United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2013 > November 12

Event Notification Report for November 12, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/08/2013 - 11/12/2013

** EVENT NUMBERS **


49493 49494 49496 49501 49518 49522 49524 49525 49526 49527 49528

To top of page
Agreement State Event Number: 49493
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: ST. FRANCIS HEALTH CENTER
Region: 4
City: TOPEKA State: KS
County:
License #: 19-B272-04
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/01/2013
Notification Time: 10:57 [ET]
Event Date: 10/31/2013
Event Time: [CDT]
Last Update Date: 11/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - RADIOPHARMACY WORKER EXTREMITY OVEREXPOSURE

The following report was received from the Kansas Department of Health and Environment via facsimile:

"Initial notification of an overexposure to the extremities of a radiopharmacy nuclear medicine technician at St. Francis Health Center, Topeka, KS, was made by the radiation safety officer.

"A Landauer report received 10/31/2013 indicated a right hand dosimeter [dose] at 55.85 rem and a left hand dosimeter [dose] at 54.29 rem. Whole body badge [dose] indicated 36 mrem. The tech has been removed from any job duties involving occupational radiation exposure. A more detailed report is being prepared [by the licensee]."

Kansas Report Number KS130009

To top of page
Agreement State Event Number: 49494
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: UNIVERSITY OF SOUTH CAROLINA
Region: 1
City: COLUMBIA State: SC
County:
License #: 405
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/01/2013
Notification Time: 12:09 [ET]
Event Date: 11/01/2013
Event Time: 09:02 [EDT]
Last Update Date: 11/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING NI-63 SOURCE

"The SC Department of Health and Environmental Control [DHEC] was notified on Friday, November 1, 2013, at 0902 hrs. [EDT], that during routine wipe testing of a Shimadzu GC14A gas chromatograph, an ECD containing 10 milliCuries of Ni-63 was found to have removable contamination exceeding 0.005 microCuries. The chromatograph was being tested in preparation for disposal when wipes of the inside of the chamber indicated contamination. The source was removed and properly bagged to prevent the spread of any further contamination. The chromatograph and source are secured in the Radiation Safety Laboratory awaiting disposal by a licensed vendor. The Radiation Safety Officer stated that wipes of the laboratory where the chromatograph had been located were analyzed and no removal contamination had been detected.

"The Radiation Safety Officer was advised by Mark L. Windham [South Carolina DHEC] to submit a written report detailing this event to the Department within 30 days. The event is open and pending the licensee's investigation and report to the Department. Updates will be made through the national NMED system."

To top of page
Non-Agreement State Event Number: 49496
Rep Org: KAKIVIC ASSET MANAGEMENT
Licensee: KAKIVIC ASSET MANAGEMENT
Region: 4
City: KUPARUK OIL FIELD State: AK
County: NORTH SLOPE
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: PAT PETTIJOHN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/02/2013
Notification Time: 00:56 [ET]
Event Date: 11/01/2013
Event Time: 17:20 [YDT]
Last Update Date: 11/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES DRAKE (R4DO)
FSME RESOURCES (EMAI)

Event Text

CAMERA SOURCE FAILED TO RETURN TO THE LOCKED POSITION

An 880D radiography camera source was retracted back to the camera but failed to lock in the stored position because of ice. The supervisor and foreman removed the guide tube and thawed out the camera in the back of the radiography truck. The source was then able to be manually locked in the stored position.

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 49501
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 SLANICK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/04/2013
Notification Time: 17:45 [ET]
Event Date: 11/04/2013
Event Time: 10:00 [CST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING OVEREXPOSURE TO BLADDER DURING PROSTATE TREATMENT

During a prostate cancer treatment, at 1000 hours [CST] on 11/04/13, it was discovered that one I-125 strand with 6 seeds was improperly inserted into the bladder. The patient's prescribed dose was 144 gray to the prostate with a 12% exposure to the bladder. The procedure to the prostate was completed with extra I-125 seeds and the estimated dose to the bladder is 18%. It is believed that shadowing from the urethra, during treatment, was the cause. An attempt to withdraw the seeds from the bladder when the problem was identified was unsuccessful. The patient has been informed and the patient's physician will be informed and will consult with the urologist as soon as possible to determine a method for seed retrieval.

