Event Notification Report for May 22, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/21/2006 - 05/22/2006
EVENT NUMBERS
4260042594425974262342624
Hospital
Event Number: 42600
Rep Org: MUNSON MEDICAL CENTER
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #: 21-08317-01
Agreement: N
Docket:
NRC Notified By: DENNIS SZMANIA
HQ OPS Officer: PETE SNYDER
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #: 21-08317-01
Agreement: N
Docket:
NRC Notified By: DENNIS SZMANIA
HQ OPS Officer: PETE SNYDER
Notification Date: 05/23/2006
Notification Time: 10:23 [ET]
Event Date: 05/22/2006
Event Time: 14:00 [EDT]
Last Update Date: 05/23/2006
Notification Time: 10:23 [ET]
Event Date: 05/22/2006
Event Time: 14:00 [EDT]
Last Update Date: 05/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
BRUCE BURGESS (R3)
GREG MORELL (NMSS)
BRUCE BURGESS (R3)
GREG MORELL (NMSS)
HOSPITAL INFORMED OF PREGNANCY AFTER DOSE
On 5/3/06 Munson Medical Center administered a 150 mCi oblation dose of I-131 for thyroid cancer to a patient. Before the dose was administered the patient signed a form indicating that she was not pregnant. The dose was dispensed to the patient around 10 am.
On 5/22/06 the patient called Munson Medical Center indicating that she had discovered that she was pregnant at the time of the dose. The licensee determined a calculated dose to the unborn child of 40 Rem. The patient was not yet informed of the dose to the unborn child at the time of the report. Expected medical effects of the dose are either immediate abortion or no harm since at the time of the dose organ development was not expected to have occurred.
The licensee is reviewing their current policy to determine actions to prevent recurrence.
On 5/3/06 Munson Medical Center administered a 150 mCi oblation dose of I-131 for thyroid cancer to a patient. Before the dose was administered the patient signed a form indicating that she was not pregnant. The dose was dispensed to the patient around 10 am.
On 5/22/06 the patient called Munson Medical Center indicating that she had discovered that she was pregnant at the time of the dose. The licensee determined a calculated dose to the unborn child of 40 Rem. The patient was not yet informed of the dose to the unborn child at the time of the report. Expected medical effects of the dose are either immediate abortion or no harm since at the time of the dose organ development was not expected to have occurred.
The licensee is reviewing their current policy to determine actions to prevent recurrence.
Power Reactor
Event Number: 42594
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: BILL HUFFMAN
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/22/2006
Notification Time: 10:13 [ET]
Event Date: 05/22/2006
Event Time: 07:01 [CDT]
Last Update Date: 05/22/2006
Notification Time: 10:13 [ET]
Event Date: 05/22/2006
Event Time: 07:01 [CDT]
Last Update Date: 05/22/2006
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARK SHAFFER (R4)
MARK SHAFFER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
MANUAL REACTOR SCRAM AS A MITIGATING ACTION DUE TO LOWERING SERVICE AIR PRESSURE
"CNS was operating at 100% power at 06:51 CDT on May 22, 2006 when Plant Service Air pressure began lowering due to an unknown cause. Additional Service Air Compressors could not be started in time to recover Service Air pressure. A rapid power reduction was performed and at 07:01 the reactor was manually scrammed as a mitigating action due to lowering Plant Service Air pressure. All control rods fully inserted and a Group 2 Isolation occurred due to low Reactor Vessel level as expected following the manual scram. Minimum Reactor level was -20 inches Wide Range. The reactor is currently shutdown and stable with level maintained at 35 inches in the green band on the Narrow Range Indicators with the Feedwater System. Reactor pressure following the scram was stabilized at approximately 900 psig using the Main Condenser Bypass Valves and is slowly lowering.
"This report is made in accordance with 10CFR50.72 as a 4 Hour Report due to a valid RPS actuation and as an 8 Hour Report due to a valid Group 2 Isolation actuation. All automatic actions functioned as expected. The plant is being maintained in Hot Shutdown while the cause of the Plant Service Air Pressure lowering is being investigated. The NRC Senior Resident inspector has been informed of the event."
The scram was characterized as uncomplicated. The licensee is not in any significant tech spec LCO and all systems functioned as required. It was noted that there are 3 service air compressors available and only one of the compressors was running at the time of the event. The licensee does not yet know the cause of the service air pressure loss or why the backup compressors did not autostart. Instrument air pressure was maintained during the event.
