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Event Notification Report for July 14, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/13/2010 - 07/14/2010

** EVENT NUMBERS **


46074 46078 46081 46086 46089 46090 46091

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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.

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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

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General Information or Other Event Number: 46081
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ALLIANCE ENGINEERING
Region: 4
City: FORT WORTH State: TX
County:
License #: 05889
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/09/2010
Notification Time: 12:07 [ET]
Event Date: 07/09/2010
Event Time: [CDT]
Last Update Date: 07/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)
MEXICO VIA FAX ()
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The following was received via email from the state of Texas:

"On July 9, 2010, the Agency [Texas Department of Health] was notified by the licensee that one of their technicians had reported that a moisture/density gauge had been stolen from his truck that morning. The gauge is a Humboldt model 5001 EZ (serial # 4438) containing a 40 millicurie Americium (Am) 241 source, and a 10 millicurie Cesium (Cs) 137 source. The technician had completed testing on concrete rebar and returned to his truck. He found the tailgate down and the two locked chains used to secure the gauge in the truck bed had been cut. The gauge and additional equipment were missing. The technician searched the area for the gauge and when he could not find it, contacted the company Radiation Safety Officer (RSO). The RSO stated that the truck was parked in a position where the technician could not see it while he was performing his testing. The RSO contacted Local Law Enforcement and informed them of the event. A reward will be offered for the gauges return. The RSO stated that he will have the technician provide a written report, which he will forward to this Agency [Texas Department of Health]. Additional information will be provided as it is received in accordance with Reporting Material Events - SA-300."

Texas Incident #: I-8761

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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Fuel Cycle Facility Event Number: 46086
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JOE O'HARA
Notification Date: 07/12/2010
Notification Time: 17:58 [ET]
Event Date: 07/12/2010
Event Time: 12:00 [EDT]
Last Update Date: 07/12/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MALCOLM WIDMANN (R2DO)
DAVID PSTRAK (NMSS)
FUELS GRP via email ()

Event Text

ELECTRICAL FAULT DISABLED PUBLIC ADDRESS SYSTEM WHICH SUPPORTS VARIOUS ALARM ANNUNCIATORS

"At approximately 1200 hours (EST) on 7/12/2010, an electrical fault was identified in the fire alarm system. This fault disabled the public address portion of the system which supports annunciation of plant alarms including the following: fire alarm, criticality alarm, take-cover alarm, [carbon dioxide] discharge alarms. Trouble shooting of the problem is continuing. There is no impact to actual detection, suppression, etc. systems. Compensatory measures include the following: stop SNM handling and movement, fire patrols, restriction of hot work, notification to facility personnel, evacuation of nonessential personnel from production areas, fire brigade on standby and radios provided to fire brigade officers and some fire brigade members.

"It is believed that the condition was associated with heavy rainfall and possible water intrusion.

"There were no actual safety consequences to workers, the public, or the environment associated with the event. Potential consequences to workers, the public, or the environment are mitigated by compensatory measures."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46089
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DEAN BRUCK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/13/2010
Notification Time: 08:15 [ET]
Event Date: 07/13/2010
Event Time: 08:10 [EDT]
Last Update Date: 07/13/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BILLY DICKSON (R3DO)

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

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 0810 EDT on Tuesday, July 13, 2010, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems have been removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance is scheduled to be completed by 1800 EDT on Tuesday, July 13, 2010.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DEAN BRUCK TO CHARLES TEAL ON 7/13/10 AT 1730 EDT * * *

"The TSC ventilation system maintenance was completed satisfactorily and the system was restored to service at 1730 EDT."

Notified R3DO (Dickson).

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Other Nuclear Material Event Number: 46090
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 1
City: FAYETTEVILLE State: NC
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: JOE O'HARA
Notification Date: 07/13/2010
Notification Time: 18:00 [ET]
Event Date: 07/02/2010
Event Time: 08:00 [EDT]
Last Update Date: 07/13/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(4) - FIRE/EXPLOSION
Person (Organization):
JUDY JOUSTRA (R1DO)
BILLY DICKSON (R3DO)
KEVIN HSUEH (FSME)
WILLIAM GOTT (IRD)

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

Event Text

FIRE INVOLVING TWO CHEMICAL DETECTION DEVICES CONNTAINING NICKEL-63

An electrical fire consumed a wooden building at Ft. Bragg, NC which housed two chemical detection devices. The first device was an Advanced Chemical Detection Alarm (M22) which contained 20 milliCuries of Ni-63 and the second device was an Improved Chemical Agent Monitor (ICAM) which contained 10 milliCuries of Ni-63. The SSDR numbers for these devices are NR0155-D-125-S and NR0155-D-103-S, respectively. The building was destroyed and the area is covered with a foot of ash. The fire department has not been able to find the devices, and they do not know the configuration of the material. The area is secured and the base RSO is sampling the area for loose surface contamination material.


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: 46091
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MEYERS
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/13/2010
Notification Time: 22:21 [ET]
Event Date: 07/13/2010
Event Time: 17:07 [CDT]
Last Update Date: 07/13/2010
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

CONTAINMENT OVERPRESSURE NOT ENSURED IN THE APPENDIX R ANALYSIS

"A review of the Appendix R analyses conducted as part of the transition to National Fire Protection Association (NFPA) 805 indicates a potential for the loss of Containment Overpressure (COP) if drywell cooling is not secured or due to fire induced spurious operation of certain primary containment isolation valves. During all Appendix R scenarios, the plant is analyzed to conduct post fire plant cool down with the MSIVs closed, and with Torus cooling provided by the Residual Heat Removal (RHR) system. Based on current design basis calculations, should the containment be depressurized due to a 'smart fire' adequate Net Positive Suction Head (NPSH) may not be available to support Residual Heat Removal (RHR) pump operation during an Appendix R fire event. The design calculations credit COP during Appendix R fire events to provide adequate NPSH to the RHR pumps, as Torus temperature may reach approximately 217 degrees, with a corresponding containment pressure of approximately 10 psig.

"There are five scenarios identified where a potential exists for COP loss. One or more of these scenarios could affect several Appendix R analysis areas. The loss of COP could affect safe shutdown capability during an Appendix R fire event. This condition is being reported under 10 CFR 50.72 (b)(3)(ii) as a condition that results in the plant being in an unanalyzed condition which significantly degrades plant safety.

"Hourly fire patrols have been established for the susceptible fire areas that do not contain both fire detection and suppression equipment. This includes several areas of the reactor and control buildings.

"This issue is a noncompliance with the current design basis, and does not result in the inoperability of any Technical Specification nor Technical Requirements Manual systems."

The licensee has notified the NRC Resident Inspector.

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