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Event Notification Report for May 4, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/03/2010 - 05/04/2010

** EVENT NUMBERS **


45747 45876 45881 45894 45896

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45747
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID HURT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/05/2010
Notification Time: 16:32 [ET]
Event Date: 03/05/2010
Event Time: 13:25 [CST]
Last Update Date: 05/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHUCK CAIN (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

UNANALYZED CONDITION - STEAM SUPPLY VALVE CREDITED AS CLOSED IN FSAR ANALYSIS IS NORMALLY OPEN DURING OPERATIONS

"Valve FBV0147, Boric Acid Batch Tank Auxiliary Steam Supply Isolation Valve, is credited with being closed in the Callaway FSAR. This eliminated the need to analyze lines FB-081-HBD and FB-082-HBD for high energy line breaks (HELB). However, FBV0147 was found to be kept normally open to allow steam service for the boric acid batching tank. This is contrary to the normal position assumed in the FSAR and HELB analyses.

"With valve FBV0147 open, the lines must considered high energy lines. The lines are in the auxiliary building and they traverse rooms containing several components including the flow transmitters for Residual Heat Removal (RHR) to train `A' accumulator injection supply header, RHR train `A' and 'B' SIS hot leg recirculation supply header, and several safety related auxiliary feedwater components. These instruments are used to provide indications during post-accident conditions. This configuration is therefore outside of current HELB analysis and potentially represents a condition that significantly degrades plant safety.

"The condition was identified to Operations at 0740. Valve FBV0147 was closed at 0810. At 1325 CST, the issue was determined to be reportable.

"The NRC Resident Inspector has been notified."

* * * RETRACTION AT 1557 EDT ON 5/3/10 FROM HURT TO HUFFMAN * * *

"On 03/05/2010, EN #45747 provided notification that valve FBV0147 was found to be kept normally open to allow steam service for the boric acid hatching tank. This configuration was not consistent with the normal position assumed in the FSAR and HELB analyses.

"An engineering evaluation was subsequently performed for the auxiliary steam inlet and outlet piping for the boric acid batching tank. This valuation identified four postulated break locations which have all been analyzed. The analyses determined that all safety-related components in the affected rooms would be able to perform their safety functions in the event of a line break. Pipe whip, jet impingement, compartment temperature and over pressurization, flooding, and internal missiles resulting from a postulated line break would not prevent any safety-related equipment from performing its design function.

"As supported by this evaluation, this condition does not meet the criteria for an unanalyzed condition that significantly degrades plant safety as stated in 10 CFR 50.72(b)(3)(ii)(B). Therefore, the notification made on 03/05/2010 is hereby retracted.

"The NRC Resident Inspector will be notified."

R4DO (Farnholtz) notified.

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General Information or Other Event Number: 45876
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MARY BIRD PERKINS CANCER CENTER
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2651-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/27/2010
Notification Time: 12:04 [ET]
Event Date: 03/15/2010
Event Time: 07:30 [CDT]
Last Update Date: 04/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

RADIATION UNDERDOSE AT PRESCRIBED LOCATION

The following information below is a summary of a facsimile provided by the State of Louisiana Department of Environmental Quality concerning a reported medical event:

"A medical event occurred involving a patient under treatment for adenocarcinoma of the prostate gland. The patient involved received a prostate brachytherapy implant on March 12, 2010, using radioactive iodine-125 seeds [95 seeds of I-125 were implanted at 0.322 mCi/seed].

"The radiation oncologist with the assistance of the urologist inserted the needles through the appropriate holes in the needle template. During the procedure, the radiation oncologist used the ultrasound to guide the needle placement. However, the radiation oncologist and ultrasound technologist had difficulty seeing the balloon location (indicating the prostate base) clearly on the sagittal view of the ultrasound during the dispensing of the seeds from the needles. It was felt that it was possible that the patient may have moved during the procedure which may have caused the balloon and ultimately the base plane to have shifted.

