| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
05/06/2011 - 05/09/2011 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 46718 | Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-001-02110
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONG HWA PARK | Notification Date: 04/01/2011
Notification Time: 16:03 [ET]
Event Date: 03/16/2011
Event Time: [CDT]
Last Update Date: 05/06/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RYAN LANTZ (R4DO)
PAUL MICHALAK (FSME)
| Event Text AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE
The following was received from the State of Arkansas via email:
"On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient.
"The facility has contacted the manufacturer of the administration device.
"On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event.
"Conditions requiring reporting of this event:
"The dose differs from the prescribed dose by more than 50 Rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy.
"Arkansas Event Number: 03-11-03"
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.
* * * UPDATE FROM KAYLA AVERY (VIA EMAIL) TO HOWIE CROUCH AT 0821 EDT ON 5/6/11 * * *
"Corrective actions concerning the TheraSphere medical event were submitted to the Arkansas Department of Health. The University of Arkansas for Medical Sciences (UAMS) now requires that all Interventional Radiology staff and residents who will participate in the injection of Y-90 TheraSpheres will receive training on the injection technique prior to administering the radioisotope. The staff will practice the injection process by using normal saline. The staff has also been instructed to administer the dose in a continuous manner without pause. Lastly, the catheter tubing was previously being flushed three times, as recommended by the manufacturer, but the tubing will now be flushed at least five times.
The Arkansas Department of Health considers this incident to be closed."
Notified R4DO (Proulx) and FSME EO (McIntosh). |
| Agreement State | Event Number: 46810 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: PORT LAVACA State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: DONG HWA PARK | Notification Date: 05/03/2011
Notification Time: 11:25 [ET]
Event Date: 05/01/2011
Event Time: [CDT]
Last Update Date: 05/04/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAVID PROULX (R4DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - STUCK SHUTTER ON OHMART/VEGA MODEL GAUGE
"On May 2, 2011, the Agency [Texas Department of Health] was notified by the licensee that during routine checks on an Ohmart/Vega nuclear gauge model SHD containing 250 millicuries of Cesium (Cs) 137 (original activity), the shutter was found stuck in the open position. The gauge is mounted on a tank and is located 100 feet above ground and does not create an exposure risk. The gauge is used for level detection. The licensee has lubricated the operating mechanism several times to get the shutter to operate, but it remains stuck. A service provider will be contacted to conduct repairs if needed. The gauge was installed in 1990 time frame and is to be replaced in the future. Addition information will be provided as it is received in accordance with SA-300."
Texas Incident Number I-8840
* * * UPDATE FROM ART TUCKER (VIA EMAIL) TO HOWIE CROUCH AT 0827 EDT ON 5/4/11 * * *
"On May 3, 2011, the Agency was notified by the licensee that the gauge was working as designed. The repeated lubrication of the operating mechanism was the only method used to make the repair to the gauge. Additional information will be provided as it is received in accordance with SA - 300."
Notified R4DO (Proulx) and FSME EO (McIntosh). |
| Agreement State | Event Number: 46815 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: AVILES ENGINEERING
Region: 4
City: HOUSTON State: TX
County:
License #: L03016
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: CHARLES TEAL | Notification Date: 05/03/2011
Notification Time: 20:12 [ET]
Event Date: 05/03/2011
Event Time: 04:30 [CDT]
Last Update Date: 05/03/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAVID PROULX (R4DO)
DIANA DIAZ-TORO (FSME)
MEXICO VIA FAX ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE - STOLEN TROXLER MODEL 3430
"On May 3, 2011, the Agency [Texas Department of Health] was notified by the licensee that a Troxler Model 3430 moisture/density gauge had been stolen from the back of one of their trucks. The gauge was stolen at the intersection of Nalor and North Main in Houston, Texas. The gauge contains a 40 milliCurie Americium (Am) - 241 source, and an eight milliCurie Cesium (Cs) -137 source. The licensee reported that their technician had completed his work and returned to the licensee's facility. When the technician went to the back of the truck to get the gauge, he found the gauge missing, one chain and lock missing, and the other lock had a busted bail. The technician contacted the other licensee's technicians who where at the work site to see if any of them had the gauge. No one did. The technician contacted his manager and reported the missing gauge. The licensee contacted local law enforcement and notified them of the theft. The Agency has sent notification of the theft to the Texas Association of Pawn Brokers. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."
The serial number of the gauge is 63670. The source numbers are 78-6298 and 77-9880.
