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Event Notification Report for April 8, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/05/2013 - 04/08/2013

** EVENT NUMBERS **


48864 48866 48867 48887 48890 48891 48893 48894

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Agreement State Event Number: 48864
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ROSA OF NORTH DALLAS LLC
Region: 4
City: DALLAS State: TX
County:
License #: 06186
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/28/2013
Notification Time: 17:58 [ET]
Event Date: 03/27/2013
Event Time: [CDT]
Last Update Date: 03/28/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE IN BRACHYTHERAPY TREATMENT DUE TO USE OF WRONG LENGTH GUIDE WIRE

The following information was provided by the State of Texas via email:

"On March 28, 2013, the Agency [Texas Department of Health] was notified by the licensee that a medical event occurred on March 27, 2013. The licensee stated that the wrong length guide wire was used during 3 of 4 HDR [High-Dose Rate Brachytherapy] treatments. The error was discovered after the third treatment. The Radiation Safety Officer (RSO) stated the desired area of treatment was under dosed by more than 50 percent. The treatment plan prescribed 2400 cGy over 4 treatments. He stated that the patient and their physician were notified as soon as the error was discovered. The RSO is not at the facility and is trying to gather the information on the event over his phone. The licensee has suspended all HDR treatments until their process and procedures have been reviewed. Additional information will be provided as it is received in accordance with SA - 300.

"Texas Incident #: I-9059"

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: 48866
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: FELINE HEALTH, INC.
Region: 1
City: WESTFIELD State: MA
County:
License #: 48-0316
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/29/2013
Notification Time: 13:46 [ET]
Event Date: 03/29/2013
Event Time: [EDT]
Last Update Date: 03/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - VETERINARY TECHNICIAN POSSIBLE OVEREXPOSURE

The following information was received via facsimile:

"The Radiation Safety Officer (RSO) called to report that the quarterly whole body dosimeter for her technician recorded 993 mrem deep, 21,900 mrem to the lens, and 58,000 mrem shallow dose. The technician's finger ring dose was negligible.

"The technician & RSO have worked for years injecting three to ten cats with I-131 on a monthly basis (approximately 3 mCi per cat) and neither have ever approached such high radiation doses.

"It is suspected that the dosimeter has malfunctioned or was inadvertently contaminated with I-131. The licensee has requested that the dosimeter manufacturer re-analyze the dosimeter.

"The Massachusetts Radiation Control Program is investigating."

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Agreement State Event Number: 48867
Rep Org: NV DIV OF RAD HEALTH
Licensee: UNKNOWN
Region: 4
City: SPARKS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ERIC MATUS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/29/2013
Notification Time: 17:22 [ET]
Event Date: 03/29/2013
Event Time: 08:30 [PDT]
Last Update Date: 03/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE FOUND

An auction lot of industrial equipment was purchased by West Tech, Inc., an electronics recycling company, at an auction in Milpitas, California. The auction lot was subsequently delivered to West Tech, Inc. in Sparks, Nevada. A CPN density gauge, s/n M17031878, manufactured 1/1/1976, originally containing 50 mCi Americium-241/Be and 10 mCi Cs-137, was found in the auction lot. After discovering the gauge, West Tech, Inc. notified InstroTek, Inc. (parent company of CPN) which notified the State of Nevada Radiation Control Program.

The State of Nevada Radiation Control Program dispatched inspectors. The gauge was found to be in its shipping container. The gauge appeared to be undamaged and intact. Swipes were taken and no contamination was found. The State of Nevada Radiation Control Program has impounded the gauge.

The State of Nevada will provide more information as it becomes available.

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Power Reactor Event Number: 48887
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: KELLEY BELENKY
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/04/2013
Notification Time: 08:35 [ET]
Event Date: 04/04/2013
Event Time: 04:06 [EDT]
Last Update Date: 04/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT DALEY (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 65 Power Operation 65 Power Operation

Event Text

FAILURE OF THE INTEGRATED PLANT COMPUTER SYSTEM

"At 0406 [EDT] on April 4, 2013, the Fermi 2 Integrated Plant Computer System (IPCS) failed. This resulted in a loss of approximately 60 percent of data on the Safety Parameters Display System (SPDS).

