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Event Notification Report for November 4, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/03/2010 - 11/04/2010

** EVENT NUMBERS **


46376 46380 46382 46383 46384 46387 46388 46391 46392

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General Information or Other Event Number: 46376
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/29/2010
Notification Time: 10:14 [ET]
Event Date: 10/29/2010
Event Time: [EDT]
Last Update Date: 10/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE - DOSE DELIVERED TO WRONG ORGAN

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

"Approximately three (3) weeks prior to therapy, the patient was scanned for extra hepatic shunting through injection of Tc-99m MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.

"On Tuesday, October 26, 2010, at approximately 1455 hours, the patient was treated with 3.959 GBq Y-90 TheraSphere microspheres per protocol. A Interventional Radiologist properly placed catheter, and confirmed by second Interventionist Radiologist.

"On Tuesday, October 26, 2010, at approximately 1930 hours, a post-procedure scan identified significant activity in the duodenum. Initial estimate indicates dose to duodenum approximately 90 Gy (90 Sv).

"Patient has been hospitalized at Cleveland Clinic for observation and possible intervention as a result of dose to the duodenum.

"[The] patient has been notified. [The] referring physician has been notified. [A] literature search indicates patient may have developed vascularization post-scan, pre-treatment."

Ohio Report #: OH 2010-060

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: 46380
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: QUALITY INSPECTION AND TESTING INC.
Region: 4
City: DUTCH JOHN State: UT
County: DAGGET
License #:
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2010
Notification Time: 13:17 [ET]
Event Date: 10/30/2010
Event Time: 07:00 [MDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
RAYMOND LORSON (NMSS)
MICHELE BURGESS (FSME)
DENNIS ALLSTON (ILTA)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY CAMERA INVOLVED IN A TRANSPORTATION ACCIDENT

A previously terminated Quality Inspection and Testing employee gained unauthorized access to keys of a company vehicle loaded with a radiography camera. The individual appeared intent to drive the vehicle to the Rock Springs Airport located in Wyoming when the truck experienced an accident on Highway 191 about 4 miles south of Dutch John, Utah. When the Utah highway patrol drove up to the accident scene, the patrol found the radiography camera outside of the truck. The SPEC Model 150 radiography camera S/N 1195 containing 40 Curies of Ir-192 was undamaged and placed into the custody of a representative of Quality Inspection and Testing Inc. The individual driving the truck was transported to a medical facility. A survey of the site indicated no spread of contamination or radiation levels above background. A survey of the radiography camera revealed no leakage.

The radiography company was a Louisiana licensee with reciprocity in the State of Utah.

Utah Incident Number: 100006

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. 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: 46382
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: AMES MUNICIPAL
Region: 3
City: AMES MUNICIPAL State: IA
County:
License #: 0147-1-85-FG
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2010
Notification Time: 17:49 [ET]
Event Date: 11/01/2010
Event Time: 10:00 [CDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN GIESSNER (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER INDICATOR SHOWED INCORRECT POSITION

The following information was received via email:

"[The licensee Radiation Safety Officer (RSO)], for Ames Municipal, Iowa License 0147-1-85-FG reported [to the state] via phone a 'sticky' shutter for their Texas Nuclear fixed gauge device, model number 5197, Cs-137, 100 mCi (September 1980), serial number B843. The RSO said that during a shutter check this morning at approximately 10:00 a.m. the shutter was in the closed position, however the indicator showed that it was not completely closed. This fixed gauge is usually in the open position as it is a level detection device for the coal hopper. They only close it when doing scheduled work on the machine/hopper that requires the shutter to be closed. He reports that a leak test on October 15th was good and that a radiation worker adjusted a detector on October 28th and was able to close the shutter on that day.

"[The RSO] reports that no employees were exposed to radiation as a result of this event and that they are going to attempt to mitigate the issue on the morning of November 2nd. He will report to the Iowa Department of Public Health for updates."

