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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/27/2004 - 01/28/2004
** EVENT NUMBERS **
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| General Information or Other |
Event Number: 40420 |
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SIMPSON TACOMA KRAFT, LLC
Region: 4
City: TACOMA State: WA
County:
License #: WN-I014-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: JOHN MacKINNON |
Notification Date: 12/31/2003
Notification Time: 15:50 [ET]
Event Date: 12/31/2003
Event Time: 12:00 [PST]
Last Update Date: 01/27/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
Tom Farnholtz (R4)
LARRY CAMPER (NMSS) |
Event Text
AGREEMENT STATE REPORT: DAMAGED GAUGE
"Licensee: Simpson Tacoma Kraft, LLC
"City and State: Tacoma, Washington
"License Number: WN-I014-1
"Type of License: Fixed Gauge
"Date of Event: 31 December 2003 (when discovered by licensee
"Location of Event: 801 Portland Avenue, Tacoma, Washington
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (department) on-site investigation; media attention):
"The licensed Radiation Safety Officer reported to the Department, on 31 December, he noticed that process fluids had eroded a ½ inch by 4 inch hole through the ½ inch thick gauge body where it attached to process piping. The damage was apparently confined to the device's body and the event is not considered to present an emergency at this time. The device had been in service for about 12 years and had reached the end of its useful service life. It was being removed to prepare it for disposal.
"The device is a Texas Nuclear Corp. Model 5176, Serial Number 2253, containing 7.4 gigabecquerels (200 millicuries) of Cesium 137.
"The licensee informed the department they would bolt a ½ inch metal plate to the device's attachment point, over the damaged area, to temporarily return the device to its normal level of shielding and integrity. After removal and the temporary repair, the licensee placed the device into secured storage, along with several other similar devices, in preparation for source removal and disposal in January 2004, by a service provider.
"The RSO, approved for device installation, relocation, removal from service, and surveys, reported that the device was reading 1.5 Mr/hr, contact at the damaged area, prior to the temporary repair. A similar, but undamaged, device read 1.2 Mr/hr at the same location. The RSO reported no activity from a wipe survey on the damaged device.
"The Department will perform an on-site investigation on 6 January 2004. No media attention has been attracted, yet.
"Notification Reporting Criteria: 10 CFR 31, General Domestic Licenses for Byproduct Material (damage to shielding)
"Isotope and Activity involved: Cesium 137, 7.4 gigabecquerels (200 millicuries)
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): N/A
"Lost, Stolen or Damaged? (mfg., model, serial number): damage confined to device body of a Texas Nuclear Corp, Model 5176 device, Serial Number 2253
"`Disposition/recovery: removed from service, temporarily repaired, secured for pending disposal
"Leak test? Wipe survey indicated no contamination, last leak test was negative
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) N/A
"Release of activity? None
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: See above
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A
"Consultant used? N/A for this event"
* * * UPDATE ON 1/16/04 AT 1315 EST FROM ARDEN SCROGGS TO GERRY WAIG * * *
The following information was received via email:
"This is an updated notification of an event in Washington State, reported to and investigated by, the WA Department of Health, Office of Radiation Protection.
"STATUS: update
"Licensee: Simpson Tacoma Kraft, LLC
"City and State: Tacoma, Washington
"License Number: WN-I014-1
"Type of License: Fixed Gauge
"Date of Event: 31 December 2003 (when discovered by licensee)
"Location of Event: 801 Portland Avenue, Tacoma, Washington
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (department) on-site investigation; media attention):
"The licensed Radiation Safety Officer reported to the Department, on 31 December, that he had discovered that process fluids (green liquor [sodium sulfite]) had eroded a 3-inch by 6-inch hole through a 1/8 inch thick aluminum gauge cover-plate on the gauge where the gauge attached to process piping. The damage was confined to the device's cover-plate and the event was not considered an emergency. The device had been in service for about 30 years and had reached the end of its useful service life. It was being removed in preparation for disposal.
