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Event Notification Report for November 7, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/04/2011 - 11/07/2011

** EVENT NUMBERS **


47391 47393 47396 47397 47399 47400 47402 47406 47414 47416 47418 47419

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Hospital Event Number: 47391
Rep Org: HOSPITAL METROPOLITAN DR. PILA
Licensee: HOSPITAL METROPOLITAN DR. PILA
Region: 1
City: PONCE State: PR
County:
License #: 52-252255-01
Agreement: N
Docket:
NRC Notified By: A. ALVAREZ de la CAMPA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/31/2011
Notification Time: 12:15 [ET]
Event Date: 08/17/2011
Event Time: [EDT]
Last Update Date: 10/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

DOSE TO AN EMBRYO

"On 8/17/2011, an oral dose of 100.2 mCi of NaI-131 (sodium iodide) was administered to a female patient of childbearing age for radioablation of papillary thyroid carcinoma post thyroidectomy. The patient became pregnant approximately a week after dose administration, despite proper pre-therapy orientation and against medical advice. This was brought to [the licensee's] attention by the patient's OB/GYN physician on 9/28/2011. On that same date, the patient was contacted via telephone and was alerted and oriented as to the possibility of harmful effects of radiation to the embryo. On 10/4/2011, that same orientation was performed more thoroughly in person. Full dosimetric analysis was performed by [the licensee's] medical physicist on 10/5/2011. A complete medical report, including possible effects and complications was given to the patient and referring OB/GYN physician on 10/19/11. The list of possible complications included: Miscarriage, neurologic system damage, intrauterine growth retardation, mental retardation, and increased risk of development of cancer.

"To prevent recurrence of this incident, [the licensee has] created a barrier system, where the department secretary and then the nuclear technologist verifies the patient's paperwork before the physician. We have also revised our patient instructions for childbearing age patients."

The licensee has verbally discussed this incident with R2 (Bermudez).

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Agreement State Event Number: 47393
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN-KETTERING CANCER CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKEMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/31/2011
Notification Time: 15:46 [ET]
Event Date: 06/29/2011
Event Time: [EDT]
Last Update Date: 10/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
LYDIA CHANG (FSME)

Event Text

OVERDOSE TO PATIENT OF 48% DURING GAMMAMED HIGH DOSE RATE TREATMENT

"Patient was treated intraoperatively following surgical removal of a metastatic lesion in the sacral region. Treatment involved Ir-192 in a Gammamed HDR (High Dose Rate).

"In standard cases implant geometry calls for a single-plane treatment, and entry of treatment plan into a commercial planning treatment system to control stopping positions of dwell times of source catheter. Size of treatment volume was such in this case that two treatment planes were required. Decision was made to select a single plane midway between the two treatment planes so that both treated regions would receive required dose.

"Prescribed dose was 15 Gray at a position 1cm away from the source plane on either side, thus simulating a volume source implant. Treatment plan in this case required manual input of treatment parameters.

"Physicist incorrectly entered distance between treatment planes as 3 cm, instead of 3 mm. A treatment plan was generated using the larger distance, and corresponding source stopping positions and dwell times for this separation. The result was incorrectly large dwell times and an overdose to the two treatment planes separated in fact by 3 mm. It was calculated that the dose delivered was 22.2 Gray rather than the prescribed 15 Gy, an overdose of 48%.

"Discovery of Event:
Event was discovered during chart rounds when a supervising physicist noticed the difference between prescribed dose and the iCheck results. After discovery of the event, it became evident upon reconstructing the timeline of events that treatment planning sheets in the patient's record had been altered.

"Effect on Patient:
In the opinion of the attending radiation oncologist, it is unlikely that there will be any medical consequences.

"Root Cause of Event: An analysis concluded that the root cause of the event included:
* Incorrect entry of data;
* Failure to follow specifics of quality assurance procedure;
* Inappropriate chart alterations;
* Perception of some members of the staff that people who make or find a mistake will be punished regardless of the specifics of the event.

"Actions Taken to Prevent Recurrence of Event:
* Training to reverse perception of some members of the staff that people who make or find a mistake will necessarily be punished, regardless.
* Retraining in actions to be taken in cases of non-standard geometry.
* Disciplinary actions against physicist and dosimetrist involved.
* Annual documented training of medical physicists, dosimetrists and radiation oncology physicians on appropriate quality assurance procedures.
* Change in cover sheet for brachytherapy radiation treatments to include iCheck calculations including quality assurance verifications.

"Inspection Results:
An inspector from the Office of Radiological Health conducted an inspection on 9/21/11. The inspector found the circumstances of the event to be as described above. In addition, the inspector found that:
* Upon check of the initial treatment plan by the physicist, the dosimetrist calculated a dose of 22.29 Gray rather than the prescribed 15 Gy.
* The dosimetrist informed the physicist of the discrepancy.
* The physicist told the dosimetrist that the iCheck results may be wrong. The reason was that the ABACUS program used by the physicist knows that there are two treatment planes, and that the iCheck which assumes one plane may be wrong.
* Dosimetrist at this point failed to follow proper QA by stopping treatment and informing the radiation oncology attending.
* After seeing the 15 Gy calculated dose at 1 cm from source plane, the attending oncology physician concluded that isodose distribution was correct.
* The dosimetrist left the OR and treatment proceeded with the incorrect dwell times.

