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Event Notification Report for August 16, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/15/2011 - 08/16/2011

** EVENT NUMBERS **


47135 47140 47144 47154

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Agreement State Event Number: 47135
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: CHARLES TEAL
Notification Date: 08/09/2011
Notification Time: 12:26 [ET]
Event Date: 08/07/2011
Event Time: [CDT]
Last Update Date: 08/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - THERASPHERE TREATMENT TO WRONG LOBE OF LIVER

The following was received via fax:

"The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on August 8, 2011 that a patient received a dose of 1.05 GBq of Y-90 Theraspheres on July 7, 2011 to the wrong side of the liver as documented on the written directive. The patient was scheduled for treatment of 1.04 GBq Y-90 Theraspheres for multinodular hepatocellular cancer (HCC) to the left lobe of the liver. The dosimetry for Y-90 Theraspheres was based on volume (mass) of the lobe bearing the tumors (the patient has tumors on both lobes, right and left). A treatment plan was created for the left lobe (using the volume of the left lobe) but during the procedure the right lobe was treated with the prescribed dose for the left lobe.

"DHS will be conducting an investigation on August 12, 2011 and the licensee will be submitting a 15 day written report concerning the medical event."

WI Event Number: 110012

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: 47140
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: WOOD RIVER REFINERY
Region: 3
City: ROXANA State: IL
County:
License #: IL-01282-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 08/10/2011
Notification Time: 16:23 [ET]
Event Date: 07/22/2011
Event Time: [CDT]
Last Update Date: 08/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

The following information was received by e-mail:

"On August 8, 2011 the licensee's radiation safety officer called to advise the Agency [Illinois Emergency Management Agency] of a gauge shutter failure. During the performance of routine operability checks and area surveys on July 22, 2011 it was found that the shutter lever on a Kay- Ray/Sensall 7062P could not be completely closed. The gauge is permanently mounted to a 12 inch pipeline in a remote area of the refinery. The line runs overhead at a height of approximately 10 to 12 feet. Arrangements were made to have personnel with duties in the area to be notified of the shutter failure and to prohibit any work in the immediate area. The nearest work station was determined to be over 200 feet away. Radiation levels at one foot from the gauge were measured at less than 1 milliR/h.

"After contacting the manufacturer on August 8 to determine the best course of action, the licensee applied a lubricant to the shutter area. Subsequently, after waiting a day, attempts to close the shutter were successful. The shutter is now operating as expected. Arrangements have been made to have a service licensee visit the site to ensure operation is as expected. As the failure was noted during performance of routine tests designed to detect such failures, no changes to the licensee's procedures or protocols are anticipated. The licensee was reminded of the importance of promptly reporting such events in the future."

The sealed source gauge is a Kay-Ray/Sensall model 7700-Y containing 0.14 Ci of CS-137. The fixed gauge is a Kay-Ray/Sensall, Model number 7063P; Serial number S96G1816.

Illinois Event Number IL11105

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Agreement State Event Number: 47144
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PAVEMENT ENGINEERING INC.
Region: 4
City: REDDING State: CA
County: SHASTA
License #: 4977-45
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/11/2011
Notification Time: 15:06 [ET]
Event Date: 08/06/2011
Event Time: 04:30 [PDT]
Last Update Date: 08/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)
DARYL JOHNSON (ILTA)
MEXICO VIA FAX/EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The following information was received from the state of California via e-mail:

"On August 8, 2011, Mr. Todd Rucker, RSO from Pavement Engineering, Inc., notified RHB [Radiation Health Branch] Sacramento that one of their moisture-density gauge operators lost a gauge at their job site on August 6, 2011 at approximately 4:30 am. The gauge had been borrowed from A. Teicher & Son, Inc., License No 4030-34. The gauge was used on a job site on HWY 70 in Yuba County, near the town of Olivehurst, CA."

The lost gauge is a Troxler, Model 4640-B, Serial number T464 1793.

This model moisture density gauge has an 8 mCi Cs-137 source.

California event number: 080611

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: 47154
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: RICK HUBBARD
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/15/2011
Notification Time: 13:10 [ET]
Event Date: 08/15/2011
Event Time: 10:55 [CDT]
Last Update Date: 08/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MICHAEL HAY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 82 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - CONTAMINATED OIL SAMPLE

"On 8/11/2011 at 1145 CDT the Turbine Driven Auxiliary Feedwater pump was declared inoperable due to oil sample results indicating high particulate (ISO Solid Contamination Code above the Action Limit IAW I-ENG-004) in the turbine lube oil. The action limit is 19/16 and the sample result was 23/21. The ISO Solid Contamination Code is a measure of particle count and size. The same sample was analyzed for metal particulate concentration and results were satisfactory. Efforts have been underway to determine the source of the contaminate and to restore the turbine lube oil to within specifications.

"On 8/14/2011 at 0945 CDT NRC Region IV granted a Notice of Enforcement Discretion NOED beginning at 1145 CDT on 8/14/2011 to expire at 1145 CDT on 8/15/2011.

"Cleaning efforts have been completed. Current sample results indicate acceptable levels. A Basic Engineering Disposition has been issued supporting the sample results and basis for operability. Technical Specification required shutdown per TS 3.7.5 condition C.1 and C.2 was initiated at 1055 CDT on 8/15/2011. The Turbine Driven Auxiliary Feedwater Pump was declared operable at 1203 CDT on 8/15/2011 and the power reduction was halted at 82% Rated Thermal Power (RTP). Power ascension to 100% RTP was commenced at 1209 CDT on 8/15/2011."

The licensee has notified the NRC Resident Inspector.

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Thursday, March 29, 2012