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Event Notification Report for May 24, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/21/2010 - 05/24/2010

** EVENT NUMBERS **


45909 45933 45936 45943 45944 45945 45946 45947

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General Information or Other Event Number: 45909
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: H&H X-RAY SERVICES, INC
Region: 4
City: RINGOLD State: LA
County:
License #: LA-2970-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 05/07/2010
Notification Time: 09:10 [ET]
Event Date: 04/26/2010
Event Time: 12:00 [CDT]
Last Update Date: 05/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK/DAMAGED RADIOGRAPHY SOURCE

Received this report from the State of Louisiana via facsimile:

"On April 26, 2010, at a temporary job site a field crew was performing an X-Ray on a pipeline when the X-Ray source could not be returned to the shielded position. Using their survey meters, the crew determined the source was exposed and could not be retrieved. They called the Assistant Radiation Safety Officer who came and did a source retrieval and [received] a 150 mrem exposure. With the source shielded, the licensee transported the camera to QSA Global in Baton Rouge, LA for analysis. The equipment was a Sentinel, model 660B, S/N 82187, loaded with 69.5 Ci of Ir-l92, S/N 60611B. QSA Global observed the source and performed further evaluation. The results were that the weld on the source cracked and the capsule was catching on the exit port of the camera. QSA Global put out a recall for that particular lot of sources and forwarded the damaged camera to QSA Global in Burlington, MA."

This event is Louisiana report # LA1000004

* * * UPDATE FROM JOHN SUMARES TO CHARLES TEAL VIA FAX AT 1054 ON 5/21/10 * * *

This report was received from the Commonwealth of Massachusetts via facsimile:

"On May 3, 2010 an agency [Commonwealth of Massachusetts Bureau of Radiation Protection] inspector visited QSA Global in response to this event. The inspector observed the route cards for all 6 sources from this production lot of the problem source assembly, serial number 60611B, manufactured for H and H X-Ray of Louisiana only. All 6 sources were returned to QSA Global for analysis and the other 5 sources were found to be properly welded and wipe testing of all 5 sources indicated no sources were leaking. In addition, wipe test of the problem source indicated this source was not leaking. [The] inspector also observed the next day's test weld which was analyzed and deemed acceptable prior to welding sources for the next days source production.

"[The] inspector observed the outer encapsulation of the source that caused this event. The outer capsule laser weld was not completed along the weld joint, but slightly below the weld joint, thus the capsule was not properly welded. At the time of manufacture, leak testing (vacuum bubble test) of the problem sources weld did not reveal an improperly welded capsule. The inner capsule was properly welded and sealed, Thus the leak test (wipe test) did not reveal contamination. QSA Global ascertained that human error allowed the improperly welded outer capsule to pass the vacuum bubble test. QSA assembled a test outer encapsulation in the same manner as the problem source (i.e. an improper weld, located below the weld joint) and found that the vacuum bubble test easily detects that the capsule was not properly welded. QSA Global committed to submit a final report to the agency within a few weeks."

Notified R4DO (Pick) and FSME (McIntosh).

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General Information or Other Event Number: 45933
Rep Org: NV DIV OF RAD HEALTH
Licensee: ST MARY'S REGIONAL MEDICAL CENTER
Region: 4
City: RENO State: NV
County:
License #: 16-12-0244-02
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: ERIC SIMPSON
Notification Date: 05/17/2010
Notification Time: 14:58 [ET]
Event Date: 05/16/2010
Event Time: [PDT]
Last Update Date: 05/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
KEITH McCONNELL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL RADIATION UNDERDOSE

The following report was received via email from the State of Nevada:

"On March 16, 2010, during a prostate Brachytherapy procedure, 112 sources of I-125 (Model I125-SL[NIST 99]), were implanted into the prostate. The activity of each source was 0.342mCi. Total prescribed dose was 145 Gy. When the patient returned for follow-up, 1 to 2 months after the implant, CT images were imported into the treatment planning system and a post-plan was created to assist in quality assurance, to determine the actual dose to the prostate and to review the overall quality of the implant.

"When the post-plan was created for this patient and reviewed, it was determined that the dose to the prostate was approximately 114 Gy, which was 79% of the prescribed dose. This exceeds the +/- 20 % limit set in 10 CFR 35.3045. The physician was notified and the dosimetry reviewed. The lower dose was in the middle, close to the urethra where there is a desire for dose sparing. The higher doses were on the periphery of where the dose was intended. Following normal protocol, the patient's blood work will be monitored to observe his PSA levels. The referring physician was contacted on May 14, 2010. The patient has not been informed.

