Event Notification Report for December 31, 2005

CALIFORNIA AGREEMENT STATE REPORT OF A STOLEN TROXER GAUGE

The State provided the following information via facsimile:

"The RSO for Twining Laboratories called to inform the State of California Radiologic Health Branch that a Troxler 3430, Serial # 32684, was stolen the evening of New Years Eve (12/31/05). The gauge was located in an employees garage in San Bernadino, CA. The gauge was chained in the bed of a pickup. The tab that locks the lid of the transport box was cut and the gauge, block, and charger were taken. The employee had worked half a day on Saturday and did not want to drive his vehicle all the way back to the company's Bakersfield office."

The police have been notified of the theft.

Although not stated in the report, Troxler gauges typically contain an 8 millicurie Cesium-137 source and a 40 millicurie Americium-241/Beryllium source.

State Report: 010306

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.

AUTOMATIC ACTUATION OF THE EMERGENCY FEEDWATER (EFW) DUE TO A TRANSIENT ON THE "B" MAIN FEEDWATER (MFW) PUMP

"The EFW actuation occurred when the 'B' MFW pump RPM rose then dropped to ~4000 rpm. The MFW pump then recovered immediately. This transient caused EFIC [Emergency Feedwater Initiation Control] to actuate and both EFW pumps received start signals on invalid low SG level from the EFIC low range level instruments. These instruments measure level based upon a dp [differential pressure] across an orifice and are not considered reliable at 95% power and full MFW flow. All other SG level instruments indicate SG level was above EFIC setpoint during the MFW pump transient. This can be concluded by reviewing the OTSG [Once Through Steam Generator] level prior to and during the transient. Prior to the transient the EFIC low range level instruments indicated a level of ~24 inches. During the transient the EFIC low range level instruments indicated as low as 4 inches. However, the Startup Range level only lowered from ~122 inches prior to the transient to ~120 inches.

"Both EFW pumps were immediately overridden and stopped once it was verified this was not an actual under feed condition to the OTSGs. No EFW injection into the OTSGs occurred due to the EFW actuation."

There was no ongoing maintenance at the time which would have explained the "B" MFW pump transient.

The licensee informed the NRC Resident Inspector.

* * * UPDATE EVENT FROM FRED VAN BUSKIRK TO JOE O'HARA ON 1/5/06 AT 0942 * * *

"On 12/31/05, an 8-hour notification (EN# 42237) was made by Arkansas Nuclear One reporting an automatic actuation of Emergency Feedwater (EFW). The report was submitted pursuant to the requirements of 10 CFR 50.72 (b)(3)(iv)(A) Valid System Actuation. The actuation of EFW occurred as a result of a "B" Main Feedwater (MFW) pump transient which caused an invalid low Steam Generator (SG) level signal from the Emergency Feedwater Initiation and Control (EFIC) instrumentation. As discussed in the original event report, the low SG level EFIC instruments do not provide valid indication at 95% power and full MFW flow. As a result of the elevated flow rate during this perturbation, an invalid indication below the low SG level setpoint was produced resulting in the system actuation. All other SG level instrumentation indicated that actual SG levels remained within the normal operating band, confirming that no low level condition existed and that this event represented an invalid actuation. Accordingly, this update revises Event Notification 42237 to be submitted pursuant to 10 CFR 50.73 (a)(2)(iv)(A) and the 60-day Optional 10 CFR 50.73 (a)(1) requirement - Invalid Actuation of EFW. EFID and EFW systems functioned as designed in response to the invalid low SG level signal.

"The original event report stated that there was no EFW injection into the steam generators as a result of the actuation; however, subsequent reviews of historical Safety Parameter Display System (SPDS) data indicated that the electric EFW pump (P-7B) fed the steam generators for approximately 5 seconds during the event."

The licensee notified the NRC Resident Inspector. R4DO (Shannon) notified.

LOSS OF GENERAL LICENSED MATERIAL DUE TO IMPROPER DISPOSAL DURING CONSTRUCTION

"My name is Gary Williams with the Department of Veterans Affairs, National Health Physics Program [NHPP]. I am calling to report a loss of radioactive materials.

"The loss occurred at a medical permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-2385301VA. The permittee is the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin.

"The loss occurred in 2005 and was discovered in April 2006. The basis for the report is under 10 CFR 31.5(c)(10) in that radioactive materials obtained under a general license were lost and the reporting requirements in 10 CFR 20.2201 must be followed.

"Specifically, the permittee stated one tritium exit sign was apparently disposed or discarded during a facility construction project in 2005. The sign was last seen in 2004.

"The sign was either of two models. The first model is a 11.5 Curie sign from Shield Source Incorporated. The second model is a 20 Curie sign from SRB Technology. These types of signs were manufactured circa 1994.

"The Department of Veterans Affairs will evaluate the circumstances related to the loss of radioactive materials and submit a written report to NRC, Region III, within 30 days."

HOO NOTE: The Department of Veterans Affairs coordinates all reports to the NRC from their NHPP Director's Office located in Little Rock, AR. NRC oversight for the VA Master Materials licensee is assigned to NRC Region III.

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.

AGREEMENT STATE REPORT INVOLVING POTENTIAL OVEREXPOSURE OF THREE EMPLOYEES

The State of Louisiana submitted the following report via fax:

"Event Date and Time: December 2005

"Nondestructive & Visual Inspection had three overexposures at the end of 2005. [The first employee] had a dose of 8445 mRem for the year 2005. He was questioned by the RSO and Vice President of the company but could not explain the readings. He was ordered to retake the 40 hour radiation safety course and finished it on February 9, 2006. [The second employee] received a dose of 5221 mRem, for the year 2005. 2092 mRem of this exposure came in September, but the September badge report did not reach Nondestructive Inspection until the end of December because of mail problems after Hurricane Katrina. The mail problem has been addressed by sending the badges to a different location. [The third employee] received a dose of 5221 mRem for the year 2005. [The third employee's] overexposure is still under investigation. The facility is still in the process of reviewing the circumstances that caused the overexposures and are implementing procedures to stop them from re-occurring."

LA Event Report ID No.: LA060002

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the State of Colorado via email:

"Event Report ID No.: CO16-I16-08

"Detail: The facility hired a contractor to remodel space within the hospital. During the construction pedestrian traffic was routed around the area. According to the facility environmental health safety office the Tritium exit signs were only in use during the project.

"Event Description: It is unknown due to the extensive passage of time and the departure of employees who were involved with the project. No further information is available related to the use or the disposition of the 6 Tritium exit signs, Model # SLXTUIGW10, Serial # 162229 to 162234, H-3, 7.3 CI."

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf