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Event Notification Report for November 4, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/03/2011 - 11/04/2011

** EVENT NUMBERS **


47384 47385 47397 47399 47400 47406 47412 47413 47414

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Hospital Event Number: 47384
Rep Org: JEPPESEN RADIATION ONCOLOGY
Licensee: BAY REGIONAL MEDICAL CENTER
Region: 3
City: BAY CITY State: MI
County:
License #: 21-18585-01
Agreement: N
Docket:
NRC Notified By: DENNIS KEHOE
HQ OPS Officer: JOE O'HARA
Notification Date: 10/28/2011
Notification Time: 15:26 [ET]
Event Date: 01/11/2011
Event Time: 07:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
LYDIA CHANG (FSME)

Event Text

MEDICAL EVENT - MISADMINISTRATION OF PROSTATE CANCER SEEDS

During a recent inspection, an NRC inspector noted two cases which occurred on 8/23/11 and 1/11/11, respectively in which two separate patients were under dosed by greater than 20% during prostate cancer treatment using Iodine 125 seeds. The underdose was determined during post operative treatments. The same physician administered the procedure in both cases. The licensee has informed the prescribing physician, and is investigating the cause of the events. There is no long term permanent functional damage suspected to any organ in either case.

The licensee discussed the issue with NRC Region 3 (Gattone).

* * * UPDATE FROM DENNIS KEHOE TO VINCE KLCO ON 11/01/11 AT 1841 EDT * * *

After the licensee reviewed 3 years of medical reports, fourteen patents were found to have been under-dosed greater than 20% of the prescribed dose. Specific under-dose dates were: 4/10/08; 4/21/08; 4/25/08; 9/15/08; 10/17/08; 11/03/08; 2/17/09; 8/27/09; 1/05/10; 1/14/10; 5/25/10; 10/12/10; 5/03/11 and 5/19/11.

The licensee discussed the issue with NRC Region 3 (Gattone).

Notified the R3DO (Valos) and the FSME EO (Camper).

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: 47385
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LANKENAU HOSPITAL
Region: 1
City: WYNNEWOOD State: PA
County:
License #: PA-0107
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/28/2011
Notification Time: 16:02 [ET]
Event Date: 10/06/2011
Event Time: 00:00 [EDT]
Last Update Date: 10/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - FETUS EXPOSED TO RADIATION DURING THYROID THERAPY TREATMENT

The following was received from the state via facsimile:

"The patient took a pregnancy test on October 5, 2011 and the results were negative. The patient was then treated with 73.7mCi of I-131 thyroid therapy treatment on October 6, 2011. The patient discovered she was pregnant and contacted the licensee on October 26, 2011. The estimated dose to the fetus is 17.4 Rads. It has been determined that the fetus was 10 days old when the therapy was given to the patient.

"The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection to review licensee's procedures and response to this ME."

Event Report ID No. PA110031

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Agreement State Event Number: 47397
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: UNKNOWN
Region: 4
City: KREBS State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 12:34 [ET]
Event Date: 10/28/2011
Event Time: 12:00 [CDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - ORPHANED SOURCE DISCOVERED AT A SCRAP METAL FACILITY

An outgoing shipment of scrap metal from the Yaffe Iron and Metal Company detected a radioactive source when going through the monitoring process. It is thought an orphaned radioactive source entered the scrap metal yard with an unmonitored shipment of aluminum. Upon further investigation, a radioactive metal rod of about 15 inches long was discovered in the outgoing shipment of scrap metal. Initial readings indicate a dose about a 200 mRem at 2 inches from a metal box that contains the source. Based on the use of a G-M detector, the activity is estimated to be 3.75 Ci. The metal box is constructed of one quarter inch steel. Initial portable gamma spectrometry indicates the source is Radium-226. The source is currently locked in the metal box. The State of Oklahoma is currently on the scene investigating and will determine a list of potential individuals who may have been exposed to the source. A preliminary assessment has determined that one individual received about 600 mRem to the hand.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. 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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Agreement State Event Number: 47399
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: NONDESTRUCTIVE AND VISUAL INSPECTION, LLC
Region: 1
City: WYALUSING State: PA
County:
License #: PA-1413
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 14:52 [ET]
Event Date: 10/28/2011
Event Time: 12:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EMPLOYEE OVEREXPOSURE

The following information was received by facsimile:

"On Friday, October 28th, two NVI [Nondestructive and Visual Inspection, LLC] employees were performing radiography on a pipeline project in Wyalusing, PA. While performing radiography on a main line the crew approached the pipe after cranking in the source to set-up and mount for their next shot. While strapping the next weld with film, one of the crew noticed the indicator which shows full retraction of the source on their Amersham Model D880 had not popped out. At this time both crew members confirmed their survey meters read zero. However, also at this point they realized one member's rate alarm was chirping, but not very loudly and the other's rate alarm was not chirping at all. It was noted both rate alarms were inspected and working properly at the beginning of the shift. The crew then approached the crank controls where one was able to make approximately one turn with the crank, fully retracting the source back into the camera. They inspected their dosimeters which were both off-scale. They informed the RSO and were immediately removed from work. The badges were sent for emergency processing and whole body dosimetry results were 5133mR and 1447mR.

