| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
11/23/2011 - 11/25/2011 ** EVENT NUMBERS ** |
 | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Fuel Cycle Facility | Event Number: 47360 | Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
FABRICATION & SCRAP
COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: VINCE KLCO | Notification Date: 10/20/2011
Notification Time: 13:03 [ET]
Event Date: 10/20/2011
Event Time: 09:10 [PDT]
Last Update Date: 11/23/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(5) - ONLY ONE SAFETY ITEM AVAILABLE
| Person (Organization):
MARK LESSER (R2DO)
DOUG WEAVER (NMSS)
| Event Text ONE HOUR REPORT DUE TO A FAILED ITEM RELIED ON FOR SAFETY
"At approximately 0910 [PST] on 10/20/2011, during discussions with an NRC inspector, the AREVA Richland NCS Manager concluded that a previous determination made on Friday, 7/22/2011 that an IROFS (a criticality drain on a HEPA filter housing) declared to be in a degraded state was, in fact, failed in that a pre-filter in the HEPA housing was sitting on the drain and could have prevented it from performing the required safety function. This original discovery was made during a routine PM of the system (a management measure prescribed to this IROFS). On 7/22/2011 (the initial day of discovery) the criticality drain was modified so that it would remain unobstructed and free flowing.
"At 1303 EDT, AREVA's EHS&L Manager notified the NRC Operations Center of this condition per the requirements of 10CFR70 Appendix A criterion (a)(5) (1 hour report) which requires reporting if '... only one IROFS remains available and reliable to prevent a nuclear criticality and has been in that state for greater than 8 hours,' and indicated that potentially criterion (b)(1) (24 hour report) was also met. This 24 hour criterion requires
reporting '... the facility being improperly analyzed, or different than analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10CFR 70.61.' Subsequent to the initial report, AREVA has concluded that the performance requirements of 10CFR 70.61 were met and the 24 hour reporting criteria (b)(1) do not apply.
"Safety Significance of Event: The safety significance of this event is low. This process is used to recover incinerator ash and the ISA team was unable to identify any mechanism whereby a critical concentration of approximately 285 g U/liter of solution could be created in the process connected to the duct work.
"Potential Nuclear Criticality Pathways Involved: The only potential pathway is for uranium bearing liquids that exceed 285 g U/liter to gradual build up in the HEPA filter housing.
"Controlled Parameters (Mass, Moderation, Geometry, Concentration, Etc.): Uranium mass/concentration is controlled.
"Nuclear Criticality Safety Control(s) or Control System(s) and description of the failures or deficiencies: No control system failures occurred.
"Corrective Actions to Restore Safety Systems and When Each Was Implemented: A grate was installed over the criticality drain inlet on July 22, 2011 and has been present since that time."
* * * RETRACTION FROM ROBERT LINK TO HOWIE CROUCH ON 11/23/11 AT 1205 EST * * *
"After careful consideration of the guidance contained in FCSS ISG-12 and NUREG 1520, Rev. 1, AREVA has concluded that this condition did not meet the reporting requirements set forth in 10CFR70 Appendix A and formally retracts the previously made report."
Notified R2DO (Freeman) and NMSS EO (Hiltz). |
| Agreement State | Event Number: 47456 | Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: PFI LLC
Region: 4
City: WICHITA State: KS
County:
License #: 10-C842
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: BILL HUFFMAN | Notification Date: 11/18/2011
Notification Time: 13:35 [ET]
Event Date: 10/27/2011
Event Time: [CST]
Last Update Date: 11/18/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAIR SPITZBERG (R4DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - EXTREMITY OVEREXPOSURE FROM FLUORINE-18
The Kansas Department of Health and Environmental Services provided a notification via facsimile concerning an employee working for a State licensee (PFI LLC) who apparently received an extremity overexposure of 53,010 mrem during the month of September while processing the radiopharmaceutical Fluorine-18. No additional details concerning the circumstance of how the overexposure occurred was provided in the State's report.
The Headquarters Operations Officer was unable to contact the originator of the report for additional information. |
| Agreement State | Event Number: 47458 | Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: SOUTH JERSEY HEALTHCARE REGIONAL MEDICAL CENTER
Region: 1
City: VINELAND State: NJ
County:
License #: 450632
Agreement: Y
Docket:
NRC Notified By: BILL CSASZAR
HQ OPS Officer: JOE O'HARA | Notification Date: 11/18/2011
Notification Time: 15:45 [ET]
Event Date: 11/17/2011
Event Time: 15:48 [EST]
Last Update Date: 11/18/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN CARUSO (R1DO)
BILL VON TILL (FSME)
| Event Text AGREEMENT STATE REPORT - PATIENT RECEIVED GREATER THAN THE PRESCRIBED DOSE
A patient had a mass surgically removed from both sides of the nose and was undergoing a topical treatment for microscopic disease using a Nucletron HDR containing 8.52 curies of Ir-192 with a Valencia Model H3 skin applicator containing a platinum filter.
