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Event Notification Report for May 4, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/03/2011 - 05/04/2011

** EVENT NUMBERS **


46791 46800 46811 46812 46813 46814

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Hospital Event Number: 46791
Rep Org: BEAUMONT HOSPITALS
Licensee: BEAUMONT HOSPITALS
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: SHERYL SCHULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/27/2011
Notification Time: 16:05 [ET]
Event Date: 04/27/2011
Event Time: 10:45 [EDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANN MARIE STONE (R3DO)
JOSEPHINE PICCONE (FSME)

Event Text

PATIENT RECEIVED LESS THAN PRESCRIBED DOSE DUE TO AN OCCLUSION IN THE DELIVERY CATHETER

A patient received 14.8 Gray rather than the 63 Gray prescribed treatment to the upper portion of the liver using SIRSpheres manufactured by Sirtex. Only 0.7 GBq of the 3 GBq Y-90 microspheres were delivered to the treatment site due to an occlusion in the micro catheter. The treating physician terminated the dose administration after encountering difficulty in "pushing" the syringe contents through the micro catheter. While removing the catheter a small release of microspheres occurred due to the trapped pressure. The spill was contained and immediately cleaned up.

The Hospital contacted the manufacturer and will return the dose unit for analysis. Both the patient and the referring physician have been informed. There was no adverse impact to the patient who has been rescheduled for a compensatory dose next week.

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: 46800
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: GREAT SALT LAKE MINERALS CORPORATION
Region: 4
City: OGDEN State: UT
County:
License #: UT2900154
Agreement: Y
Docket:
NRC Notified By: THILIP GRIFFIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/28/2011
Notification Time: 17:42 [ET]
Event Date: 04/28/2011
Event Time: [MDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
JOSEPHINE PICCONE (FSME)

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

Event Text

MISSING THERMO MEASURETECH MODEL 5201 DENSITY GAUGE

The State of Utah is making a preliminary report that a Thermo MeasureTech Model 5201 density gauge was discovered missing. The gauge was attached to a pipe that was removed. That section of pipe had been locked shut and not in use for a period of over 3 years. The last time the gauge was accounted for was October 29, 2010. The licensee is conducting a search of the site to locate the gauge.

* * * UPDATE FROM PHILIP GRIFFIN TO CHARLES TEAL ON 5/2/11 AT 1759 EDT * * *

"The Radiation Safety Officer (RSO) and the Assistant RSO (ARSO) were performing a routine 6-month physical inventory of the devices in the licensee's possession containing radioactive material when they noticed that one of the fixed gauging devices was missing. The device was a Thermo Measuretech Model 5201 (serial #B3988) densitometer containing a 100 mCi Cs-137 source that was attached to a pipe. The device had not been used for more than 3 years prior to the incident, and the licensee had 'locked out' the device at that time with the shutter in the 'closed' position. The RSO had accounted for the gauge during a physical inventory on October 29, 2010. At the time of the incident, the device and the pipe were gone.

"At the time of this report, the RSO and ARSO are continuing to contact anyone who may have any knowledge as to the location/disposition of the device. The RSO and ARSO are also contacting various waste companies and scrap metal companies to see if they received a gauge containing radioactive material, if the company has the capability of measuring for radiation, and to ask them to keep a watch out for the gauge.

"The licensee is undergoing expansion, and employs a number of contractors. The licensee stated that all of the licensee's employees are thoroughly instructed in radiation safety, and that the employees are told that no work involving the licensee's gauges can be done without the RSO or ARSO being present. The licensee's contractors are provided general radiation safety training twice a year.

"The licensee's working theory regarding the loss of the gauge is that a contractor was working in that area of the licensee's facility and was instructed to demolish that portion of the facility. Since contractor often use a demolish that portion of the facility the licensee speculates that a contractor may have placed the gauge in the waste bin with the other materials from the demolition, and the waste bin was then hauled off by a waste disposal company. The licensee is currently attempting to identify any contractors who may have been working in the area of the gauge during the time period from October 29, 2010, to the present."

