Event Notification Report for August 31, 2006

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"On 8/31/06, the Geosyntec RSO contacted the Radiologic Health Branch (RHB), Richmond office to notify that one of their Troxler gauges, Model 3430, S/N 28743 containing 8 mCi of Cs-137 and 40 mCi of [Am]-241 had been run over by a compactor at a job site in South San Francisco (333 Oyster Point Blvd.) around 2:00 pm. The RSO stated that the gauge operator tried to stop the compactor backing up towards the gauge but it was unsuccessful due to the noise. The gauge was severely damaged with the source rod in an unshielded position. The RSO contacted Troxler to have the unshielded source transported for disposal. Troxler was not able to provide transportation on 08/31/06. Per RSO, the gauge is secured on the job site inside a locked storage container and the unshielded rod is placed in a 5 gallon bucket of soil. They expect to transport the damaged gauge as soon as assistance from a local gauge manufacturer is received. The RHB will investigate this incident for any items of non-compliance."

The State has indicated that the licensee intends to contact Campbell Pacific Nuclear (CPN) to transport the damaged gauge.

TECHNICAL SPECIFICATION REQUIRED SHUDOWN DUE TO RCS LEAKAGE

"On August 31, 2006, licensed plant operators identified that Technical Specification 3.4.13 was not met due to a one to two gallon per minute unidentified reactor coolant system (RCS) leak. Plant Operators initiated a ramp of reactor power to take Unit 2 to mode 3, Hot Standby, at 1409 PDT. A containment entry has been initiated to identify the source of the RCS leak. The estimated restart date is preliminary, pending investigation of the leakage location. The Unit is currently ramping off line at 4-5 MW/min. Current reactor power level is 90% and 937 MW electric."

The licensee stated that the suspected source of the leak is the seal table room where radiation levels have risen consistent with the containment leakage. Current unidentified leak rate is 1.3 gpm. The TS limit is 1 gpm. Current coolant activity is 1.88 microCi/ml.

A press release is planned to be issued on 9/1/2006.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY D. PATTY TO O'HARA ON 08/31/06 AT 2254 EST * * *

"This is a follow up to the 4 hour notification that was initiated due to initiating a Technical Specification (TS) required shutdown when Technical Specification 3.4.13 was not met.

"Plant Operators entered containment and identified RCS leakage from one of the thimble tubes in the seal table 10 path. At 1622 on 8/31/06 the leakage was classified as identified leakage. The TS required shut down was stopped at 1623 as the leak rate is less than the TS leak rate limit for identified leakage. Operators have isolated the 10 path by closing the valve and the RCS leakage has stopped."

Notified R4DO (Cain), NRR EO (McGinty) via e-mail, IRD MOC (Leach) via e-mail.

HPCI DECLARED INOPERABLE DUE TO STOP VALVE INDICATION ISSUE

"At 1111, on August 31, 2006, during performance of SO-152-006 HPCI was declared inoperable when the HPCI Turbine Stop Valve FV-15612 had dual position indication. Local observation of the stop valve by plant operators and a report from the system engineer verified the valve was closed, and the problem appears to be a limit switch problem. With the lower limit switch not responding correctly the system engineer informed the control room the HPCI Ramp Generator is not reset, which will result in an over speed condition of the HPCI turbine if an actuation signal is received.

"To prevent possible damage to the HPCI turbine, control room personnel overrode HPCI injection in accordance with plant operating procedures.

"Plans are being developed to investigate the problem, and adjust the limit switch if required.

"This is being reported as an event or condition that could have prevented fulfillment of a safety function required to mitigate the consequences of an accident in accordance with 10CFR50.72(b)(3)(v)(D)."

The licensee has entered the provisions of TS 3.5.1 for this condition.

No other accident mitigation systems are currently inoperable.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT OF A STOLEN TROXLER MOISTURE DENSITY GAUGE

The licensee, GEOCON Inc., license number 3924, reports that a Troxler Moisture Density Gauge Model No. 3440, S/N 33526 was stolen on 8/31/06. The gauge was secured in its case in a locked storage container in the rear of a locked pickup truck parked in front of the employees residence. When the employee went to his vehicle this morning at approximately 0900, he discovered that the vehicle was missing. The gauge contained 8 milli curies of Cs-137 and 40 milli Curies of Am-241/Be. The employee filed a report with the City of San Diego Police Department. The case number is 0630914N and the incident number is 66956.

