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Event Notification Report for July 29, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/28/2011 - 07/29/2011

** EVENT NUMBERS **


47090 47095 47103 47104 47105 47106 47107

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 47090
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UW-MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/22/2011
Notification Time: 16:29 [ET]
Event Date: 07/21/2011
Event Time: [CDT]
Last Update Date: 07/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A PATIENT RECEIVING AN INCORRECT DOSAGE OF I-131

The following report was received from the State of Wisconsin via fax:

"The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on July 22, 2011 that a patient received the wrong dose of I-131 on July 21, 2011. The patient was scheduled for a diagnostic procedure involving 8 mCi of I-131, but instead received a 150 mCi therapeutic dose of I-131.

"DHS will be conducting an investigation on July 26, 2011 and the licensee will be submitting a 15 day written report concerning the medical event."

Wisconsin Event Report ID No.: WI10010

* * * RETRACTION ON 7/26/11 AT 1405 EDT VIA FAX TO HUFFMAN FROM TIMMERMAN * * *

"This is an update to [the State of Wisconsin] Event Notification WI-10010. On July 26, 2011, the licensee informed [the Wisconsin Department of Health Services] that the reported medical event on July 22, 2011 involving a patient that received 150 mCi dose of I-131 on July 21, 2011, was an internal miscommunication. Upon review of the written directive and speaking with UW-Madison staff, DHS has verified that the patient received an I-131 therapeutic dose as prescribed on the written directive.

"This medical event is retracted."

R3DO (Giessner) and FSME EO (McIntosh) notified.

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Agreement State Event Number: 47095
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: COASTAL TESTING LABORATORIES, INC
Region: 4
City: PASADENA State: TX
County:
License #: 01945
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/26/2011
Notification Time: 16:44 [ET]
Event Date: 07/26/2011
Event Time: 12:00 [CDT]
Last Update Date: 07/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
DUNCAN WHITE (FSME)
MEXICO via fax/email ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN HUMBOLDT NUCLEAR GAUGE

The following report was received from the State of Texas via email:

"On July 26, 2011, the Agency was notified by the licensee that a Humboldt model 5001 EZ moisture/density gauge serial number 3567 was stolen out of one of their trucks in Houston, Texas. The gauge contains a 40 milliCurie Americium-241 source and a 10 milliCurie Cesium-137 source. The gauge was locked in the back of a pickup parked at a training center where the user was attending safety training. When the user returned to the truck, he found the lock and chain securing the gauge had been cut and the transport case with the gauge was missing. The user contacted his employer who then contacted local law enforcement who responded to the scene. The licensee's Radiation Safety Officer also responded to the scene. The licensee believes that the gauge operating trigger was locked, but could not state that with all certainty. Additional information will be provided as it is received."

Texas Incident No.: I-8875

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: 47103
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIM MILLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/28/2011
Notification Time: 01:00 [ET]
Event Date: 07/27/2011
Event Time: 20:59 [EDT]
Last Update Date: 07/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ALAN BLAMEY (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

Event Text

LOSS OF BOTH TRAINS OF EMERGENCY RESPONSE DATA SYSTEM DUE TO LOSS OF PLANT PROCESS COMPUTERS

"At 2059 [hrs. EDT] on 7/27/11, St. Lucie Unit 1 lost both the 'A' and 'B' computer trains associated with Emergency Response Data Acquisition and Display System (ERDADS). Attempts to restore either train have been unsuccessful. The cause of the failure is not known and continues to be investigated.

"This is reportable in accordance with 10CFR 50.72(b)(3)(xiii) due to a major loss of emergency assessment capability for greater than one hour."

The loss of the plant process computers also resulted in the loss of the Safety Parameter Display System. Redundant indicators are available to operators.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47104
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: AL MANNING
HQ OPS Officer: JOE O'HARA
Notification Date: 07/28/2011
Notification Time: 02:53 [ET]
Event Date: 07/27/2011
Event Time: 23:20 [EDT]
Last Update Date: 07/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ALAN BLAMEY (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

NON-FUNCTIONAL TECHNICAL SUPPORT CENTER (TSC) CLIMATE CONTROL SYSTEM

"The Technical Support Center climate control system was found to be non-functional on 7/27/11 at 2320. System repair is in progress at this time. The time period that the Technical Support Center climate control system was non-functional has exceeded the 30 minute limit that is delineated in the Technical Requirements Manual section T3.10.1. This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG 1022, Rev. 1 since this issue affected an emergency response facility. Also, this 8 hour notification is being made in accordance with the Technical Requirements Manual section T3.10.1.B.2.

