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Event Notification Report for September 7, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/06/2011 - 09/07/2011

** EVENT NUMBERS **


46452 47227 47233 47242 47244 47246

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General Information Event Number: 46452
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GRUBBS, HOSKYN, BARTON AND WYATT, INC
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK0456-03121
Agreement: Y
Docket:
NRC Notified By: ANGELA MINDEN
HQ OPS Officer: ERIC SIMPSON
Notification Date: 12/03/2010
Notification Time: 11:18 [ET]
Event Date: 12/02/2010
Event Time: 12:30 [CST]
Last Update Date: 09/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

The following was received via email from the State of Arkansas:

"The Arkansas Department of Health, Radioactive Materials Program, was notified at 1315 CST on December 2, 2010 by licensee Grubbs, Hoskyn, Barton, and Wyatt, Inc. (ARK-0456-03121) of a missing Troxler moisture/density gauge. The gauge was being transported between their office in Little Rock, Arkansas and a job-site in Bryant, Arkansas. The authorized user observed the gauge was missing at approximately 1230 CST. The gauge had apparently fallen from the transport vehicle.

"The Troxler gauge is a Model 3430 (SN 63492) containing 40 mCi Am-241:Be and 8 mCi Cs-137.

"It appears that the gauge was not properly secured in the vehicle. The Arkansas Department of Health is investigating the circumstances surrounding this event.

"The Arkansas Department of Health prepared a press release concerning this event. Arkansas Department of Health also notified the Police Departments of Little Rock and Bryant, the Sheriff's Offices of Saline and Pulaski Counties, the Arkansas State Police, and the Arkansas Department of Emergency Management.

"Arkansas has assigned event report ID number AR-12-10-02."

* * * UPDATE AT 1147 EDT ON 9/6/11 FROM PEMBERTON TO HUFFMAN VIA E-MAIL * * *

"On August 30, 2011, the Arkansas Department of Health, Radioactive Material Division was informed by [the] Radiation Safety Officer for Grubbs, Hoskyn, Barton and Wyatt, that the Troxler 3430 Moisture/Density Gauge, SN#63492, lost on December 2, 2010, had been recovered.

"A Departmental investigation confirmed that the gauge recovered on August 30, 2011, was in fact the device lost on December 2, 2010. The Department considers this incident to be closed."

The State Department of Health Representative indicated that the gauge was returned to the licensee by a private citizen who wished to remain anonymous.

R4DO (Drake) and FSME (McIntosh) notified. ILTAB notified via e-mail.


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: 47227
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA MEDICAL CTR. OF WASHINGTON CO., INC.
Region: 3
City: HARTFORD State: WI
County:
License #: 131-1024-01
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/31/2011
Notification Time: 16:15 [ET]
Event Date: 08/30/2011
Event Time: [CDT]
Last Update Date: 08/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
GREG SUBER (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED WRONG ISOTOPE DURING A DIAGNOSTIC PROCEDURE


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

"The Wisconsin Department of Health Services (DHS) received a phone call from the Imaging Manager at Aurora Medical Center of Washington County on August 30, 2011, that a patient received a dose of 5 mCi of I-131 on February 2, 2011. The patient, according to the written directive, was to receive a dose of 5 mCi of I-123. This diagnostic procedure was ordered to evaluate whether any thyroid tissue remained following an iodine ablation dose one year earlier.

"DHS conducted an investigation on August 31, 2011 and the licensee will submit a 15-day written report concerning the medical event. At this time, the licensee is evaluating their process and is developing a new written directive form. The authorized user will discuss this with the referring physician to determine if the patient will be notified."

Wisconsin Report ID: WI110013

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: 47233
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: PDV REFINING, LLC
Region: 3
City: LEMONT State: IL
County:
License #: IL-01603-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/01/2011
Notification Time: 16:02 [ET]
Event Date: 08/31/2011
Event Time: [CDT]
Last Update Date: 09/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A FIXED NUCLEAR GAUGE SHUTTER THAT FAILED TO CLOSE

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

"Late yesterday the Agency's [Illinois Emergency Management] W. Chicago office received a call from PDV Midwest Refining (IL-01603), 135th St and New Ave., Lemont, IL 60439. The caller reported that while his crew was performing routine shutter checks of fixed gauges in his area of the plant, a shutter failed to close. The vessel the gauge was on was in use as part of a sulfur unit and needed to remain in operation with the gauge 'on-line', so no other immediate action was taken other than to advise all shift supervisors of the gauge's status and to avoid performing any work in the area.

