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Event Notification Report for July 26, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/23/2010 - 07/26/2010

** EVENT NUMBERS **


46101 46112 46120 46122 46123 46125

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General Information or Other Event Number: 46101
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/16/2010
Notification Time: 15:44 [ET]
Event Date: 07/07/2010
Event Time: [EDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERED FROM THE PRESCRIBED DOSE BY GREATER THAN 50%

The following was received via fax from the Pennsylvania Department of Environmental Protection:

"On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.

"It is believed the medical staff mis-identified the treatment location and the end of the treatment tube was placed 3.5cm short of its intended location. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.

"There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."

PA Report # PA100015

* * * UPDATE FROM DAVID ALLARD TO DONG PARK AT 0936 EDT ON 7/23/10 * * *

The following was received via fax from the Pennsylvania Department of Environmental Protection:

"Due to further information received from the licensee, an amendment is being made to the original sent July 16, 2010, the CAUSE OF THE EVENT has been modified to reflect updated information.

"Event Description: On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.

"CAUSE OF THE EVENT: The applicator was placed correctly by the medical staff as confirmed by MRI but moved 3.5 cm short of its intended location prior to treatment. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.

"ACTION: There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."

Notified R1DO (Doerflein) and FSME EO (Villamar).

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: 46112
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MEADWESTVACO TEXAS LLP
Region: 4
City: SILSBEE State: TX
County:
License #: 01095
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/21/2010
Notification Time: 08:30 [ET]
Event Date: 07/19/2010
Event Time: [CDT]
Last Update Date: 07/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE STUCK SHUTTER

The following was received via fax from the State of Texas:

"On July 20, 2010, the Agency [Texas Department of Health] was notified by the licensee's Radiation Safety Officer (RSO) that while performing a routine test of the shutter on a Ronan Engineering nuclear gauge, the shutter failed to close. The gauge is a model SA-1 serial number 9724 GG containing 10 milliCuries (original activity) of Cesium (Cs) 137 and is used for level detection. The RSO stated that while they were trying to close the shutter, they applied too much pressure to the operating arm, and the operating pin which attaches the arm to the shutter sheared off. The shutter is stuck in the open position, which is the normal operating position for this gauge. The RSO stated that the current radiation level at one foot from the gauge is 0.015 millirem per hour, and presents no additional risk of radiation exposure to any individual. The gauge is located approximately 10 to12 feet off of the ground in an area that is not routinely occupied by individuals. This gauge, along with three additional gauges, are currently only used as a back up system. The RSO believes the gauge was installed in the late 1990s. The RSO stated that they will contact a service provider and either repair the gauge, or dispose of it."

Texas Incident # I-8763

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Power Reactor Event Number: 46120
Facility: HUMBOLDT BAY
Region: 4 State: CA
Unit: [3] [ ] [ ]
RX Type: [3] GE-1
NRC Notified By: BRANDON JORDAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 14:08 [ET]
Event Date: 06/24/2010
Event Time: 12:00 [PDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MICHAEL HAY (R4DO)
PETER HABIGHORST (NMSS)
ILTAB via email ()
This material event contains a "Less than Cat 3" level of radioactive material.

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Decommissioned 0 Decommissioned

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

Event Text

CALIBRATION SOURCE DISCOVERED MISSING DURING INVENTORY

"This is a 30-day notification to inform the NRC of missing licensed material in accordance with 10 CFR 20.2201 (a)(l)(ii).

"On June 24, 2010, while conducting the quarterly inventory of radioactive sources in accordance with Humboldt Bay Power Plant (HBPP) Unit 3 Radiation Control Procedure RCP-6D, 'INVENTORY AND CONTROLS FOR RADIOACTIVE SOURCES,' it was discovered that source number 498 was missing from the count room. This source is for the calibration of gamma detectors, but had not been used for that purpose this year. The source is a filter, mixed gamma source with an activity of 1.025 microCi as of July 1, 2008. The radionuclide mix of the source is as follows:

Gammas/second Activity (Ci) 10 CPR 20 Appendix C (Ci)

Am-241 7.02e+02 5.20e-08 1.00e-09
Cd-109 9.80e+02 7.12e-07 1.00e-06
Co-57 5.10e+02 1.61e-08 1.00e-04
Ce-139 7.10e+02 2.39e-08 1.00e-04
Hg-203 1.61e+03 5.63e-08 1.00e-04
Sn-113 1.01e+03 4.19e-08 1.00e-04
Cs-137 6.29e+02 2.00e-08 1.00e-05
Y-88 2.42e+03 6.99e-08 1.00e-05
Co-60 1.18e+03 3.18e-08 1.00e-06

"The above radionuclide composition yields an aggregate quantity of missing licensed material of 53 times the quantity specified in 10 CFR 20 Appendix C, which exceeds which exceeds the 30-day reporting criterion of 10 times the quantity specified in Appendix C. An extensive search has not been successful in locating the source to date, and thus PG&E is making this 30-day notification in accordance with the requirements of 10 CFR 20.2201(a)(1)(ii).

"PG&E is continuing to investigate the cause of this event using the Technical Review Group (TRG) process and will provide a written report within 30-days in accordance with the requirements of 10 CFR 20.2201(b)(1)(a)."

This material was last accounted for on 4/8/10. The licensee informed NRC Region IV staff.