The planned administration was 7 fractions of 600 centigrays each on both the left and right side of the nose. During the initial planning for the treatment, an error was made in calculating the dwell time for each location and this incorrect data was entered into the HDR system. As a result of the error, the patient received 54% during each fraction (treatment) during two of the seven fractions on each side of the nose. Prior to the third fraction, the medical team is required per procedure to check calculations and caught the error before the third fraction (treatment) was performed.
The patient and prescribing physician have been informed, and there is no long range medical concern for disease as a result of this error. The total dose treatment has not been exceeded.
The state's licensee is revising procedures in order to prevent recurrence, and the state will be submitting an NMED report.
New Jersey Incident Number: #410674
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. |
| Agreement State | Event Number: 47465 | Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: SHAW NAPTECH, INC.
Region: 4
City: CLEARFIELD State: UT
County:
License #: 0600332
Agreement: Y
Docket:
NRC Notified By: PHILLIP GRIFFIN
HQ OPS Officer: HOWIE CROUCH | Notification Date: 11/21/2011
Notification Time: 18:19 [ET]
Event Date: 11/09/2011
Event Time: 08:30 [MST]
Last Update Date: 11/21/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY AZUA (R4DO)
BILL VON TILL (FSME)
| Event Text UTAH AGREEMENT STATE REPORT - AUTOMATIC LOCKING MECHANISM FAILED ON RADIOGRAPHY CAMERA
The following information was obtained from the State of Utah via facsimile:
"On November 9, 2011 at about 8:30 AM [MST], [the licensee RSO] was contacted by one of [their] radiographers and told that the self locking mechanism on one of [their] cameras was not working. The camera was SN D7217 manufactured by Sentinel. The model is a 880 Delta which was purchased new in January of this year and put into service February 4, 2011. Though the camera did not automatically lock when the source had been returned to the shielded position, the lock slide had been manually returned to the locked position after retracting the source and a survey by the radiographer showed that the source was shielded and the camera was then locked. [The radiographer] is a level II IRRSP [Industrial Radiography and Radiation Safety Personnel] certified radiographer who was working in [the facility's] permanent installation B cell when the incident occurred. The entrance and area alarm for B cell were working properly at the time of the event and confirmed what the survey showed which was that the source was in the shielded position. [The radiographer] demonstrated that the lock slide was not coming back over to lock the camera automatically when the source was returned to the camera as it was designed to do. After the demonstration, the camera was surveyed to ensure the source was in the shielded position, the slide lock was then slid to the lock position manually, the camera locked and [was] removed from service. The radiographer did not receive any radiation exposure associated with the failure of the slide lock mechanism.
"[The RSO] contacted the manufacturer the same day and was instructed to return the camera for repair. The camera had a 13.7 Ci Ir-192 source in it. The camera was sent overnight to Sentinel/QSA Global in Baton Rouge, La.. [The RSO] was contacted by the service technician the next afternoon, November 10, 2011. He informed [the RSO] that one of the springs had broken and that was the cause of the malfunction of the slide lock. A new rear plate assembly was installed by Sentinel and the camera was then returned to [the licensee] facility with a new Ir-192 source of 97 curies. The camera was put back into service on Monday November 14, 2011 and has been operating properly since." |
| Agreement State | Event Number: 47469 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SONIC SURVEYS, LTD.
Region: 4
City: MONT BELVIEU State: TX
County:
License #: 02622
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: HOWIE CROUCH | Notification Date: 11/22/2011
Notification Time: 18:03 [ET]
Event Date: 11/18/2011
Event Time: 07:00 [CST]
Last Update Date: 11/22/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY AZUA (R4DO)
JIM LUEHMAN (FSME)
| Event Text TEXAS AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE
The following information was obtained from the State of Texas via email:
"On November 18, 2011, the Agency [Texas Department of State Health Services] was notified that a licensee had lost, and subsequently abandoned, a logging tool containing a 20 milliCurie cobalt (Co)-60 sealed source at a depth of approximately 5,100 feet down a well in Matagorda County, Texas. The well is a brine solution well that was converted to gas storage; it is a domed salt cavern. There is no rig on the well and the source is at the bottom of the cavern. There is no danger of rupture or exposure. There are no plans to enter the well or cavern in the near future with tubing or wire line. No further action will be taken to retrieve the tool.
"Source information: 20 milliCurie Cobalt-60
"Manufacturer: Eckert and Ziegler
"Model: HEG-060
"SN: CZ3507"
Texas Incident No.: I-8906 |
| Agreement State | Event Number: 47470 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LIGHTING SYSTEMS, INC.
