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Event Notification Report for July 22, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/21/2011 - 07/22/2011

** EVENT NUMBERS **


47055 47057 47068 47070 47073 47081 47084 47085 47086

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Agreement State Event Number: 47055
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: CHIPPENHAM / JOHNSTON WILLIS HOSPITALS, INC.
Region: 1
City: RICHMOND State: VA
County: CHESTERFIELD
License #: 041-058-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/15/2011
Notification Time: 12:06 [ET]
Event Date: 06/22/2011
Event Time: 16:34 [EDT]
Last Update Date: 07/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED PATIENT / PATIENT ROOM

The following information was received via facsimile:

"On Wednesday, June 22, 2011 at 1634 EDT, an admitted patient was given a 182 mCi I-131 capsule for a thyroid ablation study. At approximately 0330 EDT on Thursday, June 23, 2011, the patient vomited onto herself and the floor. The nursing staff cleaned up the patient and the floor and then notified the Nuclear Medicine Department (NMD). NMD staff began to perform surveys of the patient and the room and found contamination. Further cleaning of the patient and room was performed. The patient was released on Saturday, June 26, 2011. The room was sealed off to allow the I-131 contamination to decay below regulatory limits. The room remains restricted. NMD staff are performing contamination surveys."

Virginian Report Number: VA-11-04

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Agreement State Event Number: 47057
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HEALTH NETWORK
Region: 1
City:  State: PA
County:
License #: PA-0232
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/15/2011
Notification Time: 11:33 [ET]
Event Date: 07/12/2011
Event Time: [EDT]
Last Update Date: 07/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING TREATMENT DOSE ADMINISTERED TO WRONG SITE

The following event report was received from the Pennsylvania Bureau of Radiation Protection:

"The licensee called the PA Department of Environment Protection (PaDEP) Southeast Regional Office at 1050 EDT on July 14, 2011 to provide a 24-hour verbal notice of a Medical Event (ME). A total treatment dose was administered to the wrong site, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(3). This event also meets the criteria for Abnormal Occurrence (AO) reporting.

"On July 12, 2011 a Yttrium-90 (Y-90) SIR-Sphere treatment was performed. The written directive was for treatment of the liver's right lobe, but the total treatment was delivered to the left lobe. The prescribed dose was 31.5 millicurie (mCi) of Y-90.

"There are several open questions regarding root cause, potential health impact on the patient and communications to the patient and their physician. PaDEP/BRP will be performing a reactive inspection, which is scheduled for Monday July 18, 2011. Updates to this NRC report will be made once we investigate the ME at Lehigh Valley Health Network and obtain the follow-up written report from the licensee."

PA report Number: PA110016

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: 47068
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: DAN RIVER INC.
Region:
City: DANVILLE State:
County: PITTSYLVANIA
License #: GENERAL
Agreement: N
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/18/2011
Notification Time: 16:30 [ET]
Event Date: 07/14/2011
Event Time: 12:00 [EST]
Last Update Date: 07/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
ROBERT LEWIS (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE - SOURCE DISCOVERED IN SCRAP SHIPMENT - TWO OTHERS STILL MISSING

"On Thursday July 14 a scrap dealer contacted the Virginia Radioactive Materials Program (VRMP) indicating a load of steel had set off their alarm. The scrap yard was able to identify the material that set off the alarm and isolate. On Friday July 15 VRMP staff went to the scrap yard to perform surveys and identify the material in question. The investigation determined that the material had come from the demolishing site of Dan River, Inc, a former textile business that closed in 2008. The gauge was determined to contain Kr-85 utilizing a radionuclide identifier and the GL database, which lists three Mahlo Controls Kr-85 gauges being possessed by Dan River, Inc. The VRMP continues to work with the scrap yard and demolishing company looking for the other two gauges. VRMP is also working with Mahlo Controls in researching the three gauges in question."

The sources in these generally licensed devices were originally 100 milliCuries each. It is estimated that they have decayed three half-lives and the current strength is estimated at approximately 13 milliCuries each.



