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Event Notification Report for November 2, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/01/2011 - 11/02/2011

** EVENT NUMBERS **


47158 47364 47371 47377 47378 47381 47394 47395 47398 47401

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47158
Rep Org: CHRISTIANA CARE
Licensee: CHRISTIANA CARE
Region: 1
City: NEWARK State: DE
County:
License #: 0712153-02
Agreement: N
Docket:
NRC Notified By: JOSEPH SOLGE
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/16/2011
Notification Time: 14:47 [ET]
Event Date: 08/09/2011
Event Time: [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

DOSE DIFFERENT THAN PRESCRIBED

A patient was scheduled to receive three separate treatments for pancreatic cancer containing Yttrium-90. Each dose was to contain 10.5 milliCuries of Yttrium-90 for a total of 31.5 milliCuries. Cardinal Health (the producer of the treatment) provided the entire dose of 31.5 milliCurie in a single syringe. The physician verified the receipt of the syringe and administered it to the patient.

When the patient was scheduled to return on 8/16/11 for the second treatment Cardinal Health realized that they had provided the entire dose instead of three separate doses of 10.5 milliCuries. Cardinal Health notified Christiana Care of the error.

The treating physician and patient have been notified. No adverse health effects are expected.

* * * RETRACTION FROM JOESPH SOLGE TO JOHN SHOEMAKER AT 1009 EDT ON 11/01/11 * * *

The original directive was correct in regard to the dose administered, therefore this event is being retracted.

Notified the R1DO (Perry) and FSME (McIntosh).

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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Power Reactor Event Number: 47364
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: TOM PROELL
HQ OPS Officer: VINCE KLCO
Notification Date: 10/21/2011
Notification Time: 16:42 [ET]
Event Date: 10/21/2011
Event Time: 12:50 [CDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

AUTOMATIC REACTOR SCRAM DUE TO LOCKOUT OF AUXILIARY POWER TRANSFORMER

"The station experienced a lockout of the 2R Auxiliary Power Transformer. The resulting transient caused an automatic actuation of the RPS system. All control rods fully inserted. A Group 2 Primary Containment isolation occurred. Both 11 and 12 Emergency Diesel Generators started on a loss of voltage signal. Equipment response was that the 11 ESW [Emergency Service Water] pump (cooling for the #11 Emergency Diesel) failed to develop required pressure. The #13-4160V non-safety related bus failed to restore after the transient [and feed the Division 1 Essential Bus]. Additionally, the #15 bus transferred to the 1AR transformer [and is feeding the Essential Bus]."

The #11 Emergency Diesel Generator is currently tagged out of service. Electrical supply is being provided by offsite power. Reactor heat is being removed through the main steam line to the main condenser and reactor water inventory is being provided by the feedwater system. The SRVs lifted and reseated. The HPCI system was manually place into a pressure control mode.

The Minnesota Pollution Control Agency is being notified due to the licensee violating the site discharge canal temperature rate of change limit.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM RYAN RICHARDS TO JOHN KNOKE AT 1730 EDT ON 11/01/2011 * * *

"Prior to this event the 'B' Control Room Emergency Filtration (CREF) and 'B' Control Room Ventilation (CRV) Systems were inoperable for planned maintenance. On 10-21-11 at 1325 CDT, the #11 EDG ESW Pump was declared inoperable due to low cooling water pump flow, resulting in the #11 EDG being inoperable, which in turn resulted in the 'A' CREF and 'A' CRV being inoperable.

"Contrary to reporting requirements this condition was not identified and reported pursuant to 10 CFR 50.72(b)(3)(v)(D) as required within 8-hours in the previous event notification. This condition resulted in a loss of safety function for both divisions of CREF and CRV. This update amends the 10-21-11 event notification to include this as an 8-hour non-emergency event pursuant to 10 CFR 50.72(b)(3)(v)(D)."

