Event Notification Report for April 19, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/18/2005 - 04/19/2005
EVENT NUMBERS
41615416164161741620
General Information or Other
Event Number: 41615
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BURCAW GEOTECHNICAL GROUP
Region: 1
City: RUSKIN State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL HUFFMAN
Licensee: BURCAW GEOTECHNICAL GROUP
Region: 1
City: RUSKIN State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/19/2005
Notification Time: 20:06 [ET]
Event Date: 04/19/2005
Event Time: 19:45 [EDT]
Last Update Date: 04/19/2005
Notification Time: 20:06 [ET]
Event Date: 04/19/2005
Event Time: 19:45 [EDT]
Last Update Date: 04/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID SILK (R1)
JOE GIITTER (NMSS)
TAS (E-MAIL)
DAVID SILK (R1)
JOE GIITTER (NMSS)
TAS (E-MAIL)
FLORIDA AGREEMENT STATE REPORT OF MISSING TROXLER GAUGE
The Florida Bureau of Radiation Control reported a missing Troxler moisture density gauge. The agreement state licensee, Burcaw Geotechnical Group, was using the gauge at a site located in Ruskin, Florida. The gauge overpack, which was thought to contain the gauge, was picked up at the end of the work day and placed into a truck. While in transit, the driver realized that he had not been verified the gauge was actually in the overpack. He checked the overpack and found it to be empty. He returned to the job site and conducted a search but could not locate the gauge.
The licensee informed the Florida Bureau of Radiation Control. The Bureau of Radiation Control requested the licensee to contact the police and report the gauge missing. The Troxler gauge (serial #34752) contained a 40 milliCurie Am-241/Be source and a 10 milliCurie Cs-137 source.
The Florida Bureau of Radiation Control reported a missing Troxler moisture density gauge. The agreement state licensee, Burcaw Geotechnical Group, was using the gauge at a site located in Ruskin, Florida. The gauge overpack, which was thought to contain the gauge, was picked up at the end of the work day and placed into a truck. While in transit, the driver realized that he had not been verified the gauge was actually in the overpack. He checked the overpack and found it to be empty. He returned to the job site and conducted a search but could not locate the gauge.
The licensee informed the Florida Bureau of Radiation Control. The Bureau of Radiation Control requested the licensee to contact the police and report the gauge missing. The Troxler gauge (serial #34752) contained a 40 milliCurie Am-241/Be source and a 10 milliCurie Cs-137 source.
Power Reactor
Event Number: 41616
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SAUER
HQ OPS Officer: BILL HUFFMAN
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SAUER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/19/2005
Notification Time: 21:59 [ET]
Event Date: 04/19/2005
Event Time: 20:52 [EST]
Last Update Date: 04/19/2005
Notification Time: 21:59 [ET]
Event Date: 04/19/2005
Event Time: 20:52 [EST]
Last Update Date: 04/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
DAVID SILK (R1)
DAVID SILK (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 78 | Power Operation |
TECHNICAL SPECIFICIATION REQUIRED SHUTDOWN RELATED TO PRESSURE BOUNDARY LEAKAGE
The licensee "entered technical specification limiting condition for operation 3.0.3 due to pressure boundary leakage on a 3/4 inch pipe on the piping for the boron injection tank. As a result of this, both trains of high head injection [have been declared] inoperable. Unit shutdown began at 2105 [EDT]. All other safety systems are operable. Current plans are to take the plant to mode 4 and isolate and replace the affected piping. The current leakage is 780 cc/hr."
The licensee discovered the leakage during operator rounds at approximately 0500 EDT. Technical Specification 3.0.3 was entered at 2052 EDT. Power reduction is currently in progress. The licensee will be notifying the NRC Resident Inspector and Lower Alloways Creek Township.
The licensee "entered technical specification limiting condition for operation 3.0.3 due to pressure boundary leakage on a 3/4 inch pipe on the piping for the boron injection tank. As a result of this, both trains of high head injection [have been declared] inoperable. Unit shutdown began at 2105 [EDT]. All other safety systems are operable. Current plans are to take the plant to mode 4 and isolate and replace the affected piping. The current leakage is 780 cc/hr."
The licensee discovered the leakage during operator rounds at approximately 0500 EDT. Technical Specification 3.0.3 was entered at 2052 EDT. Power reduction is currently in progress. The licensee will be notifying the NRC Resident Inspector and Lower Alloways Creek Township.
Power Reactor
Event Number: 41617
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RONALD L. WILLIAMS
HQ OPS Officer: WESLEY HELD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RONALD L. WILLIAMS
HQ OPS Officer: WESLEY HELD
Notification Date: 04/19/2005
Notification Time: 22:15 [ET]
Event Date: 04/19/2005
Event Time: 16:51 [CST]
Last Update Date: 04/19/2005
Notification Time: 22:15 [ET]
Event Date: 04/19/2005
Event Time: 16:51 [CST]
Last Update Date: 04/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MICHAEL SHANNON (R4)
MICHAEL SHANNON (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
DEGRADED CONDITION FOUND AT WATERFORD UNIT 3
"Waterford Unit 3 shutdown on 4/17/2005 at approximately 0047 hrs to begin refueling outage 13. During performance of the Alloy 600 Program pressurizer "bare metal" inspection, a small amount of boric acid was discovered in the annulus around Pressurizer heater sleeves C4 and D2. Entergy had already planned to weld repair/replace the Alloy 600 pressurizer sleeves and remaining Alloy 600 small bore instrument penetrations using Alloy 690 materials during this refueling outage.
"This condition constitutes a degradation of the RCS Pressure Boundary and is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(A) with a required followup written Licensee Event Report in accordance with 10 CFR 50.73(a)(2)(ii)(A)."
The NRC Resident Inspector has been notified.
"Waterford Unit 3 shutdown on 4/17/2005 at approximately 0047 hrs to begin refueling outage 13. During performance of the Alloy 600 Program pressurizer "bare metal" inspection, a small amount of boric acid was discovered in the annulus around Pressurizer heater sleeves C4 and D2. Entergy had already planned to weld repair/replace the Alloy 600 pressurizer sleeves and remaining Alloy 600 small bore instrument penetrations using Alloy 690 materials during this refueling outage.
"This condition constitutes a degradation of the RCS Pressure Boundary and is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(A) with a required followup written Licensee Event Report in accordance with 10 CFR 50.73(a)(2)(ii)(A)."
The NRC Resident Inspector has been notified.
General Information or Other
Event Number: 41620
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: CHAUNCEY GOULD
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/21/2005
Notification Time: 15:05 [ET]
Event Date: 04/19/2005
Event Time: 00:00 [CST]
Last Update Date: 04/21/2005
Notification Time: 15:05 [ET]
Event Date: 04/19/2005
Event Time: 00:00 [CST]
Last Update Date: 04/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)
DAVID HILLS (R3)
SCOTT MOORE (NMSS)
EQUIPMENT FAILED TO FUNCTION AS DESIGNED
The following information was provided by the State via facsimile:
"On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital.
"The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing.
"The licensee has developed, an action plan for this event based on possible causes:
1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule.
2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician.
3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education.
"A voluntary MedWatch form was sent in to the FDA.
"Wisconsin Radiation Protection Section plans on investigating this event."
State Event Report ID # 24.
The following information was provided by the State via facsimile:
"On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital.
"The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing.
"The licensee has developed, an action plan for this event based on possible causes:
1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule.
2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician.
3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education.
"A voluntary MedWatch form was sent in to the FDA.
"Wisconsin Radiation Protection Section plans on investigating this event."
State Event Report ID # 24.