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General Information or Other Event Number: 46383
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SOIL SURVEYS, INC.
Region: 4
City: SALINAS State: CA
County: MONTEREY
License #: 3428-27
Agreement: Y
Docket:
NRC Notified By: REZA OMOUR
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2010
Notification Time: 19:10 [ET]
Event Date: 11/01/2010
Event Time: 10:15 [PDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
CHRISTEPHER MCKENNEY (FSME)
DENNIS ALLSTON (ILTA)
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received by e-mail:

"On November 1, 2010, at [1015 PDT] the authorized user from Soil Surveys, Inc., License Number 3428-27, called RHB [Radiologic Health Branch] Richmond, [CA] to notify that a moisture/density gauge was missing from his residence located at Salinas, CA. On October 29, 2010, authorized user checked out the nuclear gauge, Troxler, Model TEL, 3440, S/N 18026 from the permanent storage location to be used on October 30, 2010. The gauge was stored inside the company's transportation truck and parked at the residence indicated above, until November 1, 2010. As the authorized user approached the company's truck the early morning of November 1, 2010, he found out that the two locks that were used to fasten the nuclear gauge case to the bed of the truck were cut with a bolt cutter, and the nuclear gauge was removed with its transportation case from the company's transportation vehicle."

The licensee notified the Salinas Police Department of 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

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: 46384
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VEGAS PAVING CORP.
Region: 4
City: LAS VEGAS State: NV
County: CLARK
License #: 00-11-0255-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2010
Notification Time: 20:18 [ET]
Event Date: 11/01/2010
Event Time: 10:00 [PDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was received via e-mail:

"At approximately 1000 [PDT] today an iron piling fell on top of a portable gauge and left significant damage. The incident happened in a sparsely populated area of Overton, Nevada. The RSO was on his way to the location with a survey meter. The gauge has been moved and a 100 foot perimeter around it has been established.

"The gauge was damaged such that the source tube can be pulled from the shielding. The RSO has secured the source tube in the shielded position and determined that the source is intact. He will be transporting the gauge directly to Instrotek for repairs and will be submitting a written report shortly."

The damaged portable gauge is a Troxler model number 3430; serial number 17916. The gauge sources include Cs-137 (.011Ci); model number A-102112; Serial Number 50-7401 and a sealed source that includes Am-Be (.044 Ci); model number A-102451; Serial number 47-13357.

Nevada Item Number: NV100021

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Power Reactor Event Number: 46387
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PHIL STONE
HQ OPS Officer: VINCE KLCO
Notification Date: 11/03/2010
Notification Time: 12:09 [ET]
Event Date: 11/03/2010
Event Time: 10:21 [CDT]
Last Update Date: 11/03/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BLAIR SPITZBERG (R4DO)
JOHN THORP (NRR)
ELMO COLLINS (RA)
BRUCE BOGER (NRR)
WILLIAM GOTT (IRD)
FRED HILL (DHS)
STEVE HOLLIS (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO AN EXPLOSION IN THE PROTECTED AREA WHICH AFFECTS NORMAL OPERATIONS

On November 3, 2010 at 1021 CDT, operators attempted to start the Unit 2 startup feedpump to support a two hour maintenance run. The feeder breaker for the startup feedpump exploded causing an undervoltage condition on Auxiliary Bus 1H and Standby Bus 1H which resulted in an automatic reactor trip due to reactor coolant pump undervoltage. All control rods inserted into the core. At 1038 CDT, the site declared an UNUSUAL EVENT (HU-2) due to an explosion in the protected area which affects normal plant operations. The standby diesel generator (EDG-23) started and loaded to the 'C' train loads which sequenced properly. The auxiliary feedwater system automatically started as expected providing feedwater to the steam generators. The normal feedwater pumps were secured. Decay heat is being removed from Unit 2 using the normal steam dump valves to the main condenser. There is no primary to secondary leakage. The plant is stable and in MODE 3 with no challenges to reactor safety. There was no impact on Unit 1.

At 1240 CDT the licensee terminated the UNUSUAL EVENT.

The licensee is investigating the cause of the breaker explosion and if the other standby diesel generator (EDG-21) should have started due to the undervoltage condition.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM TAPLETT TO KLCO ON 11/3/10 AT 1530 * * *

"A News Release is being planned so this condition is also being reported pursuant to 10 CFR 50.72(b)(2)(xi).

"During the electrical fault condition, some Train A components stopped running although no Train A low voltage ESF actuation occurred, The reason for this occurrence is not fully understood,

"The breaker malfunction did not result in a fire."

The licensee will notify the NRC Resident Inspector.