"While IPCS and SPDS are not fully functional, the Emergency Plan can still be implemented if a plant emergency does occur, as assessment capabilities are available under alternate means.

"Investigation is in progress. A follow up message will be made when IPCS and SPDS are restored to fully functional status.

"This notification is being made per the requirements of 8 Hour Non-Emergency Notification 10CFR50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM GREG MILLER TO VINCE KLCO AT 1636 EDT ON 4/5/2013 * * *

"At 1627 [EDT] on April 4, 2013, plant personnel were able to restore full functionality of IPCS and SPDS. This restored full assessment capabilities to all onsite emergency response faculties."

The licensee notified the NRC Resident Inspector.

Notified the R3DO (Daley).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48890
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JEFF EMBRY
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/05/2013
Notification Time: 07:02 [ET]
Event Date: 04/05/2013
Event Time: 06:24 [EDT]
Last Update Date: 04/05/2013
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DANIEL RICH (R2DO)
SAMSON LEE (NRR)
PAUL HARRIS (IRD)
ERIC LEEDS (NRR)
LEN WERT (R2)

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 N 0 Defueled 0 Defueled

Event Text

UNUSUAL EVENT DECLARED DUE TO A FIRE ALARM IN THE STACK FILTER HOUSE

"At 0624 [EDT], the Brunswick Steam Electric Plant (BSEP) declared an Unusual Event due to a fire alarm in the Stack Filter House. The classification of the Unusual Event is based on Emergency Action Level (EAL) HU2.1, 'Fire not extinguished within 15 minutes of control room notification or verification of a control room fire alarm.' Verification of fire could not be made within 15 minutes of fire alarm due to confined space conditions. Actual fire conditions did not exist; alarm was caused by environmental conditions.

"There is no impact on the health and safety of the public."

The licensee terminated the Unusual Event at 0650 EDT. Personnel injuries and equipment damage did not occur. Offsite assistance was not required.

The licensee has notified the state and local authorities. The licensee will notify the NRC Resident Inspector.

Notified DHS, FEMA, DHS NICC and NuclearSSA.

* * * RETRACTION FROM WILLIAM MURRAY TO VINCE KLCO AT 1644 EDT ON 4/5/2013 * * *

"This event is being retracted based upon the following:

"As stated in the original event notification, an actual fire condition did not exist and the control room fire alarm was caused by environmental conditions. Because an actual fire did not exist and the fire detection system alarm was not valid, the condition described in the Emergency Action Level (EAL) HU2.1, 'Fire not extinguished within 15 minutes of control room notification or verification of a control room fire alarm,' also did not exist. The Unusual Event was terminated at 0650 [EDT]. The Unusual Event classification was appropriately made, in accordance with the EAL basis which requires the control room alarm be validated by other indications or alarms or by an actual field report, or the classification must be made. Based on the preceding information, Event Notification 48890 is retracted."

The licensee will notify the NRC Resident Inspector.

Notified the R2DO (Rich) and the NRR EO (Lee).

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Power Reactor Event Number: 48891
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: STEVEN SNYDER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/05/2013
Notification Time: 08:20 [ET]
Event Date: 04/05/2013
Event Time: 07:30 [CDT]
Last Update Date: 04/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT DALEY (R3DO)

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

LOSS OF ASSESSMENT CAPABILITY DUE TO PLANNED MAINTENANCE

"On April 5, 2013, at approximately 0730 hours [CDT], the Kewaunee Power Station declared the Reactor Building Special Particulate Iodine Noble Gas (SPING) (Mid and Hi Range) nonfunctional for planned maintenance. The Emergency Response Organization (ERO) team has been notified of this Reactor Building Vent SPING nonfunctionality due to planned maintenance.

"The SPING is expected to be out of service for approximately 3 hours.

