| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/22/2005 - 08/23/2005 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 41919 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HTS INC CONSULTANTS
Region: 4
City: HOUSTON State: TX
County:
License #: L-02757
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: BILL GOTT | Notification Date: 08/16/2005
Notification Time: 15:00 [ET]
Event Date: 08/16/2005
Event Time: 07:00 [CDT]
Last Update Date: 08/22/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GARY SANBORN (R4)
MICHELE BURGESS (NMSS)
JIM WHITNEY email (TAS)
Mexico fax ()
| Event Text AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE
An employee parked the truck containing the Troxler Moisture Density Gauge (Model 3411B, s/n 7573, Am/Be 40 milli Curies, Cs-137 8 milli Curies) overnight at his apartment complex. The gauge was secured by a lock and chain. The truck was parked at 2200 CDT on 08/15/05. When the employee returned to the truck at 0700 on 08/16/05 the chain was cut and the gauge was gone. The theft was reported to the police.
TX report number: TX-I-8252.
Less than the quantity of an IAEA Category 3 source.
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.
For 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.
* * * UPDATE FROM CHRIS MOORE TO J. KNOKE AT 16:46 EDT ON 08/18/05 * * *
An individual called the owner of the lost Troxler gauge, indicating it was discarded on her property. The gauge was initially picked up by the local fire department, and then by the owner. The gauge was surveyed and had readings of less than 1 mr/hr. The gauge was found to have no damage, however, all the associated paperwork was missing.
Notified the R4DO (Sanborn), NMSS (Holonich) and TAS (Perez) of the update. Faxed Mexico the update.
Note: Event modified on 8/22/05 to correct the name of the individual from the State of Texas that provided the update to this event. |
| Other Nuclear Material | Event Number: 41921 | Rep Org: GEO-EXPLOR INC
Licensee: GEO-EXPLOR INC
Region: 1
City: DORADO State: PR
County:
License #: 52-25-580-01
Agreement: N
Docket: 03035886
NRC Notified By: REYNALDO RODRIGUEZ
HQ OPS Officer: BILL GOTT | Notification Date: 08/16/2005
Notification Time: 16:18 [ET]
Event Date: 08/16/2005
Event Time: [EDT]
Last Update Date: 08/22/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
RAYMOND LORSON (R1)
MICHELE BURGESS (NMSS)
JIM WHITNEY email (TAS)
| Event Text LOST/MISSING MOISTURE DENSITY GAUGE
The employee placed the CPN Moisture Density Gauge (s/n: 18098458 Am/Be, Cs-137) into its case and placed the case in the back of the pickup truck. Before the employee chained the case to the truck he was required to move away from the back of the truck. He later drove away without chaining the case to the truck or closing the back gate. About 0.3 miles down the road he noticed that the gate was open and the gauge was missing. He returned to the work site but did not see the gauge along the way and could not find the gauge at the work site. The incident was reported to the local police. The company is notifying the local news media and is offering a reward.
Less than the quantity of a Category 3 source.
Sources that are "Less than 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.
For 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.
