Event Notification Report for May 23, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/22/2012 - 05/23/2012
EVENT NUMBERS
47961479574795348389
Agreement State
Event Number: 47961
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: BRUKER AXS HANDHELD INC
Region: 4
City: KENNEWICK State: WA
County:
License #: WN-I0282-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JOE O'HARA
Licensee: BRUKER AXS HANDHELD INC
Region: 4
City: KENNEWICK State: WA
County:
License #: WN-I0282-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/24/2012
Notification Time: 19:04 [ET]
Event Date: 05/23/2012
Event Time: 00:00 [PDT]
Last Update Date: 05/25/2012
Notification Time: 19:04 [ET]
Event Date: 05/23/2012
Event Time: 00:00 [PDT]
Last Update Date: 05/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4DO)
DEBORAH JACKSON (FSME)
BLAIR SPITZBERG (R4DO)
DEBORAH JACKSON (FSME)
AGREEMENT STATE REPORT - MANUFACTURER RECEIVED AN ANALYZER WITH AN OPEN SHUTTER
The following was reported from the state via e-mail:
"A Kennewick licensee who manufactures and distributes hand-held devices used to analyze metal alloys notified the Materials Section of an incident that occurred with one of their General License customers in California. The shutter in the device which shields the radioactive material remained in the open position even after disengaging the trigger mechanism to close the shutter. This allowed radiation to stream from the device unabated. The California customer packaged the device for shipping knowing the shutter was open with nothing shielding the radiation and sent it back to the manufacturer in Kennewick for repairs. When the manufacturer received the device, a radiation reading in excess of the package limitations was noted and promptly reported to us. The licensee informed us this is the first shutter malfunction ever for this device model, which has been in service without any similar problems for many years. The Materials staff is working with the licensee to identify compliance issues and to prevent recurrence."
The Bruker AXS hand held XRF analyzer contains 5.9 milliCuries of Co-57.
Incident Number WA-12-037
* * * UPDATE FROM CRAIG LAWRENCE (VIA EMAIL) TO HOWIE CROUCH AT 1125 EDT ON 5/25/12 * * *
The XRF device is owned by Benchmark Environmental. Benchmark Environmental shipped the device to Bruker on May 22, 2012.
"Based on the dose rate measurement taken by Bruker prior to opening the package and removing the instrument, the Washington State Department of Health doesn't believe there were exposures to any member of the public in excess of regulatory limits. A dose rate measurement at 3 feet was 0.3 mR/hr as measured by their Bicron Surveyor 50 (cal date 1/19/12). Reading at approximately six inches from the surface pegged the dose rate meter on the 0 to 0.5 mR/hour scale. Bruker did not take measurements on higher scales.
"At that point, Bruker's shipping and receiving took the MAP FA4C1 analyzer out of the case and carried it at arm's length to the shielded source exchange pit. The instrument was evaluated inside the pit and the shutter was found partially open. The Co-57 source was removed from the analyzer and put into a shielded pig. Bruker examined the analyzer and found the source block was defective and [the analyzer was] sent to production for a replacement source block.
The licensee provided corrective actions in the NMED data entry form. Notified R4DO (Spitzberg) and FSME (via email).
The following was reported from the state via e-mail:
"A Kennewick licensee who manufactures and distributes hand-held devices used to analyze metal alloys notified the Materials Section of an incident that occurred with one of their General License customers in California. The shutter in the device which shields the radioactive material remained in the open position even after disengaging the trigger mechanism to close the shutter. This allowed radiation to stream from the device unabated. The California customer packaged the device for shipping knowing the shutter was open with nothing shielding the radiation and sent it back to the manufacturer in Kennewick for repairs. When the manufacturer received the device, a radiation reading in excess of the package limitations was noted and promptly reported to us. The licensee informed us this is the first shutter malfunction ever for this device model, which has been in service without any similar problems for many years. The Materials staff is working with the licensee to identify compliance issues and to prevent recurrence."
The Bruker AXS hand held XRF analyzer contains 5.9 milliCuries of Co-57.