Notified R4DO (Proulx) and FSME EO (Piccone).


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

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3"

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Power Reactor Event Number: 46811
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: GEORGE ROBERTSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 05/03/2011
Notification Time: 13:02 [ET]
Event Date: 05/03/2011
Event Time: 05:14 [EDT]
Last Update Date: 05/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID AYRES (R2DO)

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

Event Text

TWO APPENDIX R VIOLATIONS THAT CAN ADVERSELY IMPACT ABILITY TO SHUT DOWN PLANT

"On 05/03/2011 at 0514 [EDT] V.C. Summer Nuclear Station (VCSNS) determined the following:

"During circuit analysis review for transitioning the Fire Protection Program to NFPA-0805, VCSNS identified two violations of the Appendix R requirement to maintain one train of systems necessary to achieve and maintain hot shutdown conditions in accordance with Appendix R. Both instances apply to postulated fires in the Main Control Room and Cable Spreading Room.

"In the first instance, circuits were identified in the Main Control Room and Cable Spreading Room that impact a control power circuit that could result in the loss of ability to start the 'B' Emergency Diesel Generator using local controls. Because fires in these areas can result in the need to evacuate the Main Control Room, the inability to start the diesel using local controls could have an adverse impact on the ability to safely shut down the plant.

"In the second instance, VCSNS determined that a fire in either the Main Control Room or Cable Spreading Room could result in a hot short that could actuate a relay and trip all incoming breakers to the B-train essential electrical bus (Bus 1DB). Because fires in these areas can result in a loss of power to the bus, this could have an adverse impact on the ability to safely shut down the plant."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 46812
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETE WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/03/2011
Notification Time: 14:18 [ET]
Event Date: 05/03/2011
Event Time: [EDT]
Last Update Date: 05/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVID AYRES (R2DO)

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

Event Text

CONTRACT SUPERVISOR TESTED POSITIVE FOR ILLEGAL DRUG

A contract supervisor had a confirmed positive for an illegal drug during a random fitness-for-duty test. The employee's access to the plant has been terminated. The licensee has notified the NRC Resident Inspector.

Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 46813
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: KEN CARLSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/03/2011
Notification Time: 15:39 [ET]
Event Date: 05/03/2011
Event Time: 13:44 [CDT]
Last Update Date: 05/04/2011
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(1) - DEVIATION FROM T SPEC
Person (Organization):
MARK RING (R3DO)
ANNE BOLAND (R3 R)
BRUCE BOGER (NRR)
STEVEN WEST (R3)
WILLIAM GOTT (IRD)
R. BRADSHAW (DHS)
T. KUZIA (FEMA)
S. MORRONE (DOE)
B. EMERSON (HHS)
R. JONES (USDA)

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

ALERT DECLARED DUE TO FIRE AFFECTING ACCESS TO SAFETY RELATED EQUIPMENT

The licensee has declared an Alert due to a hydrogen fire on the hydrogen pad outside the protected area that resulted in evacuating outbuildings (pump house and air compressor buildings) that contain safety related equipment. The Alert is classified under Emergency Action Level HA-3.2 based on report or detection of gases in concentrations higher than lower flammability limit or contiguous to a safe shutdown or vital area. The licensee has also suspended certain security measures under 50.54(x) and 50.54(y). Security measures were suspended due to risks from the fire with no compensatory measures in-place at this time.

The fire involves hydrogen cylinders delivered to the site to a trailer pad outside the protected area. The fire developed while exchanging a newly delivered trailer of hydrogen cylinders with an expended hydrogen cylinder trailer.

The fire brigade has responded and offsite fire departments have responded to the site. Fire water is currently being sprayed on the hydrogen cylinders. There is no indication of any damage to any plant equipment other than the hydrogen trailer area equipment. The driver of the hydrogen supply truck was reported to have sustained some injuries. There are no other reported injuries to plant personnel.

