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Event Notification Report for July 1, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/30/2011 - 07/01/2011

** EVENT NUMBERS **


46826 46981 46984 46993 46994 46997 46998 46999 47001 47002 47003

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Agreement State Event Number: 46826
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SHELL OIL
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB FREE
HQ OPS Officer: PETE SNYDER
Notification Date: 05/06/2011
Notification Time: 13:05 [ET]
Event Date: 06/15/2009
Event Time: [CDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK LEVEL GAUGE SHUTTER

In June 2010, Shell identified a stuck level gauge shutter during scheduled maintenance testing. The licensee removed the gauge from service.

"The licensee intends to leave the gauge secured in storage until an undetermined future date when it is needed. This facility is a research facility and uses the gauge in its research and testing operations."

The gauge was a Berthold Model LB-440 with a 50 milliCurie Cs-137 source.

Texas Report Number: I-8842

* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA E-MAIL AT 1520 ON 6/30/11 * * *

"During the review of this file prior to closing, it was noted that the date of the gauge failure was reported to you [NRC] as June 2010. The investigation determined that the gauge failure occurred in June 2009."

Notified R4DO(J.Drake) and FSME(D.Jackson)

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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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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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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: 06/30/2011
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 Worley Parsons) 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.

* * * UPDATE FROM JOE MARSDEN TO MARK ABRAMOVITZ ON 6/30/2011 AT 1643 * * *

"Worley Parsons Investigation Results:

"Although this design was not a generic or standard design, Worley Parsons performed further evaluation, including extent of condition, for other Nuclear Power Plants that Worley Parsons performed the original design and performed Appendix R Compliance Review/Modifications.
Five plants were identified as follows:

"1) Crystal River 3: Worley Parsons discussed the issue with Progress Energy and jointly concluded that Crystal River 3 is not impacted because their corresponding current transformer circuit design has a different configuration. The circuit design is not generic or programmatic.

"2) TMI Unit 1: TMI is not impacted because their corresponding current transformer circuit design has a different configuration. The circuit design is not generic or programmatic.

"3) Perry: The Appendix R Compliance Review was accomplished by a team of Worley Parsons and others. Since Worley Parsons was involved with the Appendix R analysis and the affected electrical drawings are not readily available at Worley Parsons, it was concluded that Worley Parsons could not complete the evaluation to determine if the Perry design condition could cause a substantial safety hazard. Worley Parsons issued letter PNPP-O-CO-011-WCLT-0001 to the Perry Design Engineering Manager, recommending Perry to complete the evaluation pursuant to 10CFR21.21(a).

"4) V.C. Summer: V.C. Summer is the subject plant and is impacted. VC. Summer is issuing LER #2011-001-00, which constitutes the Part 21 Notification for this design defect, or omission.

"5) R.E. Ginna: Worley Parsons did not perform the Appendix R analysis for Ginna.

"Corrective Action:

"V.C. Summer has implemented immediate compensatory measures for this condition until a permanent solution is identified. A root cause analysis was jointly performed with V.C. Summer. The root cause analysis and Worley Parsons corrective action program review considered this an isolated incident due to human error. No programmatic/procedure corrective actions were identified due to the historical nature of the issue.

"Actions to preclude recurrence: Human performance issues from this event will be communicated to the Worley Parsons Nuclear Engineering staff under our corrective action and lessons learned program."

Notified R1DO (Welling), R2DO (Franke), and R3DO (Lipa). Notified the Part 21 Group via e-mail.

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Non-Agreement State Event Number: 46998
Rep Org: WESTERN SD COMMUNITY ACTION AGENCY
Licensee: WESTERN SD COMMUNITY ACTION AGENCY
Region: 4
City: RAPID CITY State: SD
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: WILLIAM THOMPSON
HQ OPS Officer: JOE O'HARA
Notification Date: 06/30/2011
Notification Time: 11:44 [ET]
Event Date: 06/30/2011
Event Time: 07:55 [MDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JAMES DRAKE (R4DO)
ANGELA MCINTOSH (FSME)
MATTHEW HAHN (ILTA)

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

Event Text

STOLEN NUCLEAR GAUGE CONTAINING 40 MILLICURIES CADMIUM 109

The gauge was stolen from a locked company truck along with other tools parked at the place of business sometime between 1800 on 6/29/11 and 0755 on 6/30/11. The device is a Niton machine built by Thermo-Fisher Scientific XRF Model 300 S/N U2349 used for measuring the quantity of lead in lead based paint. The source serial number is NR-1176 and contains 40 milliCuries of Cd-109. This is generally licensed material.