"CNS was operating at 100% power at 06:51 CDT on May 22, 2006 when Plant Service Air pressure began lowering due to an unknown cause. Additional Service Air Compressors could not be started in time to recover Service Air pressure. A rapid power reduction was performed and at 07:01 the reactor was manually scrammed as a mitigating action due to lowering Plant Service Air pressure. All control rods fully inserted and a Group 2 Isolation occurred due to low Reactor Vessel level as expected following the manual scram. Minimum Reactor level was -20 inches Wide Range. The reactor is currently shutdown and stable with level maintained at 35 inches in the green band on the Narrow Range Indicators with the Feedwater System. Reactor pressure following the scram was stabilized at approximately 900 psig using the Main Condenser Bypass Valves and is slowly lowering.
"This report is made in accordance with 10CFR50.72 as a 4 Hour Report due to a valid RPS actuation and as an 8 Hour Report due to a valid Group 2 Isolation actuation. All automatic actions functioned as expected. The plant is being maintained in Hot Shutdown while the cause of the Plant Service Air Pressure lowering is being investigated. The NRC Senior Resident inspector has been informed of the event."
The scram was characterized as uncomplicated. The licensee is not in any significant tech spec LCO and all systems functioned as required. It was noted that there are 3 service air compressors available and only one of the compressors was running at the time of the event. The licensee does not yet know the cause of the service air pressure loss or why the backup compressors did not autostart. Instrument air pressure was maintained during the event.
Power Reactor
Event Number: 42597
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KEN GOODALL
HQ OPS Officer: JOHN KNOKE
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KEN GOODALL
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2006
Notification Time: 22:05 [ET]
Event Date: 05/22/2006
Event Time: 22:00 [EDT]
Last Update Date: 05/26/2006
Notification Time: 22:05 [ET]
Event Date: 05/22/2006
Event Time: 22:00 [EDT]
Last Update Date: 05/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
Person (Organization):
MEL GRAY (R1)
THOMAS BLOUNT (IRD)
PATRICIA HOLAHAN (NMSS)
BENJAMIN SANDLER (TAS)
BAUMGARTNER (EPA)
MEL GRAY (R1)
THOMAS BLOUNT (IRD)
PATRICIA HOLAHAN (NMSS)
BENJAMIN SANDLER (TAS)
BAUMGARTNER (EPA)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
SPECIAL NUCLEAR MATERIAL (.003 GRAMS) LOST
During ongoing activities to remove non-fuel material from the Pilgrim Spent Fuel Pool it has been identified that an irradiated neutron detector containing a very small quantity (less than 0.003 grams) of special nuclear material is not in its expected location. Per the inventory sheets the neutron detector should have been enclosed in a "dry tube" in the Spent Fuel Pool. Processing of the "dry tube" for shipment identified that the neutron detector is not in its expected location.
This condition is being conservatively reported under 10CFR74.11. There is no evidence of theft or diversion. Investigation is continuing.
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 5/26/2006 AT 15:25 FROM MICHAEL McDONNELL TO ABRAMOVITZ * * *
"In Event Notifications 42597 and 42599 on May 22 and May 23, 2006, respectively, Pilgrim Nuclear Power Station notified the NRC that during ongoing activities to remove non-fuel material from the Pilgrim Spent Fuel Pool it had been identified that 2 irradiated neutron detectors containing very small quantities (less than 0.003 grams each) of special nuclear material were not in their expected locations. Per the inventory sheets the neutron detectors should have been enclosed in 'dry tubes' in the Spent Fuel Pool. Processing of the 'dry tubes' identified that the neutron detectors are not in their expected locations.
"There were a total of twelve (12) 'dry tubes' that our records show enclosed neutron detectors. As part of the investigation associated with Event Notification 42597, all twelve (12) of these 'dry tubes' have been inspected. Three (3) of the 'dry tubes' were found to contain neutron detectors consistent with plant records. Nine (9) of the 'dry tubes' were found to contain no neutron detector which is not consistent with the plant records. The irradiated neutron detectors would have each contained a very small quantity (less than 0.003 grams each) of special nuclear material.
"This condition is being conservatively reported under 10CFR74.11. There is no evidence of theft or diversion.
"Investigation is continuing."
The licensee notified the NRC Resident Inspector.
Notified IRD (Blount and Leach), R1DO (Gray), NRR (Haney), ILTAB (English), DHS SWO (Cassandra), FEMA (S. Kimbrell), DOE (Ronnie), EPA (Crews), USDA (Margaret), and HHS (Marcy).
During ongoing activities to remove non-fuel material from the Pilgrim Spent Fuel Pool it has been identified that an irradiated neutron detector containing a very small quantity (less than 0.003 grams) of special nuclear material is not in its expected location. Per the inventory sheets the neutron detector should have been enclosed in a "dry tube" in the Spent Fuel Pool. Processing of the "dry tube" for shipment identified that the neutron detector is not in its expected location.
This condition is being conservatively reported under 10CFR74.11. There is no evidence of theft or diversion. Investigation is continuing.
