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Event Notification Report for February 4, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/01/2013 - 02/04/2013

** EVENT NUMBERS **


47643 48307 48697 48699 48700 48711 48712

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Part 21 Event Number: 47643
Rep Org: CURTISS WRIGHT FLOW CONTROL CO.
Licensee: CURTISS WRIGHT FLOW CONTROL CO.
Region: 1
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TONY GILL
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/06/2012
Notification Time: 17:56 [ET]
Event Date: 02/06/2012
Event Time: [CST]
Last Update Date: 02/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JONATHAN BARTLEY (R2DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - DEFECTIVE PLUG INSULATORS

The following report was received via fax:

"This letter is issued to provide initial notification of a potential defect in Plug Insulators (P/N: GB-1A-1) supplied as part of GRAYBOOT 'A' (GB-1A) Connector Kits. There are two affected lots of Plug Insulators (Lot #: BA59961 and BA67711). The potential defect is an out of tolerance dimension that will possibly affect the sealing ability of the Plug Insulator to wire interface.

"The affected Customers and their associated Purchase Orders are listed below. All Customers will be notified today.

Ralph a. Hiller; PO: NUC7505, Item 1, 15 Kits (P/N: GB-1A [16-18], Lot BA59961) supplied 19JAN2012.
Bruce Power, PO: 00168187, Item 1, 20 Kits (P/N: GB-1A [12-14], Lot BA59961) supplied 13DEC2011.
Dominion - Surry, PO: 45886290, Item 1, 22 Kits (P/N: GB-S-1A, Lot BA59961) supplied 19DEC2011.
Dominion - Surry, PO: 45897749, Item 2, 30 Kits (P/N: GB-S-1A, Lot BA67711) supplied 01FEB2012.
Ringhals AB, PO: 621728-053, Item 10, 30 Kits (P/N: GB-1A [16-18], Lot BA59961) supplied 19DEC2011.
Ringhals, PO: 620625-066, Item 10, 300 parts (P/N: GB-1A-1, Lots BA59961/BA67711) supplied 30JAN2012.
Ringhals, PO: 620996-066, Item 50, 1 Kit (P/N: GB-1A [16-18], Lot BA59961) supplied 29NOV2011.
OKG, PO: 4113847, Item 4, 86 parts (P/N: GB-1A-1, Lot BA59961) supplied 30NOV2011.

"It is requested that all affected parts be returned for replacement to QualTech NP; 330 West Park Loop; Huntsville, AL 35806. Customers can contact Cindy Tidwell at (256) 895-7250 ext. 229 for freight collect shipping instructions.

"Additional details, corrective actions and root causes will be provided once complete. If you require additional information or would like to discuss this further please do not hesitate in contacting:"

Tony Gill
Quality Assurance Supervisor
QualTech NP, Huntsville
A business unit of Curtiss-Wright Flow Control Company
Office 256-722-8500 ext. 1
Cell 256-426-4558
tgill@curtisswright.com

* * * UPDATE FROM TONY GILL TO JOHN SHOEMAKER ON 02/03/2013 AT 17:55 EST* * *

"This letter provides for the formal closeout of notification 10CFR21-2012-01. The initial notification was made on February 06, 2012. All corrective actions and corrective actions to prevent recurrence have been completed and all affected parts listed on the initial notification have been returned by our customers and replacement items supplied. All affected parts in inventory at our facility were removed and discarded.

"The initial corrective action was to retrieve all affected parts both in our inventory and those provided to our customers as safety-related. As stated above, all affected parts have been returned and/or retrieved from inventory and discarded.

"There were four primary root causes identified that allowed the defective items to be manufactured and accepted. The causes are listed below:

1. Mold sections/mold inserts for the two different size plug insulators (regular and oversized) are used in the same mold assembly. Not all required mold parts were removed when changing from the manufacture of oversized to regular boots causing the defective parts to be manufactured.

