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Event Notification Report for June 30, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/29/2011 - 06/30/2011

** EVENT NUMBERS **


46980 46981 46983 46984 46993 46994 46996 46997

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Agreement State Event Number: 46980
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEAM INDUSTRIAL SERVICES, INC
Region: 4
City: ALVIN State: TX
County:
License #: 00087
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/24/2011
Notification Time: 08:25 [ET]
Event Date: 06/23/2011
Event Time: [CDT]
Last Update Date: 06/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT FROM DRIVE CABLE DURING RADIOGRAPHY ACTIVITIES

The following report was received from the Texas Department of Health Radiation Branch via e-mail:

"On June 23, 2011, the Agency [Texas Dept of Health] was notified by the licensee that a 67.5 Curie Iridium (Ir) - 192 source disconnected from its drive cable during radiographic operations. The licensee reported that the radiographer had completed the first shoot of the day and when he tried to retract the source to the QSA Global 880D camera, he noted that the source had disconnected from the drive cable. The radiographer isolated the area and contacted his Radiation Safety Officer (RSO). A source retrieval team was sent to the location. The source retrieval team verified that the source was in the collimator and then detached the guide tube from the camera. Using remote handling tools, the source was shaken out of the guide tube and placed into the camera.

"The RSO stated that no overexposure occurred and that there was no exposure to any member of the general public. The personnel dosimetry devices of the retrieval team have been sent to the licensee's processor for immediate reading. The cause for the source disconnect is unknown at this time. The camera will be returned to the manufacturer for inspection and for assistance in determining why the connector between the source pigtail and the drive cable disconnected. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I - 8865

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Agreement State Event Number: 46981
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: LONG ISLAND COLLEGE HOSPITAL
Region: 1
City: BROOKLYN State: NY
County:
License #: 91-2443-01
Agreement: Y
Docket:
NRC Notified By: GENE MISKIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/24/2011
Notification Time: 12:41 [ET]
Event Date: 06/24/2009
Event Time: [EDT]
Last Update Date: 06/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT INJECTED WITH WRONG ISOTOPE

The following information was obtained from New York City via email:

"On 6/24/09, a patient was brought to the Nuclear Medicine Department for a myocardial viability exam and was to be injected with Thallium-201.

"The Nuclear Medicine Technologist instead injected the patient with Gallium-67 and immediately realized his mistake. The Gallium vial was right next to the Thallium vial in the storage case. The Head of Nuclear Medicine was informed. He then explained the situation to the patient and advised the patient to take a mild laxative to reduce radiation dose to the large intestine. The event was documented in the patient's chart, and the referring physician was informed.

"Consequences: The estimated absorbed total body dose was 0.5200 rads and the dose to the liver was estimated at 1.2600 rads. The viability study was rescheduled.

"Corrective actions taken: The Policy and Procedures Manual was revised to include specific instructions about double checking that the correct radioisotope was being chosen; training was conducted by the Radiation Safety Officer; and a sign was posted in the lab listing the steps that must be observed before injecting any patient with radioisotopes.

"An inspection was conducted by the Office of Radiological Health on 7/16/09 and the inspector found that the licensee had made a timely report to the [New York City Bureau of Radiation Health (NYCBRH)], and the corrective actions taken were appropriate and effective. This case has been closed by the NYCBRH.


"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: 46983
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: JOE MEINIC
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/24/2011
Notification Time: 14:54 [ET]
Event Date: 06/24/2011
Event Time: [EDT]
Last Update Date: 06/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILURE DUE TO BROKEN CABLE

The following information was obtained from the State of Pennsylvania via facsimile:

The remote shutter actuator on a Texas Nuclear gauge, Model 5197 (serial #81623) with approximately 100 mCi of Cs-137 was found inoperable. The remote shutter actuator controller cable failed. The shutter is locked in the closed position and shall remain so until repairs are made.

