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Event Notification Report for November 10, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/09/2011 - 11/10/2011

** EVENT NUMBERS **


47404 47409 47415 47417 47420 47425 47426 47427

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Agreement State Event Number: 47404
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: EASTERN REGIONAL MEDICAL CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0980
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOE O'HARA
Notification Date: 11/03/2011
Notification Time: 10:29 [ET]
Event Date: 11/02/2011
Event Time: 15:50 [EDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSAGE OF Y-90 THERASPHERES

The following was received from the Commonwealth of Pennsylvania via fax:

"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 63%, which is reportable under 10CFR35.3045(a)(1)(ii).

"Notifications: On November 2, 2011, at 1550, the Department's Southeast Regional Office received notification via phone message about the ME.

"Event Description: A patient who was being treated with MDS Nordion Y-90 TheraSpheres, received only 37% of the intended dose based on the before and after survey readings of the TheraSphere accoutrements (5.8mR/hr vs. 3.8mR/hr). The licensee is in the process of notifying the patient. No more information is available at this time.

"Cause of the Event: The licensee suspects that procedural changes led to the problem. Nordion recently changed the procedure to clamp the priming line with a hemostat because the original clamp is hard to manipulate. This was their first procedure using the hemostat.

"Actions: Nordion has been contacted. The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection."

Event Report ID No. PA 110033

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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Hospital Event Number: 47409
Rep Org: BARNES-JEWISH HOSPITAL
Licensee: BARNES-JEWISH HOSPITAL
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 15:05 [ET]
Event Date: 11/02/2011
Event Time: 14:00 [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NICK VALOS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL DOSE LESS THAN INTENDED DUE TO A LEAKING CONNECTOR

The patient had a written directive to receive 81 mCi of Sm-153 (Quadramet) as a whole body exposure for bone metastases. The administered dose was 29 mCi with the rest leaking out of a connector onto the tubing and absorbent pads. Any residual contamination was cleaned up. Both the doctor and patient were notified of the underdose and a follow-on treatment has been scheduled for next week.

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: 47415
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: VALLEY INDUSTRIAL X-RAY & INSPECTION SERVICES
Region: 4
City: BAKERSFIELD State: CA
County:
License #: 4182-15
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/04/2011
Notification Time: 18:49 [ET]
Event Date: 11/03/2011
Event Time: 16:00 [PDT]
Last Update Date: 11/04/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILS TO RETRACT

The following report was received via e-mail:

"Valley Industrial X-ray and Inspection Services radiographers were unable to retract an Ir-192 source assembly into its fully shielded position and secure it in this position. The device is an Industrial Nuclear Co, Model IR-100 s/n 4100 camera which contained 49 Ci of Ir-192. Emergency procedures were enacted by evacuating the area 200 yards around the exposure device and calling the RSO for assistance. Radiation safety personnel were able to retract the source into the shield and the device was secured by 1600 [PDT]. The licensee removed the Ir-192 source from the camera and placed it into a spare shield. The IR-100 camera (without a source assembly) was sent to Industrial Nuclear Co. in San Leandro, CA for evaluation. No personnel overexposure occurred due to this event. RHB [Radiologic Health Branch] is following up with the licensee as to the cause of the event."

California Report: 5010-110311

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Agreement State Event Number: 47417
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TGR GEOTECHNICAL, INC
Region: 4
City: SANTA ANA State: CA
County:
License #: 7196-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/05/2011
Notification Time: 18:56 [ET]
Event Date: 11/04/2011
Event Time: 16:30 [PDT]
Last Update Date: 11/05/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)
JIM WHITNEY (ILTA)
MEXICO ()

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

Event Text

AGREEMENT STATE REPORT - THEFT OF A MOISTURE DENSITY GAUGE

"On 11/4/2011, at 1630, the licensee reported to [State of California] Radiologic Health Branch [RHB], Brea (and by voice mail to Sacramento) the theft of one of its portable nuclear gauges, a Troxler, Model 3440, # 34646. The theft took place from the licensee's permanent storage location, sometime in the last six weeks. The gauge was in the authorized permanent storage area and had not been used at a temporary job location for two years. The RSO stated that some employees had been recently laid off and may have been disgruntled. There was no evidence of tampering with the storage location locks. The gauge contained 0.3 GBq (9 mCi) of Cs-137 and 1.48 GBq (44 mCi) of Am-241/Be. The RSO was instructed to notify the local low enforcement agency to report the theft and place a reward notice in the local newspaper. The RSO will be providing a written report and supporting documentation to RHB within 30 days. RHB is initiating an investigation."