"Contributory Factors:
Though not known as to why the dose was lower than prescribed, it appears that the seeds were implanted more in the periphery probably due to a desire to spare the urethra. This could have been due to the urethra-gram performed during surgery.

"Consequences:
The physician is of the opinion that the therapy will still be effective since the seeds were implanted where statistically the cancer resides. The patient's blood work will be monitored regularly and additional therapy given, if necessary.

"Corrective measures:
Care will be taken to ensure that the sources are evenly distributed throughout the prostate in the future. It was the physician's desire to spare the urethra. It will be under the discretion of the physician as to how to implant the prostate and still deliver the desired prescribed dose.

"Notification:
The patient's plan/dosimetry was presented to the Physicist and the Physician on May 13, 2010 at 3.00 p.m., the State of Nevada Radiation Control Program was contacted by phone on May 14, 2010 at 9.00 a.m."

This is NV event #NV100010.

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: 45936
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DRILLING SPECIALTIES COMPANY
Region: 4
City: CONROE State: TX
County:
License #: L04825
Agreement: Y
Docket:
NRC Notified By: ANNIE BACHAUS
HQ OPS Officer: JOE O'HARA
Notification Date: 05/19/2010
Notification Time: 16:27 [ET]
Event Date: 05/19/2010
Event Time: 13:30 [CDT]
Last Update Date: 05/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
JAMES DANNA (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

"On May 19, 2010 at 1620 CDT the agency [State of Texas] received a phone call from the licensee. The licensee stated that shutter on a fixed gauge had stuck at approximately 1700 CDT on May 18, 2010. The gauge houses a 50 milliCurie Cesium (Cs) - 137 source. The licensee stated that shutter failed in the open position, the normal operating position for the gauge, and that exposure rates in the area were normal. The gauge is located high above the ground, on the side of a water tank. The licensee stated that they had contacted the manufacturer and have scheduled a repair of the gauge within the next 30 days. The licensee stated that they were going to continue to use the gauge, as it was in its normal operating state. The agency reminded the licensee that their license specifically states that they are to take the gauge out of operation if it is in need of repair, and should they continue to use the gauge, they would need to request an exemption from the agency. The licensee agreed to request the exemption so that they would not be in violation of their license."

The gauge is a Ronan Gauge S/N 936GG.

Texas I - 8743

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Power Reactor Event Number: 45943
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEE KELLY
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/21/2010
Notification Time: 18:48 [ET]
Event Date: 05/21/2010
Event Time: 13:20 [PDT]
Last Update Date: 05/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG PICK (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION TO CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

"On May 19, 2010, at approximately 1730 PDT, San Onofre Nuclear Generating Station (SONGS) was notified that scrap bushings from breakers in the Unit 2 switchyard had alarmed a radiation monitor at a metal recycling facility in Los Angeles County. The metal recycling vendor (Alpert and Alpert) shipped the bushings back to a Southern California Edison (SCE) facility in Orange County. On May 21, 2010, SONGS completed isotopic analysis of a sample of ceramic shards from six randomly selected bushings. The analysis confirms the presence of naturally occurring radionuclides (uranium and thorium series), but does not indicate the presence of licensed radioactive material.

"On May 21, 2010, at approximately 1320 PDT, SONGS confirmed that on May 19, 2010, the metal recycling vendor had called the Brea branch of the California Department of Public Health, Radiologic Health Branch (Andrew Taylor) to obtain a special permit authorizing the return shipment to SCE. SONGS is, therefore, reporting this event in accordance with 10CFR50.72(b)(2)(xi) as an event related to the health and safety of the public for which notification to another government agency has been made.

"At the time of this report, both Unit 2 and Unit 3 were operating at 100 percent power.

"The NRC Senior Resident Inspector has been notified of this occurrence and will be provided with a copy of this report. "

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Power Reactor Event Number: 45944
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WES DANIEL
HQ OPS Officer: JOE O'HARA
Notification Date: 05/21/2010
Notification Time: 22:57 [ET]
Event Date: 05/21/2010
Event Time: 19:37 [EDT]
Last Update Date: 05/21/2010
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):
DEBORAH SEYMOUR (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON TURBINE TRIP

"At 1937 Eastern Daylight Saving Time (EDT), Watts Bar Nuclear Power Plant Unit 1 experienced a reactor trip due to a turbine trip. This caused an automatic AFW Pump start from P-4 coincident with Lo Tave signal. The cause of the turbine trip has not yet been identified, and is under investigation.

