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Event Notification Report for October 15, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/14/2010 - 10/15/2010

** EVENT NUMBERS **


46319 46320 46324 46326 46328 46330 46331 46334 46335

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Hospital Event Number: 46319
Rep Org: COMMUNITY HOSPITAL
Licensee: COMMUNITY HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 130600901
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/08/2010
Notification Time: 09:57 [ET]
Event Date: 10/06/2010
Event Time: [EDT]
Last Update Date: 10/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVE PASSEHL (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

DELIVERED DOSE POTENTIALLY DIFFERENT THAN THE PRESCRIBED DOSE

During a brachytherapy treatment, the patient breast received an incorrect entry of the catheter position from a treatment planning system. Because of this, the prescribed dose was 340 centi-Gray at 1 centimeter from the tumor cavity while the actual dose received was 680 centi-Gray at 1 centimeter from the tumor cavity.

The physician notified the patient of the potential dose difference. Based on physician review, it was determined that there was no affect on the patient.

The reason for the potential dose difference was due to a missed change of a program default in the software program of the radiation treatment planning system. A new check step has been added to the Community Hospital procedure in order to correct the issue.

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: 46320
Rep Org: LIBERTY HOSPITAL
Licensee: LIBERTY HOSPITAL
Region: 3
City: LIBERTY State: MO
County: CLAY
License #: 241617801
Agreement: N
Docket:
NRC Notified By: SCOTT COZAD
HQ OPS Officer: VINCE KLCO
Notification Date: 10/07/2010
Notification Time: 11:32 [ET]
Event Date: 10/06/2010
Event Time: 09:00 [CDT]
Last Update Date: 10/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVE PASSEHL (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

DELIVERED DOSE POTENTIALLY DIFFERENT THAN THE PRESCRIBED DOSE

During a brachytherapy, a patient was prescribed a dose of 125 Gray to the prostrate. The delivered dose resulted in about 11 percent of the prescribed dose. The physician notified the patient and his guardian and also determined there was no radiation impact on the patient.

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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Power Reactor Event Number: 46324
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: AARON CHLADIL
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/11/2010
Notification Time: 12:10 [ET]
Event Date: 10/11/2010
Event Time: 11:10 [CDT]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL SHANNON (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

TECHNICAL SUPPORT CENTER OOS FOR MAINTENANCE

"This is an eight-hour report as required per 10 CFR 50.72(b)(3)(xiii) due to maintenance which will result in the Fort Calhoun Station Technical Support Center (TSC) being degraded. On Monday, October 11th scheduled maintenance will commence on the TSC Air Handling unit that will render the unit non-functional. This maintenance is scheduled to be completed on Thursday, October 14th. Station procedures contain compensatory measures to ensure appropriate habitability monitoring and, if necessary, relocation of TSC personnel should the need exist to activate the emergency response organization."

The NRC Resident Inspector has been notified.

* * * UPDATE FROM BARTON SCHAWE TO HOWIE CROUCH AT 1643 EDT ON 10/14/10 * * *

At 1519 CDT, the TSC Air Handling Unit was returned to service and is functional. The licensee will notify the NRC Resident Inspector.

Notified R4DO (Haire).

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General Information or Other Event Number: 46326
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: IESCO, INC.
Region: 4
City: WILMINGTON State: CA
County:
License #: 6571-19
Agreement: Y
Docket:
NRC Notified By: STEVEN E. FRYSINGER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/11/2010
Notification Time: 21:15 [ET]
Event Date: 10/10/2010
Event Time: 11:45 [PDT]
Last Update Date: 10/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
PAUL MICHALAK (FSME)
MICHAEL SHANNON (R4DO)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - DAMAGE TO RADIOGRAPHY CAMERA GUIDE TUBE

The following information was received from the state via email.