"The device is a Texas Nuclear Corp., Model 5176, Serial Number 2253, containing 7.4 gigabecquerels (200 millicuries) of Cesium 137.
"The licensee informed the department they would bolt a ½ inch thick metal plate to the device's attachment point, over the damaged area, to cover the whole. After removal and temporary repair, the licensee placed the device into secured storage, along with several other similar devices, in preparation for source removal and disposal. A service provider, is scheduled to remove the devices from the licensee's facility in about April, 2004.
"The RSO, approved for device installation, relocation, removal from service, and surveys, reported that the device was reading 1.5 Mr/hr, contact at the damaged area, prior to the temporary repair. A similar, but undamaged device, read 1.2 Mr/hr at the same point. A Ludlum Model 3, SN 104500, calibrated 19 November 2003, was used for stated measurements. The RSO took a leak test inside the opened area. The RSO sent the leak test sample for analysis and subsequently reported the test indicated less then detectable activity.
"The Department performed an on-site investigation on 9 January 2004, resulting in this updated report. No media attention has been attracted, yet.
"Initial Notification Reporting Criteria was: 10 CFR 31, General Domestic Licenses for Byproduct Material (damage to shielding) but now we understand that shielding was not compromised.
"Isotope and Activity involved: Cesium 137, 7.4 gigabecquerels (200 millicuries)
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): N/A
"Lost, Stolen or Damaged? (mfg., model, serial number): damage confined to device cover-plate, of a Texas Nuclear Corp, Model 5176 device, Serial Number 2253
"Disposition/recovery: removed from service, temporarily repaired, secured for pending disposal
"Leak test? Wipe survey indicated no contamination, leak test was negative
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) N/A
"Release of activity? None
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: See above
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A
"Consultant used? N/A for this event"
Notified R4DO (Jeffery Clark), NMSS (Thomas Essig)
* * * UPDATE ON 1/27/04 AT 1433 EST LAWRENCE TO GOTT * * *
"The changes include:
1. Update in status as complete,
2 Full description of the corrosive process fluids,
3. Additional information on the area of gauge that was damaged.
"This incident is considered closed as of January 27, 2004.
"This is an updated notification of an event in Washington State, reported to and investigated by, the WA Department of Health, Office of Radiation Protection.
"STATUS: complete
"Licensee: Simpson Tacoma Kraft, LLC
City and State: Tacoma, Washington
License Number: WN-I014-1
Type of License: Fixed Gauge
"Date of Event: 31 December 2003 (when discovered by licensee)
Location of Event: 801 Portland Avenue, Tacoma, Washington
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (department) on-site investigation; media attention):
"The licensed Radiation Safety Officer reported to the Department, on 31 December, that he had discovered that process fluids (green liquor comprised of [sodium sulfide, sodium sulfate, and sodium carbonate]) had eroded a 3-inch by 6-inch hole through a 1/8 inch thick aluminum gauge cover-plate on the gauge where the gauge attached to process piping. The damage was confined to the device's cover-plate and the event was not considered an emergency. A service provider subsequently reported to the licensee, the plate is to prevent contaminants from fouling the shutter mechanism. The plate has little impact on shielding. The device had been in service for about 30 years and had reached the end of its useful service life. It was being removed in preparation for disposal.
"The device is a Texas Nuclear Corp., Model 5176, Serial Number 2253, containing 7.4 gigabecquerels (200 millicuries) of Cesium 137.
"The licensee informed the department they would bolt a ½ inch thick metal plate to the device's attachment point, over the damaged area, to cover the whole. After removal and the temporary repair, the licensee placed the device into secured storage, along with several other similar devices, in preparation for source removal and disposal. A service provider is scheduled to remove the devices from the licensee's facility in about April 2004.
"The RSO, approved for device installation, relocation, removal from service, and surveys, reported that the device was reading 1.5 Mr/hr, contact at the damaged area, prior to the temporary repair. A similar, but undamaged, device read 1.2 Mr/hr at the same point. A Ludlum Model 3, SN 104500, calibrated 19 November 2003, was used for stated measurements. The RSO took a leak test, inside the opened area. The RSO sent the leak test sample for analysis and subsequently reported the test indicated less then detectable activity.