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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Agreement State Event Number: 47070
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: LA PORTE State: TX
County:
License #: L01774
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 07/19/2011
Notification Time: 09:04 [ET]
Event Date: 07/19/2011
Event Time: 07:00 [CDT]
Last Update Date: 07/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
RON ZELAC (FSME)
DENNIS ALLSTON (ILTA)
WILLIAM GOTT (IRD)
MIKE INZER (DHS)
DENNIS VIA (FEMA)
MIKE BEVERLY (USDA)
BOB JARRELL (DOE)
SAM WILLIS (HHS)
BRENT TALIAFERRO (NRC()

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY CAMERA

"On July 19, 2011, the Agency [Texas Department of Health] was notified by the licensee that one of their radiography crews had discovered that the dark room on their truck had been broken into some time during the night. The radiographers stated the radiography camera transportation container containing a QSA Global model 880 D camera with a 33.7 curie iridium (Ir) 192 source and a portable electric generator had been stolen.

"Local law enforcement was contacted and responded to the scene. The agency [Texas Department of Health] notified the Texas association of Pawnbrokers of the event and provided information on the device. Additional information will be provided as it is received."

Texas Incident # I-8871

* * * UPDATE FROM ART TUCKER TO VINCE KLCO ON 7/19/2011 AT 1659 EDT * * *

The following information was received by email:

"Local law enforcement has reviewed the security tape at the hotel and was able to identify the vehicle type and manufacturer. They do not believe they can get a license plate number from the video. The time of the theft was set at between 0400 [CDT] and 0409 [CDT]. An Agency investigator went to the location and interviewed the radiographers. He found that the guide tube and crank cables were also stolen. The radiographer stated that the tailgate of the truck was not locked, but that the dark room door was locked. He stated that they did not test the alarm that day, but it had been tested on July 17, 2011. Because of the investigation by local law enforcement, they have not been able to test the alarm system today. The radiographer stated that a cable was used to secure the transport box to the truck and that one of the pad eyes used to secure the cable to the truck had been ripped through the dark room wall freeing the transportation container. The radiographer stated that the transport box has a new Yellow II label.

"The alarm system was tested at 1141 [CDT] and found to be functioning properly. The radiographers stated that they had set the alarm when they got to the hotel, but failed to set it after returning from getting their dinner.

"The agency [Texas Department of Health] has contacted the Federal Bureau of Investigation and informed them of the event.

"The agency [Texas Department of Health] and the licensee are currently driving around the city of Austin, Texas with portable radiation detection instrumentation in an attempt to locate the camera."

Notified the R4DO (Campbell), FSME (White), IRD (Gott), ILTAB (Allston), and R4IAT(Howell).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 47073
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WESTPORT SHIPYARD, INC
Region: 4
City: PORT ANGELES State: WA
County:
License #: R1163
Agreement: Y
Docket:
NRC Notified By: BRANDY KETTER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/19/2011
Notification Time: 13:30 [ET]
Event Date: 07/10/2011
Event Time: 12:00 [PDT]
Last Update Date: 07/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
RON ZELAC (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR CONTAINING A 40 MILLICURIE PO-210 SOURCE

The following event report was received from the Washington Office of Radiation Protection via e-mail:

"On or about 10 July 2011, upon taking inventory of the static eliminators, a device was found to be missing. The device was leased from NRD, LLC on 10 November 2009. The last time the device was used was 2 June 2011. Upon discovering the device was missing, a thorough search of the facility was conducted to include personal lockers, the boat, the boat parts, the boat house, as well as other facilities around the company. At this time no one knows the location of the device, whether it was stolen, misplaced or thrown away. The company will inform the department if the device is found. Since this incident, Westport Shipyard 50 Meter Facility has changed its protocols for issuing and receiving these types of devices. They will be placed in the safety department in a locked cabinet. The will be logged out by safety on the day of use and logged back in the same day. Only leads and Supervisor will have the ability to sign for these devices and will be held accountable for their safe return at the end of the operation."