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 5/26/2006 AT 15:25 FROM MICHAEL McDONNELL TO ABRAMOVITZ * * *
"In Event Notifications 42597 and 42599 on May 22 and May 23, 2006, respectively, Pilgrim Nuclear Power Station notified the NRC that during ongoing activities to remove non-fuel material from the Pilgrim Spent Fuel Pool it had been identified that 2 irradiated neutron detectors containing very small quantities (less than 0.003 grams each) of special nuclear material were not in their expected locations. Per the inventory sheets the neutron detectors should have been enclosed in 'dry tubes' in the Spent Fuel Pool. Processing of the 'dry tubes' identified that the neutron detectors are not in their expected locations.
"There were a total of twelve (12) 'dry tubes' that our records show enclosed neutron detectors. As part of the investigation associated with Event Notification 42597, all twelve (12) of these 'dry tubes' have been inspected. Three (3) of the 'dry tubes' were found to contain neutron detectors consistent with plant records. Nine (9) of the 'dry tubes' were found to contain no neutron detector which is not consistent with the plant records. The irradiated neutron detectors would have each contained a very small quantity (less than 0.003 grams each) of special nuclear material.
"This condition is being conservatively reported under 10CFR74.11. There is no evidence of theft or diversion.
"Investigation is continuing."
The licensee notified the NRC Resident Inspector.
Notified IRD (Blount and Leach), R1DO (Gray), NRR (Haney), ILTAB (English), DHS SWO (Cassandra), FEMA (S. Kimbrell), DOE (Ronnie), EPA (Crews), USDA (Margaret), and HHS (Marcy).
General Information or Other
Event Number: 42623
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: PATHFINDER ENERGY SERVICES, INC.
Region: 4
City: LAFAYETTE State: LA
County:
License #: LA-9089-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN KNOKE
Licensee: PATHFINDER ENERGY SERVICES, INC.
Region: 4
City: LAFAYETTE State: LA
County:
License #: LA-9089-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/07/2006
Notification Time: 07:31 [ET]
Event Date: 05/22/2006
Event Time: 04:00 [CDT]
Last Update Date: 06/07/2006
Notification Time: 07:31 [ET]
Event Date: 05/22/2006
Event Time: 04:00 [CDT]
Last Update Date: 06/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)
AGREEMENT STATE REPORT - ABANDONMENT OF WELL LOGGING SOURCE
The State provided the following information via facsimile:
"[Pathfinder Energy Services (licensee) notified the State of LA that] during drilling operations on 17 May 2006 the drill string became stuck while making a connection. The hole had packed off around the drill string not allowing circulation, up and down movement or rotation of the drill pipe. All reasonable effort was used to attempt to free the drill string.
"[LADEQ Emergency & Radiological Services Division] was notified on 19 May 2006 that there might be a possibility of needing to abandon the sources over the weekend. He gave a verbal approval to abandon the sources and referred me [licensee] to [LADEQ] to follow up on Monday with the status of the abandonment. [LADEQ] was notified Monday 22 May 2006 that the sources were abandoned at 4:00 AM, 22 May 2006 and given details of the abandonment with the agreement that a formal report would be filed within 30 days of the abandonment. E-mail notification was also sent to Mr. Noble.
"It became apparent on Sunday 21 May 2006 that the drill string would be lost. A 370 foot cement plug was set above the sources. A total of 22 joints of HWDP (675 feet) were left on top of the radioactive sources to act as a mechanical deflection device to prevent inadvertent intrusion on the sources.
"A sidetrack well is planned to be drilled after 7 5/8" casing is set at 10,237' from the shoe to the original depth of 10,265 ft TVD. The sidetrack well is planned not to come within 15 ft of the sources. A liner (casing) will be set at completion of the bypass well and cemented in place.
"Description of Sources:
One 1.5 Curie, Cs-137, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number, 5080GW
AEAT Model CDC.CY6
"One 8 Curie, Am-241/Be, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number: DNS 013
Gammatron Model AN-HP"
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.
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
The State provided the following information via facsimile:
"[Pathfinder Energy Services (licensee) notified the State of LA that] during drilling operations on 17 May 2006 the drill string became stuck while making a connection. The hole had packed off around the drill string not allowing circulation, up and down movement or rotation of the drill pipe. All reasonable effort was used to attempt to free the drill string.
"[LADEQ Emergency & Radiological Services Division] was notified on 19 May 2006 that there might be a possibility of needing to abandon the sources over the weekend. He gave a verbal approval to abandon the sources and referred me [licensee] to [LADEQ] to follow up on Monday with the status of the abandonment. [LADEQ] was notified Monday 22 May 2006 that the sources were abandoned at 4:00 AM, 22 May 2006 and given details of the abandonment with the agreement that a formal report would be filed within 30 days of the abandonment. E-mail notification was also sent to Mr. Noble.
