United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2010 > January 28

Event Notification Report for January 28, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/27/2010 - 01/28/2010

** EVENT NUMBERS **


45378 45649 45650 45654 45657 45658 45659 45660 45664 45666

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 45378
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/22/2009
Notification Time: 18:32 [ET]
Event Date: 09/21/2009
Event Time: [CDT]
Last Update Date: 01/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT- PATIENT RECEIVED IMPROPER DOSAGE

On September 21, 2009, a patient undergoing mammosite brachytherapy did not receive the proper dose administration due to the Ir-192 (9.6 Ci) source failing to retract. The administering physician retrieved the source from the patient and placed it back in the device. A dose estimate is in progress, however, the licensee does not expect the dosage to exceed 50 percent of the prescribed dose. The afterloader was cleaned recently and the licensee does not expect any debris from the device. The State will report any results of the dose assessment.

Texas Incident Number: #8673

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.

* * * RETRACTION ON 1/27/2010 AT 1703 FROM ANNIE BACKHAUS TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On September 22, 2009, the Agency [Texas Department of Health] was notified of an incident that occurred on September 21, 2009 involving a patient undergoing mammosite brachytherapy. The patient did not receive the proper dose due to the Iridium (Ir)-192 (9.6 Curies) source failing to retract back into the High Dose Rate after-loader unit. The administering physician retrieved the source from the patient and placed it in a shielded container. An investigation by the Agency was performed on September 29, 2009 and it determined that this was not a reportable event because the fractionated dose delivered differed from the prescribed dose, for a single fraction, by less than 50 percent or the total dose for the prescribed treatment differed from that prescribed by less than 20 percent. Because this does not meet the criteria for a reportable medical event, the State of Texas would like to retract this report."

Notified the R4DO (Pick), and FSME (Thaggard).

To top of page
General Information or Other Event Number: 45649
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: JEWISH HOSPITAL OF CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 02120310029
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/22/2010
Notification Time: 15:44 [ET]
Event Date: 01/21/2010
Event Time: [EST]
Last Update Date: 01/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE

The following was received via E-mail:

"On January 22, 2010 the BRP [Ohio Bureau of Radiation Protection] was notified of a medical event that occurred at the Jewish Hospital of Cincinnati on January 21, 2010. The patient received 67% of the prescribed dose to the prostate implant with I-125 seeds. The physician is attempting to contact the patient. The BRP will investigate the event."

The prescribed dose was 144 Gy and the actual dose delivered was 96.48 Gy

Ohio Incident: OH100001

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.

To top of page
General Information or Other Event Number: 45650
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: ENERGY NORTHWEST
Region: 4
City: RICHLAND State: WA
County:
License #: F0953
Agreement: Y
Docket:
NRC Notified By: KELEE ATTEBERY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/22/2010
Notification Time: 18:34 [ET]
Event Date: 12/15/2009
Event Time: [PST]
Last Update Date: 01/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - LOOSE SURFACE CONTAMINATION ON A SEALED SOURCE

"On 12/15/09 an Electron Capture Detector (ECD) containing Ni-63 was discovered to have loose surface contamination in excess of 0.005 microcuries. This discovery was made while removing the ECD from a Gas Chromatograph (GC) used by Energy Northwest. The ECD was removed to prepare the GC for transfer from Columbia Generating Station to the Applied Physics and Engineering Laboratory in Richland, WA. During removal, the ECD was surveyed for loose contamination by Radiation Protection staff. Analysis of the swipes obtained during the survey was completed on 12/17/09 and indicated 0.02 microcuries on the swipe of the makeup gas adapter between the ECD and GC."