"CAUSE OF THE EVENT: Undetermined at this time, expected faulty equipment.

"ACTIONS: The licensee will be submitting a written report within 30 days. The Department [PA DEP Bureau of Radiation Protection] plans to do a reactive inspection."

Pennsylvania Event Report: PA110032

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Agreement State Event Number: 47400
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TC INSPECTION, LLC
Region: 4
City: RODEO State: CA
County:
License #: CA 5299-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 16:06 [ET]
Event Date: 10/26/2011
Event Time: 12:00 [PDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION

The following information was received by e-mail:

"On 10/31/11, the ARSO [Alternate Radiation Safety Officer] at TC Inspection informed RHB [California Radiation Health Branch] via email of an incident occurring on 10/26/11 at Valero Refinery in Benicia, CA during one of their radiography operations. The email written by the ARSO is as follows:

"On October 26, 2011, there was an incident involving RAM material; one of [the licensee's crew was] performing radiography at the Valero refinery when, while cranking out the source, the trainer noticed the crank handle started free-spinning. When he tried to crank the source back in it was still free spinning so the source was stuck out of the shielded position. When the trainer called, [the licensee] advised him to loosen one of the nuts on the crank assembly, pull back the tube and then grab the cable and pull the source back into the exposure device and into the shielded position and that [the licensee was on his way]. When [the trainer] did this he noticed that the end of the cable was inside the tube, he was able to grab it with a pair of needle nose pliers and retrieve the source back into the shielded position.

"Two things happened here, the first; the trainer or assistant (still not sure which one) did not fully connect the guide tube to the camera. This allowed the source and cable to go out of the camera into air, thus allowing the cable to reach the end where the stop at the end of the cable did not stop the cable from coming out of the crank assembly. After further investigation [the licensee] found that the aluminum body of the crank assembly was worn right at the exit hole thus allowing the stop to go through. [The licensee] just did a maintenance inspection on those cranks on 10/1/11 and saw some wear on it but not as much as was there this time. [The licensee has] been in the process of replacing the aluminum body on all of [the licensee's] INC crank assemblies with stainless steel bodies when the techs tell [the ARSO] their cranks are getting hard to crank (That is usually the first sign that the aluminum body is wearing). [The apparent cause of the event is a technician forgetting to connect all of the equipment pieces due to production pressures or] equipment failure."

CA 5010 Number: 103111

* * * UPDATE FROM KEN PRENDERGAST TO CHARLES TEAL ON 11/3/11 AT 1513 EDT * * *

The following was received via email:

"On the day of the event, the operators pocket dosimeters indicated 10 mR.

"Camera information: INC IR-100, S/N 4301, with a source activity of 40.8 Ci.

"The crank assembly has been sent to INC and we'll be visiting INC today.

"We requested written statements from the trainer assistant. The ARSO already received them and he'll be sending a copy to RHB today.

"TC was requested to process the dosimetry badges worn by trainer and the assistant."

Notified R4DO (Gaddy) and FSME EO (Camper).

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Fuel Cycle Facility Event Number: 47406
Facility: FORT SAINT VRAIN ISFSI
RX Type: ISFSI
Comments:
Region: 4
City: PLATTEVILLE State: CO
County: WELD
License #: SNM-2504
Agreement: Y
Docket: 72-9
NRC Notified By: JOE GARCIA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 13:15 [ET]
Event Date: 11/03/2011
Event Time: 10:39 [MDT]
Last Update Date: 11/04/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
72.75(d)(1) - SFTY EQUIP. DISABLED OR FAILS TO FUNCTION
Person (Organization):
VINCENT GADDY (R4DO)
ROBERT JOHNSON (NMSS)

Event Text

ISFSI BUILDING AIR VENT BLOCKED FOR 12 MINUTES

"At 1009 (all times MDT) today, 11/3/11, a Security Officer performing routine rounds noted 95-100% blockage on the inlet screens at the Fort St. Vrain Independent Spent Fuel Storage Installation (FSV ISFSI). The FSV ISFSI is located near Platteville, Colorado. The FSV ISFSI safely stores used fuel from the Fort St. Vrain Nuclear Generating Station (FSV NGS). The NGS has been decommissioned and released for unrestricted use. The fuel is stored at the ISFSI under NRC license SNM-2504. The inlet screens are in place to provide a cooling path for the used fuel.