The licensee notified the NRC Resident Inspector. Notified the R3DO (Nick Valos)

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Agreement State Event Number: 47371
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEATHERFORD INTERNATIONAL, INC.
Region: 1
City: MUNCY State: PA
County:
License #: PA-1030
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/24/2011
Notification Time: 18:07 [ET]
Event Date: 10/21/2011
Event Time: [EDT]
Last Update Date: 10/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
CHRISTIAN EINBERG (FSME)
DARYL JOHNSON (ILTA)

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

Event Text

AGREEMENT STATE REPORT INVOLVING APPARENT STOLEN DENSITY GAUGES WITH CS-137 SOURCES

"On October 22, 2011, at approximately 12:05 AM, the [Pennsylvania] Department's Director of the Bureau of Radiation Protection received notification via a phone call and email from the Pennsylvania Emergency Management Agency's Duty Officer of two 'densitometers' with radiation symbols that were found on the side of the road. It appears that the devices were stolen. This event is reportable under 10 CFR 20.2201(a)(1)(i).

"On Friday, October 21, 2011 evening (time unknown), two 'densitometers,' sealed source make and model currently unknown, each containing approximately 200 millicuries (mCi) of Cs-137, were reported found on the side of the road in Montoursville, PA in Lycoming County. A Fire Department and Emergency Response Team were deployed, and the two devices were isolated - one at or near Fairview Drive & Cherry Street, and the other on Maple Street in the same general area. Radiation measurements in the range of 30 to 40 micro-roentgens per hour at six feet were noted. The licensee was contacted and quickly recovered the two devices (Serial No. 8-7176 and 8-6891) and the Cs-137 sources at around 1:00 AM on October 22, 2011. [The devices] are now back in [the licensee's] possession. The DEP BRP Director spoke to the licensee's representative around this same time and was informed the sources were found in a shielded configuration, and, they could (now) account for all their radioactive sources. From the information known at this time, there were no noteworthy radiation exposures to the general public or any responding personnel.

"A reactive inspection is planned by the Department's Radiation Protection Program along with the PA DEP Bureau of Investigations. More details will be added as they become known.

"Media attention: None at this time

Pennsylvania Event Report ID No: PA110028

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.

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Agreement State Event Number: 47377
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PETROCHEM INSPECTION SERVICES
Region: 4
City: CORPUS CHRISTI State: TX
County:
License #: 04460
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/27/2011
Notification Time: 11:37 [ET]
Event Date: 10/12/2011
Event Time: [CDT]
Last Update Date: 10/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
ANGELA MCINTOSH (FSME)
CYNTHIA JONES (NSIR)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following was received from the state via email:

"On October 17, 2011, the Agency [Texas Department of State Health Services] was notified by a licensee that one of its radiographers had climbed a ladder to remove the guide tube from a SA Model 880 radiography camera containing a 49.3 curie Iridium (IR)-192 source that was suspended by a rope. Another employee walked by the area and observed the survey meter needle was pegged high. He yelled at the radiographer who climbed down the ladder and attempted to crank the source back into the camera. The source would not move so he cranked it all the way out and then retracted it successfully. The radiographer's badge was sent for processing. The badge had a whole-body dose reading of 4,192 millirem, bringing his total for the year to 5,196 millirem, exceeding the annual limit. The radiographer was unable to ascertain where the source had been in the guide tube. The radiographer did not carry the dose rate instrument to the camera because the safety rules for the facility he was working at does not allow an individual to climb a ladder with any articles in their hand. On October 27, 2011, the Agency [Texas Department of State Health Services] was informed by the licensee that they had completed their investigation and had calculated the dose to the radiographers left hand, which had been on the guide tube, to be between 51 and 58 rem for the event exceeding the annual limit. The licensee stated that they had not observed any changes in appearance in the radiographer's hand. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-8894

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Agreement State Event Number: 47378
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: AGRI INDUSTRIAL PLASTICS CO
Region: 3
City: FAIRFIELD State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: JOE O'HARA
Notification Date: 10/27/2011
Notification Time: 12:12 [ET]
Event Date: 10/27/2011
Event Time: 10:27 [CDT]
Last Update Date: 10/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
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 STATIC ELIMINATOR CONTAINING 10 MILLICURIES POLONIUM 210

The state's licensee reported that they lost a NRD Nuclecel Device Model P-2021-8201, serial number A2HH880, which was shipped to the company on 09/01/10. The company noticed the device was missing on October 4th. However, the company also believes it could be installed somewhere in the facility in a location where it cannot be seen.