PA Report #: PA110013

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Non-Agreement State Event Number: 46984
Rep Org: ST LOUIS UNIVERSITY
Licensee: ST LOUIS UNIVERSITY
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00196-07
Agreement: N
Docket:
NRC Notified By: MARK HAENCHEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/24/2011
Notification Time: 19:45 [ET]
Event Date: 06/21/2011
Event Time: [CDT]
Last Update Date: 06/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
JIM LUEHMAN (FSME)

Event Text

DOSAGE DELIVERED GREATER THAN PRESCRIBED

The following occurred at St. Louis University Hospital: A 30 mCi I-131 Sodium Iodide oral capsule was prescribed for administration to a patient for ablation of residual tissue following a thyroidectomy. However, a 115 mCi I-131 Sodium Iodide capsule was administered instead, due to conflicting information in the patient record.

At this time, it is believed that there will be no adverse affect to the patient. The patient has been notified of this incident.

The Radiation Safety Officer will be reviewing this incident to determine what actions to take to prevent recurrence.

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: 46993
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: MIDWEST INDUSTRIAL X-RAY
Region: 3
City: REDFIELD State: IA
County:
License #: 0075178IR1
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/27/2011
Notification Time: 09:18 [ET]
Event Date: 06/24/2011
Event Time: [CDT]
Last Update Date: 06/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

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

The Iowa Department of Public Health (IDPH) was conducting a field inspection of Midwest Industrial X-Ray on Friday, June 24, 2011. The licensee was conducting 1 minute, 15 second shots on 12" diameter gas pipeline in a 10 foot deep trench. They were using a SPEC model 150 camera with a 49 Curie Iridium-192 source and SPEC control cables. After completion of the third shot, the licensee was unable to retract the source. The lead radiographer disassembled the control cable crank mechanism and manually pulled the source back into the shielded position. The licensee then reassembled the crank mechanism and attempted a third shot. Once again, they could not retract the source. The radiographer disassembled the crank mechanism, pulled the source into the shielded position and secured from any additional radiography that day. The licensee indicated that they had similar problems with SPEC control cables in the past. The radiographer and assistant radiographer's pocket dosimeters both indicated less than 5 milliRem. The licensee will submit a written report within 30 days."

The radiography was being performed in the Redfield Gas Storage facility in Redfield, IA. The event was reported by Midwest Industrial X-ray of Fargo, ND.

Iowa Report No.: IA110004

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Agreement State Event Number: 46994
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: FAIRWAY TESTING
Region: 1
City: STONY POINT State: NY
County:
License #: NYS C2322
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: PETE SNYDER
Notification Date: 06/27/2011
Notification Time: 15:50 [ET]
Event Date: 06/26/2011
Event Time: [EDT]
Last Update Date: 06/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
JIM LUEHMAN (FSME)
CANADA (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN PORTABLE MOISTURE DENSITY GAUGE

The following was received via fax:

"Fairway Testing Co. license no. C2322, called 6/27/11 to report that a Troxler model 3411 s/n 4363 portable density gauge was stolen from a company vehicle on Sunday, June 26. The device contained 8 mCi Cesium 137 and 40 mCi of Americium 241/Beryllium.

"The employee worked late on Friday, June 24 and did not have access to the permanent storage location since the building is locked after 5:00 p.m. The driver took the vehicle to his residence on Brookside Drive in Stony Point, Rockland County and parked it in his driveway. The device was in its transport container, which was doubly chained to the bed of the pickup truck.

"On Sunday morning, the employee observed that the container was still in the bed of the pickup before he left his residence for the day in a family vehicle. When he came home that night he did not check the vehicle.

"On Monday morning, he realized that both chains were cut and the transport box along with the device was stolen. Other items were also stolen from the vehicle which leads to speculation that the perpetrators were not specifically after the density gauge.

"The local police were notified and a police report has been initiated. The licensee has thirty days to send a written response and to notify the NYS DOH of any substantial development in the case."

