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Event Notification Report for February 22, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/19/2010 - 02/22/2010

** EVENT NUMBERS **


45702 45704 45707 45711 45712 45714 45715

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General Information or Other Event Number: 45702
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY COMMUNITY HOSPITAL
Region: 1
City: TAMPA State: FL
County:
License #: 0549-3
Agreement: Y
Docket:
NRC Notified By: PHIL WEDDING
HQ OPS Officer: PETE SNYDER
Notification Date: 02/16/2010
Notification Time: 16:16 [ET]
Event Date: 02/16/2010
Event Time: [EST]
Last Update Date: 02/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT - MISPOSITIONED DOSE DURING MEDICAL TREATMENT

The following information was received from the State via e-mail:

"The two reported cases are single channel MammoSite patients. The errors resulted from erroneously placing the dwell position approximately 2 to 2.5 cm proximal to the correct position. The error was not noticed until 2/14/10 during a document review for [the second] patient after [the eighth] fraction. The last two fractions for [the second] patient were corrected. It appears that about 50% of the correct treatment volume received at least 50% of the prescribed dose. Some parts of the planned volume received greater than 700%. Also there are volumes that are not included in the planned treatment volume that exceed approximately 300% to 400% of the prescribed dose. The proximal skin received a small sliver of dose at the 125% the prescribed dose.

"First patient's treatment had been completed in January before the error was noticed. Probably 25% of the planned volume received the prescribed dose or higher. Probably 25% of the planned volume received 25% or less than of the prescribed dose. A large volume outside the planned treatment volume exceeded the prescribed dose. The maximum proximal skin dose was at approximately 220% of the prescribed dose. The desired dose was 340 cGy/fx * 10. Both doctors and patients have been notified.

"Health effects, if any, are still being determined. The licensee will send a written report on this incident."

The State of Florida is investigating. The isotope involved is 9.76 Curies of Ir-192.

Florida Incident Number: FL 10-027.

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: 45704
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: GEORGIA PACIFIC CORPORATION
Region: 4
City: MONTICELLO State: MS
County:
License #: MS-188-01
Agreement: Y
Docket:
NRC Notified By: DANNY BRANGLEY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/16/2010
Notification Time: 17:16 [ET]
Event Date: 02/11/2010
Event Time: [CST]
Last Update Date: 02/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF FIXED GAUGE SHUTTER MECHANISMS TO CLOSE

The following excerpted information was received via e-mail:

During shutter checks performed by the licensee, it was discovered that four of their fixed gauge shutter mechanisms were unable to be closed. The following is information on those gauges: (1) Berthold, Model LB-7440-D, source SN FR288, Cs-137, 30 mCi; (2) Berthold, Model LB-300-L, source SN 1080/1-05-98, Co-60, 1.16 mCi; (3) Berthold Model LB-7440-D, source SN 1080/2-05-98, Co-60, 1.65 mCi; and (4) Berthold, Model LB-7442-D, source SN 2572-8-90, Cs-137, 250 mCi. On gauge 1 the shutter handle broke off. On gauges 2, 3, and 4 the shutter stuck open. The licensee has requested service from the gauge manufacturer.

Mississippi Incident Number: MS-10002.

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General Information or Other Event Number: 45707
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH-STRATA, INC.
Region: 4
City: MURRIETA State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/17/2010
Notification Time: 18:52 [ET]
Event Date: 02/12/2010
Event Time: [PST]
Last Update Date: 02/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
TERRENCE REIS (FSME)
MEXICO (via)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was received via e-mail:

"A CPN moisture density gauge (model MC3, serial # M330506989) was reported to have been stolen over the recent four day weekend from a construction site in Hesperia, between Main St. and Smoke Tree Lane. The gauge was reportedly taken with the transportation container, which was secured inside a locked construction trailer. The RSO believed that the authorized user had locked the transportation container [prior to] the period during which the gauge was stolen.

"The [theft of the] gauge was reported to the Hesperia Police in San Bernardino County. The RSO was informed by RHB [Radiologic Health Branch] that a reward should be offered for the return of the gauge. The RSO indicated he would discuss posting of a reward with the company insurance carrier."

The gauge contains a 10 mCi Cs-137 gamma source and a 50 mCi Am-241/Be neutron source.

California Incident No: 5010-021710


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: 45711
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GARY ROBERTS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/19/2010
Notification Time: 11:33 [ET]
Event Date: 02/19/2010
Event Time: 11:11 [EST]
Last Update Date: 02/19/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JONATHAN BARTLEY (R2DO)
JOHN THORP (NRR)
JEFFERY GRANT (IRD)
BRUCE BOGER (NRR)
VICTOR McCREE (R2 R)
DHS (VEST)
FEMA (BLAN)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

UNSUAL EVENT DUE TO CARBON DIOXIDE DISCHARGE IN THE HIGH PRESSURE COOLANT INJECTION (HPCI) ROOM

The licensee reported that a CO2 discharge has occurred in the Unit 1 HPCI room. The cause and amount of CO2 released is not specifically known but the licensee judged that the room was not currently habitable based on the CO2. The licensee consequently declared an Unusual Event (UE) under EAL HU3.1 - "Toxic, Corrosive, Asphyxiant, or Flammable Material in Amounts That Could Adversely Impact Plant Operations. "

The licensee stated that activities were in progress in the room at the time of the discharge. There is no indication of a fire in the room and there were no personnel injuries as a result of the discharge. The discharge also had no impact on plant operation. The licensee at this point plans to terminate the UE when the room is properly ventilated.

