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Event Notification Report for January 11, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/10/2013 - 01/11/2013

** EVENT NUMBERS **


48609 48640 48641 48642 48643 48647 48653 48661 48662 48664

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Agreement State Event Number: 48609
Rep Org: COLORADO DEPT OF HEALTH
Licensee: VARIOUS
Region: 4
City:  State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2012
Notification Time: 11:31 [ET]
Event Date: 08/01/2006
Event Time: [MST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
FSME RESOURCES (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT- COMPOSITE LISTING OF MISSING GENERAL LICENSED DEVICES

The following fifty-four (54) lost licensee tritium signs were submitted by the State of Colorado via email:

1. American Soda LLP; (2) Isolite; Model 2040; S/N A081034 and A081076; H-3; 11500 mCi/each
2. Beaudrey American Services; (2) Isolite; Model SLX60; S/N Unknown; H-3; 6200 mCi/each
3. Boulder Manor; (8) SRB Technologies; Model BR20BK; S/N 659038 to 659039 and 659066 to 659067; H-3; 17800 mCi/each
4. Carquest; (4) Best Lighting Products; Model SLXTU1RW10; S/N Unknown; H-3; 7030 mCi/each
5. GE Johnson; (1) Safety Light; Model 880-12-6; C27200; H-3; 7500 mCi
6. Grace Management; (2) Isolite Corporation; Model SLX60; S/N 14610; H-3; 3750 mCi/each
7. Hampton Inn; ; (14) SRB Technologies; Model BXU10GS; S/N Unknown; H-3; 9210 mCi/each
8. Industrialex MFG Co; (1) NRD Inc.; Model P-2021; S/N A2HL117; PO-210; 10 mCi
9. Kinder Morgan; (4) Isolite; Model SLX60; S/N Y24490-Y24493; H-3; 7500 mCi/each
10. New Belgium Brewing; (1) Shield Source Inc.; Model SLX; S/N10-29211; H-3; 6200 mCi
11. Old West Management; (1) Isolite; Model 2040; S/N Unknown; ; H-3; 7000 mCi
12. Platt River Power Authority; (4) SRB Technologies; Model BX15WH; S/N CO12440-12443; H-3; 9210 mCi/each
13. Sisters of St. Francis; (1) Isolite; Model 2040; S/N Unknown; H-3; 7500 mCi
14. Wild Oats Markets Inc.; (1) NRD Inc.; Model T-4001; S/N Unknown; H-3; 6700 mCi
15. Wynkoop Building LLC; (8) Safety Light; Model 8801206; S/N 432968 to 432975; H-3; 7500 mCi/each


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

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Agreement State Event Number: 48640
Rep Org: TEXAS DEPARTMENT OF HEALTH SERVICES
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: 00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/02/2013
Notification Time: 09:44 [ET]
Event Date: 12/04/2012
Event Time: [CST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

THERAPY SOURCE JAMMED AT THE DEVICE ENTRY PORT

"On January 2, 2013, the Agency [Texas Department of State Health Services] was notified by the licensee that on December 4, 2012, a medical event had occurred. The licensee reported that while performing a therapy procedure using a Novoste Beta-Cath IVB device the last strontium-90 source in the ribbon of sources could not be retracted into the device. The source was jammed at the device entry port. All of the sources had been removed from the patient, therefore the patient did not receive any additional exposure. The device was placed into an emergency safety box designed for such events and the box was then covered with a lead apron. No one in the treatment room received any additional exposure form the event. The licensee will return the device to their supplier. Additional information will be provided as it is received in accordance with SA-300."

Texas State Report # I-9029

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: 48641
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ROCK-TENN COMPANY
Region: 1
City: LYNCHBURG State: VA
County:
License #: 1699
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/02/2013
Notification Time: 11:18 [ET]
Event Date: 11/29/2012
Event Time: [EST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME RESOURCES ()

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

"On December 26, 2012 the licensee reported that the shutter of one of its fixed gauges could not be closed as designed. The gauge is a Metso Automation, Inc., Model BWM-T (Serial Number 21136049). The gauge contains 400 mCi of Kr-85. The gauge is mounted on a scanning platform that traverses a paper web and is used as a sensor. The problem was noted by the on-site technician of Hoosier Technical Services Company, service provider on November 29, 2012.

"Metso Automation, Inc. was contacted and the following actions were taken: The scanning platform containing the gauge was placed in the home position and removed from the process, power was removed from the equipment, and finally the old shutter mechanism was removed and replaced with a new part.

"A radiation survey was performed and found to be within design parameters and regulatory limits. The Virginia Radioactive Material Program is not performing a site visit or follow-up as the shutter was repaired, all radiation levels are normal, and there was no public health or environmental concerns."

