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Event Notification Report for June 21, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/18/2010 - 06/21/2010

** EVENT NUMBERS **


46009 46010 46011 46025 46032

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General Information or Other Event Number: 46009
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: REDACTED
Region: 1
City: REDACTED State: NY
County: REDACTED
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: VINCE KLCO
Notification Date: 06/15/2010
Notification Time: 10:44 [ET]
Event Date: 05/26/2010
Event Time: [EDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL IMPROPER RADIATION DOSE

The following information was received by facsimile:

"A misadministration involving the implantation of radioactive seeds into the prostate (permanent brachytherapy) was reported to [the New York State Department of Health] office on May 28, 2010. The patient, a 58 year old male diagnosed with prostate cancer, Gleason score of 6, PSA of 3.8, was implanted on May 26, 2010. The prescribed dose was 145 Gy, to be delivered using Iodine-125 seeds, with an activity of approximately 0.36 mCi/seed. The patient was implanted with 112 seeds. A significant number of seeds (22) were placed outside the prostate gland, inferior to the gland (5.4 cm) and in the perineum. According to the medical physicist's calculations, the implanted area of the prostate received a D90 of 140 Gy.

"The initial indication is that the misplacement is a result of misidentification of the prostate by the radiation oncologist who performed the procedure. Ultrasound and C-arm fluoroscopy systems were used to aid with positioning the seeds. It appears that the patient's colon was not properly prepared, which caused poor ultrasound imaging. In addition, a Foley catheter was not inserted into the bladder, which made bladder localization difficult. A post implant confirmatory fluoroscopic image was obtained and the radiation oncologist observed that the sources were outside of the prostate area. On May 28, 2010, a post implant CT scan was performed which confirmed the seed locations and allowed for a calculation of the DVH [Dose-Volume Histogram] to the perineum of 10.0 Gy. The medical record has been requested and will be sent out for an expert review."

New York Event Report ID No: NYDOH-10-01

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: 46010
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SHAW
Region: 4
City: HEWITT State: TX
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/15/2010
Notification Time: 12:30 [ET]
Event Date: 05/20/2010
Event Time: [CDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

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

Event Text

TEXAS AGREEMENT STATE REPORT - TWO TRITIUM EXIT SIGNS MISSING

The following information was received via e-mail from the State of Texas Radiation Branch:

"On June 15, 2010, the Agency received a letter from a company operating under a General License in the State of Texas. [While] conducting an inventory of tritium (H-3) exit signs used at their facilities, they found that two signs containing 10 curies each of H-3 were missing from a facility in Hewitt, Texas. The signs were manufactured by SRB Technologies, Inc., Model BetaLux-E. A search of the facility was conducted and interview with the individuals working at the facility were held. The interviews did not provide any information on the location or disposition of the signs. The company is removing all exit signs containing tritium and returning them to the manufacturer to prevent a reoccurrence of the event. Additional information has been requested by this Agency and will be provided when received."

TX Incident # I-8754

* * * UPDATE FROM TEXAS (TUCKER) TO HUFFMAN (VIA E-MAIL) AT 1515 EDT ON 6/15/10 * * *

"The company provided the following information [to the Texas Radiation Branch] during a phone conversation.

"The signs were found to be missing on May 20, 2010. The loss was reported to the Health and Safety Group (HSG) on May 25,2010. The HSG Group incorrectly interpreted the reporting criteria for this event and believed that it only required a 30 day written report. The HSG manager stated that they would change their procedure to insure any future required reports would be done on time."

R4DO (Powers) and FSME (McIntosh) notified.

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: 46011
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: IPSCO KOPPEL TUBULARS CORPORATION
Region: 1
City: KOPPEL State: PA
County:
License #: PA-1049
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/15/2010
Notification Time: 13:52 [ET]
Event Date: 06/14/2010
Event Time: [EDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

PENNSYLVANIA AGREEMENT STATE REPORT - STUCK SOURCE

The following information was received from the Pennsylvania Bureau of Radiation Protection via facsimile:

"The licensee called the PaDEP Southwest Regional Office (SWRO) on the morning of June 14, 2010 to provide a 24-hour verbal notice of a stuck source. The licensee secured the location, and contacted the manufacturer and their consultant for instruction on how to proceed. Equipment appears to have failed to function as designed, thus, the licensee and DEP are doing a 24 hour report per 10CFR30.50(b)(2).