2. Vendor did not verify the affected dimension prior to shipment of the parts to QualTech.

3. The inspection drawing in the QualTech dedication guidelines was not clear as to the required dimension to be verified.

4. The QualTech Inspector incorrectly interpreted the inspection drawing and verified the wrong dimension thus accepting the defective parts.

"The corrective actions to prevent recurrence have been completed and include the following:

1. An additional mold was purchased from our supplier to prevent mixing of inserts. Now there are no mold parts utilized in the manufacture of different sized plug insulators (regular vs. oversized). This issue was one of the primary causes of the defect.

2. Notification was made to our supplier and corrective actions implemented at their facility.

3. The QualTech inspection drawing in the affected dedication guidelines was revised to better define the required dimension.

4. The error was discussed with the QualTech Inspector to ensure understanding of the critical dimension.

"Based on the above information and corrective actions this part 21 file is considered closed. If you would like to discuss this information further please contact the undersigned at 256-722-8500 ext. 131 (office), 256-426-4558 (cell), or tgill@curtisswright.com.

Tony Gill
Quality Assurance Manager
QualTech NP, Huntsville Operations
a business unit of Curtiss-Wright Flow Control Company

Notified R2DO (Haig) and the Part 21 Group via email.

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Agreement State Event Number: 48307
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA DEPARTMENT OF TRANSPORTATION
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-031
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 13:22 [ET]
Event Date: 09/13/2012
Event Time: 09:00 [MST]
Last Update Date: 02/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENT RESOURCES (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN HUMBOLDT NUCLEAR GAUGE

The following report was received from the State of Arizona via email:

"At approximately 9:00 AM September 13, 2012, the [Arizona Radiation Regulatory] Agency was informed that the Licensee had a Humboldt Model 5001, SN 3920, portable gauge stolen from the back of a truck. The theft occurred between 9:00 PM September 12, 2012, and 6:00 AM September 13, 2012. The gauge was locked in a 16 gauge steel box bolted to the bed of the truck which was parked unattended at an employee's resident. The gauge contains 370 MBq (10 mCi) of Cesium-137 and 1.62 GBq (44 mCi) of Am:Be-241.

"El Mirage PD is investigating and has issued report number 12-09000902.

"The Agency continues to investigate this event.

"The Governor's Office, the States of CA, NV, CO, UT and NM and Mexico, US NRC, and FBI are being notified of this event."

Arizona Event Number: 12-020


* * * UPDATE FROM AUBREY GODWIN TO JOHN SHOEMAKER AT 1652 EST ON 1/31/13 * * *

NOTE: The following information was originally provided as a new report by the Arizona Radiation Regulatory Agency. After additional information was obtained on 2/1/13 all information was combined into the original report concerning this event.

The following information was received from the Arizona Radiation Regulatory Agency via email:

"The Agency [Arizona Radiation Regulatory Agency], in checking a scrap metal shipment being returned to Glendale, Arizona from California, found a source rod from a moisture density gauge. No other parts of a moisture density gauge were identifiable in the shipment. Based upon experience, it is estimated that the source contained approximately 8 millicuries of Cesium-137. It was confirmed in the field that Cesium-137 was the only isotope present. The Agency was unable to locate any identifying markings with which to trace the source. The Agency has taken possession of the source and has stored the device in a secure location.

"The Agency continues to investigate this event.

"This notice is being provided to the State of California, US NRC, and FBI."

Arizona Event Report: First Notice 13-005.

Notified R4DO (Walker). Notified FSME Events Resource via E-mail.


* * * UPDATE FROM AUBREY GODWIN TO DONALD NORWOOD AT 1341 EST ON 2/1/2013 * * *

The following was received from the Arizona Radiation Regulatory Agency via email:

"The Agency, in checking a scrap metal shipment being returned to Glendale, AZ from Taiwan through California, found a source rod from a moisture density gauge. No other parts of a moisture density gauge were identifiable in the shipment. The manufacturer, Humboldt, estimated the source as approximately 10 millicuries of Cesium-137. We did confirm in the field that Cesium-137 was the only isotope present. Based on the identifying numbers found on the source rod this is part of Humboldt Model 5001, SN3920, reported stolen September 13, 2012. See First Notice 12-020 sent out September 14, 2012. The Americium-241 source has not been located.

