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Event Notification Report for February 14, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/11/2011 - 02/14/2011

** EVENT NUMBERS **


46225 46600 46601 46602 46606 46607 46610 46611 46612 46613

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Non-Agreement State Event Number: 46225
Rep Org: IDAHO STATE UNIVERSITY
Licensee: IDAHO STATE UNIVERSITY
Region: 4
City: POCATELLO State: ID
County:
License #: 1127380-01
Agreement: N
Docket:
NRC Notified By: RICHARD BREY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/02/2010
Notification Time: 15:45 [ET]
Event Date: 09/02/2010
Event Time: [MDT]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)
DARYL JOHNSON (ILTA)

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

Event Text

MISPLACED BUTTON SOURCES

On 9/2/2010, the licensee concluded that they were unable to account for two (2) Pu-239 solid sources that are about the size of a quarter each. Each source is estimated to weight about 1 gm with a source strength of 60 milliCuries and is in a non-dispersible form. The licensee noted that these sources were missing as a result of a normal inventory and leak test procedure on 8/19/10. Since that time the licensee has conducted an intensive search for the material both visually and using detection instrumentation but was unable to locate the material.

The licensee discovered that the lost sources were last checked out of their storage location as part of a group of 10 such sources in April 2010. In July 2010 records indicate that only 8 of 10 sources were checked out since only 8 were available at the time.

The licensee has restricted access to the sources and implemented additional controls for being able to check out the sources that include using a two man rule.

* * * UPDATE AT 1727 EST ON 2/11/11 FROM BREY TO HUFFMAN * * *

As of 2/11/11 at approximately 1710 EST, the licensee has formally declared the two plutonium button sources lost. The licensee stated that following extensive searching the sources are considered lost. The licensee notes that it has been in contact with responsible staff at NRC Region 4 and that the NRC had sent inspectors to the facility on October 4 and October 18, 2010. The licensee will continue to stress an awareness of the missing sources to personnel and emphasize continued vigilance for finding the sources. The licensee has not reached any conclusion as to what happened to the lost sources.

R4DO (Clark), FSME (McConnell), and ILTAB (Hahn) notified.


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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Agreement State Event Number: 46600
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: J LEEK ASSOCIATES, INC.
Region: 1
City: Edenton State: NC
County:
License #: 021-1612-0G
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 11:19 [ET]
Event Date: 02/08/2011
Event Time: [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST GAS CHROMATOGRAPH SOURCE

The following information was received via facsimile:

"On December 9, 2010, North Carolina Radiation Protection Section (NCRPS) received a phone call from the Radiation Safety Officer (RSO) of J. Leek Associates, Inc. (JLA). The RSO stated that he needed to register a new Ni-63 gas chromatograph (GC) source because the old Ni-63 source had been lost. The lost source was used in a model GC-14A PSE, Shimadzu GC. The serial number of the lost source was 608335.

"NCRPS initiated an investigation and performed an inspection on December 14, 2010. The missing source could not be located during the inspection. Three violations were issued by NCRPS to JLA in a Notice of Violation (NOV) letter dated December 21, 2010. The three violations were:

"1. Loss of Ni-63, activity-10 mCi, Serial Number 608335.
"2. Failure to perform inventory every six months.
"3. Failure to perform leak test every six months.

"JLA responded to the NOV on January 20, 2011. NCRPS is currently reviewing the JLA file for escalated enforcement actions and penalty assessment. This incident has been closed."

NCRPS believes the source may have been lost in the trash and not stolen.

NCRPS Incident No.: 11-06.