"The Security Officer immediately notified the Emergency Coordinator, who directed the screens to be cleared of the blockage at 1010. The blockage was removed at 1021, at which time the event was terminated. The blockage was caused by frost, which built up due to dense fog, high humidity, and low temperatures. Removal was accomplished by lightly hitting the screens by hand. No further action is necessary.

"Per FSV ISFSI Limiting Condition for Operation (LCO) 3.1, inlet screen blockage which equals or exceeds 95 percent must be cleared within 24 hours. The blockage was cleared in 12 minutes. Thus the REQUIRED ACTION was satisfactorily completed, and the CONDITION was exited.

"Per the FSV ISFSI Emergency Plan Implementing Procedure (EPI)-102, Emergency Action Level 1NE.6, 95% or greater blockage of the inlet screens constitutes a 1 hour NON-EMERGENCY event. Required notifications were made by the Warning Communications Center (WCC) in Idaho."

There was no increase in building temperature during this event.

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Power Reactor Event Number: 47412
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DANIEL BOWERS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 19:06 [ET]
Event Date: 11/03/2011
Event Time: 16:00 [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

UNANALYZED CONDITION FOR A POSTULATED CONTROL ROOM FIRE

"During the 2011 Triennial fire protection inspection, it was determined that the off normal procedure for control room evacuation due to fire has two defects. It does not adequately protect the steam generators from overfilling and possibly damaging the turbine driven auxiliary feedwater pump. In addition it does not protect the reactor coolant system pressurizer from filling to above 100% indicated water level, possibly causing the primary system to go solid. Both of these issues are results of inadequate assumptions used in the Post Fire Safe Shutdown Analysis of a fire in the Control Room.

"Compensatory measure of hourly fire watch for the control room is in place. The procedure for control room evacuation due to fire is being revised to include compensatory actions that will address the above events."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 47413
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: DAN GENEVA
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/03/2011
Notification Time: 23:26 [ET]
Event Date: 11/03/2011
Event Time: 18:00 [EDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NEIL PERRY (R1DO)

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

DIESEL GENERATOR STARTING AIR NOT COMPLIANT WITH APPENDIX R REQUIREMENTS

"During the conduct of a system vulnerability assessment by Engineering on the emergency diesel system. a discussion was held regarding the impact of a fire on the DG starting air system.

"Subsequently it was recognized that components of the system were vulnerable to damage during a fire. A review of the Appendix R analysis was conducted and it was determined that this vulnerability was not analyzed in the evaluation.

"This is reportable to Unit 2, as Unit 1 has a separate diesel building for the 1-Alpha emergency diesel."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 47414
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVE GOUVEIA
HQ OPS Officer: JOE O'HARA
Notification Date: 11/03/2011
Notification Time: 23:51 [ET]
Event Date: 11/03/2011
Event Time: 15:50 [PDT]
Last Update Date: 11/04/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VINCENT GADDY (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION - CONTROL ROOM VENTILATION SINGLE POINT VULNERABILITY

"On November 3, 2011, at 1550 PDT, operators determined that control room ventilation system (CRVS) contained a single failure vulnerability whereby unfiltered air supplied to the control room could exceed the flowrates used in the licensing basis analyses of design basis accident (DBA) consequences. This vulnerability was discovered during performance of control room inleakage testing required by TS SR 3.7.10.5.

"It was determined that the control room pressurization system airflow could bypass the supply filter if the CRVS booster fan in the associated train was not operating. This would allow as much as 800 cubic feet per minute of unfiltered air to be delivered to the control room following an accident that results in initiation of the CRVS pressurization mode. Operators would correct the condition approximately 10 minutes after a safety injection by manually selecting the train's redundant booster fan in accordance with existing proceduralized actions specified in the DCPP emergency procedure E-0 Appendix E. This period of unfiltered air supply to the control room due to a single failure of a CRVS booster fan had not been previously analyzed and could have potentially resulted in operator dose greater than contained in plant analyses.

"Plant staff verified that all components and redundant components in each ventilation train are currently OPERABLE. Plant staff has implemented additional compensatory measures by issuing a shift order to require that TS Action 3.7.10.A be entered for unavailability of either of the two CRVS booster fans in each CRVS train. Additionally, evaluation of the new unfiltered inleakage may result in more restrictive administrative controls to ensure operator doses are maintained less than the FSAR accident analyses."

The licensee informed the NRC Resident Inspector.

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