Virginia Report: VA-13-001

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Agreement State Event Number: 48642
Rep Org: NV DIV OF RAD HEALTH
Licensee: NEWMONT MINING CORPORATION
Region: 4
City: ELKO State: NV
County:
License #: 05-11-0041-03
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/02/2013
Notification Time: 14:19 [ET]
Event Date: 12/24/2012
Event Time: [PST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER MECHANISM FAILURE

The following report information was received from the State of Nevada Dept of Health via e-mail:

"The handle of a Berthold source, SN: 0448/09, Model No.: LB 7440, Activity: 30 mCi, Isotope: Cs-137, separated from the shutter mechanism. The shutter is closed and was verified with survey instrument RadEye B20 SN: 0515. This source will be kept in storage until the shutter can be fixed."

Nevada Event Report - NV130001

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Agreement State Event Number: 48643
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RONE ENGINEERING SERVICES LTD
Region: 4
City: DALLAS State: TX
County:
License #: 02356
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/02/2013
Notification Time: 17:46 [ET]
Event Date: 01/02/2013
Event Time: [CST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TROXLER

The following was received from the State of Texas via email:

"On January 2, 2013, the Agency [State of Texas] was notified by the licensee's Radiation Safety Officer (RSO) that a Troxler model 3430 containing an 8 millicurie cesium - 137 source and a 40 millicurie americium - 241/beryllium source could not be located. The licensee's records indicated that the gauge had been returned by their technician and locked in the storage area on December 31, 2012. The licensee's tracking system, which tracks the location of their vehicles, confirmed that the truck used by the technician had been returned to the licensee's location at the close of business on December 31. The licensee conducted an inventory of all of its gauges and this was the only gauge missing. The RSO stated that the storage area had no signs of tampering. The RSO stated that they had interviewed the technician assigned to use the gauge, but the technician did not provide any information useful to recover the gauge. The RSO stated that they were in the process of notifying the police of the theft. The RSO stated that the offering of a reward would be discussed with company management. The RSO stated that the gauge was locked inside of a transportation case and that the operating rod was locked in the shielded position. The RSO stated that he did not believe there was any risk of exposure to a member of the general public. Additional information will be provided as it is received in accordance with SA-300.

"Texas Incident Number: I-9030"

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

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 48647
Rep Org: RESEARCH MEDICAL CENTER
Licensee: RESEARCH MEDICAL CENTER
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-18625-01
Agreement: N
Docket:
NRC Notified By: STEPHEN SLACK
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/03/2013
Notification Time: 10:22 [ET]
Event Date: 01/02/2013
Event Time: 11:47 [CST]
Last Update Date: 01/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

RADIOISOTOPE ADMINISTERED TO THE INCORRECT PATIENT

While conducting a radiopharmaceutical stress test the dose was administered to the incorrect patient. The isotope was 11 mCi of Tc-99m. The patient is not expected to experience any adverse effects as a result of this treatment.

* * * UPDATE AT 1440 EST ON 01/03/13 FROM STEPHEN SLACK TO S. SANDIN * * *

The licensee is retracting this report after a discussion with NRC Region III (Gattone) which concluded that the event did not meet the reporting criteria as a medical event.

Notified R3DO (Skokowski) and FSME Events Resource via email.

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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Power Reactor Event Number: 48653
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/06/2013
Notification Time: 13:32 [ET]
Event Date: 01/06/2013
Event Time: 20:00 [EST]
Last Update Date: 01/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES NOGGLE (R1DO)

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

PLANNED CORRECTIVE MAINTENANCE ON THE TECHNICAL SUPPORT CENTER (TSC) HVAC POWER SUPPLY

"This ENS [report] is being issued in advance of planned corrective maintenance on a TSC HVAC power supply.

"On 1/6/13 at 2000 [EST], the Technical Support Center Emergency Ventilation system will be removed from service to perform corrective maintenance on the load center that supplies power to the TSC HVAC system. The emergency ventilation system will not be available and cannot be restored within the time period required to staff and activate the Emergency Response Organization (ERO). The work is scheduled to complete on Friday 1/11/13 at 1500 [EST].

"If an emergency is declared and the TSC activation is required, the TSC will be staffed and activated unless the TSC becomes uninhabitable due to ambient temperatures, radiological or other conditions. The Station Emergency Director would assess habitability in accordance with station procedures. TSC relocation of personnel would be directed as required until such time that the TSC ventilation system is returned to service.

"An update will be sent upon TSC HVAC restoration."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM WILLIAMSON TO KLCO ON 1/10/13 AT 2209 EST* * *

The TSC emergency ventilation system was restored to normal at 2200 EST on 1/10/13. The licensee notified the NRC Resident Inspector.

Notified the R1DO (Newport).

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Power Reactor Event Number: 48661
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BARRY GARBER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/10/2013
Notification Time: 10:58 [ET]
Event Date: 11/28/2012
Event Time: 23:05 [EST]
Last Update Date: 01/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK FRANKE (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

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID SYSTEM ACTUATION

"This telephone notification is being made for an invalid actuation under 10 CFR 50.73(a)(2)(iv)(A) following the reporting guidance of 10 CFR 50.73(a)(1) and is not considered a Licensee Event Report.