The State's licensee has implemented the following corrective actions:
"1) We will assign 1 device to its own machine cell and it will not be moved. 2) We have stopped the use of quick push/pull connections and replaced with threaded connections. 3) All Nuclecel devices are attached with yellow air hose ... and we don't use yellow air hoses on anything else. 4) We have added the devices to our month end inventory count."

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: 47381
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TICONA POLYMERS INC
Region: 4
City: BISHOP State: TX
County:
License #: 02441
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 10/27/2011
Notification Time: 15:26 [ET]
Event Date: 10/13/2011
Event Time: 07:00 [CDT]
Last Update Date: 10/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - BROKEN HANDLE ON BERTHOLD NUCLEAR GAUGE

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

"On October 13, 2011, the Agency [Texas Department of State Health Services] was notified by the licensee that while exercising the shutter handle on a Berthold nuclear gauge containing 20 milliCuries of cesium - 137 the handle broke off flush with the gauge housing. The gauge shutter is in the open position, which is the normal operating position of the shutter. No individual will receive any additional exposure due to the failure. The manufacture has been contacted to repair the gauge. The licensee stated that no entry to the vessel will be allowed until the gauge has been repaired. The cause for the failure is unknown at this time. Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident Number: I-8895

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Hospital Event Number: 47394
Rep Org: PROVIDENCE PARK HOSPITAL
Licensee: PROVIDENCE PARK HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: MICHELE TARRANT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/01/2011
Notification Time: 08:45 [ET]
Event Date: 11/01/2011
Event Time: 08:10 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
NICK VALOS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

CONTAMINATED PACKAGE

Providence Park Hospital received an externally contaminated package from Hot Shots Nuclear Pharmacy (HSNP). Upon receipt of the package, the Nuclear Medical Technologist (NMT) performed a routine wipe test and determined the package was externally contaminated. Wipe test indicated surface contamination of 60,608 dpm (disintegrations per minute). The Radiation Safety Officer (RSO) was notified and the package was bagged and stored in a hot lab for decay. The package contained approximately 70 mCi of technetium-99m. There was no indication of any personnel contamination or exposure. The package will be shipped back to HSNP, after isotope decay is complete, for follow up investigation and recommendation.

HOO Note: See EN #47392 for similar report.

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Power Reactor Event Number: 47395
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MICHAEL O'KEEFE
HQ OPS Officer: PETE SNYDER
Notification Date: 11/01/2011
Notification Time: 09:38 [ET]
Event Date: 10/31/2011
Event Time: 18:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
NEIL PERRY (R1DO)
PART 21 REACTOR GRP (EMAI)

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

GENERAL ELECTRIC CR-120B RELAYS SUPPLIED BY NATIONAL TECHNICAL SYSTEMS FAIL BENCH TEST

"On October 31, 2011, NextEra Energy Seabrook, LLC completed a 10 CFR 21 evaluation of a condition associated with General Electric (GE)-CR-120B relays supplied by National Technical Systems, Inc. and intended for use at Seabrook. Six (6) Quality Level 1 GE-CR-120B relays failed bench testing. During bench testing, the subject relays failed to reset when de-energized. An evaluation was performed to determine the applications where these relays could have been and were installed and to determine if the failure of the subject relays could result in a Substantial Safety Hazard as defined in 10 CFR 21.3. The evaluation concluded that there is one safety significant application relative to the failure of the GE-CR-120B relays to reset in the Seabrook Diesel Air Handling System (DAH).