Texas Incident: I-8841
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 |
| Agreement State | Event Number: 46818 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SUNBURY GENERATION LP
Region: 1
City: SHAMOKIN DAM State: PA
County:
License #: PA-G0283
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: HOWIE CROUCH | Notification Date: 05/04/2011
Notification Time: 09:58 [ET]
Event Date: 05/03/2011
Event Time: 10:30 [EDT]
Last Update Date: 05/04/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HAROLD GRAY (R1DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - SHUTTER MECHANISM FAILURE
The following information was obtained from the State of Pennsylvania via facsimile:
"It was determined that the remote shutter actuator on a device is inoperable due to foreign material in the shutter mechanism. The device is identified as Texas Nuclear, Model 5197 (Serial No. 81637) with approximately 100 mCi of Cs-137.
"The cause of the event was equipment failure.
"The shutter is locked in the closed position and shall remain so until repairs are made. Licensee will notify the Department [Pennsylvania Dept. of Environmental Protection] when licensed repairs are made."
PA Event Report ID: PA110009 |
| Agreement State | Event Number: 46819 | Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BAE SYSTEMS
Region: 1
City: BURLINGTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL WHALEN
HQ OPS Officer: CHARLES TEAL | Notification Date: 05/04/2011
Notification Time: 12:00 [ET]
Event Date: 04/12/2011
Event Time: [EDT]
Last Update Date: 05/04/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HAROLD GRAY (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE - MISSING PO-210 STATIC ELIMINATOR SOURCE
The following report was received from the Commonwealth of Massachusetts via fax:
"On March 15, 2011, BAE systems called the Massachusetts Radiation program to report a missing Po-210 static eliminator.
"In 2009, BAE ordered an air nozzle and unexpectedly received it with a Po-210 source. It is assumed that the RSO at that time removed the source from the nozzle and placed into storage. In March, 2009, the RSO left the company and did not inform the Safety, Health, and Environment Manager that an additional source had been received. It was discovered during a February, 2011 internal audit that there was a discrepancy between shipped and inventoried ionizers.
"The former RSO has been contacted and does not recall where the source was stored. BAE believes the source was never put into their laboratories for use. A search for the source in the BAE laboratories and former RSO work area, etc. has not uncovered the source.
"The source is a Staticmaster In-line Alpha Ionizer, model P-2021-2002 leased from NRD. It has Serial Number A2GP089, and contained 10 mCi on 3/4/2009.
"Corrective Actions:
"BAE has created an inventory log form, and will perform more frequent inventory checks. BAE has also assigned the inventory checks to dedicated lab technicians, who will be overseen by the site RSO."
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 |
| Power Reactor | Event Number: 46824 | Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: MICHAEL SHUMATE
HQ OPS Officer: HOWIE CROUCH | Notification Date: 05/06/2011
Notification Time: 04:07 [ET]
Event Date: 05/06/2011
Event Time: 02:09 [CDT]
Last Update Date: 05/06/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
| Person (Organization):
DAVID PROULX (R4DO)
BRIAN HOLIAN (NRR)
JANE MARSHALL (IRD)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown | Event Text DISCOVERY OF AN AFTER-THE-FACT UNUSUAL EVENT
Operators were making preparations to fill the Containment Spray System riser to support outage activities. At 0204 CDT, when Containment Spray Riser Isolation Valve CS-125A was opened, pressurizer level began to lower. The licensee suspects leak by of a valve in the Shutdown Cooling System. At 0214 CDT, the leak was stopped. Pressurizer level was lowered by 2.6%.
After reviewing the event, the licensee determined that the leak rate was greater than 25 gpm which would have resulted in a declaration of an Unusual Event under EAL CU1. Since the event had concluded, no declaration was made.
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 46825 | Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: JOE O'HARA | Notification Date: 05/06/2011
Notification Time: 10:11 [ET]
Event Date: 05/05/2011
Event Time: 15:30 [EDT]
Last Update Date: 05/06/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
MARK RING (R3DO)
|
| 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 LICENSED OPERATOR TESTED POSITIVE DURING RANDOM FITNESS FOR DUTY TEST
A licensed operator 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. Contact the Headquarters Operations Officer for additional details.
The licensee has notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 46827 | Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CHRISTINE JONES
HQ OPS Officer: PETE SNYDER | Notification Date: 05/06/2011
Notification Time: 16:46 [ET]
Event Date: 05/06/2011
Event Time: 13:00 [EDT]
Last Update Date: 05/06/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
HAROLD GRAY (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown | Event Text CHANGES IN FUEL VENDOR CALCULATION METHODOLOGY TO COMPLY WITH THE ECCS PERFORMANCE REQUIREMENTS OF 10 CFR 50.46(b)
"Nine Mile Point Nuclear Station Unit 1 has been informed of a change in its fuel vendor's (General Electric Hitachi) Calculation of the Peak Cladding Temperature (PCT) and Maximum Local Oxidation (MLO). This change was required to address four individual errors and model changes identified by the fuel vendor for the previous calculation of record. Based on 10 CFR 50.46 Appendix K inputs and assumptions, correction of one of the identified errors resulted in a calculated 60 degrees F increase in PCT and a calculated 4 percent increase in MLO, which results in exceeding the PCT and MLO acceptance criteria specified in 10 CFR 50.46 (b). In addition, corrections for two of the other identified items resulted in calculated MLO values that also exceeded the MLO acceptance criterion. However, the cumulative effect of all four of the identified errors/changes was determined to result in calculated PCT and MLO values that remain within the 10 CFR 50.46(b) acceptance criteria.
