Event Notification Report for December 23, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/22/2009 - 12/23/2009

** EVENT NUMBERS **


45509 45573 45578 45579 45581 45582 45585 45586

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General Information or Other Event Number: 45509
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: TERRACON CONSULTING INC.
Region: 4
City: BRYANT State: AR
County:
License #: ARK082003121
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: VINCE KLCO
Notification Date: 11/19/2009
Notification Time: 08:58 [ET]
Event Date: 11/18/2009
Event Time: 08:30 [CST]
Last Update Date: 12/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
LANCE ENGLISH (ILTA)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN/RECOVERED TROXLER MOISTURE DENSITY GAUGE

The following information was received via email:

"At approximately 0830 on the morning of November 18, 2009, the RSO (Radiation Safety Officer) of Terracon Consulting Inc. (ARK-0820-03121) reported the theft of a Troxler 3440 Moisture Density gauge (SN#27140) from a construction site at the Two Pines landfill in Jacksonville, Arkansas. The gauge contained an 9 mCi Cesium-137 source and a 44 mCi Americium-241/Beryllium source. According to the RSO, the gauge had been secured with two independent chains to the rear rack of an all terrain vehicle (ATV), which in turn was locked inside of a cargo shipping container after work was halted on November 17, 2009. When personnel arrived at the construction site at approximately 0700 on the 18th, they noted that the lock on the cargo container had been cut and that the ATV and gauge were missing. Local and state law enforcement were notified.

"At approximately 1340 on that same day, the Jacksonville Police Department reported that the gauge had been found along a roadside in Pulaski County. The gauge was examined by Department personnel and appeared to be undamaged, wipes tests were taken to further verify that the sources were not leaking. Terracon personnel were then allowed to take possession the gauge.

"The [Arkansas Department of Health] will keep this incident open pending the receipt of a report and corrective actions from the licensee."

Arkansas Incident Number: 11-09-01

* * * UPDATE FROM ROBERT PEMBERTON TO DONG PARK AT 1621 ON 12/22/09 * * *

The following report was received via e-mail:

"The following are the findings of the Arkansas Department of Health, Radioactive Materials Program, concerning event Number 45509 involving the theft and recovery of a Troxler 3440 moisture/density gauge from Terracon Consulting Inc. From information provided by Terracon Consulting Inc. the Department has determined that the gauge was apparently undamaged and the sources were not leaking. The Department has received corrective actions from Terracon Consulting Inc., dated December 18, 2009, and found them to be adequate. The Department considers this incident to be closed."

Notified R4DO (Walker), FSME (Villamar), and ILTAB (e-mail).

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

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General Information or Other Event Number: 45573
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: H. H. HOLMES TESTING LABORATORY
Region: 3
City: WHEELING State: IL
County:
License #: IL-01828-01
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: KARL DIEDERICH
Notification Date: 12/16/2009
Notification Time: 10:45 [ET]
Event Date: 12/16/2009
Event Time: [CST]
Last Update Date: 12/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
GLENDA VILLAMAR (FSME)
LANCE ENGLISH (ILTA)
CNSNS-MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On December 16, 2009, at 0729 hours, the licensee notified the [Texas] agency that sometime during the previous night, a company truck containing a Humboldt model 5001 EZ moisture density gauge serial # 3566 was stolen from an employee's home. The gauge contains a 10 millicurie Cesium (Cs) -137 source and a 40 millicurie Americium-241 /Beryllium (Am/Be) source. Local law enforcement was notified and a report filed. The employee is on his way to the company's office to file a complete report. The [Texas] agency has notified the Texas Association of Pawnbrokers of the theft. The company is licensed in the State of Illinois (IL-01828-01) and operating in Texas under reciprocity. It is unknown at this time how the gauge was stored in the vehicle or the address where the vehicle was located when it was stolen. This [Texas] agency will supply additional information as it is obtained."

* * * UPDATE FROM A. TUCKER TO P. SNYDER AT 0926 ON 12/22/09 * * *

The following report was received via e-mail:

"On December 22, 2009, at 0809 hours, the license notified the agency that on the evening of December 21, 2009, the stolen truck was located in an impound yard. The gauge was still on the truck. The gauge was inspected and was undamaged. The gauge has been returned to storage. No additional information is available at this time. The licensee stated that a written report will be provided within the next week."