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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Non-Agreement State Event Number: 46601
Rep Org: CRITTENTON HOSPITAL MEDICAL CENTER
Licensee: CRITTENTON HOSPITAL MEDICAL CENTER
Region: 3
City: ROCHESTER State: MI
County:
License #: 21-13562-01
Agreement: N
Docket:
NRC Notified By: V. ARTERBERY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/08/2011
Notification Time: 12:05 [ET]
Event Date: 02/07/2011
Event Time: 16:00 [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENTS - ACTUAL DOSE LESS THAN PRESCRIBED DOSE

Nine breast cancer patients were treated with a multi-channel high dose rate afterloader with the incorrect dwell positions input into the afterloader controller. The intended prescription was for 5 mm between dwell positions. The actual input was 2.5 mm between dwell positions. The prescribed dose was for 3400 cGy and the actual dose delivered was approximately 25% less. No adverse clinical effects are expected.

The doctors and patients will be notified.

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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Agreement State Event Number: 46602
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: REX HOSPITAL
Region: 1
City: Raleigh State: NC
County:
License #: 092-0160-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 13:51 [ET]
Event Date: 02/08/2011
Event Time: [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE RECEIVED DURING BRACHYTHERAPY PROCEDURE

The following information was received from the State of North Carolina via email:

"A patient undergoing a HDR [High Dose Rate] brachytherapy procedure received an under dose on three fractions.

"The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site.

"The patient has been notified and they are trying to contact the prescribing physician to notify him."

An investigation has been initiated to determine the cause of this event and corrective actions.

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: 46606
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: VINCE KLCO
Notification Date: 02/11/2011
Notification Time: 10:48 [ET]
Event Date: 02/11/2011
Event Time: 03:27 [CST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ERIC DUNCAN (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

INOPERABLE CONTAINMENT ISOLATION DAMPERS

"On February 11, 2011 at 0327 [CST], Secondary Containment isolation damper V-D-61 (Reactor Building Outboard Isolation Damper) was discovered iced closed with the actuator broken. The corresponding inboard damper, V-D-62, was found blocked partially open due to icing. Technical Specification Condition 3.6.4.2.B was entered for one Secondary Containment penetration flow path with two isolation valves inoperable. This resulted in a condition which could have prevented the fulfillment of a safety function required to control the release of radioactive material and mitigate the consequences of an accident. The required action to isolate the flow path by use of one closed and de-activated valve was completed at 0354 [CST], within the four hour completion time. Repair activities are in progress."

The licensee notified the NRC Resident Inspector and the State of Minnesota Duty Officer.

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Power Reactor Event Number: 46607
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: TODD FISHER
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2011
Notification Time: 12:35 [ET]
Event Date: 02/11/2011
Event Time: 08:45 [EST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
RONALD BELLAMY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

TEARS DISCOVERED IN FLEXIBLE PIPE SEALS

"On February 11, 2011, during a plant walk down, it was discovered that two flexible boots sealing two piping penetrations in the secondary containment boundary had a total of three small tears rendering them inoperable.

"Technical Specification 3.6.6.2, 'Secondary Containment,' is applicable in Modes 1, 2, 3, and 4 and was entered. Since Secondary Containment was rendered inoperable, Dominion is reporting that this condition could have prevented the fulfillment of the safety function to control the release of radioactive material. Further engineering review will be conducted to more fully evaluate the impact on radiological controls."

No actual release occurred as a result of this condition.

The licensee notified the NRC Resident Inspector, the State of Connecticut and the Town of Waterford.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46610
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT DENIGHT
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2011
Notification Time: 14:53 [ET]
Event Date: 02/11/2011
Event Time: 13:12 [EST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (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

HYDRAZINE SPILL ONSITE

"On February 11, 2011 at 1312 hours, a notification was made to the New Jersey Department of Environmental Protection of a spill of approximately 5 gallons of steam/water solution containing hydrazine with a concentration of 30ppb which was not cleaned up within 24 hours of identification. The spill due to a steam leak on the Unit 2 Main Steam System, was identified on February 9, 2011. The solution was spilled onto a gravel substrate next to the Unit 2 Main Steam mixing bottle. The closest storm drain leading to the Delaware river was sampled and had no detectable levels of hydrazine. Leak isolation and spill containment/cleanup are in progress.