"To ensure compliance with the 10 CFR 50.46 requirements, adjusted Maximum Average Planar Linear Heat Generation Rate (MAPLHGR) limits have been implemented to maintain the PCT and MLO values within the 10 CFR 50,46(b) acceptance criteria and restore design margins. These changes were made prior to the Nine Mile Point Unit 1 startup from the recent spring 2011 refueling outage 21 through a plant monitoring system update. The updated MAPLHGR limits have also been included in the NMP1 Core Operating Limits Report (COLR) for the current operating cycle (Cycle 20), which commenced following the 2011 refueling outage. As such, Nine Mile Point Unit 1 Cycle 20 is in full compliance with the 10 CFR 50.46 requirements.
"This notification is being made in accordance with the 10 CFR 50.46(a)(3)(ii) requirement to report this issue in accordance with 10 CFR 50.72 and 10 CFR 50.73.
"Based on current core thermal power level and existing margin to limits on power operation, there is sufficient margin for analyzed accident scenarios requiring Emergency Core Cooling System (ECCS) operation, including appropriate MAPLHGR compensation, to maintain the calculated PCT and the MLO within the 10 CFR 50.46 acceptance criteria; therefore, there is no impact on safe operation of the plant. The current LOCA analysis of record remains applicable and therefore, the calculated radiological consequences are still bounded by our current safety analysis. Therefore, this event is not significant with respect to the health and safety of the public.
"The licensee has notified the NRC Resident Inspector." |
| Power Reactor | Event Number: 46828 | Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: BRIAN KAWA
HQ OPS Officer: BILL HUFFMAN | Notification Date: 05/07/2011
Notification Time: 08:33 [ET]
Event Date: 05/07/2011
Event Time: 08:27 [EDT]
Last Update Date: 05/07/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
DAVID AYRES (R2DO)
|
| 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 EMERGENCY DATA SYSTEMS OUT OF SERVICE DUE TO PLANNED MODIFICATION
"At 0827 hours EDT, on May 7, 2010, the Emergency Response Facility Information System (ERFIS) computer system was removed from service to perform a planned modification of the ERFIS. This modification will upgrade the electrical infrastructure. The expected duration of ERFIS inoperability is approximately 4 hours. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, and the Inadequate Core Cooling Monitor (ICCM). The loss of ERFIS requires alternate methods, as described in plant procedures, to be used for the above-described functions. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still be made, if required, during the time that the ERFIS computer system is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. An additional message will be provided when the ERFIS is restored. It should also be noted that during the period of ERFIS inoperability, it is likely that the system could be restored within one hour to support Emergency Response Facility activation. This report is provided to conservatively cover the possibility that restoration within one hour may not be able to be accomplished if facility activation were to occur.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM WARREN WONKA TO JOHN KNOKE AT 1516 EDT ON 5/7/11 * * *
The licensee reported that the Emergency Response Facility Information System (ERFIS) computer system was returned to service.
The NRC Resident Inspector has been notified. Notified R2DO (David Ayres) |
| Power Reactor | Event Number: 46829 | Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BILL ARENS
HQ OPS Officer: PETE SNYDER | Notification Date: 05/08/2011
Notification Time: 13:48 [ET]
Event Date: 05/08/2011
Event Time: 08:25 [CDT]
Last Update Date: 05/08/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
DAVID AYRES (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 MALFUNCTIONING TECHNICAL SUPPORT CENTER VENTILATION
"The facility Technical Support Center (TSC) has been rendered non-functional due to a malfunctioning TSC ventilation system. Investigation into the cause of elevated TSC room temperature led to the discovery of a tripped condensing unit compressor. Repairs to the TSC ventilation system were immediately initiated with high priority.
"Compensatory measures per site procedure FNP-0-EIP-6.O (TSC Setup and Activation) for maintaining emergency assessment, off-site response, and off-site communication capabilities were immediately put in place. These measures include the conditional relocation of the TSC staff in the event of a declared emergency if the Emergency Director deems the TSC to be uninhabitable."
The licensee will notify the NRC Resident Inspector. | |