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Event Notification Report for July 29, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/28/2010 - 07/29/2010

** EVENT NUMBERS **


46117 46119 46121 46124 46126 46133 46135 46136

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General Information or Other Event Number: 46117
Rep Org: NV DIV OF RAD HEALTH
Licensee: WEST VALLEY IMAGING
Region: 4
City: HENDERSON State: NV
County:
License #: 03-12-0384-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/22/2010
Notification Time: 13:30 [ET]
Event Date: 07/21/2010
Event Time: 12:00 [PDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

"Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.

"Reported to the Nevada Radiation Control Program at around 3:00 p.m.

"The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too.

"Persons involved: Pediatric patient, mammography technician and nuclear medicine technician.

"Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures.

"Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient.

"Isotope Details: Tc-99m: 24.0 mCi.

"Procedure administered: MIRALUMA study.

"Dose intended: 17.5 mCi of Tc-99m

"Dose Administered: 24.0 mCi of Tc-99m

"Target organ: Breast

"Patient Informed: N

"% Dose Exceeds Prescribed: 37

"Diagnostic Study: Breast (MIRALUMA study)

"Radiopharmaceutical: Tc-99m MIRALUMA

"Effect on Patient: UNKNOWN

"Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM

"Manufacturer: Cardinal Health PSC

"Model Number: 190"

Nevada Report No.: NV100011

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: 46119
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: UNIVERSITY OF NEW MEXICO
Region: 4
City: ALBUQUERQUE State: NM
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL ORTIZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 13:13 [ET]
Event Date: 07/21/2010
Event Time: 15:00 [MDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT INVOLVING LESS THAN PRESCRIBED DOSE

The following information was received from the State of New Mexico via email:

"Medical Event was reported 7/23/2010 at 8:39 am by the Radiation Safety Specialist, UNM Radiation Safety Office.

"Location: UNM Nuclear Medicine Department
1801 Tucker Avenue
Albuquerque, NM 87131

"Medical Event: 7/21/2010 at 3:00 pm, patient written directive order to receive Iodine-131 Therapy treatment 200 mCi (NaI), patient received 80 mCi.

"A detailed report will be supplied to State of New Mexico Radiation Control Bureau by UNM RSO within 15 days."

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: 46121
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SHARON COATINGS
Region: 1
City: SHARON State: PA
County:
License #: PA-G0320
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 14:54 [ET]
Event Date: 07/22/2010
Event Time: [EDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

The following information was received from the State of Pennsylvania via fax:

"Event location: Sharon Coatings

"Event Type: Shutter Failure

"Notifications: A call from the licensee was received July 23, 2010 @ 1410 by the Department of Environmental Protection explaining the event. This falls under 24 hour reporting under 10CFR31.2 and 30.50(b)(2).

"Event Description: It was discovered on July 22, 2010 at 15:30 that during a calibration of an ESC Resources (Model #NDS-200, Serial #20938), by the vendor the shutter was stuck open. Vendor was able to make repairs and restore shutter. The device is currently in use. Vendor checked all other gauges and found one other (Model #SH-5000, Serial #80209B), to be stuck as well. Vendor restored both to operational use.

"CAUSE OF THE EVENT: Equipment failure

"ACTIONS: Both devices have been repaired and restored back to operation"

PA Event Report ID No.: PA100017

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General Information or Other Event Number: 46124
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: IBA MOLECULAR NORTH AMERICA
Region: 4
City: DALLAS State: TX
County:
License #: 06174
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 07/23/2010
Notification Time: 16:59 [ET]
Event Date: 06/09/2010
Event Time: [CDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)
PETER HABIGHORST (NMSS)

Event Text

AGREEMENT STATE REPORT - HIGHER THAN EXPTECTED DOSE RATE

The following information was received from the State via e-mail:

"On July 16, 2010, the Agency [Texas Department of State Health Services] was notified by the licensee that they had received notification from their dosimetry processor that an employee's badge had exceeded an annual exposure limit. The event was sent to the Nuclear Material Events Database on July 21, 2010. On July 23, 2010, the licensee reported that while conducting their investigation into the overexposure event, they found that an arrival survey conducted on June 9, 2010, exceeded the allowable limit for a type Yellow II package.

"The survey was on receipt of a package containing 494 milliCuries of Fluorine (F) - 18 and indicated that the package was reading 47 milliRem per hour at 1 meter. The dose rate on contact exceeded the measuring capabilities of their instrument. The Service Manager opened the package and found that a vial of F-18 had separated from its shielding. The vial was removed from the package by the Service Manager and taken to an appropriate storage location. A removable radioactive contamination survey was conducted on the package and found to be within the acceptable limits.