California Report: 5010-110411

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 source

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Agreement State Event Number: 47420
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: CURWOOD, INC
Region: 3
City: DES MOINES State: IA
County:
License #: 3003177FG
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/07/2011
Notification Time: 13:16 [ET]
Event Date: 11/02/2011
Event Time: [CST]
Last Update Date: 11/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN GIESSNER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE DISLODGED FROM MOUNTING

The following report was received via e-mail:

"Curwood, Inc. reported an incident involving a NDC Infrared Engineering, Inc. thickness gauge, model 103, serial number 13457, containing 150 mCi's of Americium-241 that occurred on November 2, 2011. A sample of film was cut from the web on a production line and as the sample passed the device, the tail snagged the gauge and dislodged it from the mounting bracket. The gauge fell approximately 40 inches to the treater deck platform. The fall caused the shutter to become dislodged from the device and the crystal lens was cracked. Curwood contacted NDC and was instructed to perform a survey and wipe test of the device. The survey and wipe test indicated that the source was intact and no removable contamination was present. The device is currently packaged and in storage awaiting shipment to NDC for repair. The cause of this incident was the fact that the sample was taken prior to the device and that one of the two screws mounting the device was missing. Corrective actions include now taking the samples at a location on the production line after the device, replacing and securing the missing screw, [performing] a daily spot check of the mounting screws, and a weekly check of the screws to ensure that they are secure."

Iowa Event: IA110006

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Part 21 Event Number: 47425
Rep Org: BALDOR ELECTRIC CO.
Licensee: BALDOR ELECTRIC CO.
Region: 1
City: GAINESVILLE State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FLOYD BUSH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/09/2011
Notification Time: 16:19 [ET]
Event Date: 11/08/2011
Event Time: [EST]
Last Update Date: 11/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RICHARD CONTE (R1DO)
GEORGE HOPPER (R2DO)
BRITTAIN HILL (NMSS)
Part 21 Group email ()

Event Text

PART 21 NOTIFICATION - MOTOR POWER LEADS UNDERSIZED

The following information was provided by Baldor Electric via facsimile:

"Description of Defect: Motor power leads are undersized, #12AWG should be #8AWG. [Baldor] corrected the electrical design where the lead size is specified.

"Advice Related to Defect: Motors in service are not at risk unless held at locked rotor for more than 8 seconds. Normal operation, with instantaneous inrush while starting and running at loads as high as 40% locked rotor torque as name-plated, will not result in a failure. Holding the shaft blocked for 10 seconds could result in lead failure. Baldor-Reliance recommends changing the motors out as soon as convenient, i.e. during next outage. Any motors in storage should be replaced ASAP for future use.

"Part/Component Name: Actuator Motors Limitorque P/N R-402-FO6-582100A20

"Location Of All Units:
1) AREVA or PSE&G
2) AREVA or PSE&G
3) Baldor Electric, Gainesville, GA"

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Power Reactor Event Number: 47426
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: ROB MITCHELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/09/2011
Notification Time: 21:43 [ET]
Event Date: 11/09/2011
Event Time: 17:50 [CST]
Last Update Date: 11/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MICHAEL HAY (R4DO)

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

Event Text

POTENTIAL FAILURE OF HIGH DENSITY POLYETHYLENE PIPING IN ESW SYSTEM

"On November 9, 2011 at 1715, Callaway Plant staff determined that a postulated design basis fire event in Fire Area C-1, (Control Building, elevation 1974, ESW Pipe Space, Room 3101) could result in failure of the High Density Polyethylene (HDPE) piping in the Essential Service Water (ESW) system.

"In 2008-2009 timeframe, Callaway Plant implemented a modification which replaced underground large bore carbon steel ESW piping with HDPE piping. Four short sections of this HDPE piping enter the Control Building and interface with steel piping in Room 3101. During the design of the modification, it was not recognized that a fire barrier should be installed to protect the HDPE piping from the consequences of a fire. As a result of the missing fire barrier, a postulated fire could cause a failure of one train of the large bore HDPE piping located within the fire area. The resultant pipe failure could lead to flooding in the fire area that could adversely affect both trains of ESW equipment required to achieve and maintain safe shutdown.

"An hourly fire watch has been imposed as a compensatory measure for this condition in accordance with the approved fire protection program.

"This condition is reported in accordance with 10 CFR 50.72 (b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 47427
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN KOWALSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/10/2011
Notification Time: 00:59 [ET]
Event Date: 11/10/2011
Event Time: 01:00 [CST]
Last Update Date: 11/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)

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 OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"'This telephone notification is provided in accordance with 10CFR50.72(b)(3)(xiii), loss of emergency assessment capability.

"On 11-10-11 at 0100 Central Standard Time, the Technical Support Center Emergency Diesel Generator and Technical Support Center regular lighting will be taken Out of Service to support a scheduled temporary power supply return to normal configuration. The temporary power had been in place since the last refueling outage in support of planned bus maintenance. The Technical Support Center Emergency Diesel Generator and regular lighting are scheduled to be restored at 1100 [CST] on 11-10-11.

"The licensee has notified the Senior Resident Inspector of this scheduled work."

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Thursday, March 29, 2012