* * * UPDATE FROM RODRIGUEZ TO HUFFMAN AT 1510 EDT ON 8/22/05 * * *
The licensee states that an individual retrieved the gauge from the road after it had fallen off the truck. The gauge was stored in an office building where the individual worked. The individual that recovered the gauge could not find any identifying information on the gauge container as to the owner or a contact telephone number. However, the individual did hear about the lost gauge through media coverage and was, therefore, able to track down and contact the licensee. At 12:30 EDT on 8/22/05, the licensee has recovered the gauge from the individual that found it and observed that it was in its properly stored and safe configuration. It has been examined in detail and is not damaged in any way. The licensee stated that he also planned to notify the responsible NRC Region 1 inspector (Beardsley) about the recovery of the gauge. R1DO (Cook), NMSS EO (Morell), and TAS (Perez via email) have been notified. |
| General Information or Other | Event Number: 41922 | Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: RIVER VALLEY TESTING
Region: 3
City: MENASHA State: WI
County:
License #: 139-1242-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: BILL GOTT | Notification Date: 08/17/2005
Notification Time: 12:47 [ET]
Event Date: 08/16/2005
Event Time: 14:30 [CDT]
Last Update Date: 08/17/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
KENNETH O'BRIEN (R3)
MICHELE BURGESS (NMSS)
| Event Text AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The State provided the following information via facsimile:
"A notification was made by the RSO on August 16, 2005, concerning a portable moisture density gauge that was run over at the Menasha coal plant, a temporary job site. The approximate time of the incident was 2:30 pm. The gauge was a Troxler 3440 containing 10 milliCuries of Cs-137 and 50 milliCuries of Am-241. The RSO reported that the radiation readings were verified as normal by comparing the reading at 1 meter to the Transportation Index. Visual observation confirmed that the source rod is in the normal position and the shielding is intact. Other individuals on the job site including the truck driver that ran over the gauge were surveyed. The area where the gauge was damaged was surveyed after the gauge was moved a few feet away and no radiation readings above background were noted. The gauge was transported back to the licensee's facility in Neenah [WI]. DHFS staff were dispatched to confirm that there was no contamination on August 17, 2005. The licensee has taken a wipe smear and is sending it to Troxler for counting. The gauge is locked in the transport case and has been placed in storage."
WI report number: 29 |
| General Information or Other | Event Number: 41925 | Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT | Notification Date: 08/17/2005
Notification Time: 18:57 [ET]
Event Date: 08/04/2005
Event Time: 11:30 [MST]
Last Update Date: 08/17/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
| Event Text AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via facsimile:
"This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event."
Event Report ID Number: UT-05-0006 |
| General Information or Other | Event Number: 41930 | Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNKNOWN
Region: 3
City: Dayton State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: BILL HUFFMAN | Notification Date: 08/18/2005
Notification Time: 12:19 [ET]
Event Date: 08/15/2005
Event Time: [EDT]
Last Update Date: 08/18/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
KENNETH RIEMER (R3)
JOSEPH HOLONICH (NMSS)
| Event Text AGREEMENT STATE REPORT - SOURCE OF UNKNOWN ORIGIN FOUND IN RAILCAR
The State provided the following information via email:
"On 8/15/05 a sealed source was discovered on a rail car in Norfolk and Southern rail yard in Dayton, Ohio. Rail car was parked on spur line adjacent to a scrap yard. Source was discovered when rail car was being moved. Dayton HAZMAT unit was called who, in turn, notified the ODH Bureau of Radiation Protection. Bureau staff member responded to site and found source to be made of stainless steel and aluminum, 4" diameter and 18" long. Labeled as a GL device with the following information: Thermo System, Inc. St. Paul, Minn, Kr-85, 10 mCi, June 1974, Model # 8054, SN 31112. Dose rate at contact with the source was 0.8 milliR/hr and 12 microR/hr at 3 feet, as measured with Ludlum model 19 microR survey instrument. Source was stored overnight in locked trailer at rail yard. Source was taken for disposal by a disposal contractor on 8/16/05. Bureau has been unable to date to trace source back to original owner or determine how the source came to be on the rail car."
This event involves material that is less than IAEA Category 3 sources. 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.
