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Event Notification Report for March 28, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2013 - 03/28/2013

** EVENT NUMBERS **


48831 48833 48836 48853 48854 48860

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Non-Agreement State Event Number: 48831
Rep Org: BIOCOMPATIBLES INC.
Licensee: BIOCOMPATIBLES INC.
Region: 1
City: Oxford State: CT
County:
License #: 06-30764-02MD
Agreement: N
Docket:
NRC Notified By: WAYNE RICHARDSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2013
Notification Time: 14:45 [ET]
Event Date: 02/26/2013
Event Time: 09:00 [EDT]
Last Update Date: 03/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES TRAPP (R1DO)
FSME EVENT RESOURCES (EMAI)
GREG WERNER (R4DO)
DARYL JOHNSON (ILTA)

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

Event Text

POTENTIAL LOSS OF BRACHYTHERAPY SEEDS

On 2/25/2013, four Mick applicator kits with fifteen I-125 seeds in each applicator kit (60 seeds total) were shipped to the Dameron Hospital in Stockton, CA. Each seed contained 0.45 milliCuries. On 2/26/2013, 49 seeds were implanted with one seed jamming in the applicator. After the medical procedure, the radiologist stated that only 50 seeds were in the applicators i.e. ten missing. Surveys were performed but the missing seeds could not be found. The jammed seed is being returned to Biocompatibles.

* * * UPDATE AT 0748 EDT ON 3/20/13 FROM RICHARDSON TO HUFFMAN VIA FACSIMILE * * *

The following detailed event text was received from the licensee (Biocompatibles, Inc.) via fax:

"Biocompatibles, Inc. ('Biocompatibles') has investigated a report that ten (10) I-125 sources (0.450 mCi each Ref date 2/26/13) that Biocompatibles sent to Dameron Hospital in Stockton CA (the 'Hospital') are unaccounted for.

"On February 26, 2013, Biocompatibles received a report that at the end of an implant procedure for which Biocompatibles provided (60) sealed sources in four (4) Mick magazines of fifteen (15) sources each that:

* Forty-nine (49) sources were implanted in the patient
* One (1) source had jammed in the Mick Applicator and had been retained by the Hospital
* Ten (10) sources were unaccounted for at the end of the procedure

"A Biocompatibles sales representative was present during most of the procedure performed on February 26, 2013 and reported that there was no indication that there were not four (4) full magazines of (15) sources each at the start of the procedure. In addition, the Hospital has confirmed that the decision to implant forty-nine (49) sources was made by the operating physician at the time of the surgery.

"Several communications led Biocompatibles to believe that the sources were accounted for at the Hospital, but on March 13, 2013, a conversation with relevant personnel confirmed that the Hospital did not have the sources.

"Biocompatibles received the sources from its Supplier on February 19, 2013, and loaded all sources received into four (4) magazines on the same day. Biocompatibles' production records confirm that Biocompatibles received sixty (60) sources from its Supplier (OPSRAD SOP09-01), and subsequently confirmed with its Supplier that exactly sixty (60) sources were sent to Biocompatibles. Biocompatibles verified the source counts at magazine loading. Biocompatibles also performed Ludlum meter surveys for line clearance after both the assay (OPSRAD SOP09-02) and loading operations (OPSRAD SOP09-03) to ensure that no sources had been left behind. A final inspection (OPSRAD SOP09-04), performed by the Biocompatibles Quality Department, verified that the magazine plunger heights on the four (4) full magazines were identical, indicating fifteen (15) sources per magazine. After all of these quality control measures took place, all sixty (60) sources were sent to the Hospital.

"Biocompatibles delivered a sterile Applicator Kit (Case 75152), containing four (4) Mick magazines of fifteen (15) sources each, for a total of sixty (60) sources, to the Hospital on February 25, 2013. The lot number for the I-125 sealed sources was Lot 2013-24638.

"When first notified by the Hospital on February 26, 2013 of the possible issue, the Biocompatibles Radiation Lab performed additional meter surveys. Biocompatibles performs production station surveys at the completion of each production operation, and performs meter surveys of the entire facility at shift end. All surveys performed on February 26, 2013 through March 13, 2013 have not identified any misplaced seeds.

"The empty Supplier vial and pig used to deliver the sources to Biocompatibles was shipped to the Hospital with the case in question. Biocompatibles has requested all empty packing associated with the case to be returned to Biocompatibles for further investigation."

Notified R1DO (Trapp) and R4DO (Werner). ILTAB and FSME Events Resource notified 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

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Agreement State Event Number: 48833
Rep Org: ALABAMA RADIATION CONTROL
Licensee: INTERNATIONAL PAPER
Region: 1
City: PINE HILL State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/20/2013
Notification Time: 08:17 [ET]
Event Date: 03/01/2005
Event Time: [CDT]
Last Update Date: 03/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
FSME EVENTS RESOURCE (E-MA)
DARYL JOHNSON (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST GAUGE CONTAINING RADIOACTIVE MATERIAL

The following report was received from the State of Alabama Department of Public Health via facsimile:

"On March 19, 2013, the Environmental Health & Services [representative] for International Paper of Pine Hill, Alabama notified the Alabama Office of Radiation Control that they had lost accountability of a fixed gauge. The gauge is a Kay Ray model 7062BP serial 27137, containing 100 mCi of Cs-137.

"During a routine inspection on February 7, 2013, it was noticed by the inspector that the device had been missing since the March 2005 inventory. The inspector requested that [the] Radiation Safety Officer investigate the incident due to several changes within the department and inconsistencies in record keeping. The licensee was issued two violations, one involving the loss of the accountability of radioactive material.