"There was no out-of-service safety related equipment that contributed to this event. No one was injured as a result of this event."

The licensee notified the NRC Resident Inspector and Lower Alloways Creek Township.

* * * RETRACTION FROM JACK OSBORNE TO PETE SNYDER AT 1753 ON 2/11/11 * * *

As a correction to the earlier information: the subject spill was cleaned up within 24 hours and is therefore not reportable.

Notified R1DO (Bellamy).

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Power Reactor Event Number: 46611
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVE POLAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/11/2011
Notification Time: 16:37 [ET]
Event Date: 02/11/2011
Event Time: 15:07 [CST]
Last Update Date: 02/11/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ART HOWELL (R4DR)
JACK GROBE (NRR)
PATRICK HILAND (NRR)
JEFF CLARK (R4DO)
JEFFERY GRANT (IRD)
MIKE INZER (DHS)
GENE CANUPP (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 1 Startup 1 Startup

Event Text

UNUSUAL EVENT DECLARED BASED ON FIRE ALARM IN DRYWELL

"At 1438 CST on 02/11/2011 a fire detector alarm was received for Recirculation Pump B in the Reactor Building Drywall. At 1453 CST the main control room was unable to determine the alarm was invalid. At this time the condition was met for EAL HU4 for a Fire within the Protected Area boundary that is not extinguished within 15 minutes of detection. At 1507 CST a Notification of an Unusual Event was declared. The alarm was verified to be invalid following visual inspection at 1513 CST. All Drywall parameters and operation of Recirculation Pump B verified to be normal. "

The licensee has notified State and local authorities as well as the NRC Resident Inspector. No media or press release is planned.

* * * UPDATE AT 1734 EST ON 2/11/11 FROM POLAN TO HUFFMAN * * *

At 1552 CST River Bend terminated the Notification of an Unusual Event following confirmation that no fire existed. The licensee has notified the NRC Resident Inspector. R4DO (Clark) and NRR EO (Hiland) notified. DHS (Inzer) and FEMA (Canupp) informed.

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Power Reactor Event Number: 46612
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: TRAVIS FELDER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/11/2011
Notification Time: 22:40 [ET]
Event Date: 02/11/2011
Event Time: 16:15 [PST]
Last Update Date: 02/11/2011
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
2 N Y 100 Power Operation 100 Power Operation
3 N N 0 Hot Standby 0 Hot Standby

Event Text

OFFSITE NOTIFICATION OF A SEWAGE SPILL CONTAINED ONSITE

The site Environmental Protection (EP) group notified the control room of a 3000 gallon sewage spill from the Mesa Sewage Treatment Plant. The spill overflowed to the storm water catch basin. The EP group notified the San Diego Regional Water Quality Board and the San Diego Department of Environmental Health. All sewage has been contained within the storm water catch basin. EP is currently on station to remediate the sewage spill. No sewage has been discharged offsite.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46613
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID RICHARDSON
HQ OPS Officer: JOE O'HARA
Notification Date: 02/14/2011
Notification Time: 03:09 [ET]
Event Date: 02/14/2011
Event Time: 07:00 [EST]
Last Update Date: 02/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RONALD BELLAMY (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

Event Text

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE FOR PLANNED MAINTENANCE

"A planned maintenance evolution at the James A. FitzPatrlck (JAF) Nuclear Power Plant will remove the Technical Support Center (TSC) ventilation system from service, Therefore, the TSC ventilation system will be rendered non-functional during the course of the work activities. The TSC ventilation is expected to be out of service for approximately 13 hours from 0700 to 2000 today.

"If an emergency Is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the station Emergency Plant Manager will relocate the TSC staff to an alternate TSC location in accordance with applicable site procedures giving first consideration to the Control Room. TSC facility leads have been made aware of this contingency.

"This notification Is being made in accordance 10 CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility (ERF). An update will be provided once the TSC ventilation has been restored to normal operation."

The NRC Resident Inspector has been notified.

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