NY State Event #: NY-11-11

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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Fuel Cycle Facility Event Number: 46996
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: R. J. COOK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/28/2011
Notification Time: 23:10 [ET]
Event Date: 06/28/2011
Event Time: 00:05 [CDT]
Last Update Date: 06/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MARK FRANKE (R2DO)
ROBERT JOHNSON (NMSS)

Event Text

FAILURE OF #2 FIRE WATER PUMP TO REALIGN

"At 0005 CDT, on 06-28-2011, the Plant Shift Superintendent was notified that the C-631 High Pressure Fire Water (HPFW) pumps #2 and #3 automatically started in response to low HPFW header pressure created by a line leak and rendered inoperable. Following isolation of the water leak the #2 and #3 pumps were shut down and were being configured for automatic start. The RCW operator observed the 'Auto Start' Indicator for the #2 pump was not illuminated. The pump was declared inoperable and power was removed from the #2 pump for troubleshooting and repair by electrical maintenance (EM). When power was removed from the pump the HPFWS could not perform its intended safety function of providing 4875 gpm. Two HPFW system pumps are required to be operable according to TSR LCO 2.4.4.8. EM reset a disconnect interlock switch which reenergized the 'Auto Start' controls and the pump was declared operable and returned to service.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as
designed.

"The NRC Senior Resident Inspector has been notified of this event."

* * * UPDATE FROM KEVIN BEASLEY TO PETE SNYDER AT 1613 EDT 6/29/11 * * *

"Due to the uncertain nature of the leak on the 16 inch underground High Pressure Fire Water (HPFW) distribution main, it is not known at this time if the two operable HPFW pumps would have been able to satisfy the maximum sprinkler system demand of 4875 gpm. Upon completion of excavating the area of the leak, Engineering will evaluate the failure mode to determine if system requirements were maintained."

The licensee notified the NRC Resident Inspector.

Notified R2DO (M. Franke) and NMSS (R. Johnson).

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Power Reactor Event Number: 46997
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: BRUCE THOMPSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2011
Notification Time: 09:49 [ET]
Event Date: 06/27/2011
Event Time: 16:11 [EDT]
Last Update Date: 06/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MARK FRANKE (R2DO)
PART 21 GP (email) (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

APPENDIX R ANALYSES FAILS TO RECOGNIZE HOT-SHORT FAILURE RESULTING IN THE LOSS OF AN ESSENTIAL ELECTRICAL BUS

The following Part 21 report was received via fax:

"10 CFR 21: Appendix R analyses conducted for Virgil C. Summer Nuclear Station (VCSNS) failed to identify that a fire-induced hot-short failure in an ammeter circuit would result in a loss of the B-train 7.2KV essential electrical bus (XSW1DB).

"Appendix R analyses performed by Gilbert/Commonwealth (now WorleyParsons) in the early 1980s failed to recognize the possibility of a fire-induced hot-short condition in a circuit that was identified as being required for safe shutdown. This circuit connects a set of sensing current transformers (CTs) to an ammeter on the Main Control Board, and provides over-current sensing for an over-current relay. Gilbert/Commonwealth recognized that a fire-induced open circuit in this ammeter circuit would result in damage to, or a fire in, the B-train 7.2kV essential switchgear. Thyrite protectors were added to the circuit to protect the CTs from this open circuit condition as part of the Appendix R analysis.

"However, this analysis and resolution failed to consider the hot-short-to-ground failure mode. Current from a hot-short could flow through the ammeters, or neutral conductor, and then through the bus neutral over-current relay to ground. This could actuate the over-current relay, which in turn would actuate a lock-out relay and trip all incoming breakers to bus XSW1DB. This bus provides credited B-train power to safe-shutdown components credited for this scenario. The Appendix R analyses conducted for VCSNS by Gilbert/Commonwealth did not address the hot-short scenario and is considered to be a defect, or omission. reportable under 10 CFR 21.

"This condition was identified during the circuit analysis review for transitioning the Appendix R Fire Protection Program to NFPA 805 and was reported to the NRC as an unanalyzed condition on 05/03/2011 (see Event Notification No. 46811). Corrective actions have been taken to address this issue."

The licensee informed the NRC Resident Inspector.

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Thursday, March 29, 2012