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Event Notification Report for November 24, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/23/2009 - 11/24/2009

** EVENT NUMBERS **


45502 45506 45507 45508 45517

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General Information or Other Event Number: 45502
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON COMMUNITY HOSPITAL
Region: 1
City: BOCA RATON State: FL
County:
License #: 0550-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/17/2009
Notification Time: 13:50 [ET]
Event Date: 10/26/2009
Event Time: [EST]
Last Update Date: 11/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND MCKINLEY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via facsimile:

"Patient liver is being treated by thera sphere procedure. First dose was intended to be for left lobe but was delivered to right lobe on 10/26/09. The second treatment was going to be for the right lobe. The window for the right lobe dose was 90-115 grays, but what actually delivered was 18-51 % low. Error was discovered 10/30/09. The patient will be retreated to bring dose up to required level. The patient and doctor have been notified. In the future the radiologist will submit a written statement on the treatment to be preformed before it is accomplished. Licensee will submit a written report. No further action will be taken on this incident."

Source: 1.27 GBq Y-90

Florida Incident: FL09-077

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: 45506
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MEADWEST VACO
Region: 4
City: EVADALE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 13:52 [ET]
Event Date: 04/12/2007
Event Time: [CST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE SHUTTER FAILURE

The following report was received via e-mail:

"On April 19, 2007, the Agency was notified of a generally licensed device malfunction. The general licensee reported that the 'on-off' shutter mechanism failed on a frame beta gauge, designed for measuring mass per unit area of thickness of sheet material. The device was removed from operation, repaired, and put back into operation. The failure was determined to be caused by the lack of maintenance on the device.

"The device is a General License device, a Frame Beta Gauge, Model BG-V, serial no. 940331001, with two Krypton-85 sources of 0.2 Ci each, Model KAC.D3, serial no's. KS429 and KS430."

Texas Incident: I-8408

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General Information or Other Event Number: 45507
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: JAMES HARDIE BUILDING PRODUCTS INC
Region: 4
City: CLEBURNE State: TX
County:
License #: 02040
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 14:46 [ET]
Event Date: 10/15/2007
Event Time: [CST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER STUCK IN OPEN POSITION

The following report was received via e-mail:

"On November 26, 2007, the Agency received a letter from the licensee notifying them that while conducting a routine inventory and shutter inspection of a density gauge, the shutter was found stuck in the open position. The licensee contacted a vendor to repair the gauge. The vendor determined that a bolt on the shutter had broken preventing the shutter from closing. The shutter could not be repaired. The shutter is normally open so there was no increased risk of additional radiation exposure to the workers at the facility. A new device was ordered and the old gauge was disposed of when the new one was installed.

"The gauge was an Ohmart/VEGA Corporation model SH-F1, serial number 8622 K containing a 50 milliCurie Cesium (Cs) - 137 source."

Texas Incident: I-8456

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General Information or Other Event Number: 45508
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CRYOVAC INC
Region:
City:  State:
County:
License #: 01736
Agreement: N
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2009
Notification Time: 15:09 [ET]
Event Date: 12/12/2007
Event Time: [EST]
Last Update Date: 11/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - BACKSCATTER PROBE READING ERRATICALLY

The following report was received via e-mail:

"On December 14, 2008, the Agency received notification that while restarting the line production the operator noted that a NDC model 103 backscatter probe was reading erratically. An operator standing on the first leveled looking up at the probe, which was located on the second level thought he saw a piece of tape on the end of the probe. Upon closer inspection, the operator believed that the probe had been damaged and requested assistance. The facility Radiation Safety Officer had the area around the probe evacuated. Further investigation determined that the probe shutter was in the closed position. The probe was removed by the facilities Hazardous Material Team and placed in a locked storage location. A technician from the manufacturer inspected the probe and determined that the shutter mechanism was operating properly. He removed the shutter and installed it on a spare probe. The old probe was sent to the manufacturer for inspection and repair. The manufacturer inspected the probe and performed a leak test of the source. The source did not appear to have been damaged, and the leak test results were satisfactory. The probe was returned to the facility after some routine repairs."

Texas Incident: I-8463

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Power Reactor Event Number: 45517
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: VINCE KLCO
Notification Date: 11/24/2009
Notification Time: 03:40 [ET]
Event Date: 11/24/2009
Event Time: 03:05 [EST]
Last Update Date: 11/24/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
RAYMOND MCKINLEY (R1DO)
SAM COLLINS (RA1)
ERIC LEEDS (NRR)
SAMSON LEE (NRR)
BRIAN McDERMOTT (IRD)
JOHN FROST (DHS)
WILLIAM BORDAN (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

UNUSUAL EVENT - REACTOR COOLANT SYSTEM LEAKAGE GREATER THAN 25 GPM

"Beaver Valley Unit 2 declared an unusual event due to reactor coolant system unidentified leakage greater than 25 GPM into the pressurizer relief tank. Leakage occurred during shutdown of the residual heat removal system Train-A. The Train-A suction relief valve lifted due to pressure from the in-service Train-B residual heat [removal] system. The leakage has been stopped by isolating Train-A RHR from Train-B RHR. The duration of relief valve lifting was about 9 minutes. The pressurizer relief tank remained intact. All other systems functioned as designed and the plant is stable. Containment was closed at time of the event. No radioactive release occurred."

The licensee terminated the unusual event at 0404 EST.

The licensee notified the NRC Resident Inspector.

* * * UPDATE BY DAVID HASER TO VINCE KLCO ON 11/24/2009 AT 0707* * *

Licensee clarified that the event was due to identified leakage not unidentified leakage as stated in the paragraph above.

Notified R1DO.

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Thursday, March 29, 2012