Event Notification Report for April 06, 2005

10 CFR PART 21 REPORT INVOLVING POTENTIAL DEFECT IN AN HIGH DOSE RATE AFTERLOADING DEVICE

Lankenau Hospital reported an incident involving a Nucletron V2 microselectron High Dose Rate Afterloading device. The Hospital reports that a source stuck in a GYN transfer tube during quality operational checks. The source had to be manually retracted with a hand crank back into a safe position. Inspection of the GYN tube revealed a restriction (described as an edge) that developed on the end that connects to the treatment unit. The Hospital report states that the tube had been in use for two years and may have developed the restriction from normal wear and tear. The tube was replaced and the defective tube transferred to Nucletron. The Hospital report notes that normal wire transfer checks (without the source present) did not identify the problem - but probably should have. The Hospital report also stated that the restriction should not have prevent the source from being automatically retracted to its safe location once the emergency stop was actuated. The cause of the GYN tube restriction is unknown.

AGREEMENT STATE REPORT INVOLVING THEFT OF A TROXLER PORTABLE GAUGE

The following information was received via fax:

"On 4/6/2005, Linda McLean (NRC) notified Texas DSHS at 10:30 am that their regional office had just received a phone call from the White Settlement, TX Police Department. The police department had been notified of a burglary between 5:00 am and 7:00 am on the morning of April 6, 2005 involving a stolen Troxler (model 3411B) portable gauge containing 10 mCi of Cs-137, serial number 40-9599, and 40 mCi of Am-241, serial number 47-7075. Serial Number for the gauge is 11979. [The authorized user] contacted the police department that he had stopped by his girlfriend's apartment at 5:00 am. When he went outside at 7:00 am, the passenger window had been broken out of his pickup truck and the portable gauge he was planning on using for work had been removed. He stated his radio had been stolen two weeks earlier at the same address. Police report number is 0506384."

Texas Incident No.: I-8227

*** UPDATE FROM RATLIFF TO KNOKE AT 1347 EDT ON 07/09/07 ***

The licensee provided the following information via email:

"On April 6, 2005, the Agency received a phone call from the Nuclear Regulator Commission (NRC) informing them of a reported theft of a moisture density gauge containing one 7.8 millicurie Cesium-137 source and a 40 millicurie Americium source. The NRC had received a notification of the theft from the White Settlement Police Department. The technician had taken the gauge home with him so he could get an early start the next morning. The passenger's window was broke out of the pickup and the gauge was stolen. The gauge was removed from the transport case in the bed of the pickup and had been placed in the cab of the vehicle to protect it from theft. The local police were contacted and a police report was filed. The gauge was not recovered. The technician was placed on ninety day probation and a letter stating the company's policy on returning the gauges to the laboratory prior to going home each night. The licensee was issued two violations for failure to adequately secure the sources from unauthorized removal and failure of the Radiation Safety Office to insure compliance with company procedures. File closed."

Notified R4DO (Nease), CNSNS (Email), ILTAB (Whitney), FSME (Joe Giitter)

MEDICAL EVENT INVOLVING ADMINISTRATION OF WRONG DIAGNOSTIC TEST

On the morning of 4/6, the Resident Physician reviewed the prescribing Physician's order for administration of a brain scan diagnostic test to image a tumor and instructed the technician to perform a "standard" brain scan which images blood flow. The Technician administered 30 mCi Tc-99m as instructed rather than the 3 mCi Thallium prescribed. The RSO noted that the test performed would result in a total dose of 3.22 mGy and a urinary bladder wall dose of 81 mGy (information from package insert). The RSO does not believe there will be any adverse consequences to the patient in that this was a diagnostic test. The error was identified by the Director of Nuclear Medicine during review. The patient had not been informed as of the time of this report. The patient will be rescheduled for the appropriate diagnostic test after elimination and decay of the Tc-99m.

* * * UPDATE FROM LICENSEE (STEVA) TO NRC (HUFFMAN) AT 1251 EDT ON 4/07/05 * * *

The license stated that the patient involved was a 66 year old female. The licensee does not consider that this event meets the criteria of a medical event.

R1DO (Noggle) and NMSS (Essig) notified.

PARTIAL LOSS OF OFFSITE POWER RESULTING IN AUTOSTART OF EMERGENCY DIESEL GENERATORS

"At 1655 on April 6, 2005, a trip of the 4A/4B Transformer occurred at Limerick Generating Station in the 500 KV Substation. This de-energized one of the required off site sources and the associated 20 Start-up Bus and 201 Safeguard Bus, causing a valid actuation signal for the D12, D14, D21, and D23 Diesel Generators. All Diesels started and their associated 4 KV buses swapped to the 101 Safeguard Bus as required. Cause of the 4A/4B Transformer trip is under investigation. Power reduction on Unit 2 was performed in response to lowering Main Condenser vacuum during power supply transfers. Condition was stabilized and Unit 2 Reactor power restored to 100 %."

The cause of the lowering main condenser vacuum was that when the bus transfer occurred, several air valves on Unit 2 cycled which caused the lowering vacuum. Once power transferred, Unit 2 stabilized and was restored to 100% power. Unit 1 main condenser vacuum was not affected since power was not transferred on Unit 1.

Additionally, a Group 6A valve isolation signal was generated. This caused the purge valves to receive an isolation signal but the purge valves were not in operation nor were they required to be in operation at the time of the isolation signal. Both unit's Reactor Water Clean-up (RWCU) pumps tripped due to the isolation signal. At the time of this report, the isolation signal was reset, Unit 1 RWCU pump has been reset, and preparations are being made to restart Unit 2 RWCU pump.

The only other anomaly is that Unit 2 D22 diesel is in a maintenance outage and is scheduled to be returned to service tomorrow.

Currently, both units are in a 72-hour LCO action statement due to loss of one offsite power supply.

The licensee will inform the NRC resident inspector.

MAJOR LOSS OF COMMUNICATIONS CAPABILITY DUE TO OFFSITE FIBER OPTIC CABLE CUT

"On 4/6 at approximately 0900 Emergency Planning (EP) was notified by Arkansas Department of Health that they had lost communications with their Communications Center in Little Rock and asked ANO to perform tests to validate.

"Pope County 911 advised EP that there had been a major fiber optics cut east of Russellville. The NRC Resident also notified EP that their contact with Arlington and headquarters was out including commercial lines. Subsequent investigations revealed that ERDS, ENS, and Health Physics Network (HPN) lines are not functioning at ANO. Backup methods of communications are defined in the Emergency Plan procedures and are available.

"Establishment of communications are ongoing."

The licensee informed the State and NRC Resident Inspector.

* * * UPDATE FROM LICENSEE (HARRIS) TO NRC (HUFFMAN) AT 1507 EDT ON 4/8/05 * * *

The licensee reports that the fiber optic cut had been repaired and all phone circuits returned to operable status by 1618 CST on 4/6/05. The licensee has notified the NRC Resident Inspector. R4DO (Howell) notified.