Notified: R4DO (Spitzberg); NRR (Thorp); R4RA (Collins); NRR (Boger); IRD (Gott) DHS (Hill); FEMA (Hollis)

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Power Reactor Event Number: 46388
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: MARK EGHIGIAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/03/2010
Notification Time: 13:15 [ET]
Event Date: 11/03/2010
Event Time: 12:35 [EDT]
Last Update Date: 11/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

SPDS AND ERDS REMOVED FROM SERVICE FOR MAINTENANCE

"On 11/3/10 at 1235 EDT Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) were removed from service to support activities for a planned maintenance outage on the UPS vital bus power supply. The duration of work is expected to be approximately 48 hours. During this time, the majority of the Control Room indications remain available to the plant staff, and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems, if needed. The plant is currently in Mode 5, and will remain in Mode 5, for the duration of the SPDS and ERDS unavailability. Since the unavailability will last greater than 8 hours, this is considered a Loss of Emergency Assessment Capability, and reportable under 10CFR50.72(b)(3)(xiii).

"Followup notification will be made when SPDS and ERDS have been restored."

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Power Reactor Event Number: 46391
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: VINCE KLCO
Notification Date: 11/03/2010
Notification Time: 16:36 [ET]
Event Date: 11/03/2010
Event Time: 08:13 [CDT]
Last Update Date: 11/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
72.75(d)(1) - SFTY EQUIP. DISABLED OR FAILS TO FUNCTION
Person (Organization):
BLAIR SPITZBERG (R4DO)
BRIAN SMITH (NMSS)
WILLIAM GOTT (IRD)
SHER BAHADUR (NRR)

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

FUEL STORAGE TRANSFER CASK NEUTRON SHIELD PARTIAL DRAINDOWN

"At 0813 [CDT], the Cooper Nuclear Station (CNS) Control Room (CR) received a report of a partial neutron water shield drain down on the Dry Fuel On-site Transfer Cask (TC). The TC, with a loaded Dry Storage Cask (DSC), was located in the Reactor Building (RB) Railroad Airlock area. Final preparations were being completed prior to transferring the DSC to Horizontal Storage Module (HSM) 2A. The RB and south side of the Administration Building were cleared of unnecessary personnel. No abnormally elevated RB area radiological readings were noted on CR indication. Local indication in the [Railroad] Airlock from portable radiation monitors indicated abnormally high readings due to the drain down. At 0819 [CDT], CNS entered Abnormal Procedure 5.1 RAD, Building Radiation Trouble. Surveys indicate the top of the TC had readings of about 130 mR/hr neutron at 30cm, which is above the normal readings of 2 mR/hr. Surveys of the bottom portion of the TC indicated a neutron dose rate of 10 mR/hr at 30cm. Actions per 5.1 RAD were subsequently performed. An emergency declaration was not required, because no confinement boundary was adversely affected and neutron levels did not meet a factor of 1,000 over normal levels. Since dose rates were no greater than noted above, and because neutron dose was being directed upward due to the shielding loss being in the upper portion of transfer cask, the Technical Support Center (TSC), which is located in the Administration Building, was determined to support habitability. Furthermore the TSC is provided with additional shielding for personnel protection during an event.

"This is being reported as a 24 hour report under 10 CFR 72.75(d) for an important to safety fuel storage equipment that failed to function as designed when required to prevent releases, prevent exposures in excess of regulatory limits, or mitigate the consequences of an accident and no redundant equipment was available or operable to perform the required safety function. The cause of the drain down is under investigation."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46392
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: FRANK KICH
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/2010
Notification Time: 03:05 [ET]
Event Date: 11/04/2010
Event Time: 01:23 [EDT]
Last Update Date: 11/04/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
JOHN WHITE (R1DO)

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

CHARGING PUMP '23' DECLARED INOPERABLE DURING SURVEILLANCE TESTING

"On November 4. 2010 at 0123 [EDT], '23' Charging Pump was declared inoperable due to not meeting required test parameters during surveillance testing. '23' Charging Pump is required for remote shutdown per Technical Specification 3.3.4, Remote Shutdown, and is a single component system intended to perform the inventory control safety function. Since '23' Charging Pump has been declared inoperable, a loss of safely function has occurred and is reportable per 10CFR50.72 (b)(3)(v)(A).

"The cause of the inoperability is under investigation. Per Technical Specification 3.3.4, Remote Shutdown, '23' Charging Pump must be restored to operable status within 30 days."

The licensee will inform the NY State PSC (Public Service Commission) and the NRC Resident Inspector.

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