"Although manual 'grab samples' could be used as a backup, this condition is being reported in accordance with 10CFR50.72(b)(3)(xiii) as an event that results in a major loss of emergency assessment capability (unable to sufficiently indentify the upper two emergency action levels for Offsite Radiation conditions).

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 48893
Rep Org: FLOWSERVE CONTROL - LIMITORQUE
Licensee: FLOWSERVE CONTROL - LIMITORQUE
Region: 1
City: LYNCHBURG State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JEFF McCONKEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/05/2013
Notification Time: 14:36 [ET]
Event Date: 04/04/2013
Event Time: [EDT]
Last Update Date: 04/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DANIEL RICH (R2DO)
RAY KELLAR (R4DO)
PART 21 REPORTS (E-MA)

Event Text

PART 21 REPORT OF LIMITORQUE VALVES WITH INCORRECT MOTOR NAMEPLATES INSTALLED

The following information is a synopsis of a report received from Flowserve - Limitorque via facsimile:

"During routine Motor Operated Valve testing of a Limitorque SMB-000 actuator prior to being placed into operation, Duke Energy, Catawba Nuclear Station measured motor current readings higher than expected. This actuator was equipped with a 2 ft-lb motor. This motor was returned to Limitorque and subsequently to the motor Original Equipment Manufacturer (OEM). Investigation revealed that this motor was a 5 ft-lb motor mislabeled with the nameplate from a 2 ft-lb motor which explains the measured current draw.

"This notification is limited to a quantity of two motors for Limitorque SMB-000 actuators. Both affected licensees have been notified of this occurrence and both motors have been returned to Flowserve - Limitorque for replacement. [Catawba and Arkansas Nuclear One]

"The defect which occurred is that the 2 ft - lb motor was identified on the nameplate as a 5 ft - lb motor. Similarly the 5 ft - lb motor was identified on the nameplate as a 2 ft - lb motor. Had these motors been placed into service, this defect has the potential to affect safety related operation due to a possible reduction of MOV capability.

"The cause of the defect was due to two motor nameplates being inadvertently interchanged by Flowserve personnel during the painting process prior to shipment. The two motors which are both 48 frame, SMB-000 flanged, Baldor Reliance AC motors were being painted in the same timeframe. The painting process requires the OEM supplied nameplate to be temporarily separated from the motor. Upon the completion of the painting process, Flowserve personnel inadvertently interchanged the nameplates resulting in the 2 ft-lb motor being incorrectly identified as a 5 ft-lb motor. Similarly the 5 ft-lb motor was incorrectly identified on the nameplate as a 2 ft-lb motor. Inspections of the returned motors by Flowserve and the motor OEM confirmed the problem.

"To prevent recurrence of this issue, Flowserve has reviewed and strengthened the relevant procedures regarding verification of motor identification during the installation of the OEM supplied motor nameplate. All personnel associated with this process have been trained by Flowserve QA to the latest revision of the procedures."

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Power Reactor Event Number: 48894
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: THOMAS MORSE
HQ OPS Officer: VINCE KLCO
Notification Date: 04/07/2013
Notification Time: 17:47 [ET]
Event Date: 11/17/2010
Event Time: [EDT]
Last Update Date: 04/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
ROBERT DALEY (R3DO)
SAMSON LEE (NRR)
PAUL HARRIS (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled

Event Text

AFTER THE FACT DISCOVERY OF AN UNUSUAL EVENT ENTRY CONDITION

"During an extent of condition review of past radiological events, it was identified that an event on November 17, 2010 met the E-Plan entry criteria for GU1, 'Unexpected Increase In Plant Radiation Levels'. Due to an equipment deficiency, dose rates in one section of the Radwaste building rose from 0.08 mrem/hr to 80 mrem/hr. This satisfied the E-Plan criteria of a 1000 times change over normal radiation levels. This was initially identified in [Perry] Condition Report 2010-85937."

The licensee notified the NRC Resident Inspector and will notify State and local authorities.

Page Last Reviewed/Updated Monday, April 08, 2013
Monday, April 08, 2013