The hydrogen water chemistry system has been isolated and makeup hydrogen to the main generator is isolated. The hydrogen isolation has no impact on the licensee at this time. The plant continues to operate at full power and there have been no immediate impacts from the fire to plant operation.

The licensee has notified State, and local authorities and the NRC Resident Inspector.

* * * UPDATE FROM SCHWERTFEGER TO TEAL AT 1550 EDT ON 5/3/11 * * *

The licensee made a one-hour notification of deviation from technical specifications under 10 CFR 50.54(x) and (y) due to the ongoing hydrogen fire. This was due to safeguards system degradation related to monitoring and detection of the OCA. Contact the Headquarters Operations Officer for details.

R3 IRC was notified of this report.

* * * UPDATE FROM SCHWERTFEGER TO HUFFMAN AT 1925 EDT ON 5/3/11 * * *

The licensee reported all safeguards systems have been restored and they have exited 10 CFR 50.54(x) and (y).

R3 IRC was notified of this report.

* * * UPDATE FROM CARLSON TO HUFFMAN AT 2023 EDT ON 5/3/11 * * *

At 1855 CDT, Duane Arnold has re-classified the hydrogen trailer fire event to an Unusual Event level. The event is classified as an UE under EAL HU-5.1 based on other conditions that exist which, in the judgment of the emergency director, indicate events are in progress or have occurred which indicate a potential for degradation for the level of safety of the plant.

The licensee has allowed access to all areas that were previously restricted due to potential safety concerns from the ongoing fire. The hydrogen trailer cylinders are still being sprayed with water and several cylinders are still showing thermal images above ambient. The licensee will evaluate event termination when the fire can be conclusively demonstrated to be extinguished. The licensee has notified state and local authorities and the NRC Resident Inspector.

NRC Region 3 continues to monitor the event. Notified R3 (West), NRR EO (Holian), FEMA (Via), and DHS (Knox).

* * * UPDATE FROM RUSHWORTH TO KLCO AT 0302 EDT ON 5/4/11* * *

At 0135 CDT on 5/4/11, Duane Arnold terminated from the Unusual Event. The fire was verified to be out, with no hot spots. The hydrogen tanks have been isolated and the licensee verified no hydrogen is present in the area of the hydrogen pad.

The licensee has notified State, local authorities and the NRC Resident Inspector.

R3 IRC was notified of this report. Notified R3 (West), NRR (Boger), FEMA (Via), DHS (Hill), HHS (Collins), USDA (Timmons) and DOE (Yates). Will notify R3DO (Ring), NRR EO (Holian), IRD (Marshall).

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Power Reactor Event Number: 46814
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JEREMY MORTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/03/2011
Notification Time: 17:55 [ET]
Event Date: 05/03/2011
Event Time: 10:36 [CDT]
Last Update Date: 05/03/2011
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
1 N Y 100 Power Operation 100 Power Operation

Event Text

NOTIFICATION TO OFFSITE AGENCY REGARDING POTABLE WATER RESIDUAL CHLORINE LEVEL

"The following is a non-emergency notification in accordance with 10CFR50.72(b)(2)(xi), Offsite Notification.

"At 1036, May 3, 2011, Callaway Plant notified the Missouri Department of Natural Resources (DNR) of an issue with the potable water supply system at the facility. This notification to the Missouri DNR was made in accordance with 10 CSR 60-4.055, 'Disinfection Requirements,' due to circumstances that adversely affect the quality of potable water.

"Specifically, loss of function of the potable water chlorine pumps resulted in residual chlorine in the potable water system falling below the levels specified by the regulation. DNR has not restricted drinking of Potable Water at Callaway Plant.

"Required compensatory actions have been initiated, including planned repairs of the potable water chlorination system.

"The NRC Resident Inspectors have been notified."

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Thursday, March 29, 2012