"A variance was suspected by the radiation oncologist after reviewing the post implant seed count x-ray. The patient was called to return for an early post-implant CT on March 22, 2010 to confirm the implanted seed locations. Using these images, a treatment plan was constructed using the treatment planning system's post-plan software. Based on this postoperative plan, it has been estimated that the entire implanted volume was shifted approximately 3.0-cm inferiorly, resulting in D90% of 12.88 Gy (dose that covers 90% of the prostate volume outlined on the post implant CT images). The prescription dose was 145.0 Gy. The post-implant planning results were referred to the Radiation Safety Committee (RSC) for review. After review, the RSC decided to interpret the implant as a medical event. This decision was made based on the fact that the V100 (volume of the prostate that received 100% of the prescribed dose) was less than 50% and the event classification was felt to be that of a wrong site.

"The information provided to the patient was that a treatment delivery inaccuracy occurred on March 15, 2010. The radiation oncologist explained to the patient that the dose delivered was not as planned and that supplemental treatment is recommended to treat his prostate cancer. A waiting period is recommended to allow the sources to decay and to determine any possible complications."

Louisiana Report # LA100003

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: 45881
Rep Org: NV DIV OF RAD HEALTH
Licensee: ROBINSON NEVADA MINING COMPANY
Region: 4
City: RUTH State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: PETE SNYDER
Notification Date: 04/29/2010
Notification Time: 16:31 [ET]
Event Date: 04/29/2010
Event Time: 07:45 [PDT]
Last Update Date: 04/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
JAMES DANNA (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON GAUGES FAILS TO FUNCTION

The following was received via email:

"While doing the shutter checks it was discovered that the shutters were inoperable on the following fixed gauges:

"Serial #1015GK, Cs-137, 50 mCi, Source holder SR-A, at the Pump House North Train;

"Serial #1017GK, Cs-137, 50 mCi, Source holder SR-A, at the Pump House Center Train.

"Density gauges are installed on the piping going to the tails impoundment. The pipes are in the pump house and are not readily accessible. [An] Ohmart representative will be there on 5/5/10 for the necessary repairs.

"All personnel have been briefed about the safety implications. The area has been cordoned off. No concerns of exposure to anyone. This is an ongoing investigation."

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Other Nuclear Material Event Number: 45894
Rep Org: WALTER REED ARMY MEDICAL CENTER
Licensee: WALTER REED ARMY MEDICAL CENTER
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01738-02
Agreement: N
Docket:
NRC Notified By: ANDREW SCOTT
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2010
Notification Time: 11:27 [ET]
Event Date: 05/01/2010
Event Time: 12:49 [EDT]
Last Update Date: 05/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
WILLIAM COOK (R1DO)
ANGELA MCINTOSH (FSME)

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

Event Text

MISPLACED RADIOACTIVE MATERIAL

On 5/1/10, at 1249 EDT, a 2 Ci Mo-99 generator was delivered to the Walter Reed Army Medical Facility. An unauthorized person signed for the package and stored it in an improper location. On the evening of 5/1/10, the health physicist did not know the location of the package, because it was supposed to be delivered earlier in the day. The package was located at 0815 EDT on 5/3/10 at the facility. The licensee has now stored the package in proper location and is in process of conducting a dosage calculations for any individuals who may have been in the vicinity of the package where it was improperly stored.

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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Other Nuclear Material Event Number: 45896
Rep Org: FOLA COAL COMPANY, LLC
Licensee: FOLA COAL COMPANY, LLC
Region: 1
City: BICKMORE State: WV
County:
License #: 47-25325-01
Agreement: N
Docket:
NRC Notified By: JOE RICHARDS
HQ OPS Officer: ERIC SIMPSON
Notification Date: 05/03/2010
Notification Time: 15:29 [ET]
Event Date: 04/30/2010
Event Time: 12:00 [EDT]
Last Update Date: 05/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
WILLIAM COOK (R1DO)
JAMES DANNA (FSME)

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

Event Text

SOURCE HOLDER MALFUNCTION

On Friday, April 30, 2010, at approximately 1200 EDT, while replacing sources in a Gamma-Metrics Model 2000 Bulk Material Analyzer, it was discovered that the right side source holder had dropped three Cf-252 sources back into the stored and shielded position. Two of the three sources have been recovered, but one remains in the body of the instrument inside the safe and shielded compartment. Exposure rate measurements have been taken and no exposure or safety hazards exist. Efforts to retrieve the remaining source will continue on May 6, 2010.

Each Cf-252 source is 0.8 micrograms, which is approximately 4.3 mCi in activity.

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

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