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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/12/2010 - 07/13/2010
** EVENT NUMBERS **
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| General Information or Other |
Event Number: 46071 |
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: IREDELL MEMORIAL HOSPITAL
Region: 1
City: STATESVILLE State: NC
County:
License #: 049-0412-2
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: DONG HWA PARK |
Notification Date: 07/06/2010
Notification Time: 11:17 [ET]
Event Date: 05/05/2010
Event Time: [EDT]
Last Update Date: 07/06/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ANGELA MCINTOSH (FSME) |
Event Text
AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED
The following information was received from the State of North Carolina via email:
"On 05/05/10, a physician at Iredell Memorial Hospital (NC License 049-0412-2) performed a prostate seed implant procedure. The prescribed dose was 1440 cGray (~1440 REM). After the seeds were implanted, they did a scan and discovered a seed in the urethra. They removed the seed and it was part of a strand of four seeds.
"On 05/19/10, the patient returned for a follow-up and had an additional strand of three seeds. The patient said the seeds had come out during urination about a week before.
"The patient went through the post-implant CT scan. On 07/02/10, the post-dose calculations were performed. The D-90 actual dose (dose to 90% of the mass) was calculated as 77% of the prescribed dose.
"The hospital has made the notification [to the North Carolina Division on Radiation Protection] and is attempting to make the physician and patient notification. A report will be prepared and delivered within 15 days."
State Event No.: NC 10-32
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. |
| Hospital |
Event Number: 46074 |
Rep Org: WEST VIRGINIA UNIVERSITY HOSPITAL
Licensee: WEST VIRGINIA UNIVERSITY HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: NASSER RAZMIANFAR
HQ OPS Officer: MARK ABRAMOVITZ |
Notification Date: 07/07/2010
Notification Time: 11:37 [ET]
Event Date: 01/20/2010
Event Time: [EDT]
Last Update Date: 07/07/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE |
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ANGELA MCINTOSH (FSME) |
Event Text
MEDICAL TREATMENT TERMINATED PRIOR TO ADMINISTERING FULL DOSE
A patient's liver was being treated using SIR-Spheres through a catheter. During the administration of the Y-90 SIR-Spheres, the physician believed that there was leakage around the stopper and halted the medical procedure with only 21.9 mCi administered instead of the complete dose of 30.7 mCi i.e. 71% of the prescribed dose. The manufacturer was notified of the potential manufacturing defect and the hospital was directed to ship the delivery apparatus (as is) back to the manufacturer after the Y-90 had decayed. The equipment was returned to the manufacturer on April 5, 2010 and a report was received from the manufacturer on June 21, 2010. "The manufacturer noted that there was leaking but could not conclude that it was a manufacturer defect or if the physician applied too much pressure to the V-vial during the procedure." The patient was notified of the dose received.
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. |
| General Information or Other |
Event Number: 46078 |
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: POLYMER GROUP INC
Region: 1
City: WAYNESBORO State: VA
County:
License #: 1031
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: DONG HWA PARK |
Notification Date: 07/08/2010
Notification Time: 15:25 [ET]
Event Date: 07/08/2010
Event Time: [EDT]
Last Update Date: 07/09/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
KEVIN HSUEH (FSME)
ILTAB VIA EMAIL () |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
AGREEMENT STATE REPORT - MISSING THICKNESS GAUGE
The following information was received from the Commonwealth of Virginia via email:
"On July 8, 2010 the licensee reported a missing thickness gauge, NDC Model 103, serial number 3794. The gauge contains a 150 milliCurie Americium-241 sealed source. The gauge had been in storage for several years and was last visually verified in March 2010. It was discovered to be missing on the morning of July 8th. The licensee stated that the original labels were on the gauge and that the gauge housing was intact. The licensee has initiated a site search and has conducted interviews with personnel."
Event Report No.: VA-10-05
* * * UPDATE FROM MICHAEL WELLING TO CHARLES TEAL ON 7/9/10 AT 1559 * * *
"On July 9, 2010 a Radiation Safety Specialist from the Virginia Radioactive Materials Program performed an investigation at Polymer Group, Inc.'s site. During the investigation, a radiation survey of the storage location was performed which indicated 20 mrem/hr. Further investigation revealed that the spring on two NDC 103 gamma gauges shutters were not properly working, thus leaving the shutter open. The shutters were placed in their closed position and tape secured over them to ensure their position. A lock was placed on the storage cabinet to ensure further security of the remaining gauges. Polymer Group, Inc. is working with a licensed broker for proper disposal of the remaining 5 gauges. A visual inspection of the facility was performed and all employees were questioned. The gauge remains lost at this time."
Notified R1DO (Dimitriadis) and FSME EO (Hsueh).
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 |
| Power Reactor |
Event Number: 46084 |
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL BURWINKEL
HQ OPS Officer: PETE SNYDER |
Notification Date: 07/12/2010
Notification Time: 03:37 [ET]
Event Date: 07/12/2010
Event Time: 03:40 [EDT]
Last Update Date: 07/12/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
MALCOLM WIDMANN (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
PLANNED TECHNICAL SUPPORT CENTER OUTAGE
"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance being performed on the TSC HVAC.
"Alternate facilities are available to provide emergency response functions and actions are proceeding to return the TSC to FUNCTIONAL status with high priority. A 10CFR50.54 (q) evaluation has been performed for this planned maintenance activity."
The licensee notified the NRC Resident Inspector. |
| General Information or Other |
Event Number: 46085 |
Rep Org: ROSEMOUNT NUCLEAR INSTRUMENTS, INC.
