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Event Notification Report for September 15, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/14/2010 - 09/15/2010

** EVENT NUMBERS **


46182 46224 46236 46239 46245 46250 46251

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46182
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEON RAFNER
HQ OPS Officer: JOE O'HARA
Notification Date: 08/17/2010
Notification Time: 13:56 [ET]
Event Date: 08/17/2010
Event Time: 03:00 [PDT]
Last Update Date: 09/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEOFFREY MILLER (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

Event Text

UNANALYZED CONDITION DUE TO POTENTIAL WIRING DISCREPANCY

"On August 16, 2010, at about 0100 PDT, SONGS Unit 2 Train 'A' Emergency Diesel Generator (EDG) 2G002 was removed from service for planned maintenance. Train 'A' EDG is the Appendix R protected Train.

"At about 1545 the same day, Southern California Edison (SCE) discovered a potential wiring discrepancy in the electronic governor. At 0300 on August 17, 2010, SCE determined two wires on a fire isolation fuse were confirmed to be terminated differently than specified in plant drawings and that the discrepancy would prevent the fuse and associated fire isolation switch from performing its Appendix R fire isolation function for the Train 'A' EDG. In accordance with NUREG-1022, Rev. 2, SCE is reporting this occurrence in accordance 10CFR50.72(b)(3)(ii)(B).

"While the incorrect wiring impacted the Appendix R qualifications of the Train 'A' EDG, it did not impact its other design functions and the EDG was capable to fulfill its safety function for all other Design Basis Events. Therefore, SCE considers the safety significance of the condition to be minimal.

"In accordance with LCS specification 3.7.113.1 Condition A, SCE will implement hourly Fire Watches for the impacted plant areas until such time that the wiring on the Unit 3 Train 'A' Emergency Diesel Generator 3G002 is conformed to be correct or has taken actions to correct any wiring discrepancy. An evaluation will be conducted to determine the cause of this condition.

"At the time of this occurrence, Unit 2 and Unit 3 were both at 100% power."

"The NRC Resident Inspector will be notified of this occurrence and will be provided with a copy of this report."

* * * RETRACTION FROM KELMENSON TO KLCO ON 9/14/10 @ 1528 [EDT]* * *

The licensee is retracting the event based on the following:

"Upon further investigation, SCE determined the suspected wiring discrepancy was only an issue with an elementary diagram that was used for circuit verification. SCE had already flagged this elementary diagram as requiring revision and a change to the diagram was pending and had not been released to the field. The fire isolation fuse was wired correctly."

"Consequently, SCE is retracting the 8-Hour Telephone Notification made to the NRC on August 17, 2010 (Event Log No. 46182)."

"The NRC Resident Inspector will be notified of and will be provided with a copy of this retraction."

Notified the R4DO (Clark)

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Hospital Event Number: 46224
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: VRINDA NARAYANA
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/02/2010
Notification Time: 13:30 [ET]
Event Date: 08/30/2010
Event Time: 14:00 [EDT]
Last Update Date: 09/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MISPLACED PALLIATIVE SOURCE IMPLANTS

On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus.

More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants.

The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark.

No long term complications are anticipated.

Both patient and physician have been informed.

* * * UPDATE AT 1330 EDT ON 09/14/10 FROM VRINDA NARAYANA TO S. SANDIN * * *

The licensee is updating this report to provide the results of the normal tissue doses from the permanent implants at the end of the treatment plan to the following organs:

Bladder: Prescribed .07 Gy - Delivered 3.75 Gy
Seminal Vesicles: Prescribed 5.38 Gy - Delivered 25.17 Gy
Prostate: Prescribed 6.24 Gy - Delivered 4.2 Gy
Rectum: Prescribed 45.18 Gy - Delivered 3.16 Gy

The above information will be provided in the 15-day written report. Notified R3DO (Hills) and FSME (Burgess).

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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Hospital Event Number: 46236
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERAN AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS E. HUSTON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 14:00 [ET]
Event Date: 09/08/2010
Event Time: [CDT]
Last Update Date: 09/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL DOSE DIFFERENT THAN PRESCRIBED DOSE

The following information was received by e-mail from a program manager with the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA), National Health Physics Program (NHPP):

" [The VHA is] notifying the NRC of 11 medical events at G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi. These medical events occurred for Iodine-125 permanent prostate seed implant brachytherapy.

"As historical information, 10 medical events were reported to NRC on earlier dates for prostate seed implants at this medical center under NRC Event Report No. 44522.