"This morning, the radiation safety officer was contacted for additional information and instructions regarding necessary actions on their part. The RSO advised that the gauge was an Ohmart model SH-F1-45, containing 15 milliCi of Cs-137 as of April 2002. It was one of two gauges on that vessel. The other gauge which was lower on the vessel showed no difficulties in its operation. However, he noted that a similar problem had occurred in the past with the same model gauge on a parallel sulfur unit in the same physical position. At that time, field notes prepared by the manufacturer's representative who inspected the device indicated that some corrosion was present on the device. Both vessels and thus all four gauges are exposed to the full range of seasonal cycles of weather. All site staff have been made aware of the gauge condition and to ensure all 'lock out - tag out' practices are in effect in the area to preclude any work on the vessel until such time the manufacturer's rep has repaired the device or removed it from the vessel.

"The radiation safety officer was advised of the need to file a written report within 30 days in keeping with Illinois regulations.

"Source/Radioactive Material: SEALED SOURCE GAUGE Radionuclide: CS-137
"Manufacturer: OHMART CORP. Activity: 0.015 Ci [or] 0.555 GBq
"Model Number: A-2102
"Serial Number: unk

Illinois Item Number: IL11117

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Power Reactor Event Number: 47242
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/06/2011
Notification Time: 05:54 [ET]
Event Date: 09/06/2011
Event Time: 01:04 [EDT]
Last Update Date: 09/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

CONTROL ROOM INDICATION OF HPCI MINIMUM FLOW VALVE POSITION LOST

"On September 6, 2011 at approximately 0104 EDT during surveillance testing of the High Pressure Coolant Injection (HPCI) system, control room position indication was lost on the HPCI Minimum Flow Valve, E4150F012 as the valve was stroking closed following shutdown of HPCI. The Minimum Flow Valve main power fuses were checked (found blown) and replaced in accordance with plant procedures. During stroke time testing of E4150F012, control room position indication was again lost when the operator depressed the open pushbutton.

"HPCI had been removed from service for quarterly surveillance testing at 2219 EDT September 5, 2011. The unplanned inoperability condition began at 0104 EDT when position indication was lost on the Minimum Flow Valve during system shutdown. The valve was locally verified closed to comply with the action of LCO 3.6.1.3 to isolate the penetration. A 14-day LCO was entered and back dated to the time that HPCI was removed from service for surveillance testing. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident, based on loss of a single train safety system. RCIC was and has remained operable.

"The NRC Resident Inspector has been notified. The failure is currently under investigation."

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Non-Agreement State Event Number: 47244
Rep Org: ENVIRONMENTAL PROTECTION AGENCY
Licensee: ENVIRONMENTAL PROTECTION AGENCY
Region: 1
City: ATLANTA State: GA
County:
License #: GL-703353-15
Agreement: Y
Docket:
NRC Notified By: STEPHEN BALL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/06/2011
Notification Time: 14:36 [ET]
Event Date: 06/30/2000
Event Time: [EDT]
Last Update Date: 09/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
TODD JACKSON (R1DO)
ANGELA MCINTOSH (FSME)
JIM WHITNEY E-MAIL (ILTA)

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

Event Text

STOLEN AND RECOVERED GENERALLY LICENSED X-RAY FLOURESCENCE ANALYZER

A representative for the EPA reported that a Thermo Fisher Scientific Niton XLp 722W XRF metal analyzer was stolen and subsequently recovered. The analyzer was inside a car parked at a hotel in Anderson, South Carolina and was stolen sometime during the night of 6/30/11. The technician using the gauge discovered the theft in the morning and filed a police report. Shortly thereafter, on 6/30/11, the police recovered the gauge at a nearby dumpster. The gauge appear to be undamaged but was sent to the vendor for inspection. The gauge has been returned to the EPA and is currently back in service. The gauge contains a 40 milliCurie Cd-109 source and two Am-241 sources with a total activity of 14.005 milliCuries.

The licensee did not originally recognize the reportability of this event. After discussions with NRC R1 (Welling) and NRC FSME HQ (McIntosh), the licensee is making this report.

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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Part 21 Event Number: 47246
Rep Org: ROSEMOUNT NUCLEAR INSTRUMENTS
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DUYEN PHAM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/06/2011
Notification Time: 15:59 [ET]
Event Date: 08/30/2011
Event Time: [CDT]
Last Update Date: 09/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
TODD JACKSON (R1DO)
DANIEL RICH (R2DO)
JAMES DRAKE (R4DO)
CHRISTINE LIPA (R3DO)
PART 21 E-MAIL GROUP ()

Event Text

NOTIFICATION THAT CERTAIN ROSEMOUNT PRESSURE TRANSMITTERS MAY NOT PERFORM THEIR INTENDED SAFETY FUNCTION

The following is a summary of a Part 21 notification was received from Rosemount via facsimile:

"Re: Notification under 10 CFR Part 21 on certain Rosemount Model 1153 Series B, 1154 and 1164 Series H Pressure Transmitters

"Pursuant to 10 CFR Part 21, section 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform [the NRC] that one (1) Model 1153 Series B, fourteen (14) Model 1154, and twenty (20) Model 1154 Series H pressure transmitters may not perform their intended safety function.