"The [licensee's response to the] notification [of violation] letter included both the response to the violations and a attachment. The attachment was a memorandum dated September 12, 2010, referencing losing the gauge, and indicating the loss had been discussed with the [Alabama of Public Health] Director of Licensing. This was discussed with [Director] and he does not recall this conversation nor could this memorandum be found in any of the [Alabama of Public Health] International Paper files. Due to this, the [Alabama of Public Health] considers the response letter the notification of the device being lost.

"As of today [March 20, 2013], at 7:15 AM CDT, the device containing radioactive material has not been recovered. This incident remains open until further investigation can be completed."

Alabama Incident 13-06

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: 48836
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: TULSA GAMMA RAY
Region:
City: TULSA State:
County:
License #: OK-17178-02
Agreement: N
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/20/2013
Notification Time: 16:20 [ET]
Event Date: 03/20/2013
Event Time: [EST]
Last Update Date: 03/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following report was received via e-mail:

"[The Oklahoma Department of Environmental Quality was] informed of an over-exposure of a radiographer employed by Tulsa Gamma Ray (OK-17178-02). The dose involved is 6700 mR, but it isn't clear if this is the dose from just this exposure or if that is for the year to date. We [Oklahoma] will provide more details as they become available."

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Power Reactor Event Number: 48853
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DREW GRIFFITHS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/27/2013
Notification Time: 04:21 [ET]
Event Date: 03/27/2013
Event Time: 02:45 [CDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
GREG PICK (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

REACTOR PRESSURE BOUNDARY LEAKAGE

"On March 26, 2013, at 1635 [CDT], with Unit 1 shutdown for refueling, leakage was identified from the 2-inch reactor head vent line during a Reactor Pressure Vessel (RPV) pressure test. The leakage was approximately 20 drops per minute. The RPV pressure test was stopped and the reactor vessel depressurized to facilitate examination of the piping and associated flange connections. At 0245 hours on March 27, 2013, the leak was confirmed to be through-wall originating from a socket weld (i.e., pipe elbow). The cause and resolution are under evaluation. The condition is being reported under 50.72(b)(3)(ii)(A) given the defect was associated with the primary coolant system pressure boundary."

The licensee notified the NRC Resident Inspector

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Power Reactor Event Number: 48854
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: ROBERT ANDERSEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/27/2013
Notification Time: 07:30 [ET]
Event Date: 03/27/2013
Event Time: 06:01 [EDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
PAUL KROHN (R1DO)
ALLEN HOWE (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby

Event Text

SAFETY INJECTION ACTUATION DURING TESTING

"On March 27, 2013 at 0601 EDT, the Safety Injection System automatically actuated while in Mode 3 during performance of I&C [Instrument and Control] testing due to faulty test equipment. All plant equipment responded normally to the safety injection. This is reportable under 10 CFR 50.72(b)(2)(iv)(A). The plant is stable in Mode 3 at this time.

"The Auxiliary Feedwater System actuated following the safety injection signal as expected. This is reportable under 10 CFR 50.72(b)(3)(iv)(A). The unit remains on offsite power and all electrical loads are stable. No primary or secondary relief valves lifted. The plant is in Hot Standby at 1140 psig and 395 degrees F with decay heat removal using auxiliary feedwater to the steam generators and normal heat removal through the atmospheric steam dumps. There was no radiation released.

"Indian Point Unit Two was not affected by this event and remains at 100% power.

"Notified NRC Resident Inspector. Notified NRC Emergency Operations Center Duty Officer."

The Safety Injection was reset and all plant equipment was restored to normal alignment. Pressurizer level remained in the indication range during the Safety Injection. The cause of the Safety Injection is still under investigation, but appears to be related to a faulty jumper necessary for the test.


* * * UPDATE FROM MICHAEL McCARTHY TO DONALD NORWOOD AT 1335 EDT ON 3/27/2013 * * *

"The event reported above resulted in additional reportable actuations under 10 CFR 50.72(b)(3)(iv)(A). These were: 1) RPS actuation, 2) Phase A containment isolation, 3) Containment fan cooler unit actuation, and 4) Emergency Diesel Generator actuation (start but did not load).

"The licensee notified the NRC Resident Inspector of the 1335 EDT update."

Notified R1DO (Krohn).

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Power Reactor Event Number: 48860
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JON FORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/28/2013
Notification Time: 00:43 [ET]
Event Date: 03/27/2013
Event Time: 22:45 [EDT]
Last Update Date: 03/28/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DEBORAH SEYMOUR (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

ONE EMERGENCY WARNING SIREN ENERGIZED FOR A SHORT TIME

"At 2245 [EDT] on 3/27/2013, Surry Power Station (SPS) Operations Department received a report from Virginia State Emergency Operations Center (VEOC) that a concerned citizen had called James City County (JCC) law enforcement to report that an Early Warning System (EWS) siren, #62 in James City County NW side of Route 682, was sounding. VEOC reported JCC police received call at 2240 [EDT] from a concerned citizen that an EWS siren was sounding. SPS Security contacted JCC police and subsequently reported that JCC police responded approximately 10 minutes later to the site of the siren, but the siren was no longer sounding. Maintenance will investigate in the morning. All plant conditions/parameters are normal, and no releases to the environment have occurred.

"The site NRC Resident Inspectors have been notified.

"This notification is being transmitted due to notification of other Government Agencies in accordance with 10CFR50,72(b)(2)(xi)."

Page Last Reviewed/Updated Thursday, March 28, 2013
Thursday, March 28, 2013