"Following up on those medical event reports, VHA initiated a comprehensive external review and reanalysis of post-treatment dose parameters for all prostate seed implants performed at the medical center.

"Upon evaluation of updated dose information generated by the external review, medical center staff, working with NHPP, discovered on September 8, 2010, that 11 additional medical events need to be reported.

"10 of the 11 events were based on updated D90 values (considered to be final values) for the planned treatment site being 80% or less than the prescribed dose. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(1)(i).

"1 of the 11 events was based on absorbed dose to a tissue other than the treatment site exceeding the expected dose by 50% or more. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(3).

"As additional information, medical center staff, working with NHPP, has determined that 4 of the 10 previously reported medical events under NRC Event Number 44522 could be retracted because updated D90 values (considered to be final values) from the external review are above 80% of the prescribed dose. If retraction of these 4 events is pursued, NHPP will discuss the dose information with NRC Region III prior to notifying the NRC Operations Center of the retractions.

"NHPP will ensure that the medical center follows NRC requirements for notification of the referring physician and patient for these medical events. The patients involved in the medical events have been tracked by the medical center and the clinical outcomes for the patients have been verified to be consistent with expected clinical outcomes for successful prostate seed implants.

"A 15-day written report of these medical events will be submitted to NRC Region III.

"[The VHA] will notify the NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events.

"In summary, [VHA is] confirming a total of 17 medical events for the medical center. 11 medical events are reported today (10 based on a low dose to treatment site; 1 based on elevated dose to other organs and tissues). 6 medical events were reported previously under NRC Event No. 44522. 4 of the 10 medical events previously reported under NRC Event No. 44522 no longer meet criteria as medical events and might later be retracted.

"Additional Information:

"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.

"VHA permit number of permittee involved in event: Permit No. 23-08786-01."

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: 46239
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TTM TECHNOLOGIES
Region: 4
City: SAN DIEGO State: CA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RON YONEMITSU
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 18:45 [ET]
Event Date: 09/09/2010
Event Time: 14:50 [PDT]
Last Update Date: 09/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
JACK FOSTER (FSME)

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

Event Text

MISSING TRITIUM EXIT SIGN

The following information was received by e-mail:

"[The licensee] reported that during demolition work by their Maintenance Staff a wall with a tritium exit sign was demolished and the debris was removed from the facility.

The manufacturer of the sign is Safety Light. [The licensee] will investigate the model of the sign that was installed.

[The licensee] confirmed that the debris has left their facility as waste.

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: 46245
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: JELD-WEN WOOD FIBER OF OREGON
Region: 4
City: KLAMATH FALLS State: OR
County: KLAMATH
License #:
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/10/2010
Notification Time: 17:29 [ET]
Event Date: 02/22/2010
Event Time: [PDT]
Last Update Date: 09/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE REPORT - BROKEN FIXED GAUGE SHUTTER

The following information was received via facsimile:

"Jeld-Wen Wood Fiber of Oregon located in Klamath Falls possesses 5 fixed gauges at their wood door manufacturing facility.

"In late December 2009, the Radiation Protection Services [RPS] office [State of Oregon] received a phone call from [the Jeld-Wen] Maintenance Manager, who talked to [the] RPS Licensing Manager and stated that he wished to report that there were two gauges at their facility that were having shutter mechanism problems. [The Maintenance Manager] stated he would elaborate on the issue in an email.

"On February 22, 2010, [the Maintenance Manager] emailed [the RPS Licensing Manager] and stated that the gauge with the broken shutter mechanism (Ronan, model SA-8, serial M2119, 20 mCi Cs-137, high level indicator gauge, installed 12-15-88) was operating in the open shutter position and unable to close. [The Maintenance Manager] stated that the licensee had manufactured a 1.5" thick shutter (by approximately 8 inches wide by approximately 1 meter long) that fits between the gauge and the vessel it is attached to. He also stated that this gauge is in a restricted access area that is roped off and the closest area of worker frequency is 20 feet away. [The Maintenance Manager] stated that the other gauge with the 'sticking' shutter (Ronan, model GS-200, serial 3401, 50 mCi Cs-137, digester level indicator, installed 12-15-88) is closable and is also operating. He stated that he would be scheduling a repair for the 50 mCi gauge and would be evaluating whether a replacement will be needed for the 20 mCi gauge.