Notified R4DO (Walker), FSME (Villamar), and ILTAB (e-mail).

The Texas agency notified the State of Illinois. Texas Incident Number I-8693.

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

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General Information or Other Event Number: 45578
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ALL STATE ENGINEERING TESTING CONSULTANTS
Region: 1
City: HIALEAH State: FL
County:
License #: 1113-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/17/2009
Notification Time: 09:13 [ET]
Event Date: 12/17/2009
Event Time: [EST]
Last Update Date: 12/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1DO)
GLENDA VILLAMAR (FSME)
LANCE ENGLISH (ILTA)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received via facsimile:

"[A] technician contacted this office at approximately 0810 [EST] to report that a Troxler gauge was stolen. The gauge was stored in the truck bed inside the case. The case with locked gauge inside was chained to the truck. The office compound has a locked gate and fence. The gate was found to be open upon his arrival, the supervisor was there but was not aware of the missing gauge until informed by [the technician]. The truck that had the gauge was parked in the back parking lot. [The] Miami office will investigate."

Florida Incident Number: FL09-086.
Troxler Model Number: 3411-B
Serial Number: 7648

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

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General Information or Other Event Number: 45579
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: COOKEVILLE REGIONAL MEDICAL CENTER
Region: 1
City: COOKEVILLE State: TN
County:
License #: R-71026-D10
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/17/2009
Notification Time: 10:59 [ET]
Event Date: 12/15/2009
Event Time: [EST]
Last Update Date: 12/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION OF RADIOACTIVE MEDICAL TREATMENT

The following report was received via facsimile:

"[Tennessee Division of Radiological Health] TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee."

Tennessee Report Number: TN-09-155

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: 45581
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: MISTRAS GROUP INC.
Region: 4
City: KENT State: WA
County:
License #: WN-IR011-1
Agreement: Y
Docket:
NRC Notified By: KELEE ATTEBERY
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2009
Notification Time: 11:36 [ET]
Event Date: 12/15/2009
Event Time: [PST]
Last Update Date: 12/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following report was received via email:

"The department received a notification from a radiography company [on 12/16/09] located in Kent, Washington, about an event while performing radiographic operations in a fabrication shop in Sedro Wooley, Washington. A 2 inch pipe fell onto the source guide tube and the radiography crew was unable to retract their source past the damage. The crew called the company's Radiation Safety Officer who sent an assistant to the site with lead blankets. The assistant was able to normally retract the source through the damaged area and into the shielded safe storage position of the radiographic exposure device. The dose to the assistant RSO was reported as 480 mRem. No other individuals were reported to have received an elevated dose. A full report from the company's RSO will be made after they perform a reenactment of the incident."

WA Incident Number: WA-09-093
Source material: 80 Ci, Ir-192

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General Information or Other Event Number: 45582
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MARS PETCARE US, INC
Region: 3
City: COLUMBUS State: OH
County:
License #: 00006GL0138
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/18/2009
Notification Time: 13:47 [ET]
Event Date: 11/26/2009
Event Time: [EST]
Last Update Date: 12/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
GLENDA VILLAMAR (FSME)
CNCNS - CANADA (FAX)

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

Event Text

AGREEMENT STATE - LOST LEVEL INDICATOR

The following was received via email:

"General licensee (GL) reported to BRP (Bureau of Radiation Protection) on 12/18/09 that a generally licensed device was unaccounted for. The device has been identified as an Industrial Dynamics FilTech FT-50 [fixed gauge] level indicator, serial number 113216, containing 100 mCi of Am-241.

"The licensee last reported that the device was in their possession with the annual GL registration to BRP on 10/11/02. The device was not listed on the next GL registration submitted by the licensee on 11/26/03. During an internal audit by the licensee it was determined that a report of disposition of the device had not been submitted to BRP. The device had been installed in a process line which was decommissioned and dismantled in June 2003. As the licensee investigated the matter they determined that they could not account for the current location of the device. The manufacturer had no record of receipt of the device and the licensee could not locate the device anywhere within their facility.