"It became apparent on Sunday 21 May 2006 that the drill string would be lost. A 370 foot cement plug was set above the sources. A total of 22 joints of HWDP (675 feet) were left on top of the radioactive sources to act as a mechanical deflection device to prevent inadvertent intrusion on the sources.
"A sidetrack well is planned to be drilled after 7 5/8" casing is set at 10,237' from the shoe to the original depth of 10,265 ft TVD. The sidetrack well is planned not to come within 15 ft of the sources. A liner (casing) will be set at completion of the bypass well and cemented in place.
"Description of Sources:
One 1.5 Curie, Cs-137, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number, 5080GW
AEAT Model CDC.CY6
"One 8 Curie, Am-241/Be, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number: DNS 013
Gammatron Model AN-HP"
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.
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
General Information or Other
Event Number: 42624
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF ROTTON
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/07/2006
Notification Time: 08:54 [ET]
Event Date: 05/22/2006
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2006
Notification Time: 08:54 [ET]
Event Date: 05/22/2006
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)
AGREEMENT STATE REPORT - UNSECURED DELIVERY OF RADIOACTIVE MATERIAL
The State provided the following information via facsimile:
"On May 22, 2006, a package containing 300 [microcuries] of I-123 in two (2) capsules was prepared for shipment at the Cardinal Health Nuclear Pharmacy Services ('Cardinal Health') facility in Dallas, TX. This package was a Type 7A container and was given a Yellow II label. This package was consigned to a contract courier, Tradewind, Inc., for delivery to Cardinal Health in Shreveport, LA.
"Delivery of this package to Cardinal Health Shreveport was attempted sometime after it closed at 5:00 PM. It was discovered by a parking lot cleaning crew at approximately 11:30 PM that evening. The package had been left behind a dumpster outside the pharmacy and covered with a Tradewind jacket. The cleaning crew contacted the police, who arrived at the scene shortly afterwards and contacted the fire department, who dispatched a HazMat team. The police also contacted our pharmacist on call by using the emergency contact number posted on the outer vestibule door to our pharmacy. The fire and/or police departments took control of the material until a representative from Cardinal Health arrived on site. All radioactive material listed on the shipping paper was present and accounted for.
"Root Causes: The cause of this event was a failure by the courier, Tradewind, to properly perform their contracted duties. The package in question was left unsecured behind a dumpster. This is not how Tradewind has been instructed to deliver packages to our pharmacy. They have been instructed to deliver radioactive material packages in a designated area (that is appropriately marked) inside the vestibule, in the rear of our building. Tradewind was issued a vestibule key for this sole purpose.
"The driver who originally arrived to deliver the package did not have the vestibule key. An interview with him revealed that his intent was for another Tradewind driver to arrive later with the key and deliver the package into [licensee's] secured vestibule.
"Actions Taken to Prevent a Recurrence: Cardinal Health will be working with Tradewind to review training documents required by the DOT and to formulate corrective measures taken to prevent reoccurrence of this type of event."
LA Event Report ID No.: LA060008
The State provided the following information via facsimile:
"On May 22, 2006, a package containing 300 [microcuries] of I-123 in two (2) capsules was prepared for shipment at the Cardinal Health Nuclear Pharmacy Services ('Cardinal Health') facility in Dallas, TX. This package was a Type 7A container and was given a Yellow II label. This package was consigned to a contract courier, Tradewind, Inc., for delivery to Cardinal Health in Shreveport, LA.
"Delivery of this package to Cardinal Health Shreveport was attempted sometime after it closed at 5:00 PM. It was discovered by a parking lot cleaning crew at approximately 11:30 PM that evening. The package had been left behind a dumpster outside the pharmacy and covered with a Tradewind jacket. The cleaning crew contacted the police, who arrived at the scene shortly afterwards and contacted the fire department, who dispatched a HazMat team. The police also contacted our pharmacist on call by using the emergency contact number posted on the outer vestibule door to our pharmacy. The fire and/or police departments took control of the material until a representative from Cardinal Health arrived on site. All radioactive material listed on the shipping paper was present and accounted for.
"Root Causes: The cause of this event was a failure by the courier, Tradewind, to properly perform their contracted duties. The package in question was left unsecured behind a dumpster. This is not how Tradewind has been instructed to deliver packages to our pharmacy. They have been instructed to deliver radioactive material packages in a designated area (that is appropriately marked) inside the vestibule, in the rear of our building. Tradewind was issued a vestibule key for this sole purpose.
"The driver who originally arrived to deliver the package did not have the vestibule key. An interview with him revealed that his intent was for another Tradewind driver to arrive later with the key and deliver the package into [licensee's] secured vestibule.
"Actions Taken to Prevent a Recurrence: Cardinal Health will be working with Tradewind to review training documents required by the DOT and to formulate corrective measures taken to prevent reoccurrence of this type of event."
LA Event Report ID No.: LA060008