"On March 15, 2010, [the Maintenance Manager's] email to [the RPS Licensing Manager] was given to [an RPS employee] in radioactive materials licensing. From [the RPS Licensing Manager's] email, another staff member may be working on this incident. [The RPS employee] phoned [the Maintenance Manager] and found that this was an event possibly not entered into the system but he would check with materials inspectors to see if that was the case. [The Maintenance Manager] stated that he was scheduling for repair of the 50 mCi gauge and possibly the 20 mCi gauge but not sure of the latter. [The Maintenance Manager] also stated that he would be submitting an amendment request naming him as Radiation Safety Officer.

"On May 21, 2010, [the RPS employee] requested an update on the repairs/actions by the licensee for the two gauges. No response was received.

"On June 9, 2010, [the Maintenance Manager] phoned [the RPS employee]. He stated that the company did not have the fiscal ability to replace the 20 mCi gauge and asked if the company could continue operating the gauge for approximately 2 more years. [The RPS employee] stated that the SS&D sheet would have to be reviewed as well as an onsite inspection of the gauge.

"On June 23, 2010, [the RPS employee] reviewed the SS&D for the 20 mCi device. For a 500 mCi Cs-137 source, exposure rates with the shutter open were listed as 43 mR per hr at 2 inches, 4.3 mR per hr at 1 foot, and 0.6 mR per hr at 1 meter. At 4 percent of maximum activity allowed, the 20 mCi source located in a restricted access area using 1 meter distance should give an exposure rate of approximately 300 microR per hr maximum. It was also determined that an inspection would be made of the facility in Klamath Falls in late July [in order] to verify exposure rates around the gauge with the shutter open.

"On July 27, 2010, an inspection of the facility was performed by [another employee of RPS]. [This other RPS employee] determined exposure rates around the 20 mCi gauge to be approximately 100 microR per hr at 1 meter. [This other RPS employee] also noted that the gauge is located at or below the catwalk that accesses that area. The licensee was allowed to continue operation with the shutter. [The other RPS employee] also discovered that the 50 mCi gauge with the sticking shutter was not actually sticking but merely hard to open and close due to residue/resin buildup. The licensee cleaned the residue off and covered the shutter mechanism and gauge with a metal canopy to prevent future buildup. Vendor work on this gauge was not performed as the licensee corrected the issue internally. Management approval for the modified shutter of the 20 mCi gauge will be sought at this time. [The Maintenance Manager] noted also during the inspection that the issues with the two gauges had been known by the licensee for approximately 2 years and was only then being reported because he was to become the new RSO and thought it should be.

"On September 10, 2010, a review of this incident was performed and it was found that the NRC HOO had not been notified. A copy of open NMED events for Oregon was also reviewed and no mention of this incident was found. NRC was notified of the incident at this time. Oregon RPS management has not made a final decision on the 20 mCi gauge with the broken shutter mechanism."

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Power Reactor Event Number: 46250
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: J. BREEN
HQ OPS Officer: VINCE KLCO
Notification Date: 09/14/2010
Notification Time: 14:49 [ET]
Event Date: 09/14/2010
Event Time: 09:17 [EDT]
Last Update Date: 09/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAY HENSON (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

LOSS OF COMPUTER TRAINS ASSOCIATED WITH ERDADS

"At approximately 0917 [EDT], St. Lucie Units 1 and 2 lost both of the computer trains associated with the Emergency Response Data Acquisition and Display System [ERDADS]. After some troubleshooting, the system was restored to service at 1155 [EDT]. This is reportable in accordance with 10 CFR 50.72(b)(3)(xiii), as a major loss of emergency assessment capability."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46251
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MURRELL EVANS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/14/2010
Notification Time: 15:04 [ET]
Event Date: 09/14/2010
Event Time: 08:15 [PDT]
Last Update Date: 09/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JEFF CLARK (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

MINOR DIESEL FUEL SPILL INTO THE OCEAN

"On September 14, 2010, at approximately 0815 PDT, a minor diesel fuel spill was discovered at the boat dock in the intake cove at the Diablo Canyon Power Plant. A rainbow sheen was observed on the water around the kelp harvester. Harvester operators immediately began deploying absorbent booms and absorbent pads to contain the sheen. It is estimated that less than 2 ounces of diesel fuel reached the water. Mechanics on scene discovered that a small hose clamp had failed on the diesel fuel return line. Repairs were made and the spill was contained. Absorbent pads were used to clean up the residual diesel fuel on the pontoons of the harvester. Repairs were complete and most of the diesel fuel has been absorbed by pads and booms."

"The licensee notified the NRC Resident Inspector."

The licensee also notified the California State Office of Emergency Services, National Response Center, San Luis Obispo County Environmental Health and the Regional Water Quality Control Board.

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