The static eliminator was manufactured by NRD, LLC; Model # P-2030-0010 / Serial # A2GY503. The device contains a Po-210, 40 milliCurie sealed source.

Washington State Report: WA110035

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: 47081
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT LOVITT
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/21/2011
Notification Time: 00:53 [ET]
Event Date: 07/20/2011
Event Time: 21:29 [EDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARVIN SYKES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO NEGATIVE RATE TRIP FOLLOWING RAPID TURBINE LOAD REDUCTION

"At 2129 EST on 7/20/2011, Unit 1 reactor/turbine automatically tripped.

"Following the reactor trip, all safety-related equipment operated as designed. Auxiliary Feedwater automatically actuated as expected from the Feedwater Isolation Signal. Primary PORVs and/or safety valves lifted and reseated as indicated by tailpipe temperatures and PRT pressure.

"Unit 1 is currently being maintained in Mode 3 at NOT/NOP, approximately 548 F and 2235 psig, with Auxiliary Feedwater supplying the steam generators.

"At the time of the trip, maintenance was in progress on Preferred Inverter #1. AOP-P.09 'Loss of 120VAC Preferred Power' was used to restore power to #1 Preferred board after the trip.

"Method of decay heat removal is via steam dumps to the condenser with MSIVs open.
"Current temperature and pressure: Temperature - 548 degrees Fahrenheit and stable, Pressure 2235 - psig and stable
"No indication of any primary/secondary leakage.
"All rods are inserted.
"Electrical alignment is normal, supplied from off-site power.
"No impact on Unit 2. Unit 2 is operating at 100% power/Mode 1"

The NRC Resident Inspector has been informed. The licensee notified the State of Tennessee.

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Power Reactor Event Number: 47084
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID T. HURT
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/21/2011
Notification Time: 16:45 [ET]
Event Date: 07/21/2011
Event Time: 11:00 [CDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VIVIAN CAMPBELL (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

POTENTIAL ADVERSE EFFECT ON ESW TRAIN DURING A POSTULATED CONTROL ROOM FIRE

"On July 21, 2011 at 1100 [CDT] Callaway Plant staff determined that a design deficiency could adversely affect the 'B' Train of Essential Service Water (ESW) in the event of a Control Room fire. 'B' Train is the credited train for completion of a post-fire safe shutdown as a result of a Control Room evacuation.

"As a result of this deficiency, normally closed valve EFHV0060 could spuriously open during a postulated control room fire. EFHV0060 is located on the ESW return line from the 'B' Component Cooling Water (CCW) heat exchanger. If EFHV0060 spuriously opened as a result of this postulated fire, the flow balance in the 'B' Train of the ESW system would be affected. In this scenario, cooling water flow to other essential components could be reduced to below the minimum requirements.

"A fire watch has been imposed as a compensatory measure for this condition. Additionally, EFHV0060 has been closed and de-energized to preclude spurious opening in the event of a postulated control room fire.

"This condition is reported in accordance with 10 CFR 50.72 (b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.

"The NRC Resident Inspector has been notified."

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Non-Agreement State Event Number: 47085
Rep Org: WEATHERFORD INTERNATIONAL
Licensee: WEATHERFORD INTERNATIONAL
Region: 4
City: BENBROOK State: TX
County:
License #: 42-26891-01
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER SHAWN PERRY
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/21/2011
Notification Time: 17:45 [ET]
Event Date: 04/20/2011
Event Time: [CDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
VIVIAN CAMPBELL (R4DO)
GLENN DENTEL (R1DO)
DUNCAN WHITE (FSME)

Event Text

POTENTIAL OVEREXPOSURE OF WELL LOGGING SUPERVISOR

The RSO for Weatherford International located in Benbrook, TX was provided the 2nd quarter dosimetry readings of 7545 mRem for a well logging supervisory in their Weston, WV office. The supervisor has been removed from activities involving radioactive sources pending results of an investigation. Preliminary findings are that the individual involved was returning a 1.5 Ci Cs-137 source to storage and had placed his dosimetry, a Luxel, about 1 foot from the source at which time he had to use the restroom. When he returned he discovered that the storage area door had automatically locked requiring him to contact the custodian to reopen the area to recover his dosimetry. He estimated that the time involved was between 1-1.5 hours. The licensee investigation is on-going.