"The inspector found licensee to be highly cooperative and believes that actions taken in the wake of this event were satisfactory. No formal violation was issued."

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: 47396
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: UNKNOWN
Region: 1
City: UNKNOWN State: NY
County: UNKNOWN
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 11:11 [ET]
Event Date: 10/13/2011
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)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received by facsimile:

"NYS Incident 935 - On 10/31/2011 a NY radioactive materials licensee reported a diagnostic misadministration which occurred on 10/13/2011 and discovered on 10/28/2011. A patient undergoing diagnostic imaging of the thyroid using Iodine-123 was administered 4.21 mCi instead of the intended 400 uCi. The estimated dose to the patient's thyroid is 58 rem.

"This is a preliminary 24 hour notification report.

"The facility is performing an investigation and root cause analysis.

"Telephone communications with the facility [and the State of New York] are ongoing.

"The facility is required to submit a written report within 15 days."

New York Event: NY-11-25

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: 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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Agreement State Event Number: 47402
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ALL STAR METALS LLC
Region: 4
City: BROWNSVILLE State: TX
County:
License #: 02239
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/02/2011
Notification Time: 16:45 [ET]
Event Date: 11/01/2011
Event Time: [CDT]
Last Update Date: 11/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER STUCK CLOSED

The following information was received via fax:

"On November 2, 2011, the Agency [Texas Department of Health] was notified by a general licensee that the shutter on a NITON XLp818 nuclear gauge containing 30 milliCuries of americium (Am) - 241 used for metal analysis was stuck in the closed position. The gauge appeared to have suffered an impact locking the shutter closed. The screen displays this error. The licensee has sent gauge to the manufacturer for repairs. The serial number is #7625. There is no exposure since the shutter failed in the closed position. The investigation in to this incident is ongoing. Further details will be provided in accordance with SA 300."

Texas report: I-8896

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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: 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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Power Reactor Event Number: 47416
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE BURTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/05/2011
Notification Time: 12:18 [ET]
Event Date: 11/05/2011
Event Time: 09:00 [EDT]
Last Update Date: 11/05/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT HAAG (R2DO)

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

TECHNICAL SUPPORT CENTER VENTILATION MAINTENANCE

"Maintenance activities are being performed on the Hatch Nuclear Plant's Technical Support Center (TSC) Emergency Ventilation System starting on November 5, 2011 at 0900. These maintenance activities include the replacing the TSC HVAC cooling coils, condensing unit and controls. The maintenance activity will be worked 24 hours per day until completion. The scheduled completion date is November 10, 2011.

"During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity. If an emergency is declared requiring activation of the TSC during the time these work activities are being performed, then the contingency plans call for utilization of the TSC during the time of these work activities, as long as environmental and radiological habitability conditions allow. Procedure 73EP-EIP-063-0, Technical Support Center Activation, provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the primary TSC so that TSC functions can be continued.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev.1 since this work activity affects an emergency response facility for the duration of the evolution."

The licensee notified the NRC Resident Inspector.

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Non-Agreement State Event Number: 47418
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: KUPARUK OIL FIELD State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/06/2011
Notification Time: 13:04 [ET]
Event Date: 11/05/2011
Event Time: 22:00 [YST]
Last Update Date: 11/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

RADIOGRAPHY CAMERA SOURCE LOCK MALFUNCTION

A radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunction of the locking system on an INC IR-100 exposure device.

After completing radiography activities, the source was cranked in however, the source was still 1/4 to 1/2 inch from the fully retracted position. There were no abnormal readings observed and the key was turned to the locked position. The crew has been trained for this type of situation. They dismantled the lock, cleaned it, rebuilt it, and retracted the source to its fully retracted position.

Exposure Device: Industrial Nuclear IR-100
Device S/N: 6774
Source S/N: 70129B
Source Activity: 80 curies
Source Type: Ir192

There was no exposure from this event.

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Power Reactor Event Number: 47419
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: CLINT SIX
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/06/2011
Notification Time: 22:30 [ET]
Event Date: 11/06/2011
Event Time: 20:03 [EST]
Last Update Date: 11/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL PERRY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

LOSS OF SPDS AND PLANT PROCESS COMPUTER DUE TO PLANNED MAINTENANCE

"At 1203 EST on 11/06/2011, the Safety Parameter Display System (SPDS) was removed from service for planned maintenance of the Plant Process Computer. The Plant Process Computer and the SPDS function were restored at 2015 EST on 11/06/2011. This event is reportable per 10 CFR 50.72(b)(3)(xiii) since the SPDS was out of service for greater than 8 hours resulting in a major loss of emergency assessment capability."

The licensee will inform the NRC Resident Inspector.

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