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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Power Reactor Event Number: 46999
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/30/2011
Notification Time: 12:08 [ET]
Event Date: 06/30/2011
Event Time: 05:16 [CDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
TAMARA BLOOMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 80 Power Operation 80 Power Operation

Event Text

POWER RANGE MONITOR CHANNELS OUT OF ALIGNMENT

"At 0516 [CDT] on 6/30/11 after control rod movements to support rod pattern adjustment, 3 of 4 APRMs were out of required Technical Specification deviations of +/-2% power in relation to calculated Core Thermal Power. APRM #1 was at -3.6% deviation, APRM #3 was at +2.5% and APRM #4 was at +3.1 %. APRMs 1, 3, and 4 were declared inoperable. With 3 of the 4 APRM channels affected, the functions of the APRM were inoperable and that RPS trip capability had not been maintained. Technical Specification Conditions 3.3.1.1.A and 3.3.1.1.C were entered at 0516. All three (3) APRM gains were adjusted and the Tech Spec Conditions were exited at 0540 [CDT].

"Thermal Limits were evaluated and no limits were challenged.

"This event is reportable under 10CFR50.72 (b)(3)(v) as an event that could have prevented the fulfillment of the safety function of a system needed to: 50.72(b)(3)(A) shutdown the reactor and 50.72(b)(3)(D) mitigate the consequences of an accident."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47001
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: TIMOTHY BUSSEY
HQ OPS Officer: JOE O'HARA
Notification Date: 06/30/2011
Notification Time: 16:37 [ET]
Event Date: 06/30/2011
Event Time: 14:23 [CDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES DRAKE (R4DO)

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

OFFSITE NOTIFICATION DUE TO PERSON BEING EVACUATED

"At 1423 CDT, the Control Room was notified of a fire inside the protected area isolated to a portable water evacuation pump. At 1425 CDT, the Control Room was notified the fire was extinguished and the presence of an injured person; the Control Room immediately notified Washington County 911 to request emergency medical assistance. At 1511 CDT, injured person was transferred off-site by medical helicopter.

"This four-hour notification is being made pursuant to 10 CFR 50.72(b)(2)(xi), event or situation related to health and safety of on-site personnel for which notification to other government agencies has been made. NRC Resident informed.

"Due to this event, 1/2 gallon of gasoline was discharged to the Missouri River. The spill was reported to the State of Nebraska on 6/30/2011.

"This condition is also being reported pursuant to 10 CFR 50.72(b)(2)(xi) for News Release or Notification of Other Government Agency. Applicable state agencies have been notified per plant procedures."

The injured person is a plant employee and was injured while refueling a portable generator. The injured person suffered burns to the forearms and neck. The licensee intends to issue a press release.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 47002
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MICHAEL STODICK
HQ OPS Officer: JOE O'HARA
Notification Date: 06/30/2011
Notification Time: 19:49 [ET]
Event Date: 06/30/2011
Event Time: 14:25 [PDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES DRAKE (R4DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT SIREN ACTUATION

"On June 30th, 2011 at 1425 PDT, a public evacuation siren was inadvertently activated for ~ 40 seconds. Preventative maintenance was being performed on the siren at the time of actuation.

"The licensee has notified Benton County, Franklin County, and the Department of Energy. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 47003
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DAVID RENN
HQ OPS Officer: JOE O'HARA
Notification Date: 06/30/2011
Notification Time: 21:03 [ET]
Event Date: 05/01/2011
Event Time: 02:44 [CDT]
Last Update Date: 06/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK FRANKE (R2DO)

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

Event Text

INVALID RPS (SCRAM) ACTUATION

"This 60-day telephone notification is being made under the reporting requirements specified by 10 CFR 50.13(a)(2)(iv) and 10 CFR 50.73(a)(I) to describe an invalid RPS (Scram) actuation.

"On May 1, 2011, at 0244 hours Central Daylight Time (CDT), during a non-refueling outage, Browns Ferry Unit 2 was at 000 percent power in Mode 4 with all control rods already inserted into the core when an invalid full scram signal was received.

"The reactor scram signal was determined to be the result of a failure of the Unit 2 Unit Preferred Motor-Motor-Generator Set, which caused an electrical transient and resulted in noise In adjacent nuclear instrumentation cables.

"The scram signal was Initiated due to Invalid Indications (spikes) associated with the C and D Intermediate Range Monitors (IRMs). The spikes did not render the IRMs inoperable as these were momentary spikes. Therefore, the actuation was invalid.

"The scram was reset at 0312 CDT.

"This event was entered In the Corrective Action Program as Service Request (SR) 362127, which generated Problem Evaluation Report (PER) 362897.

"There were no safety consequences or impact on the health and safety of the public as a result of these events.

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

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Thursday, March 29, 2012