Incident Number WA-12-037
* * * UPDATE FROM CRAIG LAWRENCE (VIA EMAIL) TO HOWIE CROUCH AT 1125 EDT ON 5/25/12 * * *
The XRF device is owned by Benchmark Environmental. Benchmark Environmental shipped the device to Bruker on May 22, 2012.
"Based on the dose rate measurement taken by Bruker prior to opening the package and removing the instrument, the Washington State Department of Health doesn't believe there were exposures to any member of the public in excess of regulatory limits. A dose rate measurement at 3 feet was 0.3 mR/hr as measured by their Bicron Surveyor 50 (cal date 1/19/12). Reading at approximately six inches from the surface pegged the dose rate meter on the 0 to 0.5 mR/hour scale. Bruker did not take measurements on higher scales.
"At that point, Bruker's shipping and receiving took the MAP FA4C1 analyzer out of the case and carried it at arm's length to the shielded source exchange pit. The instrument was evaluated inside the pit and the shutter was found partially open. The Co-57 source was removed from the analyzer and put into a shielded pig. Bruker examined the analyzer and found the source block was defective and [the analyzer was] sent to production for a replacement source block.
The licensee provided corrective actions in the NMED data entry form. Notified R4DO (Spitzberg) and FSME (via email).
Power Reactor
Event Number: 47957
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RYAN TREGRE
HQ OPS Officer: JOE O'HARA
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RYAN TREGRE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/24/2012
Notification Time: 15:21 [ET]
Event Date: 05/23/2012
Event Time: 17:00 [CDT]
Last Update Date: 05/24/2012
Notification Time: 15:21 [ET]
Event Date: 05/23/2012
Event Time: 17:00 [CDT]
Last Update Date: 05/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BLAIR SPITZBERG (R4DO)
BLAIR SPITZBERG (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTRABAND FOUND INSIDE THE PROTECTED AREA
"On May 23, 2012, at approximately 1700 hours, a beer bottle was discovered in a trash can inside the protected area. The bottle was discovered during trash collection by housekeeping personnel who reported the discovery to their supervision. The bottle was determined to contain remnants of moisture and had an odor of beer, constituting the potential presence of alcohol. This report is submitted pursuant to 10 CFR 26.719 (b)(1) based on the presence of alcohol in the protected area. The NRC Senior Resident Inspector has been notified.
"We do not know if it was consumed in the Protected Area. It was found in the Construction Support Building, not in a Vital Area. This has been entered into the Corrective Action Program and investigation has been in progress."
"On May 23, 2012, at approximately 1700 hours, a beer bottle was discovered in a trash can inside the protected area. The bottle was discovered during trash collection by housekeeping personnel who reported the discovery to their supervision. The bottle was determined to contain remnants of moisture and had an odor of beer, constituting the potential presence of alcohol. This report is submitted pursuant to 10 CFR 26.719 (b)(1) based on the presence of alcohol in the protected area. The NRC Senior Resident Inspector has been notified.
"We do not know if it was consumed in the Protected Area. It was found in the Construction Support Building, not in a Vital Area. This has been entered into the Corrective Action Program and investigation has been in progress."
Power Reactor
Event Number: 47953
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: DONG HWA PARK
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/23/2012
Notification Time: 19:54 [ET]
Event Date: 05/23/2012
Event Time: 16:00 [CDT]
Last Update Date: 05/23/2012
Notification Time: 19:54 [ET]
Event Date: 05/23/2012
Event Time: 16:00 [CDT]
Last Update Date: 05/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BLAIR SPITZBERG (R4DO)
BLAIR SPITZBERG (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
CRACK IDENTIFIED IN PRESSURIZER HEATER
"During inspections to determine the physical integrity of a failed pressurizer heater it was determined that the heater (number 26) was cracked. Due to the location of the pressurizer heater crack, this is considered a degradation of the RCS Barrier. The initial visual inspection of heater 26 in November of 2011, did not identify the cracking. During efforts to remove the heater, a crack was observed on May 21, 2012. The crack is above and below the heater support plate. The crack is an axial crack showing some branching. The crack is about an inch above and inch below the heater support plate. These inspections were being performed as a result of the operating experience at the Sizewell B reactor in the United Kingdom."
The licensee has notified the NRC Resident Inspector.