For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
Ohio Report Number OH2005-092 |
| General Information or Other | Event Number: 41932 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIV OF TX SW MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL HUFFMAN | Notification Date: 08/19/2005
Notification Time: 16:20 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 08/19/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
| Event Text AGREEMENT STATE - MEDICAL EVENT
The State provided the following information via facsimile:
The State received a telephone call from an RSO with The University of Texas Southwestern Medical Center (UTSWMC) at Dallas on August 16, 2005 at 4:00 p.m. to report a patient misadministration of a therapy dose at UTSWMC Moncrief Medical Center. The event occurred on August 15, 2005 around 4:00 pm. The patient was scheduled to receive 1100 centiGray in two fractions for cancer treatment. Each fraction was supposed to be 550 centiGray to the vaginal vault. The first dose was oriented interior 4 1/2 cm, i.e. too close. The true target point of the vaginal vault received a dose of 1451 centiGray. The second dose was not administered and the patient is not returning for further treatment. Source was an Ir-192 HDR (high dose rate) afterloader. |
| General Information or Other | Event Number: 41937 | Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LEKSELL
Region: 1
City: LANCASTER State: PA
County:
License #: 37-11866-04
Agreement: N
Docket:
NRC Notified By: TONY MONTAGNESE
HQ OPS Officer: JOHN MacKINNON | Notification Date: 08/22/2005
Notification Time: 15:05 [ET]
Event Date: 08/22/2005
Event Time: 15:05 [EDT]
Last Update Date: 08/22/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
| Person (Organization):
WILLIAM COOK (R1)
CAUDLE JULIAN (R2)
KENNETH O'BRIEN (R3)
LINDA SMITH (R4)
LYDIA CHANG (NMSS)
TOM ESSIG (email) (NMSS)
| Event Text PART 21 - GAMMA KNIFE MICROPHONE CLIP
Lancaster General Hospital has been using a Leksell Model No. 23005 Type "B" Gamma Knife since 2000. The Gamma Knife unit has a metal clip which is velcroed to the patient's couch and it holds a microphone in which the patient can talk. A patient knocked the clip off, causing the clip to become detached from the couch (it was velcroed to the couch) and the microphone. The clip ended up in the Gamma Knife shielding. Due to the metal clip being stuck in the Gamma Knife shielding, the microswitches inside the Gamma Knife would not allow the jaws of the shielding to open. This prevented the patient from receiving the third treatment. Therefore the patient received only 2 out of 5 scheduled treatments (patient was underdosed) due to the clip failure.
See event number 41928 called in by Lancaster General Hospital on 08/18/2005 for background information. |
| Power Reactor | Event Number: 41939 | Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: STEVE BANKS
HQ OPS Officer: JOHN MacKINNON | Notification Date: 08/22/2005
Notification Time: 20:10 [ET]
Event Date: 08/22/2005
Event Time: 16:05 [MST]
Last Update Date: 08/22/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
| Person (Organization):
LINDA SMITH (R4)
JAMES LYONS (NRR)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 55 | Power Operation | Event Text TECHNICAL SPECIFICATION SHUTDOWN DUE TO CORE PROTECTION CALCULATOR SYSTEM (CPCS) SOFTWARE NOT CONSISTENT WITH SYSTEM DESIGN REQUIREMENTS.
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On August 22, 2005, at approximately 1605 hours Mountain Standard Time (MST), Palo Verde Nuclear Generating Station (PVNGS) Unit 2 commenced a reactor shutdown required by Technical Specification 3.0.3.
"Westinghouse notified Palo Verde that the current version of the Common Q based Core Protection Calculator System (CPCS) software is not consistent with the system design requirements and Technical Specification Bases regarding the system response to analog input module errors. In that a failed sensor input or failure of the two analog input modules in a given CPCS channel (four total channels) would not result in a CPCS channel trip. At Palo Verde, the CPCS provides the reactor trip functions for Low Departure from Nucleate Boiling Ratio (DNBR) and High Local Power Density (LPD). A failed input sensor would be the most likely cause for both of the redundant input modules to indicate errors simultaneously because the two redundant input modules within a safety channel are connected to a single sensor. A similar scenario would occur if both analog input modules simultaneously failed. In both cases the result would be a failure of the channel without initiating a trip signal.
"Operations evaluated the non-conforming condition and declared all four channels of the CPCS inoperable. Limiting Condition for Operability (LCO) 3.3.1 only addresses up to two automatic RPS trip channels inoperable, therefore Operations entered LCO 3.0.3 at approximately 13:26 MST.
"The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public. The required offsite power sources are operable and the electrical grid is stable.
"The Common Q based CPCS is installed at the following nuclear power plant site in the United States: Palo Verde Unit 2. At this time, this condition is not transportable to Palo Verde Units 1 and 3."
All Emergency Core Cooling systems and their Emergency Diesel Generators are fully operable if needed.
The NRC Resident Inspector was notified of this event by the licensee. | |