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Power Reactor Event Number: 47086
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE NIEMEYER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/21/2011
Notification Time: 20:39 [ET]
Event Date: 07/21/2011
Event Time: 11:53 [CDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VIVIAN CAMPBELL (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

VULNERABILITY FROM A POTENTIAL CONTROL ROOM FIRE ON "A" SAFEGUARDS BUS

"A potential scenario has been identified that has not been analyzed in the Comanche Peak Nuclear Power Plant Fire Safe Shutdown Analysis (FSSA). This situation is described below for Unit 1, but also applies to Unit 2. Listed below is the configuration for 1EA1. The basic configuration is typical for 1EA2, 2EA1 and 2EA2 as well (ref. E1-0001)

- Safeguard Bus 1EA1 is a 6.9 kV switchgear with a Main-Tie-Main configuration.
- The normal lineup has one feeder breaker closed, the other feeder breaker open and the tie breaker closed.
- 1EA1 receives normal power from the secondary side of Startup Transformer XST2 through breaker 1EA1-1.
- 1EA1 receives alternate power from the secondary side of Startup Transformer XST1 through breaker 1EA1-2.
- 1EA1 receives emergency power from diesel generator 1EG1 through breaker 1EG1.
- An alternate source of power for 1EA1 is also available from Train C through breaker 1EA1-3.

"The control wiring for the 1EA1-1 circuit breaker contains the following attributes that are important to understand the issue:

- Switch 43/1EA1-1, located in the Shutdown Transfer Panel (STP) is used to transfer control of 1EA1-1 from the Control Room (1-CB-11 switch CS-1 EA1-1) to the Hot Shutdown Panel (HSP) switch CS-1 EA-1 L. (Ref. E1-0031-01&02)
- There is a trip circuit fuse located in the 6.9 kV switchgear compartment for 1EA1-1 for control of the trip circuit when the breaker is controlled at 1CB-11 and a separate fuse for the trip circuit when the breaker is controlled by the HSP.
- The trip circuit for 1EA1-1 has a contact routed through the Control Room to the Solid State Protection System (SSPS) Cabinet. This contact is in the trip circuit when control is from the Control Room or when control is from the HSP. (Ref. E1-0031-01)

"The scenario is based on a fire in the Control Room. If the fire in the Control Room causes a ground in the wiring routed in the Control Room to the SSPS cabinet, the fuse for the 1E1-1 trip circuit would open. In the event of a fire in the Control Room, control of the plant is transferred to the HSP. When the control of breaker 1EA1-1 is transferred to the HSP and the ground condition in the SSPS wiring still exists, the second 1EA1-1 trip circuit would open. At this time there would be no way to remotely trip open 1EA1-1. The breaker could still be tripped mechanically at the breaker. Therefore, if 1EA1-1 is closed, 1EA1 could remain energized if off-site power is available. If off-site power is not available, but 1EA1-1 remains closed, bus 1EA1 would remain electrically connected to XST2. As part of the transfer of control from the Control Room to the HSP, operators start up the diesel generator and close 1EG1 to place 1EA1 loads on the generator. If 1EG1 is closed and 1EA1-1 breaker is still closed with off-site power available, the generator will be immediately connected to grid power through XST2 without synchronizing. If 1EG1 is closed and 1EA1-1 breaker is still closed with off-site power not available, the generator will be immediately connected to XST2 and attempt to energize XST2. This large current draw associated with energizing XST2 would likely stall and damage diesel generator 1EG1.

"Compensatory Action is being implemented through procedure revisions to preclude damage to the diesel generator during this scenario."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012