The licensee has notified State and local authorities and the NRC Resident Inspector and does not plan a press release.

* * * UPDATE FROM GARY ROBERTS TO DONG PARK @ 1354 EST ON 02/19/10 * * *

At 1330 EST on 2/19/10, the Unusual Event was terminated. The atmosphere in the HPCI room is back to normal. The CO2 source was from cylinders located in the HPCI room which is part of the fire suppression system.

The licensee has notified the NRC Resident Inspector. Notified IRD (Grant), R2DO (Bartley), NRR EO (Thorp), DHS (Vestal) and FEMA (Fuller).

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Other Nuclear Material Event Number: 45712
Rep Org: SIKORSKY AIRCRAFT CORPORATION
Licensee: SIKORSKY AIRCRAFT CORPORATION
Region: 1
City: STRATFORD State: CT
County:
License #: 06-02269-03
Agreement: N
Docket:
NRC Notified By: STEVE MAYO
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/19/2010
Notification Time: 12:10 [ET]
Event Date: 01/22/2010
Event Time: 14:30 [EST]
Last Update Date: 02/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
TODD JACKSON (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB (via email) ()

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

Event Text

LOST NUCLEAR GAS LEAK DETECTOR

On January 22, 2010, the Radiation Safety Officer discovered two missing Leakmeter 200 gas leak detectors during an inventory inspection. The Leakmeter 200 is manufactured by USON and each contain a 10 mCi Ni-63 source. After investigating the incident, one of the employees believes that these leak detectors were sent to a scrapping facility back in September of 2009. The licensee believes that the sources have been disposed of properly and does not pose a safety threat to the public.

#1 Leakmeter Serial number/Source number: 2002053/977502
#2 Leakmeter Serial number/Source number: 2002054/977506

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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Power Reactor Event Number: 45714
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEON RAFNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/19/2010
Notification Time: 18:12 [ET]
Event Date: 02/21/2010
Event Time: 08:00 [PST]
Last Update Date: 02/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEOFFREY MILLER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown
3 N Y 100 Power Operation 100 Power Operation

Event Text

PLANNED POWER OUTAGE AT PRIMARY EMERGENCY OPERATIONS FACILITY (EOF)

"Southern California Edison has planned work scheduled for the San Onofre Emergency Operations Facility (EOF), for Sunday, February 21, 2010. The work is being done in order to replace a faulty circuit breaker and will result in area lighting being out in the building from approximately 0800 through 1600. During the time that the lighting is out, the EOF will be considered non-functional. Should conditions occur that would merit activation, EOF responders would be directed to the alternate EOF located in Irvine, CA.

"This planned EOF outage is being reported in accordance with 10 CFR 50.72(b)(3)(xiii).

"The licensee has notified the NRC Resident Inspector."

* * * UPDATE FROM TOM SIMMONS TO DONG PARK AT 2042 EST ON 2/21/2010 * * *

"Follow up phone call to one made on 2/19/10 regarding planned power outage at normal EOF. Commenced 1145 [PST] today (2/21); restored 1715 [PST]."

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Miller)

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Power Reactor Event Number: 45715
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TIM HOLLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/20/2010
Notification Time: 03:49 [ET]
Event Date: 02/19/2010
Event Time: 21:45 [CST]
Last Update Date: 02/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GEOFFREY MILLER (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

Event Text

SPECIFIED SYSTEM ACTUATIONS DUE TO LOSS OF THE 'A' SAFEGUARDS TRANSFORMER

"At 2145 CST on 2/19/2010, the Callaway Plant experienced a loss of switchyard bus 'A'. This resulted in a loss of off site power to 'B' train vital 4160 volt bus NB02. Technical specification LCO 3.8.1 was entered. The 'B' train emergency diesel generator started and the shutdown sequencer actuated for bus NB02. 'B' motor driven auxiliary feed water pump, 'B' centrifugal charging pump, and both 'A' and 'B' essential service water pumps started. The turbine driven auxiliary feed water pump actuated, and steam generator blowdown and sample isolation occurred. 'A' train offsite vital power and emergency diesel generator were available. The actuations that occurred were consistent with the loss of one vital AC train. All emergency systems responded as expected with the exception of steam generator blowdown valve BMHV0002 which was manually isolated when it failed to fully close.

"The loss of switchyard bus 'A' was due to a fault on the 'A' safeguards transformer. The faulted transformer has been isolated, and switchyard bus 'A' was reenergized at 0132 on 2/20/2010. The 'B' train vital 4160 volt bus NB02 was tied to offsite power at 0222 on 2/20/2010, and the 'B' emergency diesel generator was secured at 0233 on 2/20/2010. Technical specification LCO 3.8.1 was exited.

"Currently the plant is at 100% power.

"The licensee has notified the NRC Resident Inspector."

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