Region: 4
City: BERKELEY State: CA
County:
License #: 5490-1
Agreement: Y
Docket:
NRC Notified By: CURT PRENDERGAST
HQ OPS Officer: DONALD NORWOOD | Notification Date: 11/22/2011
Notification Time: 18:20 [ET]
Event Date: 08/15/2011
Event Time: [PST]
Last Update Date: 11/22/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY AZUA (R4DO)
JIM LUEHMAN (FSME)
MEXICO (via)
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following information was received via telephone:
On or about August 15, 2011, Lighting Systems, Inc. shipped three tritium exit signs to a customer via UPS. Upon delivery, the customer refused receipt of the signs. UPS retained possession of the signs. UPS has not returned the signs to Lighting Systems, Inc. and has been unable to locate the signs.
Each sign contained 7.5 Curies of tritium. Model number: SLX-60. Serial numbers: 11-14985, 11-14986, and 11-14987.
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 |
| Power Reactor | Event Number: 47473 | Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: ROBERT KROS
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 11/23/2011
Notification Time: 01:43 [ET]
Event Date: 11/22/2011
Event Time: 17:00 [CST]
Last Update Date: 11/23/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
| Person (Organization):
RAY AZUA (R4DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Refueling Shutdown | 0 | Refueling Shutdown | Event Text TEMPORARY LOSS OF SHUTDOWN COOLING
"During walkdown of scheduled work it was discovered that HCV-335 (Shutdown Cooling Heat Exchanger Inlet Header Isolation Valve) would not be able to be manually positioned open due to a missing idler gear key.
"Upon a loss of instrument air, HCV-335 would have failed closed, interrupting shutdown cooling flow with no ability to open HCV-335 manually.
"Alternate shutdown cooling pump and paths were available at the time of discovery. No loss of instrument air or interruption in shutdown cooling flow occurred while preparing to align alternate shutdown cooling. An 8 hour LCO under Technical Specification 2.8.1(3)2 was entered at 1700 CST. Alternate shutdown cooling was established on a containment spray pump as allowed by procedure. The 8 hour LCO was exited at 2306 CST. A replacement idler key has been fabricated for HCV-335."
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 47475 | Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ALTON DeWEESE
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 11/24/2011
Notification Time: 00:05 [ET]
Event Date: 11/03/2011
Event Time: 03:48 [CST]
Last Update Date: 11/24/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
| Person (Organization):
SCOTT FREEMAN (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown | Event Text INVALID ACTUATION OF A SAFETY INJECTION VALVE
"This telephone notification is being made in lieu of submitting a written LER under 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of MOV 8803A, High Head Safety Injection (HHSI) to RCS Cold Leg, resulting in ECCS injection into the RCS.
"On November 3, 2011 at 03:48 CST, during a maintenance replacement activity for the K604 slave relay in Solid State Protection System, MOV 8803A unexpectedly opened. The relay was not recognized to be in a latched condition when the lead associated with MOV 8803A was landed causing it to stroke open. This actuation was invalid since the stroke signal was not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the safety function of the system. MOV 8803A was subsequently closed from the control room in approximately 2 minutes and power was removed at 03:57 CST to prevent another stroke. After investigation, the relay was installed in the correct configuration and system tested to restore operability. This event did not adversely affect the safe operation of the plant or health and safety of the public.
"The following required information is being submitted per NUREG-1022, Rev. 2:
(a) MOV 8803A is an 'A' Train component.
(b) The stroke open of MOV 8803A and ECCS injection is a partial train actuation.
(c) Given the conditions, MOV 8803A functioned as expected and all other systems functioned per design."
The licensee notified the NRC Resident Inspector |
| Power Reactor | Event Number: 47476 | Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MIKE TERRY
HQ OPS Officer: JOHN KNOKE | Notification Date: 11/24/2011
Notification Time: 11:17 [ET]
Event Date: 11/24/2011
Event Time: 03:15 [CST]
Last Update Date: 11/24/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
JULIO LARA (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 | Event Text EMERGENCY 4160 VOLT AC BUSSES DECLARED INOPERABLE
"On Thursday, November 24, 2011, at 0315 CST, with the reactor at 100% steady state thermal power, Kewaunee Power Station declared both emergency 4160 Volt AC busses inoperable due to voltages being high outside of the procedurally directed voltage band. As a result, in accordance with Technical Specification 3.8.9, Distribution Sources - Operating, Kewaunee entered Technical Specification LCO 3.0.3 to, within 1 hour, initiate shutdown of the unit. At 0410 [CST], per management direction, the load tap changers for the supply transformers were adjusted to reduce the emergency bus voltages to within their procedural operating band. At this time, both emergency busses were declared Operable and LCO 3.0.3 was exited. Minimum required accident voltages were met at all times.
"The NRC Resident Inspector has been notified." | |