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Event Notification Report for October 9, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/08/2013 - 10/09/2013

** EVENT NUMBERS **


49393 49396 49399 49418 49419 49420

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Agreement State Event Number: 49393
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CITY OF PALM COAST UTILITIES
Region: 1
City: PALM COAST State: FL
County:
License #: 3543-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/30/2013
Notification Time: 10:30 [ET]
Event Date: 09/28/2013
Event Time: 12:30 [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE RUN OVER BY DUMP TRUCK

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

"On Sept 28, 2013, at approximately 12:30 pm (EDT), the Florida Department of Radiation Control, received a call from the licensee, City of Palm Coast Utilities, concerning a Troxler soil moisture density gauge that had been run over by a dump truck. The licensee's RSO (Radiation Safety Officer) made the initial call from the scene where the gauge was left under truck to it keep out of the rain. However, the driver drove off and ran over the gauge. The licensee technicians had no survey meter on scene and the licensee's ARSO [Assistant Radiation Safety Officer] was on his way to assess the area with a survey meter. The Florida Department of Radiation Control verified with the licensee's RSO that the source was in the shielded condition and this was later verified by the ARSO with a survey meter. The plastic case and digital gauge face was damaged. The gauge will be retained by the licensee and later sent to Troxler for repair and leak test. Corrective action consists of training personnel and procedure changes as necessary. The Florida Department of Radiation Control has assigned the event to the Orange Park Inspection Office and Materials Office for further investigation. This office will take no further action on this incident.

"The gauge is a Troxler Model 3430 Soil Moisture Density Gauge, Serial # 20850, with Am-241 40 mCi and Cs-137 8 mCi sources."

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Agreement State Event Number: 49396
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2013
Notification Time: 15:37 [ET]
Event Date: 08/15/2013
Event Time: [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION OF Y-90

The following information was received from the City of New York via email:

"Incident: Due to the technical difficulties, physician could not deliver the full prescribed dose of Y-90.

"Radiation Dose evaluation: As per physician's medical judgment, the dose given to the patient was adequate for the treatment of this volume and tumors within the region.

"Health effects: Patient will be followed up to determine if an appropriate therapeutic result is achieved.

"Corrective Actions: Administered radiological agent was Y-90 SIRTex. RSO and administering physician have come to the conclusion to wait until the vial and related accessories reach background [radiation levels] in order to investigate this matter. It is unknown whether this was a human error or manufacturer defect.

"As per facility's report, as a precautionary measure, derma bond will be applied to the v-vial before administration of the dose in order to prevent any possibility of leakage."

The prescribed dose of Y-90 was 30 mCi; the delivered dose was 19.26 mCi. NYC Incident Report Identification Number: 75-2885-01

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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Non-Agreement State Event Number: 49399
Rep Org: NANTICOKE MEMORIAL HOSPITAL
Licensee: NANTICOKE MEMORIAL HOSPITAL
Region: 1
City: SEAFORD State: DE
County:
License #: 07-17618-01
Agreement: N
Docket:
NRC Notified By: MARIANNA RETZLAFF
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/01/2013
Notification Time: 11:52 [ET]
Event Date: 06/28/2013
Event Time: [EDT]
Last Update Date: 10/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JUDY JOUSTRA (R1DO)
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

TWO GERMANIUM-68 CALIBRATION SOURCE RODS LOST DURING SHIPPING

On June 28, 2013, the licensee shipped two boxes to Eckert & Ziegler Isotope Products, Inc., located in Burbank, CA. One box contained a cylinder phantom and the other box contained two source rods, serial numbers D689 and D690, containing 1.35 mCi Ge-68 each.

On July 8, the licensee received confirmation from the shipper that the boxes arrived and were signed for at their destination. In September, the licensee followed up with the manufacturer who informed them that they had received the cylinder phantom but the box containing the source rods was empty.

The shipper confirmed that the boxes were not identified as damaged at the time of delivery. The licensee searched their lab and shipping areas and could not find the sources. The manufacturer's RSO said that the incident is still under investigation but that they could not locate the sources.