"The shipper has been notified of the event. This Agency will provide additional information as it is received."

Texas Incident #: I-8762

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General Information or Other Event Number: 46126
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: BURGESS ENGINEERING AND TESTING
Region: 4
City: MOORE State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 07/24/2010
Notification Time: 16:22 [ET]
Event Date: 07/24/2010
Event Time: 11:00 [CDT]
Last Update Date: 07/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

On 7/24/10, after doing work in Oklahoma City, an employee of the licensee put a Troxler Model 3440 moisture density gauge in the back of a pick-up truck. The gauge was in its locked case and was locked with a single chain to the truck.

When the employee arrived at his destination he found that the gauge was missing. The employee did not notice anything unusual while driving. The licensee searched the route traveled with no results. During the search the licensee informed the police of the missing gauge. The licensee will offer a reward for the proper return of the gauge.

The State of Oklahoma is investigating and is formulating a notice to the media on the incident.

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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Power Reactor Event Number: 46133
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: RONALD KELMENSON
HQ OPS Officer: ERIC SIMPSON
Notification Date: 07/28/2010
Notification Time: 16:32 [ET]
Event Date: 07/28/2010
Event Time: 09:45 [PDT]
Last Update Date: 07/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVID PROULX (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 OF A SULFURIC ACID SPILL

"On Wednesday, July 28, 2010, at about 0945 PDT, Southern California Edison (SCE) determined that a spill of a total of about 110 gallons of sulfuric acid had occurred from two different locations earlier in the same day. All the acid was contained within the chemical berms around the acid transfer pumps in the Unit 3 intake area at the 9 foot level and the 30 foot level caustic berm. No acid was released to the environment.

"At 1050 PDT, SCE initiated notification to the San Diego County Department of Environmental Health (Report # 10-063463), the California Emergency Management Agency (CalEMA) (Report # 10-4518) and the National Response Center (Report # 949176). Notifications were completed by 1100 PDT.

"SCE is making this notification in accordance with 10CFR50.72(b)(2)(xi). "

The NRC Senior Resident Inspector has been notified.

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Power Reactor Event Number: 46135
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: TODD CREASY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/28/2010
Notification Time: 17:45 [ET]
Event Date: 07/28/2010
Event Time: 17:00 [EDT]
Last Update Date: 07/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JOHN ROGGE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 94 Power Operation 94 Power Operation

Event Text

FITNESS FOR DUTY REPORT

A licensed operator was determined to have violated the licensee's Fitness for Duty Policy related to self-reporting a legal action. The employee's access to the Protected Area has been revoked. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 46136
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PRESTON LAWSON
HQ OPS Officer: VINCE KLCO
Notification Date: 07/28/2010
Notification Time: 19:04 [ET]
Event Date: 07/28/2010
Event Time: 14:22 [CDT]
Last Update Date: 07/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID PROULX (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

THREE AUXILIARY FEEDWATER (AFW) TRAINS DECLARED INOPERABLE

"At 1422 CDT, while operating in MODE 1 at approximately 100% rated thermal power (RTP), Wolf Creek Generating Station (WCGS) entered Technical Specification 3.7.5, 'Auxiliary Feedwater (AFW) System,' Condition D for three AFW trains inoperable. The AFW pumps are equipped with recirculation lines to prevent pump operation against a closed system. The recirculation line for each pump combines into a common header that flows to the condensate storage tank (CST). The common recirculation line transitions from safety-related to non-safety related at the AFW to CST pipe tunnel. During a review of the system design information, it was identified that a seismic event or tornado could result in damage to this portion of the recirculation line and thereby restrict or block the recirculation flow causing pump damage.

"TS 3.7.5, Required Action D.1, requires the immediate initiation of action to restore one AFW train to OPERABLE status. The Note to Required Action D.1 specifies that LCO 3.0.3 and all other LCO Required Actions requiring MODE changes are suspended until one AFW train is restored to OPERABLE status. The plant remains in MODE 1 at approximately 100% RTP with activities that could lead to the need to maneuver the plant being suspended.

"WCGS personnel are developing an evaluation to support the OPERABILITY of the AFW trains with the reliance on compensatory measures as an interim action until final corrective action to resolve the condition are completed.

"The NRC Resident Inspector has been notified."

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