"On October 10, 2010, at approximately 11:45 P.M., an IESCO radiography team was performing radiography operations at the Conoco Phillips Refinery in Wilmington, CA. The team was exposing a small pipe when a 6 inch pipe spool fell approximately 2 feet from a work bench to the ground where the source guide tube was lying while the source was extended during an exposure. The flange end struck the guide tube and it crimped the tube, preventing the source from being retracted after the exposure time had elapsed. The RSO was contacted at approximately 1150 and he responded to the scene. While waiting for the RSO to arrive, the radiographer sent the assistant away from the area and proceeded to adjust the boundary around the scene to where the dose rate at the boundary was 2 mr/hour (actual dose rate) or less and to maintain constant surveillance of the boundaries so that no one could enter the area where the incident had occurred.

"When the RSO arrived, he had both the radiographer and assistant stay out of the area of the incident and he proceeded to retrieve the source. He proceeded to straighten the guide tube and then placed 20 lb. lead shot bags on the source (the collimator had fallen off when the pipe spool struck the guide tube) to shield the source. The RSO then proceeded to cut open the source guide tube with tin snips. He then flattened the guide tube with lead sheets to expose the drive cable at the area where the guide tube was crimped to allow the source to be retracted back to the exposure device. While he was cutting the guide tube, the RSO placed his survey meter between himself and the source to monitor his exposure, along with two direct reading pocket dosimeters (DRPD) place at his chest (on had a 0-200 Mr range and the other had a 0-500 Mr range). He stated that his hands and chest were both approximately the same distance from the source during this phase of the recovery. While cutting the guide tube, the RSO periodically went to the crank to attempt to retrieve the source and then returned to cut more of the guide tube until the source was able to cranked without any resistance. After enough of the guide tube was removed to allow source to bypass the crimp, the RSO then went to retract the source. After the source had been retrieved, the exposure device was surveyed to ensure that the source was in the shielded position and then the exposure device was locked. The whole retrieval operation took approximately 30-45 minutes.

"The estimated dose to the RSO during this incident was 110 millirem on both DRPD's, which is equivalent to being exposed by a radiation field of 200 mR/hr for 33 minutes. The radiographer was discovered to have a DRPD that was off scale and thus was told to stay out of the area of the incident and his dosimeter was sent to Mirion Technology (formerly Global Dosimetry) for emergency processing. The radiographers assistant's dose was estimated at 10 millirem as read by his DRPD. An estimate of the radiographer's dose will need to be reported to determine if an over exposure has occurred. Since all reporting of the incident was timely and the procedures were followed for this incident and for the off-scale DRPD, there is no evidence that a violation has occurred and the licensee will not be cited at this time. Any future actions will be determined after a review of the 30 day report which will be provided by the licensee as required under 10 CFR 34.101(a)."

The radiography camera is a QSA Global A424-9 with Ir-192 35.6 Ci source.

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General Information or Other Event Number: 46328
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KANSAS DEPARTMENT OF TRANSPORTATION
Region: 4
City: TOPEKA State: KS
County:
License #: 22-B315-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/12/2010
Notification Time: 13:26 [ET]
Event Date: 10/12/2010
Event Time: [CDT]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE - TROXLER MOISTURE DENSITY GAUGE MISSING IN TRANSIT

One Troxler moisture/density gauge and three thin layer density gauges were transported to InstroTek, Inc. on September 23, 2010. The licensee was later notified that only three Troxler thin layer density gauges had arrived. The licensee searched their loading docks and did not find the missing gauge. InstroTek and R and L Trucking have also performed searches, but did not locate the gauge. The information about the gauge is below:

Troxler Model 3440 Nuclear Moisture/Density gauge
Serial Number 22504
CS-137, 8 mCi, Serial Number 47-4236
Am-241 Be, 40 mCi, Serial Number 47-18335

KS NMED KS100012

* * * UPDATE ON 10/14/2010 AT 1052 FROM DAVID WHITFILL TO MARK ABRAMOVITZ * * *

The Troxler Moisture Density Gauge was found at the R and L Trucking Terminal in Wilson, NC (about 40 miles from the intended destination of Raleigh, NC). The gauge is being delivered to InstroTek today (10/14/2010).

Notified the R4DO (Haire) and FSME (McIntosh).

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: 46330
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRANDON SHULTZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/13/2010
Notification Time: 09:50 [ET]
Event Date: 10/14/2010
Event Time: 01:00 [EDT]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (R1DO)

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

TECHNICAL SUPPORT CENTER EMERGENCY VENTILATION SYSTEM SCHEDULED MAINTENANCE

"This ENS is being issued in advance of a planned activity.