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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Power Reactor Event Number: 49418
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ROGER ORZELL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/08/2013
Notification Time: 00:07 [ET]
Event Date: 10/07/2013
Event Time: 22:04 [EDT]
Last Update Date: 10/08/2013
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

SERVICE WATER RADIATION MONITOR OUT OF SERVICE

"At 2204 EDT on October 7, 2013, Nine Mile Point Unit 2 received DRMS [Digital Radiation Monitor System] low sample flow alarm and sample pump trip for 2SWP*CAB146B. The chemistry department was notified to collect and analyze grab samples per ODCM 3.3.1 as a compensatory measure with the Service Water Radiation Monitor 2SWP*CAB146B out of service.

"Attempts to restart 2SWP*CAB146B within 1 hour were unsuccessful. 2SWP*CAB146B remains Non-Functional. Technicians are being called in to restore the monitor to Functional status.

"The Service Water Radiation Monitors are necessary for accident assessment and are credited for Emergency Action Level (EAL) classification. The inability to classify an EAL due to an out of service monitor is considered a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). This condition does not affect the health or safety of the public or the operation of the facility. Compensatory actions remain in place to sample per the requirements of the ODCM 3.3.1.

"The NRC Resident Inspector has been notified."

* * * UPDATE ON 10/8/13 AT 1546 EDT FROM JASON SAWYER TO DONG PARK * * *

"At 1027 EDT on October 8th, 2013 Nine Mile Point Unit 2 received a DRMS low sample flow alarm and sample pump trip for 2SWP*CAB146A. Service Water Radiation Effluent Monitor SWP*CAB146B remains NONFUNCTIONAL, but in service from the previous shift with required compensatory measures per ODCM 3.3.1 already in place (12 hour grab samples/30 day restoration).

"Attempts to restore 2SWP*CAB146A within 1 hour were unsuccessful. As of 1220 EDT on October 8th, 2SWP*CAB146A monitor has been restored to service and is now capable of providing information for emergency assessments, the monitor is in confidence run for restoration to FUNCTIONAL status.

"The Service Water Radiation Monitors are necessary for accident assessment and are credited for Emergency Action Level (EAL) classifications. The inability to classify an EAL due to an out of service monitor is considered a loss of assessment capability per 10 CFR 50.72 (b)(3)(xiii). This condition does not affect the health or safety of the public or the operation of the facility because the monitor is currently back in service.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49419
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN RASMUSSEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/08/2013
Notification Time: 15:42 [ET]
Event Date: 10/08/2013
Event Time: 12:40 [CDT]
Last Update Date: 10/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MARK HAIRE (R4DO)

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

POSTULATED HOT SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"A review of industry operating experience regarding the impact of unfused Direct Current (DC) ammeter circuits in the control room has determined the described condition to be applicable to Comanche Peak Nuclear Power Plant resulting in a potentially unanalyzed condition with respect to 10CFR50 Appendix R analysis requirements. The original plant wiring design and associated analysis for the Class 1 E batteries control room ampere indications do not include overcurrent protection features to limit the fault current.

"In the postulated event, a fire in the control room could cause one of the ammeter wires to hot short to the ground plane. Simultaneously, the fire causes another DC wire from the opposite polarity on the same battery to also hot short to the ground plane. This could cause a ground loop through the unprotected ammeter wiring. This event could result in excessive current flow (heating) in the ammeter wiring to the point of causing a secondary fire in the raceway system. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10CFR50 Appendix R.

"This condition is reportable in accordance with 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition. Compensatory measures (fire watches) have been implemented for affected areas of the plant."

The licensee has notified the NRC Resident Inspector.

See related Event #49411.

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Power Reactor Event Number: 49420
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: ANGELO LEONE
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/08/2013
Notification Time: 16:31 [ET]
Event Date: 10/08/2013
Event Time: 14:26 [EDT]
Last Update Date: 10/08/2013
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

STACK RADIATION MONITOR REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

The Millstone Power Station Unit 2 Stack Radiation Monitor, RM-8169 is being removed from service for preplanned maintenance. The radiation monitor is estimated to be out of service for approximately 6 hours. This action is reportable as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

The NRC Resident Inspector has been notified. State and local authorities were notified by the licensee.

Page Last Reviewed/Updated Wednesday, October 09, 2013
Wednesday, October 09, 2013