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Event Notification Report for September 21, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/20/2011 - 09/21/2011

** EVENT NUMBERS **


47195 47266 47270 47272 47276

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47195
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/23/2011
Notification Time: 23:10 [ET]
Event Date: 08/23/2011
Event Time: 15:30 [CDT]
Last Update Date: 09/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK HAIRE (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

CREFS WAS DECLARED INOPERABLE

"This telephone report is being made in accordance with 10 CFR 50.72(b)(3)(v) as a loss of safety function for a single train safety system. On August 23, 2011 at 1530 CDT, the clevis pin that connects the valve with the air operator was found not fully inserted on the Control Room HVAC Emergency Bypass System Inlet Valve, HV-AO-271 AV. This valve is normally closed and opens in response to a Group 6 isolation signal to align the Control Room Emergency Filtration System) (CREFS) to outside air. A retaining clip at one end of the pin was found to be missing, allowing the pin to partially back out of the clevis. The pin was found engaged with half of the clevis. This condition resulted in declaring CREFS inoperable at 15:30 CDT, and CNS entered LCO 3.7.4 Condition A which requires the CREF system to be restored to OPERABLE status in 7 days. The cause of the displaced clevis pin is under investigation."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM RANDY KOUBA TO JOE O'HARA AT 1406 EDT ON 9/20/11 * * *

"This notification is being made to retract Event Notification EN# 47195 which reported a loss of safety function for a single train safety system due to the unplanned inoperability of the Control Room Emergency Filtration System (CREFS). CREFS was declared inoperable on August 23, 2011 per LCO 3.7.4 due to finding a clevis pin not fully inserted on the valve operator for the Control Room HVAC Emergency Bypass System Inlet Valve IIV-AOV-271AV. This normally closed valve opens on a Primary Containment Group 6 Isolation signal to align CREFS to outside air. The retaining clip at one end of the pin was found missing which allowed the pin to partially back out of the clevis.

"Cooper Nuclear Station (CNS) recently completed its trouble shooting of the as-found condition of the pin and a subsequent evaluation of its ability to withstand seismic loading. CNS determined that CREFS would have been able to fulfill its safety function. The clevis pin was shown via testing to remain engaged when the valve was stroked. The seismic evaluation showed that the maximum seismic force is less than one-tenth of the estimated force required to remove the pin, and consequently it is not credible that the pin would have become disengaged in a seismic event. CREFS did not lose the ability to perform its safety function."

The NRC Resident Inspector has been notified.

Notified the R4DO (Walker).

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Agreement State Event Number: 47266
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/14/2011
Notification Time: 15:03 [ET]
Event Date: 09/09/2011
Event Time: 18:00 [CDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A LESS THAN PRESCRIBED DOSE ADMINISTRATION

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

"On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received."

Texas Incident No.: I-8883

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: 47270
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: MOTTS, LLP
Region: 1
City: ASPERS State: PA
County:
License #: PA-G0234
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/16/2011
Notification Time: 12:01 [ET]
Event Date: 09/14/2011
Event Time: [EDT]
Last Update Date: 09/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ASSEMBLY FAILED IN OPEN POSITION

This event was received via facsimile.

"On September 15, 2011 at 1600, the Department's central office [PA Department of Environmental Protection] received notification of a shutter failure reportable under 10 CFR 30.50(b)(2), which was discovered on September 14, 2011 at 45 Aspers Road North, Aspers, PA 17304.

"The device was manufactured by Heuft USA Inc., Model (45US), Serial # (7533LQ), Isotope (Am-241), Activity (44.2mCi). No radiation exposure to personnel ensued during this event.

"The cause of the event is unknown at this time.

"The gauge manufacturer, Heuft, has been notified and is scheduled to make repairs today, September 16, 2011. A Departmental [PA Department of Environmental Protection] reactive inspection is planned to investigate this event further. More details will be provided when known."

Report No: PA 110024

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Agreement State Event Number: 47272
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: INTEGRITY INSPECTION SOLUTIONS
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-11357-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/16/2011
Notification Time: 18:01 [ET]
Event Date: 07/31/2011
Event Time: [CDT]
Last Update Date: 09/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE TO RADIOGRAPHER

The following report was received from the State of Louisiana via facsimile.

"On Monday, September 12, 2011, LA DEQ [ Louisiana Department of Environmental Quality] received a notification from Integrity [Inspection] Solution that a radiographer's personnel monitoring device received an excessive exposure of 10811mrem for the month of July 2011. The RSO [Radiation Safety Officer] has begun an investigation into the exposure. The individual left the monitor at the office while he was on a week off. The individual was referred to a physician for blood work and will have follow up check ups. Preliminary findings were no unusual activities. Updates will be provided when available."

Event Report ID No: LA-1100XXX

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Agreement State Event Number: 47276
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: FLOWSERVE US INC.
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0121-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/18/2011
Notification Time: 13:42 [ET]
Event Date: 09/07/2011
Event Time: [EDT]
Last Update Date: 09/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ADELAIDE GIANTELLI (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY CAMERA LOCKING MECHANISM

The following information was received via e-mail:

"On September 7, 2011, the licensee discovered a failure of the locking mechanism of a QSA 880-Delta radiography exposure device. This is a 30-day notification event. Device: 880 Delta. S/N: D7822.

"During the installation of the 880 camera, it was discovered that the locking mechanism would not return to the 'Stored / Locked' position. While investigating the malfunction, it was determined that possibly one of the springs in the locking mechanism was bad. The manufacturer (QSA Global / Sentinel) was called and the malfunction was explained and it was requested that the camera be sent back for further investigation and correction of the malfunction.

"This camera did not have a radioactive source in it or attached to the drive cable at the time of the malfunction discovery. This is a brand new 880 Delta camera and has not had a radioactive source in it. The source to be installed in the camera is being stored in a 650L changer, serial number 2168 and secured in [the licensee's] radiography booth.

"The RSO was the only person in the radiography booth when the malfunction was discovered and no potential exposure occurred.

"Updates will be provided through NMED.

North Carolina Incident Number: NC 11-48

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Thursday, March 29, 2012