* * * UPDATE ON 11/8/13 AT 1150 EST FROM STEPHEN SLACK TO DONG PARK * * *

The following was received via email:

"The event took place during an implant of I-125 seeds into the prostate of a patient. One strand of six seeds was instead implanted into the bladder. Attempts to remove the strand of seeds at that time were unsuccessful.

"Renewed attempts were made to remove the strand this morning and they were successful. The implant was planned for 144 Gy to the prostate over the full decay time of the I-125. This would have resulted in a mean dose to the bladder of 22.34 Gy. If the extra seeds had remained in place, the mean dose to the bladder would have been 39.15 Gy; hence the report of a Medical Event.

"By removing the seeds this morning, the mean dose to the prostate has been reduced to 23.09 Gy. This is more than 50 rads to the organ but less than a 50% increase over what the organ would have gotten in the planned treatment."

Notified R3DO (Riemer) 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.

To top of page
Power Reactor Event Number: 49518
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: CASPER JERNIGAN
HQ OPS Officer: PETE SNYDER
Notification Date: 11/08/2013
Notification Time: 09:05 [ET]
Event Date: 11/07/2013
Event Time: 09:51 [EST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ALAN BLAMEY (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

Event Text

FITNESS FOR DUTY - CONFIRMED POSITIVE FOR A NON-LICENSED CONTRACT SUPERVISOR

A non-licensed, contract, supervisory employee had a confirmed positive during a for-cause fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

To top of page
Part 21 Event Number: 49522
Rep Org: FLOWSERVE
Licensee: LIMITORQUE
Region: 1
City: LYNCHBURG State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JEFF MCCONKEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/08/2013
Notification Time: 16:26 [ET]
Event Date: 09/04/2013
Event Time: [EST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ALAN BLAMEY (R2DO)
CHRISTINE LIPA (R3DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - MACHINING ERROR IDENTIFIED IN GEARED LIMIT SWITCHES

The following is a summary of information received from Flowserve via facsimile:

"On September 4, 2013, in-house inspection of Limitorque SMB Geared Limit Switch (GLS) cartridges revealed a machining error in a subcomponent used in the GLS. The deviation was caused by a dimensional error concerning the location of a drilled hole in a drive pinion shaft. This error results in a reduction of gear tooth engagement inside the GLS which could potentially reduce the service life of the GLS causing a loss of function. To date, Limitorque's investigation of this machining error has not shown this deviation to be significant enough to affect the safety related function of the GLS. However, Limitorque has requested all switches certified for nuclear safety related service which were manufactured in the designated time frame be returned for inspection and replacement as needed."

The components were sent to Perry Nuclear Generating Station.

To top of page
Fuel Cycle Facility Event Number: 49524
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/08/2013
Notification Time: 18:10 [ET]
Event Date: 11/08/2013
Event Time: 10:45 [PST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ALAN BLAMEY (R2DO)
JAMES ANDERSEN (NMSS)

Event Text

APPARENT DETERIORATION OF PRIMARY AND SECONDARY HEPA FILTERS

"On November 8, 2013, at approximately 1045 PST, an Air Balance Technician at AREVA NP's Richland fuel fabrication plant discovered that the primary and secondary HEPA filters servicing the ammonium diuranate (ADU) area showed visible signs of deterioration. The apparent deterioration is being reported in accordance with 10 CFR 70.50(b)(2).

"The K-32A HEPA filters were examined by air balance personnel at approximately 1045 PST on November 8, 2013 based on a request to follow-up on some stack monitoring results which indicated some elevated levels (still below required administrative action levels). Air flow was diverted to HEPA filters in a parallel upper housing in order to check the filters in the lower housing. Investigation showed apparent deterioration of both the primary and final HEPA filters.

"The processes running at the time served by these HEPAs were the ammonium diuranate process, miscellaneous uranium recovery process, and cylinder wash. Air monitor samples were pulled on the K-32A system. Air monitoring samples showed negligible release levels. A Health and Safety Technician survey of the downstream side of the final HEPA housing of K-32A revealed no surface contamination above 'clean' criteria.

"Potential dose to a member of the public and the effect on the environment are essentially negligible. External conditions are not known to have affected the event.

"A Corrective Action Report, 2013-8809, was written on November 8, 2013. The cause of the apparent deterioration is under active investigation. Steps to prevent recurrence will be developed as appropriate."

The licensee will notify the NRC Regional office and the Washington State government.