"With Unit 2 at Cold Shutdown (about 105?F and depressurized), an invalid actuation of the Unit 2 'A' train of the High High Consequence Limiting Safeguards (Hi-Hi CLS) system occurred at 2305 [EST] during reinstallation of fuses in preparation for return to service testing. The fuses were pulled to implement a design modification to replace existing relays with a new design. The 'A' train of the High High CLS actuated as soon as the fuses were installed. Plant systems and components responding to the Hi-Hi CLS 'A' train signals started and functioned successfully as designed with the exception of those systems and components procedurally rendered inoperable due to the RCS being below 350?F and 450 psig. Shutdown cooling was not lost due to safety injection leads being tagged out.

"The signal could not be reset from the Main Control Room due to system design in this configuration requiring manual local manipulations to address affected components. The relays on both trains were replaced with the original design and the fuses reinstalled. The affected systems were restored to their pre-event configuration.

"Specific trains and systems that actuated as a result of the "A" train of Hi-Hi CLS signal are described below:
-- Component Cooling from the A Reactor Coolant Pump isolated.
-- Containment Spray realigned and gravity flowed the Refueling Water Storage Tank and Caustic Addition Tank to the Containment Sump. The level did not reach the point where any components in the containment basement were affected.
-- Service Water flowed to the A and C Recirculation Spray Heat Exchangers.
-- Containment Instrument Air isolated.
-- Emergency Diesel Generator (EDG) No.2 started but did not load since its associated Emergency Bus remained energized by offsite power. The EDG was stopped and returned to automatic.

"A root cause evaluation is in progress."

The licensee notified the NRC Resident Inspector

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Power Reactor Event Number: 48662
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BARRY GARBER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/10/2013
Notification Time: 11:04 [ET]
Event Date: 11/29/2012
Event Time: 22:00 [EST]
Last Update Date: 01/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK FRANKE (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

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID SYSTEM ACTUATION

"This telephone notification is being made for an invalid actuation in accordance with 10 CFR 50.73(a)(2)(iv)(A) following the reporting guidance of 10 CFR 50.73(a)(1) and is not considered a Licensee Event Report.

"With Unit 2 at Cold Shutdown (about 105?F and depressurized), an invalid actuation of the Main Feedwater (FW) isolation occurred at 2200 [EST] during removal of the 'A' Train Hi Consequence Limiting Safeguards (CLS) fuses. This action caused the 'A' train FW isolation relay to actuate and, as designed, tripped the operating 'B' Main Feed Pump (MFP) and the Main Turbine, which was latched for testing. The 'A' MFP was not in operation at the time of the event.

"This was a partial actuation of the SI system. SI signals were inhibited prior to removal of the Hi CLS fuses by the tagging of the lead connecting the Hi CLS relay to the SI master relay. Although FW isolation occurs with SI actuation, the relay associated with the FW isolation circuitry is separately actuated and had not been tagged out. When the Hi CLS fuses were removed, the FW isolation relay was energized.

"Plant systems and components responding to the signal started and functioned as designed with the exception of those inhibited by tag out. The affected components were restored to their pre-event configuration, The action to determine and initiate corrective actions is complete, and the necessary procedures are under revision."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48664
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOESPH BRACKEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/10/2013
Notification Time: 19:05 [ET]
Event Date: 01/10/2013
Event Time: 15:34 [EST]
Last Update Date: 01/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

REACTOR PROTECTION ACTUATION (SCRAM) - RECIRCULATION PUMP TRIP

"On Thursday, January 10, 2013 at 1534 hour [EST], with the reactor at 100% core thermal power, both recirculation pumps spuriously tripped and a manual reactor scram was inserted as required by station procedures. The cause of the recirculation pump trip is under investigation.

"Following the reactor scram, all rods were verified to be fully inserted and the Primary Containment Isolation System Group II (Reactor Building) and Group VI (Reactor Water Cleanup System) actuations occurred as designed due to the expected reactor water level shrink associated with the scram signal. All other plant systems responded as designed.

"Currently reactor pressure is being maintained between 900 and 1050 psig with the Mechanical Hydraulic Control System (turbine by-pass valves). The Reactor Protection System has been reset; Reactor Water Cleanup System and normal reactor building ventilation have been restored. Reactor water level is being maintained in normal bands with the Condensate and Feedwater System. Off-site power is being supplied to the station by the Start-up Transformer (normal power supply for shutdown operations) and the switchyard ring bus has been restored.

"This event had no impact on the health and/or safety of the public.

"The USNRC Senior Resident Inspector is on-site and has been notified.

"This 4-hour notification is being made in accordance with 10 CFR 50.72 (b)(2)(iv)(B)."

The scram was uncomplicated and decay heat is being released to the main condenser via the turbine by-pass valves.

Page Last Reviewed/Updated Friday, January 11, 2013
Friday, January 11, 2013