"The Agency has taken possession of the Cesium-137 source and will store it in a secure location. Arrangements for proper disposal are being made.

"The Agency continues to investigate this event.

"This notice is being provided to the State of California, US NRC, and FBI."

Arizona Event Report: Supplemental Notice 13-005.

Notified R4DO (Walker) and ILTAB (Johnson). Notified FSME Events Resource and Mexico via E-mail.


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: 48697
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NEBRASKA MEDICAL CENTER
Region: 4
City: OMAHA State: NE
County:
License #: 018801
Agreement: Y
Docket:
NRC Notified By: BRYAN MILLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/24/2013
Notification Time: 16:07 [ET]
Event Date: 01/21/2013
Event Time: [CST]
Last Update Date: 01/24/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME RESOURCE (EMAI)
BARRY WRAY (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED

On January 21, 2013, a patient was undergoing a radioactive procedure using a 275 microCurie I-125 seed as well as a resection procedure for a breast tumor. The seed was implanted on the surface of the skin and taped into place. During post-surgical clean-up after the resection procedure was performed, the iodine seed was lost. It is believed it was removed with the tape and thrown away as medical waste.

After discovery of the loss, the patient, her car, her home and her clothing were surveyed with negative results. The surgical suite and all bedding and gowns used were surveyed with negative results. The surgical waste had already been removed by the time the suite was surveyed.

The licensee believes the seed is in the local landfill and has considered it to be lost.

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: 48699
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: CRAIG JONES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2013
Notification Time: 11:01 [ET]
Event Date: 01/16/2013
Event Time: 14:00 [MST]
Last Update Date: 01/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME_EVENTS-RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - DOSE DIFFERENT FROM PRESCRIBED USING YTTRIUM-90 THERASPHERE TREATMENT

The following event report was received from the State of Utah Division of Radiation Control via facsimile:

"The Utah Division of Radiation Control was notified at 11:45 a.m. MST on Thursday, January 17, 2013 of a medical event associated with a radioembolization brachytherapy treatment of liver cancer. Notification was provided by the licensee's Radiation Safety Officer. This incident report is the initial notification to the NRC Operations Center.

"The licensee's radiation safety officer reported to the Division that the treatment plan prescribed 1.33 GBq of yttrium-90 for treatment of liver cancer. The patient received 0.798 GBq of yttrium associated with the TheraSphere product. After the administration of the dosage, a nuclear medicine technologist determined that the total prescribed dosage was not delivered to the patient, as radioactive material was found to remain in the dosage vial and the administration apparatus. The licensee is working with the manufacturer of the treatment delivery system to determine the cause of the medical event."

Utah Event Report ID : UT130001

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: 48700
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: HALLIBURTON ENERGY SERVICES, INC.
Region: 4
City: ROOSEVELT State: UT
County:
License #: G3-039
Agreement: Y
Docket:
NRC Notified By: CRAIG JONES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2013
Notification Time: 11:02 [ET]
Event Date: 01/22/2013
Event Time: 06:00 [MST]
Last Update Date: 01/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME_EVENTS_RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - PROCESS METER SOURCE SUBJECTED TO INTENSE FIRE AT WELL SITE

The following information was obtained from the State of Utah via facsimile:

"The Utah Division of Radiation Control was notified at 3:40 p.m. MST on January 22, 2013 of a fire at a natural gas well. Notification was provided by the licensee's Radiation Safety Officer. This incident report is the initial notification to the NRC Operations Center.

