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Event Notification Report for January 4, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/31/2009 - 01/04/2010

** EVENT NUMBERS **


45594 45595 45596 45599 45601 45603 45604

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General Information or Other Event Number: 45594
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SANCHEZ RADIOLOGY
Region: 1
City: MIAMI LAKES State: FL
County:
License #: 4063-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/29/2009
Notification Time: 15:57 [ET]
Event Date: 12/29/2009
Event Time: 15:00 [EST]
Last Update Date: 12/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
CHRISTEPHER MCKENNEY (FSME)
ILTAB email ()

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

Event Text

AGREEMENT STATE - LOST SOURCE

The following is a summary of information received via fax:

The licensee reported a lost 189 micro-Curie Cs-137 source at 1500 [EST] on 12/29/09. Also missing was the certificate for the source. Miami Inspection Office will investigate. The incident occurred at the Miami Diagnostic Interventional Center located in Miami Lakes, FL.

* * * UPDATE FROM FURNACE TO TEAL AT 1631 ON 12/30/2009 * * *


"[An] investigator determined that source became missing sometime between December 8th to the 23rd. [As a] corrective action [the] licensee will restrict who has possession of Hot Lab keys to, the owner, office manager, and nuclear medicine technologist. Incident referred to Materials and Licensing for any further investigation. This office will take no further action on this incident."

FL Incident #: FL09-088

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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General Information or Other Event Number: 45595
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: LAKE NORMAN REGIONAL MEDICAL CENTER
Region: 1
City: MOORESVILLE State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDY CROWE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/29/2009
Notification Time: 17:09 [ET]
Event Date: 11/19/2009
Event Time: [EST]
Last Update Date: 12/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - BRAYCHYTHERAPY DOSE DIFFERED FROM THE PRESCRIBED DOSE BY MORE THAN 20%

The following was received via facsimile:

"During a prostrate brachytherapy procedure using a Mick applicator and I-125 sources, 41 of 41 sources were implanted into the patient's perineal soft tissue, inferior to the prostrate [resulting in:] 1. Dose was greater than 5 rem effective dose equivalent, and/or 50 rem to an organ or tissue and 2. the total dose delivered differs from the prescribed dose by 20% or more.

"Explain the effect, if any, on the individual who received the administration: Possible perineal soft tissue fibrosis. The patient is currently without symptoms six weeks following the implant.

"Additional notes:

"Licensee's evaluation of why the event occurred: Visualization of the prostrate was difficult on ultrasound due to poor image quality, leading to needle placement inferior to the prostrate.

"What actions, if any, have been taken or are planned to prevent recurrence: Discontinuation of the procedure if the locations of the needles are not known to relative certainty.

"The patient and the referring physician were notified [of this event].

"No follow-up is required."

NC Incident Report Number: 09-63

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: 45596
Rep Org: NV DIV OF RAD HEALTH
Licensee: ACCLAIM MATERIALS TESTING AND INSPECTION SUNBELT, LLP
Region: 4
City: HENDERSON State: NV
County:
License #: 00-11-0470-01
Agreement: Y
Docket:
NRC Notified By: TIMOTHY MITCHELL
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/29/2009
Notification Time: 19:36 [ET]
Event Date: 12/28/2009
Event Time: 18:15 [PST]
Last Update Date: 12/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT- DAMAGE TO PORTABLE GAUGE

The following was received via email:

"At 6:15 PM, on 12/28/09, the Nevada Radiation Control Program (RCP) received a phone call from NHP [Nevada Highway Patrol] and was informed that a nuclear density gauge [model CPN MC3 Am-241/Be 50 mCi and Cs-137 10 mCi nominal] had fallen out of a truck in Las Vegas and that the gauge had been destroyed.

"At 6:35 PM, NHP, Las Vegas, contacted [the Nevada RCP Senior RSO] and reported that a nuclear density gauge had fallen from a truck at I-15 and 215 and that his initial instrument reading was 415 micro R/hr at 10 feet. The instrument was destroyed; however the source tube was not ruptured. The NHP was also on the line with [RCP] who was arranging for Metro All Regional Multi-Agency Operations and Response (ARMOR) to respond with other instruments. [The RCP] coordinated from that point with subsequent calls to [the Nevada RCP Senior RSO] to discuss how to proceed. The subsequent instrument readings received from Metro ARMOR indicated that the surface of the device case was 600 mR/hr.

"On the morning of 12/29/09, RCP learned that Instrotek was on the way to the licensee to conduct wipe tests and determine if the gauge could be shipped for repair.

"RCP also took measurements on December 29, 2009 with a calibrated Victoreen 451 P. The measurements were 70 mR/hr at contact with the outside of the shipping container that held the gauge pieces. It was indicated that the licensee was to call the program [State] on 12/29/09 to report the incident. As of this writing the program is awaiting contact from the licensee.

"The state has an inspector in the area, and will continue to keep the NRC informed of the status of our investigation."

The RCP stated that both sources were recovered, intact, and leak tested satisfactory.

Nevada Event #: NV-01-001

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General Information or Other Event Number: 45599
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: GEORGIA PACIFIC CONSUMER DIVISION
Region: 4
City: CAMAS State: WA
County:
License #: WN-I0228-1
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/30/2009
Notification Time: 19:02 [ET]
Event Date: 12/30/2009
Event Time: [PST]
Last Update Date: 12/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE - STUCK SHUTTER ON FIXED DENSITY METER

The following was received via email:

"A fixed gauge licensee operating a paper mill in Camas, Washington, reported that the shutter mechanism of an Ohmart Vega fixed gauge, Model Number SH-F1B-0, containing a 100 mCi sealed source of Cesium 137 failed to close during a routine six-month shutter check.