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC.
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DUYEN PHAM
HQ OPS Officer: STEVE SANDIN |
Notification Date: 07/12/2010
Notification Time: 10:57 [ET]
Event Date: 07/12/2010
Event Time: [CDT]
Last Update Date: 07/12/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH |
Person (Organization):
TAMARA BLOOMER (R3DO)
JUDY JOUSTRA (R1DO)
PART 21 via email () |
Event Text
PART 21 REPORT FOR CERTAIN MODEL 3051N PRESSURE TRANSMITTERS
Pursuant to 10 CFR Part 21, section 21.21 (b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you that a limited number of Model 3051N pressure transmitters listed in the attachment may exhibit non-linear and non-repeatable performance. The affected transmitters were shipped from RNII between August 12, 2002 and September 27,2006.
1.0 Name and address of the individual providing the information;
Mr. Marc D. Bumgarner
Vice President & General Manager
Rosemount Nuclear Instruments, Inc.
8200 Market Boulevard
Chanhassen, MN 55317
2.0 Identification of items supplied:
Certain Model 3051N pressure transmitters identified in the attachment.
3.0 Identification of firm supplying the item:
Rosemount Nuclear Instruments. Inc.
8200 Market Boulevard
Chanhassen, MN 55317
4.0 Nature of the failure and potential safety hazard;
The Model 3051N Smart Pressure Transmitter is dedicated for nuclear use consistent with the requirements of 10 CFR Part 21. It is qualified for use in safety related applications per IEEE 323-1983 (mild environment) and IEEE 344À1987 for seismic applications as documented in its associated qualification reports.
Procurement and production records indicate that 53 Model 3051N pressure transmitters (Ranges 1, 2 and 3) manufactured between August 2002 and September 2006 have sensor module castings that were not solution annealed, and therefore may contain elevated levels of hydrogen in the sensor module fill fluid. Solution annealing is a heat treatment process for castings. It is used to homogenize the casting by reducing any segregated elements that include carbon, which can greatly reduce corrosion resistance. This process also reduces the level of mobile hydrogen in the casting to a point where out gassing is no longer a reliability concern.
Elevated levels of hydrogen in the sensor module casting can create a reliability concern because mobile hydrogen can diffuse through the metal into the sensor module fill fluid and may eventually reach gas solubility limits of the fill fluid. When this occurs, gas vapor bubbles may form, primarily under vacuum process conditions, resulting in a sensor output shift. A transmitter with hydrogen bubbles in the sensor module fill fluid will annunciate
itself by exhibiting non-linear and non-repeatable performance.
To date, RNII has not received any 3051N field returns for this issue. However, there have been two confirmed failures related to this issue on a commercially available Rosemount product using the identical sensor module casting. Additionally, there have been other confirmed failures related to this issue on a commercially available Rosemount product using a similar, but not identical casting. These commercial grade product returns
prompted additional internal testing and analysis that indicated a potential reliability concern on 3051N transmitters that were manufactured with non-solution annealed module castings.
As a result, a thorough evaluation was completed and a notification about the potential substantial safety hazard identified on 7/1/10 is being made in accordance with 10 CFR Part 21 to customers that purchased a 3051N pressure transmitter from the potentially affected population.
5.0 The corrective action which is taken, the name of the individual or organization responsible for that action, and the length of time taken to complete that action:
- The last shipment of a 3051N transmitter With a non-solution annealed sensor module casting was September 2006.
- Following September 2006, all sensor module castings utilized on the 3051N have been solution annealed.
- Procurement drawings for the module castings have been reviewed and the requirement to solution anneal all module castings for a model 3051N transmitter has been verified.
- Model 3051N pressure transmitters affected by this notification may be returned to RNII for replacement at no charge.
6.0 Any advice related to the potential failure of the item:
The end user is advised to determine the impact of this potential reliability issue upon its plant's operation and safety, and take action as deemed necessary. Affected transmitters may be returned to RNII for replacement at no charge.
Rosemount Nuclear Instruments, Inc. is committed to the nuclear industry and remains dedicated to the supply of high quality products to our customers. If you have any questions, or require additional information related to this issue, please contact: [REDACTED].
The attachment provided with this notification identified pressure transmitters delivered to the following power plants: Vermont Yankee (U.S.), Krsko (Slovenia), Santa Marie de Garona (Spain), Kuosheng Nuclear Power Station (Taiwan), and Ulchin 5 and 6 facilities (Korea). |
| Power Reactor |
Event Number: 46087 |
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WALTER MILLER
HQ OPS Officer: JOE O'HARA |
Notification Date: 07/12/2010
Notification Time: 18:31 [ET]
Event Date: 07/12/2010
Event Time: 13:10 [CDT]
Last Update Date: 07/12/2010 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION |
Person (Organization):
MALCOLM WIDMANN (R2DO) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
Y |
100 |
Power Operation |
100 |
Power Operation |
Event Text
HPCI INADVERTENTLY ISOLATED DURING TESTING
"On 07/12/10 at 1310 CDT, while performing 2-SR-3.3.6.1.2(3B), High Pressure Coolant Injection (HPCI) System Steam Supply Low Pressure Functional Test, HPCI inadvertently isolated. The cause of isolation is unknown with an]investigation in progress. HPCI has been returned to standby readiness.
"This incident is reportable as an 8-hour ENS notification under 10CFR 50.72 (b)(3)(v) as any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. It also requires a 60 day written report.
"The NRC Resident Inspector has been notified." |
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