"Rosemount Nuclear Instruments, Inc. does not have complete information relating to specific plant applications and therefore cannot determine the potential effects of the condition on plant operation.

"The thirty-five (35) potentially affected Model 1153 Series B, 1154, and 1154 Series H pressure transmitters were shipped from RNII between April 19, 2011 and August 12, 2011. [The list of Plant Sites that have received the affected transmitters is provided at the end of this report.]

"If you have any questions, or require additional information related to this issue, please contact: Mike Dougherty (208) 865 -1112 or Tracy Kaluzniak (952) 949-7159.

"Identification of items supplied:
"One (1) Model 1153 Series B, fourteen (14) Model 1154, and twenty (20) Model 1154 Series H potentially affected units have been shipped.

"Identification of firm supplying the item:
"Rosemount Nuclear Instruments, Inc. 8200 Market Boulevard Chanhassen, MN 55317

"Nature of the failure and potential safety hazard:
"On each Model 1153 Series B, 1154, and 1154 Series H transmitter, four diodes are used on a circuit card assembly which is installed within the welded sensor module subassembly. These diodes convert the AC oscillator signal to a DC current proportional to the pressure applied to the sensor. The diodes (P/N DZ911218A) are manufactured by Microsemi Corporation (MSC).

"Recently an unexpected drop in yield was identified during electrical testing of the circuit card assembly. A hold was placed on production to further investigate the issue. It was determined that the drop in yield was caused by intermittent open diodes on the circuit card assembly. Failure of one diode will result in an off-scale failure of transmitter output. Failure of two or more diodes may result in an on-scale failure of transmitter output.

"MSC determined that the intermittent open electrical failures were the result of a poor solder bond formation within the diode at the cathode lead. This was caused by either inadequate heat flow or surface contamination during the component manufacturing process.

"Working with MSC, RNII used material traceability data to confirm the potential problem was limited to one manufacturer's lot code of the diode. RNII was then able to utilize material traceability data to further identify the specific shipped transmitters affected by this notification.

"On August 30, 2011, it was concluded that a substantial safety hazard may exist. Rosemount Nuclear Instruments, Inc. does not have sufficient information to determine the safety impact related to the potentially anomalous output in plant applications. As a result, a notification about the potential substantial safety hazard is being made in accordance with 10 CFR Part 21 to customers who purchased one or more of the thirty-five (35) potentially affected Model 1153 Series B, 1154, or 1154 Series H pressure transmitters.

"The corrective action which is taken, the name of the individual or organization responsible for that action, and the length of time taken to complete that action:
"(a) RNII held shipments of completed Model 1153 Series B, 1154, and 1154 Series H transmitters and determined which specific units were assembled with diodes from the suspect lot code.

"(b) RNII quarantined all Model 1153 Series B, 1154, and 1154 Series H transmitters and sub-assemblies in manufacturing while a determination was made as to which specific units were assembled with diodes from the suspect lot code.

"(c) RNII worked with the diode supplier (MSC) to determine the root cause and identify the suspect lot code. Since this part is no longer being manufactured by MSC, no corrective actions were implemented at MSC.

"(d) RNII is in the process of reworking all unshipped Model 1153 Series B, 1154, and 1154 Series H transmitters and subassemblies that were completed or in manufacturing that contained diodes from the suspect lot code.

"(e) Potentially affected pressure transmitters can be returned and reworked at the factory at the end user's request.

"(f) RNII is qualifying a substitute diode to replace the obsolete DZ911218A diode. The qualification is expected to be complete within the next six months. This qualification will be documented in an update to the Model 1153 Series B, 1154, and 1154 Series H qualification reports

"Any advice related to the potential failure of the Item:
"RNII recommends that users review the application where any of the thirty-five (35) potentially affected Model 1153 Series B, 1154 and 1154 Series H transmitters are used to determine any safety considerations in the operation of the plant. RNII recommends that potentially affected transmitters be returned to RNII for rework at the end user's earliest opportunity."

List of Affected Sites:

U.S Facilities
Calvert Cliffs -5 Transmitters
Oconee -2 Transmitters
San Onofre -1 Transmitter
River Bend -1 Transmitter
Waterford -1 Transmitter
Diablo Canyon -1 Transmitter
Farley -4 Transmitters

Foreign Facilities
Shin Kori -1 Transmitter
Ringhals -3 Transmitters
Fuqing -4 Transmitters
Fangjishan -4 Transmitters
Yangjiang -4 Transmitters
Tihange -1 Transmitter
Asco II / Vandellos II -3 Transmitters

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