To top of page
Power Reactor Event Number: 49525
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BARRETT NICHOLS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/09/2013
Notification Time: 16:09 [ET]
Event Date: 11/09/2013
Event Time: 15:13 [EST]
Last Update Date: 11/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES NOGGLE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 95 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOSS OF CONDENSER VACUUM

Millstone Unit 2 automatically tripped following a turbine trip due to a loss of condenser vacuum. The loss of vacuum was caused by the trip of the "C" circ water pump with the "D" circ water pump out of service. The licensee is still investigating the trip of the "C" circ water pump. The MSIVs are open with steam generators discharging steam to the main condenser. Auxiliary feedwater automatically started as expected following the reactor trip.

All rods fully inserted and there were no complications following the reactor trip. All systems functioned as required and the unit is stable in Mode 3. There was no impact on Unit 3.

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

To top of page
Power Reactor Event Number: 49526
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BILL SOKSO
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/10/2013
Notification Time: 16:16 [ET]
Event Date: 11/10/2013
Event Time: 13:51 [EST]
Last Update Date: 11/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
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

Event Text

SECONDARY CONTAINMENT INTEGRITY MOMENTARILY DECLARED INOPERABLE

"Station personnel simultaneously opened the inner and outer air lock doors from the unit 1 reactor enclosure to the radwaste enclosure. Reactor enclosure secondary containment integrity was declared INOPERABLE per TS 4.6.5.1.1.b.2 due to report of both containment airlock doors on the 217 foot elevation being momentarily open at the same time. Reactor enclosure D/P [differential pressure] remained steady at .35 inches water column.

"Reactor enclosure secondary containment integrity was declared OPERABLE following verification that at least one airlock door to each access of secondary containment was closed per U1 TS 4.6.5.1.1.b.2. Total LCO time was approximately 10 seconds."

The licensee has notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 49527
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: COREY A. GRAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/11/2013
Notification Time: 08:48 [ET]
Event Date: 11/11/2013
Event Time: 05:20 [EST]
Last Update Date: 11/11/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
ALAN BLAMEY (R2DO)
DAVID SKEEN (NRR)
SCOTT MORRIS (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 20 Power Operation 13 Power Operation

Event Text

UNIT 1 COMMENCED A TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO RCS LEAKAGE

"Oconee Nuclear Station identified a small Reactor Coolant System (RCS) pressure boundary leak on ONS [Oconee Nuclear Station] Unit 1 and initiated a Unit 1 shutdown at 0520 hours [EST] on November 11, 2013 in accordance with procedures and Technical Specifications. Visual inspection confirmed the leak is located on the 1B2 loop High Pressure Injection Line. ONS Unit 1 was operating at full power when the leak was identified and a down power to 20% was commenced at 2141 hours [EST] on November 10, 2013 in order to characterize the leak and leak location. The measured RCS leak rate was 0.13 gpm [gallons per minute] at the time of commencing the down power.

"This issue is reportable per 10 CFR 50.72(b)(2)(i) and 10 CFR 50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been notified. This event poses no threat to the public or station employees."

Unit 1 entered TS 3.4.13 Condition B at 0520 EST on 11/11/13. This TS requires Unit 1 be in Mode 3 Hot Standby within 12 hours and Mode 5 Cold Shutdown within 36 hours. The generator is currently offline and the licensee anticipates entering Mode 3 at 1000 EST. Unit 1 entered their Abnormal Operating procedures for leak determination at 0442 EST on 11/09/13.

To top of page
Power Reactor Event Number: 49528
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOE HESSLING
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/12/2013
Notification Time: 01:23 [ET]
Event Date: 11/12/2013
Event Time: 00:02 [EST]
Last Update Date: 11/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ALAN BLAMEY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 90 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO UNISOLABLE LEAK IN DIGITAL ELECTRO-HYDRAULIC SYSTEM

"At 0002 EST, Unit 1 Manually tripped the Reactor from 90% power due to an unisolable leak in the Digital Electro-Hydraulic [DEH] System. All CEAs fully inserted into the Reactor Core. All systems responded as expected on the trip. Decay Heat removal currently using Main Feedwater and Steam Bypass Control System. After the trip, DEH pumps were secured to stop the transfer of fluid from the DEH system to the Turbine Building. Investigation ongoing to determine exact location of the leak. This condition is reportable pursuant to 10CFR50.72(b)(2)(iv)(B)."

The was no impact on Unit 2. The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Tuesday, November 12, 2013
Tuesday, November 12, 2013