycle Facility Event Number: 45446
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: JENNIFER WHEELER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/19/2009
Notification Time: 17:00 [ET]
Event Date: 10/13/2009
Event Time: [EDT]
Last Update Date: 10/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
RANDY MUSSER (R2DO)
JANE MARSHALL (NMSS)
FUELS OUO GROUP ()

Event Text

NITROUS OXIDE (NOx) GENERATION RATE HIGHER THAN EXPECTED AFTER ALUMINUM FINES WERE INTRODUCED

"Bldg 333's U-Aluminum Bowl Cleaning system is designed to remove uranium from centrifuge bowls by circulating nitric acid through the bowls. The system has historically produced NOx (nitrous oxide, etc) during the nitric acid dissolution process. Safety controls designated as Items Relied On For Safety (IROFS) include a NOx detection system (IROFS BPF-43) with sensors located at the nitric acid knockout column's siphon break potential NOx release point if process ventilation fails and at employee working level.

"On October 13, 2009, NFS began using the Bowl Cleaning system to dissolve U-Al fines (very small particles of U-AI) rather than adding them to the normal dissolver column. The fines were loaded into strainers and placed directly into the bowls to be dissolved with nitric acid. After the dissolution process began, the Operator noticed that the temperature of the system was increasing and that NOx (in the form of a brown cloud) was beginning to form inside the Bowl Cleaning station containment vessels. The system was shutdown. The NOx detector designated as an IROFS alarmed and the facility was evacuated. Immediate corrective actions included building, and health and safety personnel re-entry in SCBA to validate shutdown conditions and remote monitoring of NOx levels in Bldg 333. Based on re-entry data and remote NOx detector readings, NOx levels inside the building (outside of containment) were not significant.

"Laboratory analysis of similar U-AI fines material was conducted October 14-October 16. It behaved in the laboratory in the same manner as what was observed during the operational event. Based on the lab testing, a NOx generation rate specific for the fines material was estimated. Based on engineering calculations, it was determined that the NOx generation for the fines was significantly higher than the previously analyzed NOx generation for the U-AI ingots. The previous Nox evaluation for the U-Al Bowl Cleaning station resulted in an intermediate occupational consequence. Using the generation rate specific for the fines results in high occupational consequences.

"On October 19, 2009, based on the revised NOx generation rate, it was determined that insufficient lROFS were in place and that the performance criteria of 10 CFR 70.61 were not met.

"a) Radiological Hazards involved including: High- enrichment Uranium: quantity Approx 1,000 g; Isotope: U-235 quantity Approx 710 g

"b) Chemical Hazards involved including: Chemical: NOx gas; Quantity: Approx. 1.85 lbs.

"c) Discuss the actual or potential health and safety consequences to the workers, the public, and the environment, including relevant chemical and radiation data for actual personnel exposures to radiation or radioactive materials or hazardous chemicals produced from licensed materials. Include in the discussion below the concentration of chemicals and duration of exposure, if any: Potential worker and public exposure to NOx. Process ventilation and NOx detection worked as designed. No actual exposure to workers or the public were recorded.

"d) Discuss the sequence of occurrences leading to the event, including degradation or failure of structures, systems, equipment, components and activities of personnel relied on to prevent potential accidents or mitigate their consequences: See above.

"e) Discuss whether the remaining structures, systems, equipment components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences are available and reliable to perform their function: IROFS BPF-43 is in place and functioned correctly during the event. Operating personnel responded to the alarm as specified in the operating procedure and evacuated the facility.

"External conditions affecting the event: None.

"Additional actions taken in response to the event: Discussed situation with Operations, Safety management and with the NRC Resident Inspector. The U-Al Bowl Cleaning system is currently not operating."

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General Information or Other Event Number: 45447
Rep Org: BASIN ELECTRIC POWER COOPERATIVE
Licensee: BASIN ELECTRIC POWER COOPERATIVE
Region: 4
City: WHEATLAND State: WY
County:
License #: 33-18224-01
Agreement: N
Docket:
NRC Notified By: DAVID CUMMINGS
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/20/2009
Notification Time: 11:05 [ET]
Event Date: 10/19/2009
Event Time: [MDT]
Last Update Date: 10/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
NEIL OKEEFE (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

SHUTTER ON NUCLEAR GAUGE STUCK OPEN

During an inspection on October 19, 2009, a process nuclear gauge was found to have a stuck open shutter. The gauge is a Kay Ray Model 7062P, serial number 5757, containing 100 milliCurie Cs-137 source. It was mounted 20 feet above the floor and no exposure to personnel occurred.

"At this time it appears that Radiation Technology, Inc. of Austin, TX will provide repair service at a date yet to be determined. In the meantime, the crusher is in service and the gauge is in use with no plans to work on associated equipment. As the gauge is located about 20 feet above
the floor with no immediate access, it is not likely to present a hazard. A notification of hazard will be placed in the operations log to prevent any unintentional access until the gauge can be repaired."

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Power Reactor Event Number: 45448
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DANIEL HAUTALA
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/20/2009
Notification Time: 17:36 [ET]
Event Date: 10/20/2009
Event Time: 07:10 [MST]
Last Update Date: 10/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NEIL OKEEFE (R4DO)

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 N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

RANDOM FITNESS FOR DUTY FAILURE

A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employees access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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