"The Department performed an on-site investigation on 9 January 2004, resulting in this updated report. No media attention has been attracted, yet."
Notified NMSS (Kokajko) and R4DO (William Johnson) |
| General Information or Other |
Event Number: 40464 |
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: HILLCREST HOSPITAL
Region: 3
City: MAYFIELD HEIGHTS State: OH
County:
License #: OH02120180042
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: STEVE SANDIN |
Notification Date: 01/22/2004
Notification Time: 09:29 [ET]
Event Date: 01/16/2004
Event Time: 16:10 [EST]
Last Update Date: 01/22/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ROGER LANKSBURY (R3)
ROBERTO TORRES (NMSS) |
Event Text
AGREEMENT STATE REPORT INVOLVING AN ABNORMAL OCCURRENCE (AO)
On 11/20/03 a 19 year old female patient received 140.1 millicuries I-131 for thyroid carcinoma as prescribed. At the time she was unaware and had completed the required forms indicating she was not pregnant. On 12/5, 12/8 and 12/11/03 quantitative tests confirmed that she was pregnant. The results were provided to her endocrinologist who recommended that a fetal dose calculation be performed. The hospital was notified and their consultant informed the endocrinologist that the fetus would have received 19.6 rads. The Endocrinologist sent the results to the Center for Human Genetics at University Hospital in Cleveland where as assessment was performed that the pregnancy could safely continue.
The Ohio Bureau of Radiation was informed on 1/16/04 and submitted the information to the NRC Region III office. NRC Region III (Lynch) recommended making a telephonic notification due to the incident meeting the criteria of an AO even though Ohio is not required to conform with the revised reporting requirements for a period of three years (October 2005) after the final rule is issued.
Hillcrest Hospital has implemented pregnancy testing for child bearing age female patients receiving radiation therapy. |
| General Information or Other |
Event Number: 40466 |
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: AMERSHAM/MEDI PHYSICS
Region: 3
City: ARLINGTON HTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH KLINGER
HQ OPS Officer: MIKE RIPLEY |
Notification Date: 01/22/2004
Notification Time: 17:29 [ET]
Event Date: 01/21/2004
Event Time: [CST]
Last Update Date: 01/23/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ROGER LANKSBURY (R3)
LAWRENCE KOKAJKO (NMSS)
CLIFFORD ANDERSON (R1) |
Event Text
MEDICAL SOURCES MISSING IN TRANSIT
"The Director of Nuclear Regulatory Assurance of Amersham/Medi Physics (IL-01109-01) called late yesterday to report that a package of small activity sources intended for medical use had not arrived at its intended destination. The details are as follows:
"On January 9, a package containing sixty-six sealed iodine-125 sources was sent from the Arlington Heights, IL facility intended for the St. John's Riverside Hospital in Yonkers, New York. The sources are stainless steel encapsulations of I-125, each originally 0.942 millicuries of activity. The total activity at the time of packaging was 62 millicuries. The sources are about the size of a grain of rice and designed for implantation in cancerous tumors of the prostate gland via a needle. The package was shipped in a standard 'Type A' box and had a surface dose rate of less than 0.5 millirem/hr. The package was due to arrive in Yonkers on the 12th of January for a treatment on the 14th. As part of Medi Physics customer service, a routine call to the client revealed that the package had not arrived as of the end of the day on the 12th. When the carrier, Federal Express, was queried by the licensee, Federal Express claimed that the package had been accidentally set aside at their Newark, New Jersey facility with some other packages and would be delivered the next day. Additional tracking by Medi Physics on subsequent days showed that the package never left the Federal Express sorting facility in Newark, New Jersey. To date, efforts by Medi Physics and those reported by Federal Express have not located the missing package.