Washington State Item: WA100008

Current source activity 12.3 milliCi
ECD model: G2397 A; Serial Number: U2055
GC Model: 6890

To top of page
General Information or Other Event Number: 45654
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NDE INC
Region: 1
City: TAMPA State: FL
County:
License #: 3404-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2010
Notification Time: 10:01 [ET]
Event Date: 01/22/2010
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OCCUPATIONAL OVEREXPOSURE

The following report was received from the State of Florida Bureau of Radiation Control via facsimile:

"Employee's TLD recorded an overexposure of 6.261 rem. Date [of potential overexposure] was between 10 Dec 2009 to 9 Jan 2010. Affected employee claims he left his leather pouch with TLD [and pocket dosimeter] in work bucket over night, second shift used bucket not noticing TLD pouch at bottom. Pocket dosimeter reading was also off scale. Other employees who worked with him during same time period have no excessive exposures. RSO calculates dose should be approximately 195 mr during month as per records. RSO believes [that this exposure is] not an occupational overexposure. RSO contacted Licensing and Materials office on 22 Jan 2010. RSO received Landauer's dosimetry report on 21 Jan 2010. [The State of Florida] Tampa Inspection Office will investigate."

FL report #FL10-009

To top of page
General Information or Other Event Number: 45657
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: TEI ANALYTICAL SERVICES
Region: 1
City: HOUSTON State: PA
County:
License #: 37-28004-02
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/25/2010
Notification Time: 22:09 [ET]
Event Date: 09/23/2008
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE / RADIOGRAPHY SOURCE DISCONNECT

The following information was received via fax:

"Notifications: DEP [Department of Environmental Protection] received a phone call September 24, 2009 about the incident.

"On Wednesday, September 24, 2008 the PA DEP SWRO [Pennsylvania Department of Environmental Protection Southwest Regional Office] received a telephone call from TEI Analytical Services in Washington, PA notifying them of a source disconnect at a facility in Houston, PA. At approximately 1005 pm, Tuesday, September 23, 2008, a 99 curie Ir-192 source became disconnected from the cable while performing radiography on a gas extraction facility along PA Route 519. The source became separated from the guide tube and could not be returned to the camera. The company was notified and sent a rescue team to assist in the recovery and control of the source. No overexposures occurred and the team managed to get the source back into its camera via tongs. This operation was concluded at 12:08am. Doses are as follows: radiographer 51 millirem whole body; assistant 25 millirem; rescue radiographer 42 millirem whole body, 800 millirem extremity; second member of rescue team 160 millirem whole body, no extremity dose. The cause was found to be limitations of the work environment, i.e., the positioning of the exposure device was very limiting and darkness reduced visibility. No modifications in operating procedures to prevent a re-occurrence were mentioned."

Event Report ID No: PA080025

To top of page
General Information or Other Event Number: 45658
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ACUREN
Region: 1
City: ERIE State: PA
County:
License #: PA-1063
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/25/2010
Notification Time: 22:12 [ET]
Event Date: 02/19/2009
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE / RADIOGRAPHY SOURCE DISCONNECT

The following was received from the Commonwealth via e-mail:

"DEP [Department of Environmental Protection] received a letter dated March 9, 2009 from Acuren describing the incident. It was received March 16, 2009.

"Event Description: A technician was performing radiography in Erie, PA (Booth #2) at 8:55am. A few seconds after his fourth exposure, the technician heard the spool piece fall off the table. He immediately tried to retract the source but was unsuccessful. The RSO traveled to the facility, calculated the exposure rates and executed a safe retrieval of the source. He received 35 mrem of exposure during the retrieval. The damaged guide tube was disposed. A 1.75" lead sheet was used to shield the source while the guide tube was reshaped to allow a safe retrieval to the secured position. A whole body dose of 32 mrem was received by retrieval technician.

"Causes of the event: Spool piece was not properly secured in a safe position on the table. Piece was not properly blocked or braced, and located too close to the end of the table, so any movement would result in a fall. The jack stands that were available were not used, nor was shooting the parts on the floor considered. Guide tube and camera were not properly positioned to avoid contact with falling spool piece."

Event Report ID No, PA090016

To top of page
General Information or Other Event Number: 45659
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEATHERFORD INTERNATIONAL
Region: 1
City: ELDERTON State: PA
County:
License #: 42-29288-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/25/2010
Notification Time: 22:21 [ET]
Event Date: 04/18/2008
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING WELL LOGGING SOURCE

The following excerpted information was received via facsimile:

"Notifications: Phone call made to South West Regional Office on April 18, 2009 to notify PA DEP of the situation.

"The PA DEP SWRO [Pennsylvania Department of Environmental Protection Southwest Regional Office] was notified on Friday, April 18, 2008, by Weatherford International, who were doing reciprocity work in western PA, of a leaking well logging source containing 1.5 Ci of Cs-137. A rag used to clean of the tool was surveyed and was found to contain elevated radiation levels. The tool was removed from service and further leak tests were done, confirming the presence of contamination. It was found that the tool was leak tested in March 2008 and found to be contaminated then (at approximately 0.04 microcuries). No reason given why it was kept in service. On Saturday April 19, 2008 all likely areas of contamination were surveyed, with none showing higher than the 0.005 microcuries limit. Weatherford them contacted NSSI of Huston TX, and asked them to verify the test results and to inspect the tool itself. The source was packed and shipped to NSSI in Texas the week of April 20 for evaluation. NSSI conducted surveys and collected wipe samples of the facility before leaving and found no evidence of contamination at the facility other than the known area on the logging unit. The contamination on the logging unit was cleaned and re-wiped and showed no evidence of removable contamination after the clean-up. Urine samples for bioassays were collected from facility employees and sent to GEL Laboratories for analysis. Bioassay results for the employees were returned and showed no evidence of Cs-137 above the minimum detection limit of 10 pCi/L."

Event Report ID No: PA080008

To top of page
General Information or Other Event Number: 45660
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: INTEGRITY TESTLAB
Region: 1
City: CONOCO PHILIPS TRAINER State: PA
County:
License #: PA1181
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/25/2010
Notification Time: 22:30 [ET]
Event Date: 05/18/2009
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - DIFFICULTY RETRACTING GAMMA SOURCE

The following excerpted information was received via facsimile:

"Notifications: A letter dated June 6, 2009 was received by DEP [Department of Environmental Protection] on June 15, 2009 that described the incident.

"Radiography crew was performing their 7th exposure at a location within the FCC Scrubber Unit (PV-7923). Upon completion of the exposure time (2 minutes), the crew attempted to retract the gamma source to its shielded / safe position. It was during the retraction sequence that the crew had difficulty returning the source to the shielded position. Both individuals made several attempts to retract the source. The crew re-established the posted radiation boundary to where the radiation levels were at or below regulatory limits for this situation (2 mR/hr), and implemented their source recovery procedures."

Event Report ID No: PA090025

To top of page
Power Reactor Event Number: 45664
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: THOMAS WAECHTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/27/2010
Notification Time: 07:39 [ET]
Event Date: 01/27/2010
Event Time: 07:30 [EST]
Last Update Date: 01/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
SAM HANSELL (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 POWER TEMPORARILY REMOVED FROM THE EMERGENCY OPERATIONS FACILITY FOR MAINTENANCE

"This is an eight hour report per 10 CFR 50.72(b)(3)(viii). Seabrook Station will be implementing a modification to improve reliability of the electrical system serving the Emergency Operations Facility (EOF). Specifically, the existing manual transfer switch between the backup power diesel generator and the EOF building will be replaced with an automatic transfer switch.

"This work will require that the main power feed to the EOF building be removed for a period of approximately 3 hours today. During this time, a secondary power feed will remain in service which can supply some building loads. A second 3-hour period of 'partial power' may be necessary to complete the job; it is currently anticipated that this second 'partial power' period, if needed, will occur tomorrow, January 28.