On January 22, 2013, a representative of Halliburton Energy Services, Inc. radiation safety called the Division to report a fire involving a natural gas well. The fire erupted about 6:00 a.m. that morning. The licensee was using a truck with a slurry densimeter (Sealed Source Device Registry Number NR-340-D-101-G) in-line after a chicksan on a down-hole pump. The truck was parked approximately 40 feet from the blowout preventer (well head). An 8.8 milliCurie cesium-137 sealed source (Gammatron GT-GHP) is contained within the slurry densimeter. As of Thursday afternoon, January 24, 2013, the fire continued to occasionally flare, but a Halliburton representative was able to gain brief access to the slurry densimeter. He reported to a Department of Environmental Quality representative (on-scene presence) that the sealed source is not leaking and the device containment housing was still intact. Fire control operations continue and efforts to drag the licensee's truck away from the drill rig may occur on Friday, January 25, 2013.

Utah Report No: UT130002

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Power Reactor Event Number: 48711
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEPHEN SEILHYMER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/03/2013
Notification Time: 13:20 [ET]
Event Date: 02/03/2013
Event Time: 12:08 [CST]
Last Update Date: 02/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO RELEASE OF AMERTAP BALLS

"At 1208 CST, Xcel Energy notified the Minnesota State Duty Officer that up to 950 Amertap Balls had been lost from the Prairie Island Nuclear Generating Plant Unit 2 Condenser Tube Cleaning System. Since the Minnesota State Duty Officer for the Division of Emergency Management was notified, this constitutes a 4 hour non-emergency notification per 10CFR50.72(b)(2)(xi)."

The licensee notified the NRC Resident Inspector. The licensee also notified the local county sheriff's office.

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Power Reactor Event Number: 48712
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOE BRACKEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/03/2013
Notification Time: 19:40 [ET]
Event Date: 02/03/2013
Event Time: 12:45 [EST]
Last Update Date: 02/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
RONALD BELLAMY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 80 Power Operation

Event Text

INFORMATIONAL NOTIFICATION - SAFETY RELIEF VALVE POTENTIALLY INOPERABLE

"On February 3, 2013 at 1245 EST, with the reactor at 100% core thermal power (CTP) safety relief valve, RV-203-3B was declared inoperable as required by station procedural direction due to an observed reduction in first stage pilot valve temperature of greater than 35 degrees F from baseline temperatures. At 1300 EST, reactor power was lowered to approximately 80% CTP at which time the relief valve parameters returned or trended to normal steady state values. Consistent with a reactor power reduction, reactor pressure also lowered from 1035 psig to 1000 psig. This action was taken consistent with industry operating experience related to three stage target rock relief first stage pilot valve leakage.

"Currently, station engineering is evaluating the operability of RV-203-3B. Additionally, the current valve performance is being closely monitored by the main control room operating crew.

"Station Technical Specification 3.6.D.1 requires that the safety modes of all relief valves (four for [Pilgrim Nuclear Power Station] PNPS) shall be operable during reactor power operating conditions and prior to reactor startup from a Cold Shutdown, or whenever reactor coolant pressure is greater that 104 psig and temperature is greater than 340 degrees F. If this specification is not met, Technical Specification 3.6.D.2 requires that an orderly shutdown shall be initiated and the reactor coolant pressure shall be below 104 psig within 24 hours.

"This is an informational notification at this time. PNPS has not initiated an orderly shutdown as of this notification; rather reactor power was lowered to reseat the safety relief pilot valve and there is a high degree of confidence that the high standard of operability will be restored for RV-203-3B and the associated Technical Specification will be exited. If RV-203-3B is not restored to an operable status, a formal and required notification will be completed in accordance with 10 CFR 50.72(b)(2)(i), 'Initiation of any plant shutdown required by the Technical Specifications.'

"This event has no impact on the health and safety of the public.

"The USNRC Senior Resident Inspector has been informed [by the Licensee]."

Page Last Reviewed/Updated Monday, February 04, 2013
Monday, February 04, 2013