"During inspections to determine the physical integrity of a failed pressurizer heater it was determined that the heater (number 26) was cracked. Due to the location of the pressurizer heater crack, this is considered a degradation of the RCS Barrier. The initial visual inspection of heater 26 in November of 2011, did not identify the cracking. During efforts to remove the heater, a crack was observed on May 21, 2012. The crack is above and below the heater support plate. The crack is an axial crack showing some branching. The crack is about an inch above and inch below the heater support plate. These inspections were being performed as a result of the operating experience at the Sizewell B reactor in the United Kingdom."
The licensee has notified the NRC Resident Inspector.
Agreement State
Event Number: 48389
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNADINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNADINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/09/2012
Notification Time: 15:15 [ET]
Event Date: 05/23/2012
Event Time: 00:00 [PDT]
Last Update Date: 10/25/2012
Notification Time: 15:15 [ET]
Event Date: 05/23/2012
Event Time: 00:00 [PDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT
The following was received from the State of California:
"During a routine inspection on Oct. 8, 2012, RHB inspectors discovered a potential medical event had occurred on May 23, 2012. A patient was admitted to the hospital for carcinoma treatment of the endometrium near both ovaries on May 22, 2012 and treatment began at 1800 PDT. The treatment plan called for 3000 cGy to each ovary, using two 18.5 mg Ra eq. CS-137 sources and an ovoid applicator. [The] dosimetrist placed one source at a time into an insert, which was to be verified by the physician, a second year medical resident, who then placed the insert into the applicator and patient. The source inserts are individually screwed into the ovoid applicator, which prevents the source from movement. The patient treatment was to take 26.5 hrs. On May 23, 2012 at 2030, [the doctor] and the dosimetrist were removing the implant from the patient, starting with the right side. That source was verified to be in the insert and then placed into the pig. The doctor then proceeded to remove the left side insert, which was handed to the dosimetrist, who found the insert to be empty. The radiation survey meter was used immediately around the patient, rolling her back and forth as it appeared the source may be on the bed somewhere. The source was found on an IV monitor stand, which was approx. 2 foot from the patients head partially blocked by a portable lead shield that had been placed the day before. The source recovery was completed around 2045. Hospital staff (supervising MD, lead dosimetrist and RSO) were notified of the event and the patient treatment of the left side was completed on May 29, 2012, after revising the original patient treatment plan. The investigation did not discover how the source ended up on the IV stand. The licensee's RSO evaluated the event and did not feel that it qualified as a medical event per 10CFR35.3045 and therefore did not inform RHB within the 24 hour timeframe."
5010 #: 052312
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.
The following was received from the State of California:
"During a routine inspection on Oct. 8, 2012, RHB inspectors discovered a potential medical event had occurred on May 23, 2012. A patient was admitted to the hospital for carcinoma treatment of the endometrium near both ovaries on May 22, 2012 and treatment began at 1800 PDT. The treatment plan called for 3000 cGy to each ovary, using two 18.5 mg Ra eq. CS-137 sources and an ovoid applicator. [The] dosimetrist placed one source at a time into an insert, which was to be verified by the physician, a second year medical resident, who then placed the insert into the applicator and patient. The source inserts are individually screwed into the ovoid applicator, which prevents the source from movement. The patient treatment was to take 26.5 hrs. On May 23, 2012 at 2030, [the doctor] and the dosimetrist were removing the implant from the patient, starting with the right side. That source was verified to be in the insert and then placed into the pig. The doctor then proceeded to remove the left side insert, which was handed to the dosimetrist, who found the insert to be empty. The radiation survey meter was used immediately around the patient, rolling her back and forth as it appeared the source may be on the bed somewhere. The source was found on an IV monitor stand, which was approx. 2 foot from the patients head partially blocked by a portable lead shield that had been placed the day before. The source recovery was completed around 2045. Hospital staff (supervising MD, lead dosimetrist and RSO) were notified of the event and the patient treatment of the left side was completed on May 29, 2012, after revising the original patient treatment plan. The investigation did not discover how the source ended up on the IV stand. The licensee's RSO evaluated the event and did not feel that it qualified as a medical event per 10CFR35.3045 and therefore did not inform RHB within the 24 hour timeframe."
5010 #: 052312
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.