"The Radiation Safety Officer reported the gauge is mounted on a vertical section of six-inch piping and is still functioning correctly as a density meter. The device is not part of any lockout or confined space entry permit and there is currently no safety hazard potential for exposure to radiation associated with the failure of the shutter mechanism.

"The environment where the gauge is mounted is susceptible to messy process conditions which allows water and lime-mud to accumulate on the fixed gauge. This appears to have contributed to the failure of the shutter mechanism. The manufacturer's representative was called by the licensee and has scheduled a visit to the facility to make corrective repairs."

Report #: WA090097

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Fuel Cycle Facility Event Number: 45601
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: RANDY SHACKELFORD
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/31/2009
Notification Time: 05:17 [ET]
Event Date: 12/31/2009
Event Time: 05:17 [EST]
Last Update Date: 12/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
CHARLIE PAYNE (R2DO)
EUGENE PETERS (NMSS)
JEROME KETTLES (DHS-)
FUELS GROUP email ()
ELIOTT BRENNER (OPA)

Event Text

TEMPORARILY SUSPEND CERTAIN PROCESS AREAS

A press release is being issued by NFS [Nuclear Fuels Services]. NFS is implementing organizational, facility and management changes that will ensure an even more stringent level of safety controls and processes at the facility. During the implementation, NFS will temporarily stand down certain process areas. NFS developed these changes following consultation with the Nuclear Regulatory Commission (NRC), to ensure that the highest levels of safety commitment, culture and compliance are in place for licensed operational processes. NFS is making these specific changes following a recent NRC review. Suspended operations include production operations, the Commercial Development Line and the down blending facility. These facilities will be brought back on line pending a third-party review and NRC review of the safety improvement implementations. Other areas of the plant will continue to operate.

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Power Reactor Event Number: 45603
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEPHEN SPEIRS
HQ OPS Officer: JOE O'HARA
Notification Date: 01/02/2010
Notification Time: 04:12 [ET]
Event Date: 01/01/2010
Event Time: 23:10 [CST]
Last Update Date: 01/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN GIESSNER (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

DIESEL GENERATOR AUTO START DUE TO FAILED LINE ARRESTOR IN SWITCHYARD

"This report is being made under 10CFR50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in Paragraph (b)(3)(iv)(B) of this section' due to an auto start of the 'A' Standby Diesel Generator.

"The auto start of the 'A' Standby Diesel Generator occurred on a valid bus undervoltage condition caused by a momentary fault on the 161 kV Vinton line. Switchyard inspection revealed a failed 161 kV line arrestor [on] one of the phases of the Vinton line. The 'A' Standby Diesel Generator supply breaker was not required to close onto its respective essential bus as it remained powered from its normal power supply, 1X003 Start-up Transformer, during and after the event. Offsite power remained fully operable during and following the event. The 'A' Standby Diesel Generator has been returned to the standby/readiness condition.

"As designed, the 'A' Emergency Service Water systems auto started when the 'A' Standby Diesel Generator started. The Emergency Service Water systems have been returned to the standby/readiness condition.

"The 'B' Well Water Pump tripped as a result of the electrical transient. The 'A' Well Water pump and 'B' Emergency Service Water pump were manually started by operators in accordance with Abnormal Operating Procedure 408, Well Water System Abnormal Operation.

"The in-service Reactor Water Cleanup pump tripped which removed RWCU from service. The RWCU system has been returned to service.

"The in-service Spent Fuel Pool Cooling pump tripped as a result of the electrical transient. Spent Fuel Pool Cooling has been returned to service. Spent fuel pool temperature rose 0.7 [degrees] F while the pump was out of service.

"All ECCS systems were available before the event and have remained available following the event."

The licensee is not in any Technical Specification LCO's as a result of this event. The in-service Spent Fuel Pool Cooling pump was OOS for approximately 58 minutes.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45604
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ENRICAS VILLAR
HQ OPS Officer: VINCE KLCO
Notification Date: 01/03/2010
Notification Time: 11:52 [ET]
Event Date: 01/03/2010
Event Time: 08:04 [EST]
Last Update Date: 01/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 82 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF CIRCULATORS AFTER UPTAKE OF RIVER ICE

"A manual trip of Salem Unit 2 was initiated due to a loss of 4 circulators due to an excessive uptake of river ice. Strong northwest winds, freezing temperatures and abnormally low tide levels contributed to the ice formation on the river. The operating crew entered EOP-TRIP-A, appropriately transitioned to EOP-TRIP-2 and stabilized the plant at no load conditions (MODE 3 Hot Stand-by).

"All rods fully inserted on the trip and all systems responded as designed with decay heat being removed via the Steam Dump system, with condenser vacuum maintained. All three AFW Pumps auto started due to low Steam Generator level due to closure of 21-23CN27, low pressure feed water heater inlet isolation valves. There were no other significant equipment challenges associated with the reactor trip.

"Salem Unit-2 is currently in mode 3. The Reactor Coolant System temperature is 547 [degrees] F with pressure at 2235 psig [NOT and NOP]. All ECCS and ESF Systems are available and no ECCS systems actuated during the event. No personnel injuries occurred as a result of the trip. [The Unit 2 reactor trip recovery is uncomplicated.]."

Unit 1 power was also reduced to 80%. Although the combination of strong northwest winds, freezing temperatures and an abnormally low tide contributed to the ice formation on the river, operators foresee no further complication due to the ice conditions.

The licensee has notified the NRC Resident Inspector and will notify the States of Delaware and New Jersey.

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