| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/01/2012 - 08/02/2012 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 48128 | Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WATERTOWN MEMORIAL HOSPITAL
Region: 3
City: WATERTOWN State: WI
County:
License #: 055-1335-01
Agreement: Y
Docket:
NRC Notified By: ROYSTON NGWAYAH
HQ OPS Officer: VINCE KLCO | Notification Date: 07/24/2012
Notification Time: 14:23 [ET]
Event Date: 07/24/2012
Event Time: [CDT]
Last Update Date: 07/24/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
TAMARA BLOOMER (R3DO)
FSME via email ()
| Event Text AGREEMENT STATE REPORT- UNDERDOSE DURING A BRACHYTHERAPY TREATMENT
The following information was received by email:
"Wisconsin Department of Health Services (DHS) received notification via voicemail from the licensee on July 23, 2012 regarding the discovery of a brachytherapy medical event that occurred on July 17, 2007. The medical event involved a procedure during which the administered dose differed from the prescribed dose by more than 20% (underdose) for permanent prostate implants using Cs-131 seeds. The prescribed dose was 115 Gy. The delivered dose was 60 Gy. The medical event was identified by DHS inspectors during a recent routine inspection, at which time the inspectors also determined that the licensee had not conducted adequate review of their prostate brachytherapy cases against their medical event criteria.
"Per the licensee's procedures, a post-implant CT is performed the same day as the procedure and analyzed within two working days after. If the post-implant analysis reveals an underdose, which occurred in this situation, additional seeds are implanted and another post-implant CT/analysis process follows. The licensee is currently reviewing additional cases dating back to 2003 for medical events against the revised medical event criteria submitted to DHS on June 22, 2012. DHS is investigating the event and is currently in the process of communicating with the licensee regarding decisions on patient notifications. A special inspection team will be sent following the licensee's review."
Wisconsin Event: WI 120009
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: 48129 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EASTMAN CHEMICALS COMPANY
Region: 4
City: LONGVIEW State: TX
County:
License #: 00301
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD | Notification Date: 07/24/2012
Notification Time: 14:24 [ET]
Event Date: 07/23/2012
Event Time: [CDT]
Last Update Date: 07/24/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JAMES DRAKE (R4DO)
FSME via E-mail ()
| Event Text AGREEMENT STATE REPORT - BROKEN PROCESS GAUGE SHUTTER MECHANISM
The following information was received via E-mail:
"On July 24, 2012, the licensee notified the Agency [Texas Department of State Health Services] that on July 23, 2012, it discovered a shutter mechanism on an Ohmart SH-F2-45 gauge mounted on the side of a tank at the licensee's facility was broken and the shutter could not be closed. The gauge contained 200 millicuries of cesium-137. The 3/8 inch cast iron shutter rod broke approximately 1/4 inch below the top surface of the gauge. The licensee has submitted the appropriate request to the Agency for the gauge to remain in operation until repairs can be made. The licensee contacted the manufacturer and scheduled the repair. Further information will be provided as it is obtained.
"Gauge information:
Ohmart SH-F2-45
Serial number: 5334GK
"Source information:
cesium-137
200 millicuries
Serial number: 9-1999"
Texas Incident #: I - 8971 |
| Agreement State | Event Number: 48130 | Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: FLINT HILLS RESOURCES CHEMICAL INTERMEDIATES
Region: 3
City: JOLIET State: IL
County:
License #:
Agreement: Y
Docket: 01337-01
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO | Notification Date: 07/24/2012
Notification Time: 15:50 [ET]
Event Date: 07/18/2012
Event Time: [CDT]
Last Update Date: 07/24/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
TAMARA BLOOMER (R3DO)
FSME via email ()
| Event Text AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE
The following information was received by email:
"On the evening of July 18, 2012 the licensee's radiation safety officer contacted the [Illinois Emergency Management] Agency's Radiation Duty Officer to advise that a fixed gauge had failed to perform as expected when an attempt was made to close the shutter in advance of work scheduled to be performed on the vessel it was mounted on. The RSO reports that although the spindle of the handle rotated, the shutter did not close. The shutter remained stuck in the 'open' position and would not close. As a result, the planned work was deferred and access to the confined space has been prohibited. The gauge is mounted such that there are no adjacent work stations and unrestricted access is not possible. Radiation monitoring performed by the radiation safety officer showed no abnormal readings.
"The gauge shutter had been successfully tested in March with no abnormalities at that time. The gauge is mounted in such a way that although it is exposed to ambient temperatures, it is not directly exposed to the elements by virtue of an overhead cover. The gauge has not been subjected to any corrosives or solvents or other conditions which exceed the gauge prototype's test conditions. Arrangements have been made to have the manufacturer's representative on-site to conduct an evaluation and effect repairs as necessary at the end of the week."
The fixed gauge is a model SA-1 manufactured by Ronan Engineering (serial number 69094). The gauge contains a Cs-137 sealed source (.082 Ci).
Illinois Incident: IL 12011 |
| Part 21 | Event Number: 48146 | Rep Org: QUALTECH NP CURTISS WRIGHT
Licensee: QUALTECH NP CURTISS WRIGHT
Region: 3
City: CINCINNATI State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TIM FRANCHUK
HQ OPS Officer: BILL HUFFMAN | Notification Date: 08/01/2012
Notification Time: 10:56 [ET]
Event Date: 08/01/2012
Event Time: [EDT]
Last Update Date: 08/01/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
| Person (Organization):
TAMARA BLOOMER (R3DO)
PART 21 GROUP (EMAI)
| Event Text POTENTIAL PART 21 ISSUE RELATED TO TYCO TIMING RELAY
The following information was provided via facsimile:
"QualTech NP is providing this notification as a potential 10 CFR Part 21 issue. We have discovered a manufacturing defect in a timing relay which prevents the relay from operating at a specific setting. This relay was purchased as a commercial grade item and dedicated through our dedication process for safety related applications at our Cincinnati facility.