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.

LOST RADIOGRAPHY CAMERA ON WAKE ISLAND

The licensee reported a loss of a 10 Ci [based on source decay starting December of 2005] IR-192 radiography camera on Wake Island. In preparation for evacuation of the island on 8/29/2006 the camera was loaded in a type B(U) storage container. On 8/30/2006 Super Typhoon Yoke made land fall on Wake Island producing 150 mph winds and 30 - 40 ft storm surge. The status of the camera is unknown due to the uncertain condition of Wake Island. There currently is no information of the habitability of Wake Island and thus it is uncertain when a search can be conducted.

The licensee will update the status of the material as more information becomes available.

* * * UPDATE ON 09/25/06 AT 1300 ET BY PETE MILLAR TO MACKINNON * * *

Per Pete Millar the US NAVY landed on Wake Island and the CONEX shipping container, in which the Industrial Nuclear Radiography Camera is stored, is still on the island and it has not been opened. In about 2 weeks a barge will leave Wake Island to ship the CONEX shipping container back to Alaska Industrial X-Ray. Mr. Millar said that they should have Industrial radiography camera back in their possession in about 3 weeks.

R4DO (Zach Dunham) & NMSS EO (Greg Morell) notified.

* * * UPDATE ON 03/20/07 AT 1346 EDT FROM PETE MILLAR TO MACKINNON * * *

Alaska Industrial X-Ray, regained possession of their radiography camera on 12/15/06.

R4DO (Greg Pick) & FSME (Greg Morell) notified.


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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event.

Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3"

PLANT REQUIRED SHUTDOWN DUE TO 'A' AND 'B' EDG INOPERABLE.

"On August 31, 2006 at 1530 EST Seabrook Station initiated a plant shutdown in accordance with TS 3.8.1.1 Action (f). On August 28, 2006 the Train 'A' Emergency Diesel Generator (EDG) was removed from service for planned maintenance. During the planned maintenance, an emergent issue [suspected diode failure on the control circuitry] was discovered. That required starting the Train 'B' EDG in accordance with the provisions of TS 3.8.1.1 Action (b). During the start of the Train 'B' EDG a voltage control anomaly was discovered that required the Train 'B' EDG to also be declared inoperable.

"With two EDG's inoperable, TS 3.8.1.1 requires a plant shutdown. This event is reportable pursuant to 10CFR50.72(b)(2)(i) as the initiation of plant shutdown required by the plant's Technical Specifications. The Station currently has all three offsite power supplies and the Supplemental Emergency Power System operable."

The licensee is in the process of shutting down and is currently at 60% power at a 20%/hr ramp rate with the intention of entering Mode 3.

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT INVOLVING HIGHER THAN PRESCRIBED DOSE

On August 31, 2006 a female patient received mammosite treatment for a breast lesion using a HDR with an Ir-192 source. The treatment consisted of placing a catheter into the treatment site, inflating a balloon with between 35-75 ml saline and positioning the Ir-192 source inside the catheter into the center volume of the saline balloon. This allows for a homogenous dose to the treatment site. While in the OR (Operating Room), the catheter was inserted and saline introduced through one of the two catheter connections to inflate the balloon. The patient was taken to the HDR location where the technologist inadvertently connected the HDR to the saline vice the HDR connector. This resulted in draining the saline balloon into the HDR unit. The technologist recognized that the HDR was improperly connected, broke the connection and reconnected to the proper port. When the prescribed 416 second treatment was commenced, the HDR automatically shutdown after 223 seconds retracting the Ir-192 source to the safe position. An evaluation by the licensee concluded that the incident was not reportable since it did not meet the criteria for an underdose.

During an inspection conducted 7/26/07 (Inspection Report No. 2007-001), the NRC Inspector noted that since the saline balloon had been inadvertently drained tissue in a .5 cubic centimeter volume adjacent to the source received a significantly higher dose (approximately 20 Gray) than prescribed. In a follow-up call from NRC Region I on 10/03/07, the licensee was requested to notify the NRC Operations Center of this finding.

The licensee informed the prescribing physician and the patient was also notified. No adverse effects to the patient have been noted.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.