Event Notification Report for August 28, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2006 - 08/28/2006

** EVENT NUMBERS **


42785 42793 42794 42796 42798 42799 42802 42804 42805 42806 42807

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General Information or Other Event Number: 42785
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RANEY GEOTECHNICAL
Region: 4
City: OROVILLE State: CA
County:
License #: 3497-57
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2006
Notification Time: 15:40 [ET]
Event Date: 08/17/2006
Event Time: [PDT]
Last Update Date: 08/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
GREG MORELL (NMSS)
ILTAB (VIA EMAIL) ()
MEXICO (FAX) ()

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

Event Text

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"A Troxler 3430, serial # 35800 was stolen out of the back of a pickup truck parked at the RSO's residence on the evening of 8/17/06. The lock securing the gauge was cut. The gauge was found three blocks away from the RSO's residence on the morning of 8/18/06 in a ditch. A leak test of the gauge is being performed this same date. An inspection of Raney Geotechnical will be performed on 8/22/06."

A Troxler 3430 typically contains:
8 mCuries Cs-137
40 mCuries Am-241:Be

* * * UPDATE FROM K. FUREY TO P. SNYDER AT 1532 ON 8/25/06 * * *

The State provided information stating that the original incident happened between 9pm and 6am the evening of August 17, 2006 and confirmed that the gauge contained 8 mCi of Cesium 137 and 40 mCi of Americium 241.

Notified R4DO (T. Pruet) and NMSS EO (C. Reamer).

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: 42793
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: THERMO NITON ANALYZERS
Region: 1
City: BILLERICA State: MA
County:
License #: 55-0238
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/22/2006
Notification Time: 12:09 [ET]
Event Date: 08/14/2006
Event Time: 00:00 [EDT]
Last Update Date: 08/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1)
MICHELE BURGESS (NMSS)
ILTAB (E-MAILED) (NSIR)

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

Event Text

COMMONWEALTH OF MASSACHUSETTS AGREEMENT STATE REPORT - LOST/MISSING RADIOACTIVE MATERIAL

The State provided the following information via facsimile:


"As a result of re-labeling effort by Thermo Niton Analyzers LLC (Thermo Niton) to add Am-241 check source information to the device label, the Radiation Safety Officer of Thermo Niton discovered that the device is lost or missing and provided the following information:

"With regard to Unit 5213 (Model XLi 848, serial number 5213), we [Thermo Niton] have visited Morris Iron and Steel in person to re-label Unit 5213 and they did not have it in their inventory of devices. An exhaustive review of our [Thermo Niton] records indicate that the last time we [Thermo Niton] were in possession of this device was when we [Thermo Niton] sent it to Morris Iron and Steel at 7345 Milnor Street, Philadelphia, PA 19136 under General License on 9/17/04. The device had 40 mCi (millicuries) Cd-109 source (reference date 4/23/02), a 20 mCi Fe-55 source (reference date 4/20/02), and a 1 microCurie Am-241 Check Shutter source. Morris claims to have sent it back to us but has not been able to produce a tracking number or any other evidence of their shipment. We [Thermo Niton] have contacted Federal Express who is our primary carrier and they have reportedly not maintained records of shipments going back that far. We [Thermo Niton] have also contacted Valley Safety Services who performs leak tests for us and many of our customers and they have not leak tested this device for anyone since prior to 9/14/04. We [Thermo Niton] have put a flag in our database system that will automatically flag us if the device is received here at any time in the future.

"As of 8/22/06, the approximate calculated activities of the sources are 3.8 milliCuries for the Cd-109 source; 6.6 millicuries for the Fe-55 source and 1 microCurie for the Am-241 check source."


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 42794
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: ALPHA TESTING LABS, INC
Region: 4
City: SANDY State: UT
County:
License #: UT 1800485
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/23/2006
Notification Time: 11:01 [ET]
Event Date: 08/21/2006
Event Time: 18:00 [MDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
MICHELE BURGESS ()

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHIC CAMERA DISCONNECTED SOURCE

The State provided the following information via facsimile:

"This event involved a Source Production & Equipment Company radiographic exposure device (model SPEC 150, serial number 948; with sealed source model SPEC G-60, serial number NH0807). The activity contained in the radiographic exposure device at the time of the incident was 4.912 terabecquerels (133 Ci) of Iridium-192. The radiographer noticed that the crank turned out more turns than normal when he exposed the source. He then realized that the guide tube was not connected tightly to the device. The radiographer cranked the source in with the guide tube not connected. The pigtail hit against the radiographic exposure device and disconnected. The radiographer followed the licensee's emergency procedures and controlled the area until the radiation safety officer arrived. The radiation safety officer began and completed the source retrieval procedures without further incident. The licensee contacted the manufacturer regarding the disconnect. The manufacturer informed the licensee that when the source was outside the guide tube, and oriented 90 degrees to the travel direction of the cable, the source can disconnect.