"The subject equipment is TYCO Model CNT-35-96, a timing relay with adjustable trip ranges from seconds up to 9,990 hours. QualTech NP has recently identified a failure mode for this relay in that the device will not trip in the 10H setting. In communications with the manufacturer, they have confirmed that there is a flaw in the design that prevents this specific setting from tripping.
"QualTech NP has only sold this unit to two plants, both Exelon. We recognize, however that other utilities could have these installed. Based on the information in hand we are evaluating the need for a 10 CFR Part 21 notification. Since the item was qualified under the EPRI SQURTS [Seismic Qualification Reporting and Testing Standardization] Program, the recommended corrective action is to notify EPRI of the condition in order for SQURTS members to perform an impact evaluation.
"Additional details will be provided in the formal written report. Please contact Tim Franchuk at 513-528-7900, ext. 176 (office), [redacted] or via email tfranchuk@curtisswright.com for any additional information." |
| Power Reactor | Event Number: 48148 | Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: JULIE BISSEN
HQ OPS Officer: DONALD NORWOOD | Notification Date: 08/01/2012
Notification Time: 13:24 [ET]
Event Date: 08/01/2012
Event Time: 10:10 [CDT]
Last Update Date: 08/01/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
GREG WERNER (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 | Event Text LOSS OF ENS, HPN, PMC, AND RSC PHONE LINES
"At 0327 CDT, a call was received from the NRC Operations Center for Emergency Notification System (ENS) phone status check on the commercial phone line. The ENS phone system had no incoming rings, nor a dial-tone. The NRC Headquarters Operations Officer (HOO) was to submit a trouble ticket.
"At 0949 CDT, Emergency Planning personnel were working with Verizon Communications to determine the cause of the loss of the ENS phone. Verizon had isolated the problem to the American Broadband network and was working to resolve the problem.
"At 1010 CDT, Emergency Planning personnel identified that the Health Physics Network (HPN) line, the Protective Measures Counterpart [PMC] and Reactor Safety Counterpart [RSC] lines with the NRC had also been lost. The Conference Operations Network (COP) and all other commercial phone lines were functional and remained available. All areas were reachable by commercial phone lines.
"At 1022 CDT, the FCS Control Room was informed by Emergency Planning personnel of the communication means that were lost. The Emergency Plan per EPIP-OSC-1 was reviewed and verified no initiating conditions applied.
"At 1034 CDT, Emergency Planning personnel verified the communications problem with ENS, HPN, the Protective Measures Counterpart and Reactor Safety Counterpart lines was limited to the Fort Calhoun site. The Emergency Operations Facility (EOF) was not affected.
"At 1054 CDT, the ENS phone was restored to the FCS Control Room. This was verified by FCS placing a call to the NRC Operations Center. The NRC Operations Center then returned the call. All communications were satisfactorily restored.
"At 1132 CDT, the Protective Measures Counterpart line was restored.
"At 1142 CDT, the HPN and Reactor Safety Counterpart lines were restored.
"This is being reported per 10CFR50.72(b)(3)(xiii) for 'Any event that results in a major loss of emergency assessment capability, off site response capability, or communications capability.'"
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 48149 | Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: TYLER HALYE
HQ OPS Officer: DONALD NORWOOD | Notification Date: 08/01/2012
Notification Time: 16:08 [ET]
Event Date: 08/01/2012
Event Time: 12:12 [EDT]
Last Update Date: 08/01/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
MIKE ERNSTES (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 | Event Text TSC INOPERABLE DUE TO NON-FUNCTIONAL VENTILATION SUPPORT SYSTEM
"At 1212 EDT on August 1, 2012, Harris Operations discovered that cooling function was degraded on Technical Support Center (TSC) air handler 17. The TSC has three air handlers that provide the ventilation function, and the other two are operating with no known problems. Air Handler 17 has been removed from service and troubleshooting is in progress. This event is reportable per 10CFR50.72(b)(3)(xiii) due to the Technical Support Center ventilation support system being potentially non-functional. The on-call Site Emergency Coordinator and Emergency Response Manager have been notified. The Alternate TSC is available per plant procedure if required.
"The NRC Senior Resident Inspector has been informed." |
| General Information | Event Number: 48150 | Rep Org: BETTER ROADS ASPHALT CORP
Licensee: BETTER ROADS ASPHALT CORP
Region: 1
City: SAJARDO State: PR
County:
License #: 52-19845-01
Agreement: N
Docket:
NRC Notified By: DAVID RHOE
HQ OPS Officer: CHARLES TEAL | Notification Date: 08/01/2012
Notification Time: 17:14 [ET]
Event Date: 08/01/2012
Event Time: [EDT]
Last Update Date: 08/01/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
| Person (Organization):
PAUL KROHN (R1DO)
FSME EVENT RESOURCE (EMAI)
| Event Text DAMAGED CPN MOISTURE DENSITY GAUGE
A construction roller damaged the outer housing of a CPN moisture density gauge while it was sitting on the asphalt. The sources were fully contained. A portable radiac verified no abnormal radiation and swipe tests were performed to verify the sources were not leaking.
Gauge Model : MC-1 DRP CPN
Sources:
Cs-137 10 milliCuries
Am-241 50 milliCuries | |