"On June 14, 2010, the SWRO of the Department received verbal notification of a stuck radioactive source. DEP was informed the threaded cap on the end of their cobalt-60 source became stuck within the mold they were checking. The licensee moved the unit to a secure location, roped-off this area, and began to conduct surveys. The manufacturer (Berthold Technologies), along with an outside consultant were contacted for support on recovering the source. We were told the activity of the source is 5.3 millicurie (mCi), but it is not clear if that is a decayed or initial activity. The source information from their license is as follows: Berthold Technologies, source model P2608-100, Co-60 sealed source capsule.

"DEP Central Office is awaiting further details from its Western Regional Office and the licensee's facility staff and consultant to confirm radiation survey measurements and source recovery. It is anticipated that Regional staff will conduct a follow-up inspection. Final even details will be communicated in a NMED report."

PA Report ID: PA-100011

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Power Reactor Event Number: 46025
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: BRIAN FERGUSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 12:04 [ET]
Event Date: 06/18/2010
Event Time: 08:08 [MST]
Last Update Date: 06/18/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
WILLIAM JONES (R4DO)
MIKE CHEOK (NRR)
WILLIAM GOTT (IRD)
ART HOWELL (R4)
JACK GROBE (NRR)
MIKE INZER (DHS)
STEVEN HOLLIS (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 25 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO DAMAGED ENERGIZED EQUIPMENT

"On June 18, 2010, at approximately 0807 MST, a manual turbine trip was initiated due to loss of cooling for Main Transformer X01C. The power supplies for the transformer cooling system was lost due to an inadvertent actuation of the transformer fire protection deluge system. The damage to the energized equipment met the definition for an Emergency Action Level HU 2.2. Based on HU 2.2 the Unit 1 Shift Manager declared a Notification of an Unusual Event (NOUE) at 0808 MST applicable to Palo Verde Unit 1 only.

"The manual trip of the turbine initiated a Reactor Power Cutback Large Load Rejection actuation which was successful. The reactor is stable at 25% with Heat Removal via main feedwater and steam bypass to main condenser. A down power to approximately 12% power is being planned.

"No anomalies were noted during the manual turbine trip. [There is] no release in progress and no safety systems actuations were required."

Palo Verde Unit 1 is in a normal post-trip electrical lineup. State and local authorities have been notified as well as the NRC Resident Inspector.

* * * UPDATE FROM BRIAN FERGUSON TO DONG PARK @ 1333 EDT ON 6/18/10 * * *

The licensee terminated the Unusual Event at 1030 MST. The reactor remains stable at approximately 12% power, and heat removal is via main feedwater and steam bypass to the main condenser.

Notified IRD (Gott), NRR EO (Cheok), R4DO (Jones), DHS (Inzer) and FEMA (Hollis).

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Power Reactor Event Number: 46032
Facility: POINT BEACH
Region: 3 State: WI
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: JOE O'HARA
Notification Date: 06/19/2010
Notification Time: 11:25 [ET]
Event Date: 06/19/2010
Event Time: 06:36 [CDT]
Last Update Date: 06/19/2010
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):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

MANUAL REACTOR TRIP DUE TO GENERATOR LOCKOUT

"At 0636 hours, control room personnel initiated a manual reactor trip of Unit 2 from MODE 2 at 0% power. Just prior to the initiation of the manual reactor trip, an automatic turbine trip had occurred as a result of the receipt of a generator lockout signal. Prior to the automatic turbine trip, an orderly power reduction to 44% power had been completed and the unit was being maintained in a stable condition in MODE 1. At the time of the turbine trip, two sets of condenser steam dump valves were isolated, in preparation for scheduled condenser waterbox tube cleaning. Following the manual reactor trip, all safety systems and equipment operated as expected. The cause of the turbine trip, including receipt of the generator lockout signal, is under investigation. The unit is stable in MODE 3 at normal RCS temperature and pressure.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B) t and 10 CFR 50.72(b)(3)(iv)(A). The NRC Senior Resident Inspector has been notified."

Just prior to the trip, the unit was critical in Mode 2. All rods are fully inserted into the core.

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