"Event Location: Chevron Refinery VGO Unit, 2351 N 1100 W, Salt Lake City, Utah 84116"

The Utah Division of Radiation Control was notified by the licensee in a telephone call on August 22, 2006.

Utah Event Report ID No.: UT-06-0003

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General Information or Other Event Number: 42796
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: FLAGSTAFF MEDICAL CENTER
Region: 4
City: FLAGSTAFF State: AZ
County:
License #: 03-03
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 13:20 [ET]
Event Date: 08/18/2006
Event Time: 12:30 [MST]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
MICHELE BURGESS (NMSS)

Event Text

ARIZONA AGREEMENT STATE REPORT - TRASH CONTAINING IODINE -131 TAKEN TO LANDFILL

The State provided the following information via e-mail:

"At approximately 12:30 PM 8/18/2006 the Agency was informed by the Licensee that a patient receiving Iodine 131 therapy was discharged 8/16/2006. The Radiation Safety Staff proceeded to clean the patient's room. The containment items were placed into a plastic bag. The bag was transported to the waste storage area, where the Staff was unable to unlock the door. Security was called and they were unable to open the door. The Staff then moved the materials to the nuclear medicine preparation room which could be locked. The trash read 1.3mr/hr at the surface. The trash was not marked as being radioactive.

"Upon arrival the next day, the Staff discovered that the cleaning crew had removed the trash. The cleaning crew were trained that if the trash is not marked 'Radioactive' they were to remove it. They attempted to catch the trash before removal to the landfill, but they were unsuccessful. The Staff also went to the landfill and attempted to recover the trash but were unsuccessful.

"The material represents minimal public health risk if disposed into the landfill.

"The Agency continues to investigate the event.

"Press coverage is not anticipated."

First Notice: 06-07

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General Information or Other Event Number: 42798
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PORVIDENCE PORTLAND MEDICAL CENTER
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90946
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 19:35 [ET]
Event Date: 10/03/2005
Event Time: 00:00 [PDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

OREGON AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO THE INCORRECT AREA OF THE PATIENT

The State provided the following information via facsimile:

"Doctor treated wrong Trigeminal nerve. Patient received 32 Gray before error was noted. Doctor informed patient of error then proceeded to treat correct nerve.

"In order to prevent a reoccurrence of this mistake, there will be three different double checks undertaken on the day of treatment. Prior to being sedated, the patient will be asked which side his or her pain is on. When the patient, is framed the nurse shall ask the neurosurgeon which side is to be treated. This will be verified with the patient. Lastly, just prior to treatment, both the neurosurgeon and the radiation oncologist will be once again asked which side is to be treated on the patient. This triple check system should prevent this mistake from happening again."

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General Information or Other Event Number: 42799
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90731
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 19:35 [ET]
Event Date: 02/24/2006
Event Time: 00:00 [PDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

OREGON AGREEMENT STATE REPORT - VIAL CONTAINING IODINE-125 THROWN IN TRASH DUMPSTER

The State provided the following information via facsimile:


Event Description: "A researcher reported that a vial containing I-125 labeled hormones is missing. They had received a shipment from another university that was supposed to have had 3 vials. The person who checked in the package did not realize there were supposed to be three vials. The material was packaged with dry-ice. Only two vials were removed from the package and the package was placed in the trash. When it was discovered that they were supposed to be three vials, the trash had already been removed and the dumpster taken away. The estimated amount is 237 microCuries of I-125.

Corrective Actions: "Licensee will double check inventory of each box during unloading.

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Power Reactor Event Number: 42802
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KEN TIEFENTHAL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/25/2006
Notification Time: 10:36 [ET]
Event Date: 08/25/2006
Event Time: 10:30 [EDT]
Last Update Date: 08/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD CONTE (R1)

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

EMERGENCY RESPONSE DATA SYSTEM AND SAFETY PARAMETER DISPLAY SYSTEM WILL BE UNAVAILABLE

"The BVPS Unit 2 Plant Computer System (PCS) will be taken out of service for approximately 5 weeks (8/25/06 to 9/26/06) to implement a planned modification. The current PCS is being replaced and a computer outage is required to allow for the installation of a new PCS. During this time period the Emergency Response Data System (ERDS) and Safety Parameter Display System (SPDS) will not be available at BVPS Unit 2. ERDS and SPDS parameters will be monitored by control board indications and a temporary computer system (with limited analog inputs). Compensatory actions have been developed, which include a revised emergency implementing procedure specifically addressing temporarily unavailable indications and having an extra Operations Communicator respond to the Control Room during any potential Unit 2 emergency to facilitate data transfer while ERDS/SPDS is out of service. Work on replacing the PCS and returning ERDS/SPDS will be ongoing continuously until complete.