"As of this time, the activity of each source is 810 microcurie for a total package activity of 53.5 millicuries. Although in the past such packages have been located and recovered and returned to Medi Physics by the carrier, the extended length of time from the date of expected delivery to now is unusual. Both Medi Physics and Federal Express have indicated they will continue monitoring this situation. The U.S. NRC Region III Liaison Officer has been made aware of the situation and has indicated he will contact his U.S. NRC Region I counterpart to advise him of the situation.
"Form of Radioactive Material: SEALED SOURCE
Radionuclide: I-125; Source Use: BRACHYTHERAPY; Activity: 53.5E-3 Curies
Manufacturer: MEDI+PHYSICS, Model Number: 6711; Serial Number: NA"
* * * UPDATE ON 01/23/04 AT 10:27 FROM JOE KINGLER TO ARLON COSTA * * *
Federal Express has located the package containing sixty-six sealed iodine-125 sources in Newark, NJ. Federal Express is in the process of returning the package back to Amersham/Medi. Notified R1DO (Anderson), R3DO (Lanksbury) and NMSS EO (Kokajko). |
| General Information or Other |
Event Number: 40470 |
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UTAH INSPECTIONS
Region: 4
City: State: CO
County:
License #: CO 1043-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: MIKE RIPLEY |
Notification Date: 01/23/2004
Notification Time: 14:36 [ET]
Event Date: 12/31/2003
Event Time: [MST]
Last Update Date: 01/23/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
LINDA HOWELL (R4)
DOUG BROADDUS (NMSS) |
Event Text
RADIOGRAPHER EXCEEDED ANNUAL RADIATION DOSE LIMIT
When film badge dosimetry for December 2003 was processed, it was determined that a radiographer, employed by an inspection firm in Utah but working in Colorado, received an annual radiation dose of 5.035 Rem for the year ending 12/31/03. The radiographer claimed, however, that his film badge had fell on the ground during radiography such that the dose was not actually received. No additional information has been provided at this time. |
| General Information or Other |
Event Number: 40471 |
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LFR, INC.
Region: 1
City: BRAINTREE State: MA
County:
License #: 49-0143
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: MIKE RIPLEY |
Notification Date: 01/23/2004
Notification Time: 16:10 [ET]
Event Date: 01/22/2004
Event Time: 17:20 [EST]
Last Update Date: 01/23/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
CLIFFORD ANDERSON (R1)
LAWRENCE KOKAJKO (NMSS) |
Event Text
AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGE
"The Radiation Safety Officer (RSO) who works for LFR Inc. of Braintree, MA reported his personal pick up truck stolen while on an errand at a gas station-mart in Providence, RI. His pick up truck contained a 4 x 2 foot case which contained his Niton XL series Xray florences gauge [Serial # U-472] which contains about 14 millicuries Cd-109 byproduct material. He left his pick up truck unlocked, and keys on seat, while he went into mart for purchase.
"RI state police were notified of theft, and they reported theft to MA state police at approx 5:17 PM [ET] on 1/22/04. MA state police in turn notified a MA radiation control officer at home at approx. 5:30 PM who then notified his MA Radiation Control Supervisor. At 9:39 on 1/23/04 AM, the supervisor notified the RI Radiation Program by e mail that theft had occurred.
"A MA radiation control officer, called the RSO at approx. 10:30 AM and 1:50 PM and was told vehicle had not been recovered yet. The RSO was asked to fax MA RCP a copy of police theft report and copy of RI radioactive license, and to call us if vehicle is recovered. The RSO lives in RI. The RSO said he would perform a leak test if tester is ever recovered.