"Power to all EOF loads will be available in between the two 3-hour periods discussed above. In addition, should an emergency be declared during one of the 3-hour periods, full power to the facility can be restored within approximately 2 hours. As a compensatory measure, the TSC will perform the key planning standard functions assigned to the EOF during the two 'partial power' time periods should the EOF be unable to do so; this includes offsite dose projections, development of protective action recommendations and offsite notifications. Emergency plan implementing procedures for the TSC contain the instructions necessary for TSC responders to perform functions.

"During the 2-day period that this work is being performed, there will be no backup power source for the EOF.

"All work associated with this switch upgrade will be performed in an expeditious manner consistent with the goal of minimizing EOF unavailability.

"All EOF responders have been briefed on this work and expected contingent actions.

"This job will start at approximately 0730 am this morning. We anticipate that all work will be completed by sometime tomorrow afternoon. We will provide a notification update upon completion of the job."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM MIKE TAYLOR TO JOE O'HARA AT 1738 ON 01/27/10 * * *

"Seabrook station has completed the installation of the automatic transfer switch at the Emergency Operations Facility (EOF). There is no planned work affecting EOF availability."

Notified R1DO(Hansell).

To top of page
General Information or Other Event Number: 45666
Rep Org: SULZER PUMPS INC
Licensee: SULZER PUMPS INC
Region: 1
City: CHATTANOOGA State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOMMY CRAIG
HQ OPS Officer: JOE O'HARA
Notification Date: 01/27/2010
Notification Time: 16:28 [ET]
Event Date: 01/27/2010
Event Time: [EST]
Last Update Date: 01/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MALCOLM WIDMANN (R2DO)
S. PANNIER (EMAIL) (NRR)
J. THORP (EMAIL) (NRR)
O. TABATABAI (EMAIL) (NRO)

Event Text

DEFECT IN PUMP SHAFT JOURNAL COATING CAUSED SERVICE WATER PUMP (2E) FAILURE AT FARLEY NUCLEAR STATION

The following was received via fax:

"1. Name and address of the individual or individuals informing the Commission:
Response: General Manager, Nuclear Services 4126 Caine Lane Chattanooga, TN 37421

"2. Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains defect:
Response: Facility: Farley Nuclear Plant; Basic Component: Unit 2 Service Water Pump (2E)

"3. Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect:
Response: Sulzer Pumps (US) Inc, Chattanooga Nuclear Service Center

"4. Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply:
Response: Defect of pump shaft journal coating resulting in failure of basic component (Service Water Pump 2E) .

"5. The date on which the information of such defect or failure to comply was obtained:
Response: December 5, 2009

"6. In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part:
Response: Sulzer Pumps (US) Inc, Chattanooga Service Center received Farley Purchase Order QP060449 for eleven (11) Service Water Pumps. The following table outlines current status of the pumps on this order:

Serial Number Status Ship Date Location
08C02139 Shipped 12/18/07 Farley
08C02140 Shipped 5/19/08 Farley
08C02141 Shipped 11/5/08 Farley
08C02142 In Manufacturing N/A Sulzer Chattanooga
08C02143 In Manufacturing N/A Sulzer Chattanooga
08C02144 In Manufacturing N/A Sulzer Chattanooga
08C02145 Failed in Plant - Originally Shipped 11/14/06 for evaluation to Sulzer Chattanooga
08C02146 Shipped 8/3/07 Farley
08C02147 Shipped 7/30/08 Farley
08C02148 In Manufacturing N/A Sulzer Chattanooga
08C02149 In Manufacturing N/A Sulzer Chattanooga

"7. The corrective action which has been, is being , or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action:
Response : A joint root cause evaluation has been completed by Sulzer Pumps (US) and Farley. Corrective actions will include replacement parts with updated and corrected design. Sulzer is developing a manufacturing schedule to implement the corrective actions (estimated completion for schedule, 1st Quarter 2010).

"8. Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been. Is being or will be given to purchasers or licensees:
Response: A comprehensive root cause report has been jointly developed and accepted by Sulzer and Farley."

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