"This is an 8-hour reportable event per 10 CFR50.72(b)(3)(xiii) Major Loss of Assessment Capability. The operation of BVPS Unit 1 and Unit 2 plant systems will not be affected due to this planned action. BVPS Unit 1 ERDS and SPDS will not be affected by these modifications.

"The NRC resident inspector has been notified."

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Power Reactor Event Number: 42804
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JAMES HURCHALLA
HQ OPS Officer: PETE SNYDER
Notification Date: 08/25/2006
Notification Time: 17:57 [ET]
Event Date: 08/25/2006
Event Time: 15:30 [EDT]
Last Update Date: 08/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MALCOLM WIDMANN (R2)
NMSS EO ()

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

TRITIUM FOUND IN AN ONSITE SETTLING POND

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to notification of other government agencies at 15:30 on 8-25-06.

"Florida Power & Light Company (PPL) has identified a small amount of tritium in a settling pond at its St. Lucie Nuclear Plant Site. The level of tritium detected in the settling pond, 3.0 E-6 microCuries per milliliter (uCi/ml), is well below the Environmental Protection Agency's (EPA) drinking water standards of 2.0 E-5 uCi/ml and is less than two per cent of the Nuclear Regulatory Commission's (NRC) safe standards for tritium that apply to water in an unrestricted area.

"The source of the tritium is under investigation. The most likely source was from a leaking drain valve off a recirculating line associated with the Refueling Water Storage Tank. The leak has been stopped.

" This discovery presents no health or safety risk to employees or the public. The St. Lucie Plant does not have drinking water wells on site and the plant does not impact drinking water off site. The settling pond is a part of the normal drainage process at St. Lucie. Any water that is released from the settling pond is sampled for radioactivity and the results of any findings are included in a Radioactive Effluent Release Report that is filed annually with the NRC. Monitoring of the settling pond is conducted on a monthly basis. The previous measurements of the pond water on July 20, 2006 indicated that there was no tritium present.

"Notification to the State of Florida and St. Lucie and Martin county agencies has been reported in accordance with the Nuclear Energy Institute's voluntary reporting initiative."


The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42805
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: SCOTT LINDQUIST
HQ OPS Officer: PETE SNYDER
Notification Date: 08/26/2006
Notification Time: 13:38 [ET]
Event Date: 08/26/2006
Event Time: 09:45 [CDT]
Last Update Date: 08/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TROY PRUETT (R4)

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

ELECTRICIAN FLASH BURNED IN SWITCHGEAR ROOM

"Offsite Notifications have been made to Blair Rescue Squad due to an OPPD electrician suffering second and third degree burns to arms, face and torso while working on switchgear. The employee has been transported via life flight helicopter to Creighton University Hospital. The flash actuated the Switchgear Room Halon system. Operations verified that there was no fire in the Switchgear Rooms. Recovery efforts are under way.

"A media release is expected."

A continuous fire watch has been established in the Switchgear Room as a compensatory measure.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42806
Facility: VOGTLE
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL H. WILLIAMS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/27/2006
Notification Time: 09:20 [ET]
Event Date: 08/27/2006
Event Time: 06:31 [EDT]
Last Update Date: 08/27/2006
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):
MALCOLM WIDMANN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP TRIP

"On Sunday, August 27, 2006 at 0631 EDST, Unit Two was at 99.7% RTP when RCP #4 tripped generating a Low Flow Reactor Trip. All systems functioned as required. AFWAS [Aux Feedwater Actuation Signal] was actuated as expected due to lo-lo Steam Generators levels. RCS Letdown isolated on a momentary low level signal on one channel of Pressurizer level, and has since been restored. The reactor is currently stable in Mode 3 while the cause of the trip of the RCP is investigated."

Decay heat is being rejected to the condenser via the steam dumps. ESF systems remain operable and the electrical grid is stable. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42807
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: E. TIEDEMANN
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/27/2006
Notification Time: 21:35 [ET]
Event Date: 08/27/2006
Event Time: 17:05 [CDT]
Last Update Date: 08/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ERIC DUNCAN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 96 Power Operation 0 Hot Shutdown

Event Text

REACTOR TRIP DUE TO REACTOR HIGH WATER LEVEL

"At 1705 CDT on August 27, 2006, a high water level trip occurred resulting in a reactor scram. All control rods fully inserted on the scram signal. Reactor water level is being controlled in the normal operating band and reactor pressure is being controlled in a normal band.

"The apparent cause of the high level trip was a High Pressure Core Spray (HPCS) system initiation. There is no indication that the HPCS initiation was caused by an actual parameter reaching a trip setpoint. Division four nuclear system protection system (NSPS) is the current focus of troubleshooting activities.

"The Reactor Core Isolation Cooling (RCIC) system isolated after the scram. Troubleshooting is in progress to determine the cause. Both offsite power sources are operable and emergency diesel generators are operable and available if required. All safety related systems are available if required."

The licensee notified the NRC Resident Inspector.

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