"MA sent email to RI Radioactive Materials Program at 2:45 PM with status. Immediate notification requirement means complete investigation is pending." |
| Power Reactor |
Event Number: 40482 |
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: A. T. HALL
HQ OPS Officer: DICK JOLLIFFE |
Notification Date: 01/27/2004
Notification Time: 11:16 [ET]
Event Date: 01/27/2004
Event Time: 08:05 [EST]
Last Update Date: 01/27/2004 |
Emergency Class:
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
CAUDLE JULIAN (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 |
Event Text
OFFSITE NOTIFICATION OF LOSS OF COMMUNICATIONS
"On January 27, 2004, at 0805 hours, the Unit 1 Control Room Bell (Commercial) telephones, Unit 1 State Warning Point / Hot Ringdown phone, the Unit 1 NRC Emergency Notification System phone, and the Unit 1 ESATCOM phone communications capabilities were lost, due to inadvertent severing of cables. The Technical Support Center (adjacent to Unit 1 Control Room), and Unit 2, communications telephones, including the Bell (Commercial) phones, State Warning Point / Hot Ringdown phones, NRC Emergency Notification System phones, and ESATCOM phones, were verified operational and satisfactory. The Unit 1 Cellular Telephone and the Portable (Wireless) Telephone continued to remain operable. The licensee has restored all these temporarily disrupted communications capabilities as of 01/27/04 @ 1100 hours. State and Local Government Agencies, and the NRC Resident, have been notified.
"This non-emergency notification is being made pursuant to 10 CFR 50.72 (b)(1)(xi), due to the 'Other Government Notifications' (State & Local Government Agencies), NUREG-1022 Section 3.2.12, and 10 CFR 50.72(b)(3)(xiii), due to the 'Loss of Emergency Assessment, Offsite Response, or Communications Capability,' NUREG-1022 Section 3.2.13."
This event had no effect on Unit 2. |
| Power Reactor |
Event Number: 40483 |
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: EDDIE BYARS
HQ OPS Officer: BILL GOTT |
Notification Date: 01/27/2004
Notification Time: 13:33 [ET]
Event Date: 01/27/2004
Event Time: 12:00 [EST]
Last Update Date: 01/27/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
GEORGE KUZO (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 |
Event Text
LOSS OF ENS TELEPHONE AND SIREN SYSTEM
The licensee reported intermittent problems with the ENS telephone and Early Warning Siren System (EWSS) capability. EWSS capability is less than 75% and is currently 58%. The ENS phone system is repaired. Ice storms are the cause of the communication problems.
The licensee notified the NRC Resident Inspector. |
| Power Reactor |
Event Number: 40484 |
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: EURMAN HENSON
HQ OPS Officer: BILL GOTT |
Notification Date: 01/27/2004
Notification Time: 22:15 [ET]
Event Date: 01/27/2004
Event Time: 17:30 [CST]
Last Update Date: 01/28/2004 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL |
Person (Organization):
WILLIAM JOHNSON (R4) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
A/R |
Y |
100 |
Power Operation |
0 |
Hot Standby |
Event Text
AUTOMATIC REACTOR TRIP
"At 1730, 1/27/04, Callaway Plant experienced a reactor trip. Auxiliary feedwater actuated as expected to stabilize steam generator levels. All other plant systems responded as expected. At present the cause of the reactor trip is undetermined. Initial indications are that there were no voltage or frequency perturbations on the electrical grid and that the trip signal originated from Callaway's switchyard breaker circuitry. Plant staff is currently engaged in a review of all indications that occurred at the time of the trip and systematically investigating potential problem areas in an effort to identify the cause of the trip."
The licensee also reported that all control rods inserted on the reactor trip, no primary or secondary system relief valves operated, and that reactor temperature is being maintained using steam dump to the condenser. Steam generator water levels are being maintained using auxiliary feedwater. The station electrical system is available and in a normal configuration.
The licensee notified the NRC Resident Inspector.
* * * UPDATE 0250 EST ON 1/28/04 FROM EURMAN HENSON TO S. SANDIN * * *
The licensee provided the following information as an update to their initial report:
"The cause of the reactor trip has been identified as a failed electrical relay in the main generator protection circuitry. The relay is designed to sense a fault in the main electrical generator and trip the generator output breakers. The failed relay was designated as a 321/G relay and provides phase fault backup protection to prevent exceeding thermal limits of the stator windings.
"After determining the cause of the reactor trip, preparations for a reactor startup are in progress."
The licensee will inform the NRC Resident Inspector. Notified R4DO(Johnson). |
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