"The plant is stable and is being maintained in Mode 3, at normal operating pressure and temperature, with steam generator and pressurizer levels normal.

"Plant systems responded to return the plant to a stable condition without complication, and all systems performed as expected with one exception:

"The 'B' Motor Driven Auxiliary Feedwater Backpressure Control Valve failed closed, but the Steam Driven Auxiliary Feedwater Pump provided sufficient feedwater so that all Steam Generators were provided sufficient feedwater to maintain cooling and normal steam generator level.

"Plans for plant restart are pending awaiting the cause investigation.

"All control rods inserted into the core. Plant decay heat removal is through the steam dumps to the main condenser. Offsite power is available and lined up to plant system loads.

"Watts Bar [NRC] Resident Inspector has been notified of this event."

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Power Reactor Event Number: 45945
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOSHUA SPALTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/22/2010
Notification Time: 17:46 [ET]
Event Date: 05/22/2010
Event Time: 16:45 [EDT]
Last Update Date: 05/22/2010
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):
MARIE MILLER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF STEAM GENERATOR WATER LEVEL CONTROL

"The licensee experienced a feedwater transient which initiated the event. All safety systems are available. All control rods fully inserted. The electrical lineup is normal. The decay heat path is through the condenser steam dumps. No relief valves or safety valves lifted during the transient. Primary plant temperature is 533 degrees Fahrenheit and primary plant pressure is 2256 psia. The licensee is investigating the cause of the feed transient.

"The licensee notified the NRC Resident Inspector, the Waterford Dispatch, and the State Department of Environmental Protection."

Earlier, the licensee was experiencing oscillations in the feedwater regulating valve (FRV) for the #2 steam generator when the valve was in automatic control. Troubleshooting planning was underway but no troubleshooting activities were in progress at the time of the trip. When the operator placed the #2 steam generator FRV in manual control, the steam generator water level began to increase and could not be recovered. The operator then manually tripped the reactor prior to reaching the high steam generator level trip setpoint. An Auxiliary Feed Water system actuation did occur during the transient. The trip and plant response was considered uncomplicated.

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Power Reactor Event Number: 45946
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICK LULLING
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2010
Notification Time: 19:10 [ET]
Event Date: 05/22/2010
Event Time: 16:34 [CDT]
Last Update Date: 05/22/2010
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):
DEBORAH SEYMOUR (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF STEAM GENERATOR WATER LEVEL CONTROL

"Unit 2 was operating at 100% power in the normal operating procedure, FNP-2-UOP-3.1, Power Operation, when multiple alarms were received associated with 2C Steam Generator (S/G) level, and a process cabinet failure. The control room team noticed there was no power or control capability on the 2C S/G Feedwater Regulating Control Valve (FRV), and 2C S/G level was decreasing. The control room team attempted to take manual control of the 2C FRV, which did not respond. The reactor was manually tripped when 2C S/G narrow range level reached 40%. The automatic trip set point for S/G level is 28%. All systems responded properly for the reactor trip and there were no complications.

"The investigation indicates there was an Nuclear Controller Driver (NCD) card failure in Process Control Cabinet 8. The controller card controls the 2C S/G FRV controller, which prevented any automatic, or manual control of the 2C S/G FRV, or 2C S/G level."

There were no safety or relief valves that lifted and decay heat is being removed via steam dump control valves. Auxiliary feedwater pumps are maintaining level in the steam generators. Electrical lineup is normal.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45947
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: AL MANNING
HQ OPS Officer: PETE SNYDER
Notification Date: 05/23/2010
Notification Time: 21:52 [ET]
Event Date: 05/23/2010
Event Time: 16:30 [EDT]
Last Update Date: 05/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

NONFUNCTIONAL TECHNICAL SUPPORT CENTER VENTILATION

"The Technical Support Center (TSC) ventilation system was found to be non-functional on 5/23/10 at 1630 EDT. The system repair was complete at 1747 EDT on 5/23/10. The time period that the TSC ventilation system was non-functional exceeded the 30 minute time limit that is delineated in the Technical Requirements Manual section T 3.10.1. This event is reportable per 10 CFR 50.72 (b)(3)(xiii) as described in NUREG 1022 Rev. 1 since this issue affected an emergency response facility. Also, this 8 hour notification is being made in accordance with the Technical Requirements Manual section T 3.10.1.B.2.

"The alternate TSC facility remained functional during this entire time period."

The licensee notified the NRC Resident Inspector.

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