Additional investigation and information is being requested by BRP. "

Ohio Report #: OH090012

Source Model #: 06110

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

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Power Reactor Event Number: 45585
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MURRELL EVANS
HQ OPS Officer: PETE SNYDER
Notification Date: 12/22/2009
Notification Time: 11:14 [ET]
Event Date: 11/21/2009
Event Time: 21:13 [PST]
Last Update Date: 12/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
WAYNE WALKER (R4DO)

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

UNEXPECTED AUTOMATIC START OF THE 2-1 EMERGENCY DIESEL GENERATOR (EDG)

"This notification is being made in accordance with 10 CFR 50.73(a)(i), which states, in part; that in case of an invalid actuation reported under 10 CFR 50.73(a)(2)(iv)(A), other than the actuation of the Reactor Protection System when the reactor is critical, the licensee may provide a telephone notification to the NRC within 60 days after discovery of the event instead of submitting a written Licensee Event Report.

"On November 21, 2009, at 2113 PST, EDG 2-1 automatically started, but did not load, due to an attempted replacement of an indicating light that caused a control circuit electrical short and opening the power supply fuse. EDG 2-2 and EDG 2-3 were unaffected by this event. Plant operators entered TS 3.8.1, AC Sources - Operating, due to the loss of the Startup Feeder indication circuit. No actual condition requiring the start of EDG 2-1 existed.

"The EDG 2-1 4kV Bus Start up Transfer Feeder Undervoltage Relay was placed in bypass (knife switch #10 for relay 27 HGU opened), the EDG was shutdown at 2147 PST and placed in standby operation at 2148 PST. This inadvertent start relay input is not a required safety function, but provides an anticipatory start of the EDG. The actuated relay input is not required for operability, thus the EDG was operable at 2148 PST.

"Electrical Maintenance replaced the affected sensing relay circuit fuse (52HG14 "UA" fuses), tightened the indicating light socket for SUT 2 2 Potential C A Phase, and reset 27HGU (Startup Feeder UV for 4kV Bus G). On November 22, 2009, at 0729 PST, TS 3.8.1 was exited.

"The consequences of this event were limited to the unplanned start of EDG 2-1. The EDG started and functioned in accordance with its design. Since no valid signal which required the EDG to start, and since the start occurred inadvertently as the result of a known maintenance action (resulting in a single component failure, a protective fuse opening), this event has been classified as an invalid actuation.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 45586
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: FRANCIS CLIFFORD
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/22/2009
Notification Time: 16:30 [ET]
Event Date: 12/22/2009
Event Time: 08:45 [EST]
Last Update Date: 12/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
NEIL PERRY (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

LOSS OF WATER SEAL TO SECONDARY CONTAINMENT

"On December 22, 2009, at 0845 hours, with the reactor at 100% core thermal power and steady state conditions, Pilgrim Nuclear Power Station (PNPS) declared Secondary Containment inoperable due to the loss of a water seal on two 14 inch drain lines in the Torus Compartment designed to mitigate the consequences of a flood in the Reactor Auxiliary Bay. An initial assessment of the condition indicates that the cross-sectional area of pipes, as found, have the potential to exceed the analytical value of allowable Secondary Containment leakage pathway size documented in the design calculations. The Limiting Condition for Operation (LCO) for Technical Specification (TS) 3.7.C.2.a, was immediately entered at 0845 until the condition was corrected. The TS LCO was subsequently exited at 0945 hours at which time Secondary Containment was declared operable.

"As background, each Reactor Auxiliary Bay (2) is equipped with a sump containing two 14 inch drain lines that discharge into separate trough in the Torus Compartment in the event of a flooding condition. The trough is approximately 4 feet by 4 feet by 4 feet deep and is equipped with a high and low level alarm which annunciates in the Control Room. One of the functions of the alarm is to indicate a low level condition prior to the pipes losing their water seal which maintains Secondary Containment for those penetrations. When the water level in the trough dropped below the low level setpoint, the alarm failed to annunciate. This condition was discovered during an engineering walk down of the Torus Compartment.

"Immediate actions taken were to refill the trough to the correct level, initiate repairs to the level switch, which was found to be defective, and to enhance the weekly tour requirement of the Torus Compartment performed by plant operations.

"This notification has no impact on the health and safety of the public.

"The NRC Resident Inspector is onsite and has been notified.

"This is an 8 hour notification made in accordance with 50.72(b)(3)(v)(C)."

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