Event Notification Report for July 27, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/26/2006 - 07/27/2006

** EVENT NUMBERS **


42719 42721 42730 42732

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General Information or Other Event Number: 42719
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GILCHRIST CONSTRUCTION
Region: 4
City: ALEXANDRIA State: LA
County:
License #: LA-7890-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/21/2006
Notification Time: 10:02 [ET]
Event Date: 07/20/2006
Event Time: 18:30 [CDT]
Last Update Date: 07/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
GREG MORELL (NMSS)
ILTAB EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

A technician who works for the licensee left his vehicle at his residence and then went to have dinner about 30 minutes away. Upon returning to his home and vehicle, the technician found that all equipment had been stolen, including the Troxler moisture/density gauge, model 3430, s/n 32187. The gauge contained 40 milliCi of Am-241/Be and 8 milliCi Cs-137. The licensee had the Troxler chained and locked to the truck bed.

The licensee filed a police report with the Opelousas State Police, and will be offering a reward.

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.

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General Information or Other Event Number: 42721
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ADVENTIST HEALTH SYSTEM
Region: 1
City: ALTAMONTE SPRINGS State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: JOHN WILLIAMSON
HQ OPS Officer: ARLON COSTA
Notification Date: 07/21/2006
Notification Time: 18:31 [ET]
Event Date: 07/21/2006
Event Time: [EDT]
Last Update Date: 07/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KINNEMAN (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

FLORIDA AGREEMENT STATE NOTIFICATION OF MEDICAL EVENT

The State provided the following information via email:

"The RSO [Deleted] of Florida Hospital called. Florida Hospital in Ormond Beach (873 Sterthaus Ave, Ormond Beach, FL 32174) had a medical misadministration.

"They were using a HDR (Nucleotron Microselectron Classic, 8 Ci Ir-192 activity) to deliver vaginal treatment of 500 cGy per fraction. A typical patient gets 3-5 fractions. The delivery tube was 18.5 cm too long resulting in the source being outside the patient. The RSO indicated that the dose to the prescribed area was zero. [Due to the patients position, it was determined that] the dose to the skin is probably not too high.

"The Medical Physicist [MP] [deleted] has not yet determined what the skin dose estimate would be.

"[The MP] discovered the mistake after observing a treatment. The mistake happened because two different types of applicators are used. One has a longer tube than the other. The tubes were mixed up, which resulted in the misadministration. At least one patient is affected by this and maybe as many as 4 others. The MP believes that using film recorded for each treatment, the hospital can determine how many and which patients are affected.

"The treating physician has been notified, the referring physician and the patient have not.

"The State of Florida Bureau of Radiation Control will investigate."

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Power Reactor Event Number: 42730
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DUANE KANITZ
HQ OPS Officer: PETE SNYDER
Notification Date: 07/26/2006
Notification Time: 14:20 [ET]
Event Date: 07/26/2006
Event Time: 07:35 [MST]
Last Update Date: 07/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
THOMAS FARNHOLTZ (R4)
JACK FOSTER (NRR)

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

Event Text

VARIABLE OVERPOWER REACTOR TRIP FOLLOWING TURBINE CONTROL VALVE MAINTENANCE

"On July 26, 2006, at approximately 07:34 Mountain Standard Time (MST) Palo Verde Unit 2 experienced an automatic reactor scram on Variable Overpower. Unit 2 was operating at 90% power at normal operating temperature and pressure prior to the event. A main turbine control valve (CV02) was being returned to service following maintenance. CV02 initially started to open which caused reactor power to decrease to approximately 89%. During the evolution, six steam bypass control valve opened (three valves opened 100 percent, one opened 60 percent, and two opened 5 percent). Reactor power rapidly increased to 98% which resulted in an auxiliary Variable Power Trip (VOPT). The VOPT trip set point is 8 percent. The main turbine automatically tripped in response to the reactor trip. All rods inserted, as required. No ESF actuations occurred and none were required.

"No emergency classification was required per the Emergency Plan. Safety related buses remained energized during and following the reactor trip. The Emergency Diesel Generators did not start and were not required. The offsite power grid is stable. No LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event. The maximum power level during the transient was approximately 98%."

"Unit 2 is stable at normal operating temperature and pressure in Mode 3. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The maximum RCS pressure was approximately 2260 psia (normal 2240). The maximum steam generator pressure was approximately 1090 psia (normal 1055). The event did not adversely affect the safe operation of the plant or the health and safety of the public."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42732
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID OAKES
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/27/2006
Notification Time: 03:07 [ET]
Event Date: 07/26/2006
Event Time: 19:00 [MST]
Last Update Date: 07/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS FARNHOLTZ (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text


LIMITING CONDITION FOR OPERATION 3.7.4 DEEMED TO BE NONCONSERVATIVE

"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.

"Palo Verde Nuclear Generating Station Technical Specification Limiting Condition for Operation (LCO) 3.7.4 requires only one of two atmospheric dump valves (ADV) per steam generator (SG) to be operable. Palo Verde Unit 3 currently has one ADV inoperable on the #2 SG. All other ADVs in Unit 3 (and all ADVs in Units 1 and 2) are OPERABLE. On July 26, 2006 at approximately 19:00 MST, Palo Verde Engineering personnel determined that this LCO is nonconservative since it does not satisfy the single failure criterion for the safety analyses for the accidents that would render one SG inoperable, specifically steam generator tube rupture (SGTR) with loss of offsite power (LOOP) which utilizes both ADVs on the unaffected SG. In case of one SG inoperable due to the event, and single failure of one ADV fail to open, the plant cannot be brought to safe shutdown condition during those accidents and may result in exceeding the acceptance criteria. This LCO should have required two ADVs per SG to be operable in order to satisfy safety analysis assumptions.

"An administrative control in accordance with NUREG-1432, Standard Technical Specifications will be put in place for immediate compensatory action. NUREG-1432 LCO 3.7.4 Condition A, one required ADV line inoperable requires restoration of the ADV line to OPERABLE status within 7 days. Reperformance of the safety analyses is expected to be the long term solution.

"The event did not result in any challenges to the fission product barrier or result in any releases of radioactive materials. There were no adverse safety consequences or implications as a result of this event. The event did not adversely affect the safe operation of the plant or health and safety of the public."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, March 24, 2021