"Each DAH system train (includes one supply fan and one exhaust fan per train) has one relay that provides a start permissive for the ventilation fans. An analysis of the failure of a GE-CR-120B relay in the DAH system determined that, if the relays were installed, the condition could create a substantial safety hazard due to a subsequent loss of the emergency power function. Therefore, this report is being submitted pursuant to the requirements of 10 CFR 21.21(d)(3)(i). A written notification will be made to the NRC within 30 days pursuant to 10 CFR 21.21(d)(3)(ii).

"No actual safety consequences resulted from this condition because the GE-CR-120B relays were not installed in the plant in this safety significant application."

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 47398
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: SEAN PATTERSON
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 13:56 [ET]
Event Date: 11/01/2011
Event Time: 08:45 [CDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
ROBERT HAAG (R2DO)
ROBERT JOHNSON (NMSS)

Event Text

UNPLANNED MEDICAL TREATMENT OF AN INDIVIDUAL INVOLVING CONTAMINATION

"A person working in an office area began feeling excessive heartburn and nausea. The individual was taken to the site dispensary for evaluation. An ambulance was requested to take the employee to the hospital for further evaluation. The employee had contamination on his coveralls and boots. Before leaving the site for the hospital, the employee's plant clothing was removed and the individual was surveyed. There was no detectable contamination on the employee when he was transferred to the hospital.

"Isotope, Quantities and Chemical Form: Uranium Ore Concentrates, U308

"NRC Region II informed: Richard Gibson- Senior Fuel Cycle Inspector"

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Power Reactor Event Number: 47401
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: EDGAR DEGIVANNI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 18:08 [ET]
Event Date: 11/01/2011
Event Time: 14:50 [PDT]
Last Update Date: 11/01/2011
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VINCENT GADDY (R4DO)
JACK GROBE (NRR)
ELMO COLLINS (R4)
JEFFERY GRANT (IRD)
WAYNE (DHS)
JACKSON (DOE)
KRAUF (USDA)
DELL (HHS)
FULLER (FEMA)

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

Event Text

ALERT DECLARED DUE TO AN AMMONIA LEAK

On November 1, 2011 at 1450 PDT, San Onofre Unit 3 declared an ALERT and entered EAL HA3.1 due to an ammonia leak that prevented access to local areas. The plant is in a stable condition while the leakage is being secured. The turbine building on Unit 3 has been evacuated. Plant personnel are in the process of verifying no presence of ammonia in the turbine building. There was no impact on Unit 2.

* * * UPDATE FROM KEN HOUSEMAN TO JOHN KNOKE AT 2115 EDT ON 11/01/11 * * *

At 1807 PDT licensee exited the ALERT and EAL HA3.1. The leak was at the Ammonia day tank and was flowing through an overflow vent into the berm. The high level in the Ammonia day tank was due to a leaking closed valve between the Demineralizer system and the ammonia bulk storage. The berm area was drained of all fluids. The wind direction caused the ammonia fumes to travel to the Unit 3 turbine deck. No off-site HAZMAT personnel came on-site. At 1756 PDT the precautionary evacuation of on-site personnel was terminated. Unit 2 was not affected from this event.

The NRC Resident Inspector was notified. Notified NRR EO (Fredrick Brown), R4DO (Vincent Gaddy, IRDMOC (Jeff Grant), DHS (Hill), DOE (Doyle), USDA (Krauf), FEMA (Fuller) and HHS (Fajardo).

* * * UPDATE FROM LEE KELLY TO VINCE KLCO AT 2228 EDT ON 11/01/11 * * *

"On November 1, 2011, Southern California Edison notified the California Emergency Management Agency at 1755 PDT and the San Diego Department of Environmental Health at 1810 PDT that approximately 25 gallons of Ammonium Hydroxide was spilled under the Ammonium Hydroxide day tank located outside the Unit 3 turbine building. The spill was contained in a berm under the tank and subsequently cleaned up.

"Both Units 2 and 3 were at approximately 100% power at the time of the event."

Notified the R4DO (Gaddy).

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Thursday, March 29, 2012