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: 46122
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: GERARD F. COUTURE
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 16:32 [ET]
Event Date: 07/23/2010
Event Time: 13:27 [EDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
70.74 APP. A - ADDITIONAL REPORTING REQUIREMENTS
Person (Organization):
JONATHAN BARTLEY (R2DO)
PETER HABIGHORST (NMSS)

Event Text

24 HOUR REPORT - DISCOVERY THAT WASTE WATER FILTER PRESS NOT CONFIGURED FOR PASSIVE DESIGN FEATURE

"Facility:

"Westinghouse Electric Company LLC, Commercial Fuel Fabrication Facility, Columbia SC, low enriched (less than or equal to 5.0 wt.% U-235) fuel fabricator for commercial light water reactors. License: SNM-1107.

"Time and Date of Event:

"July 23, 2010, 1:27 p.m. EST

"It was reported to EH&S Management that on July 23, 2010, two filter plates (P1 and P2) in the Integral Fuel Burnable Absorber (IFBA) waste water system filter press were found to be missing pegs utilized in the 'peg-and-hole' passive design of feature SSC-IFBA-MISC-101. The press did not contain more than the allowed four filter press plates. Operations involving the filter press were immediately stopped and EH&S notified of the event by phone and the 'Redbook' reporting system. (Redbook Issue #16126.) The actual configuration remained bounded by the analysis evaluated in the criticality safety calculations and sub-critical margins were not compromised. There was no actual safety consequence to the workers, the public or the environment.

"Notification is made based on 10CFR70 Appendix A (b)(1) 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10CFR70.61.' The potential for an inadvertent criticality event was evaluated in Criticality Safety Evaluation (CSE) CSE-14-C for Miscellaneous Operations in the Integrated Fuel Burnable Absorber Area and the applicable Integrated Safety Analysis for this system.

"The CSE evaluated scenario's addressing the installation of the incorrect number or type of filter plates which had the potential to lead to an inadvertent criticality event. These scenarios were determined to be not-credible. Certain safeguards were identified, including SSC-IFBA-MISC-101, to maintain the basic process design of the system. Failure to identify this sequence event was credible led to that event not being included in the ISA Summary and therefore no Items Relied on For Safety (IROFS) were designated for this accident sequence.

"Immediate Corrective Actions:

"As stated previously, the IFBA area Filter Press operation was shutdown and will remain so until appropriate analysis is completed and IROFS are properly selected and identified.

"Similar Filter Press operations in the Uranium Recovery and Recycle System were shutdown and will remain so until appropriate analysis is completed and IROFS are properly selected and identified.

"This event has been entered into the Facility Corrective Action Process CAPS#10-204-C012."

The licensee will inform the NRC Project Manager.

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Power Reactor Event Number: 46123
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DARRIN GARD
HQ OPS Officer: PETE SNYDER
Notification Date: 07/23/2010
Notification Time: 16:31 [ET]
Event Date: 07/23/2010
Event Time: 08:52 [CDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JONATHAN BARTLEY (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

TEMPORARY OUTAGE OF PUBLIC PROMPT NOTIFICATION SYSTEM DUE TO A BOMB THREAT OFFSITE

"The Siren Control Panel at the Houston County Courthouse was unavailable due to a bomb threat [FNP-0-EIP-8.0, step 13.6.3] which caused a loss to the Public Prompt Notification System (i.e.. Tone Alert Radio system and the Sirens) for greater than one hour. The bomb threat occurred at 0852 [07/23/10] and Houston County Courthouse evacuation was commenced. Farley Nuclear Plant was notified of the bomb threat and subsequent evacuation at approximately 0945 [07/23/10]. The bomb threat resulted in the Houston County Emergency Management Agency (HCEMA) and the Houston County Sheriff's dispatcher to be evacuated, which resulted in the Alert Notification System (ANS) activation consoles being inaccessible.

"The HCEMA office was evacuated at 0915 [07/23/10] and the Houston County Sheriff Dispatcher evacuated at 0925. When Farley Nuclear Plant was notified of the bomb threat, Farley Nuclear Plant Emergency Preparedness personnel were dispatched to the local MET Tower console for ANS actuation (TAR's and Sirens) per approved plant procedures, if required. Farley Nuclear Plant Emergency Preparedness personnel were on station at the MET Tower ANS console at 0959 [07/23/10] with capability to activate the ANS console if required. Farley Nuclear Plant Emergency Preparedness personnel were in contact with HCEMA at 1000 [07/23/10].

"All clear from bomb threat given by Houston County Sheriff's Department and normal access was restored to the HCEMA office at 1100 [07/23/10]. At 1109 [07/23/10] HCEMA notified Farley Nuclear Plant Emergency Preparedness personnel that the HCEMA office was manned and the MET Tower ANS console manning was secured.

"During the time that the HCEMA office was unmanned, Alabama Emergency Management Agency (AEMA) was the notification point for HCEMA and that any decision to activate the ANS console could be made by HCEMA by direction of AEMA and then performed by Farley Nuclear Plant Emergency Preparedness personnel.

"The total length of time that the Alert Notification System was unavailable was 68 minutes. This was based on the bomb threat and evacuation time at 0852 [07/23/10] until Farley Nuclear Plant Emergency Preparedness personnel were in contact with HCEMA at 1000 [07/23/10]."

The licensee notified Alabama and Georgia Emergency Management Agencies as well as Houston County and Early County Management Agencies.

The licensee also notified the NRC Resident Inspector.

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Power Reactor Event Number: 46125
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 17:43 [ET]
Event Date: 07/23/2010
Event Time: 10:00 [CDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
HIRONORI PETERSON (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

Event Text

FITNESS-FOR-DUTY REPORT INVOLVING A NON-LICENSED SUPERVISOR

A non-licensed employee supervisor had a presumptive positive based on a failure to report for a random fitness-for-duty test. The employee's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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