"The alternate Technical Support Center facility remains functional."

The NRC Resident Inspector has been notified.

* * * UPDATE FROM FRANK GORLEY TO PETE SNYDER AT 2149 ON 7/28/11 * * *

At 2100 EDT on 7/28/11 the TSC climate control system has been restored and the TRM action statements have been exited.

The licensee notified the NRC Resident Inspector. Notified R2DO (Blamey).

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Power Reactor Event Number: 47105
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: MICHELE ZIETLOW
HQ OPS Officer: JOE O'HARA
Notification Date: 07/28/2011
Notification Time: 09:57 [ET]
Event Date: 07/28/2011
Event Time: 01:15 [CDT]
Last Update Date: 07/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)

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

CONTROL ROOM TEMPERATURE RECORDER INOPERABLE

"On July 28, 2011, at 0115 hours, a main control room recorder failed. The recorder functions to remotely monitor plant area temperatures, including eight areas used in accident classification (specifically, Emergency Action Level classifications when predetermined temperature levels are exceeded).

"Troubleshooting efforts have been initiated to determine the cause of the recorder failure; the eight affected areas are being monitored locally twice per shift during operator rounds.

"Given this recorder is used for accident classification, this event is reportable under 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

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Non-Agreement State Event Number: 47106
Rep Org: MALLINCKRODT, INC.
Licensee: MALLINCKRODT, INC.
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 02-04206-01
Agreement: N
Docket:
NRC Notified By: DAN HOFFMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/28/2011
Notification Time: 13:03 [ET]
Event Date: 07/28/2011
Event Time: 12:00 [CDT]
Last Update Date: 07/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN GIESSNER (R3DO)
ANGELA MCINTOSH (FSME)
DARYL JOHNSON (ILTA)

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

Event Text

DEPLETED URANIUM-238 SHIELDS ARE MISSING

Between April and June of 2010, the licensee shipped shielded Tc-99m generators to customers in Ohio and Hawaii. Each generator was shipped with a 8.1mCi depleted U-238 shield. Ohio State University (OSU) Medical Center received 2 generators and Tripler Army Medical Center in Hawaii received 1 generator. Once the generators are depleted, they are returned to Mallinckrodt in the depleted uranium shields. OSU Medical Center shipped one depleted generator in April 2010 (shield s/n 004631) and one in May 2010 (shield s/n 004042). Tripler Army Medical Center in Hawaii shipped their depleted generator in June 2010 (shield s/n 002426). Records confirm that all three shields were picked up by the carriers at the respective facilities but Mallinckrodt has no records of the shields being returned to their facility. The shields are returned to a courier contracted by Mallinckrodt who in turn delivers the shields to the Mallinckrodt facility. The carriers used for the return shipments were contacted about the missing shields and are presently investigating there whereabouts. The licensee, as well as the customers, are also searching their facilities. This matter is under investigation.

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: 47107
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOHN CLARK
HQ OPS Officer: JOE O'HARA
Notification Date: 07/29/2011
Notification Time: 01:02 [ET]
Event Date: 07/28/2011
Event Time: 21:15 [EDT]
Last Update Date: 07/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAMELA HENDERSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 53 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO FISH KILL EVENT

"At 2115 on 7/28/2011, Oyster Creek experienced a fish kill of greater than 100 fish caused by a loss of the thermal dilution plant power. The loss of thermal dilution plant power was based on a faulted breaker in the Oyster Creek/JCP&L substation.

"The reported failure was a relay failure inside a 34.5KV substation breaker. Oyster Creek is holding at 53% power until thermal dilution is restored for environmental limitations."

The New Jersey Department of Environmental Protection has been notified. The NRC Resident Inspector will be notified.

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