"On 10/14/10 at 0100 hours Limerick Generating Station will apply a clearance to inspect and repair fire suppression equipment associated with the onsite Technical Support Center (TSC) Emergency Ventilation System and perform corrective maintenance associated with the MD-1 (outside air) damper. While the clearance is applied, the TSC Emergency Ventilation system will not be available to be restored within the time period required to staff and activate the TSC Emergency Response Organization (ERO). This work is expected to be completed 10/14/10. If an emergency is declared requiring TSC ERO activation, the TSC will be staffed and activated using emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of TSC staff becomes necessary, the Station Emergency Director will relocate the staff to an alternate TSC location in accordance with applicable procedures.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility because of the planned unavailability of the TSC Emergency Ventilation system. The NRC Resident Inspector has been informed."

* * * UPDATE FROM JOHN WEISSINGER TO HOWIE CROUCH AT 1833 EDT ON 10/14/10 * * *

The Technical Support Center Emergency Ventilation System maintenance is complete and the system has been returned to service.

The licensee has notified the NRC Resident Inspector. Notified R1DO (Jackson).

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Power Reactor Event Number: 46331
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE RODRIGUEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/14/2010
Notification Time: 13:18 [ET]
Event Date: 10/14/2010
Event Time: 09:15 [MST]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK HAIRE (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
3 N N 0 Refueling 0 Refueling

Event Text

EMERGENCY SIRENS WILL BE TAKEN OUT OF SERVICE FOR PLANNED MAINTENANCE

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"From October 14, 2010 to October 22, 2010, Palo Verde personnel will be performing maintenance on public prompt notification system sirens. Sirens will be removed from service one at a time, and then each will be restored prior to continuing to the next siren.

"Siren #36 provides notification to approximately 470 members of the public within five miles of Palo Verde.
"Siren #23 provides notification to approximately 614 members of the public within five miles of Palo Verde.
"Siren #25 provides notification to approximately 335 members of the public within five miles of Palo Verde.
"Siren #18 provides notification to approximately 586 members of the public within five miles of Palo Verde.
"Siren #15 provides notification to approximately 1133 members of the public within five to ten miles of Palo Verde.
"Siren #22 provides notification to approximately 1015 members of the public within five miles of Palo Verde.
"Siren #17 provides notification to approximately 1196 members of the public within five miles of Palo Verde.

"Each of these are considered by Palo Verde to be a 'large segment of the population.'

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii). The Palo Verde Emergency Plan has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area. The MCSO is prepared to implement this contingency should it become necessary.

"There are no events in progress that require siren operation. A follow-up call will be placed when the affected sirens are returned to service.

"The NRC Resident Inspector has been notified of the siren maintenance and this ENS call."

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Power Reactor Event Number: 46334
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RICKY LIDDELL
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/14/2010
Notification Time: 15:15 [ET]
Event Date: 10/14/2010
Event Time: 04:22 [CDT]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK HAIRE (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

BOTH TRAINS OF CONTROL ROOM AIR CONDITIONING INOPERABLE

"While Control Room Air Conditioning System 'A' was tagged out for planned maintenance, the 'B' Control Room Air Conditioning System tripped and could not be restarted. TS 3.7.4 Condition B was entered at 0422 [CDT] 10/14/10, for both Control Room Air Conditioning systems inoperable. Temporary cooling was used to assist in maintaining control room temperature below TS limit of 90 degrees F. Corrective maintenance was performed on Control Room Air Conditioning System 'B' and it was restored to functional status at 1017 [CDT] 10/14/10. No TS limits were exceeded and no plant shutdown actions were required."

The licensee noted that their report was late and did not meet the 8-hour reporting criteria. The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 46335
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: PAULO ALBUQUERQUE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/14/2010
Notification Time: 16:55 [ET]
Event Date: 10/14/2010
Event Time: 07:54 [EDT]
Last Update Date: 10/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MARVIN SYKES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

CONTRACT NON-LICENSED SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A non-licensed contract employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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