Event Notification Report for April 24, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/23/2007 - 04/24/2007
EVENT NUMBERS
4332143315433164331743327
General Information or Other
Event Number: 43321
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: MEMORIAL MISSION HOSPITAL
Region: 1
City: ASHVILLE State: NC
County:
License #: 011-0091-6
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: BILL HUFFMAN
Licensee: MEMORIAL MISSION HOSPITAL
Region: 1
City: ASHVILLE State: NC
County:
License #: 011-0091-6
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2007
Notification Time: 18:19 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 04/26/2007
Notification Time: 18:19 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 04/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1)
ROBERT PIERSON (NMSS)
JAMES TRAPP (R1)
ROBERT PIERSON (NMSS)
AGREEMENT STATE REPORT - NORTH CAROLINA - MISADMINISTRATION OF IODINE-131
The State provided the following information via facsimile:
The State of North Carolina was notified on 4/26/07 of a misadministration of diagnostic Iodine-131. The event involved a "misdrawn and mislabeled dose from Shertech Pharmacy in Ashville NC (NC licensee 011-1203-1). The written directive [from the hospital] was for 30 microcuries for a diagnostic thyroid scan but 33.9 millicuries was delivered labeled as 33.9 microcuries. Nuclear Medical Technologist at Memorial Mission missed the error because they read the numbers (33.9) but not the units (millicuries vs. microcuries). Dose was administered on 4/24/07 and the error was found on 4/26/07. Patient and physician notified. Licensee is following up with Shertech." No information is available on any potential medical impact of the misadministration on the patient.
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.
The State provided the following information via facsimile:
The State of North Carolina was notified on 4/26/07 of a misadministration of diagnostic Iodine-131. The event involved a "misdrawn and mislabeled dose from Shertech Pharmacy in Ashville NC (NC licensee 011-1203-1). The written directive [from the hospital] was for 30 microcuries for a diagnostic thyroid scan but 33.9 millicuries was delivered labeled as 33.9 microcuries. Nuclear Medical Technologist at Memorial Mission missed the error because they read the numbers (33.9) but not the units (millicuries vs. microcuries). Dose was administered on 4/24/07 and the error was found on 4/26/07. Patient and physician notified. Licensee is following up with Shertech." No information is available on any potential medical impact of the misadministration on the patient.
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.
Power Reactor
Event Number: 43315
Facility: LIMERICK
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: NED DENNIN
HQ OPS Officer: STEVE SANDIN
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: NED DENNIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/24/2007
Notification Time: 04:04 [ET]
Event Date: 04/24/2007
Event Time: 02:10 [EDT]
Last Update Date: 04/24/2007
Notification Time: 04:04 [ET]
Event Date: 04/24/2007
Event Time: 02:10 [EDT]
Last Update Date: 04/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(2)(iv)(A) - ECCS INJECTION 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)(2)(iv)(A) - ECCS INJECTION 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES TRAPP (R1)
JAMES TRAPP (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM WITH ECCS INJECTION ON LOWERING REACTOR VESSEL WATER LEVEL
"Limerick Unit 2 automatically shutdown on low reactor water level (+12.5 inches) at 0210 on 4/24/07. The cause is under investigation at this time.
"All control rods inserted as required. HPCI and RCIC initiated, injected and restored reactor water level. Lowest reactor water level noted was -73 inches.
"Primary containment isolation signals on +12.5 inches and -38 inches occurred. All isolations completed as required."
"The plant is currently in hot shutdown maintaining normal reactor level with feedwater in service."
Approximately 16000 gallons was injected in 4 minutes. There was no indication of RCS leakage. The licensee is investigating whether a feedwater runback had occurred. No SRVs lifted with the highest pressure observed at 1050 psi. The main condenser remains in service for decay heat removal. All EDGs are available, if needed.
The licensee informed the NRC Resident Inspector and will inform both the State and Local authorities.
"Limerick Unit 2 automatically shutdown on low reactor water level (+12.5 inches) at 0210 on 4/24/07. The cause is under investigation at this time.
"All control rods inserted as required. HPCI and RCIC initiated, injected and restored reactor water level. Lowest reactor water level noted was -73 inches.
"Primary containment isolation signals on +12.5 inches and -38 inches occurred. All isolations completed as required."
"The plant is currently in hot shutdown maintaining normal reactor level with feedwater in service."
Approximately 16000 gallons was injected in 4 minutes. There was no indication of RCS leakage. The licensee is investigating whether a feedwater runback had occurred. No SRVs lifted with the highest pressure observed at 1050 psi. The main condenser remains in service for decay heat removal. All EDGs are available, if needed.
The licensee informed the NRC Resident Inspector and will inform both the State and Local authorities.
General Information or Other
Event Number: 43316
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ROOFING CONSULTANTS LTD
Region: 3
City: CRETE State: IL
County:
License #: 133-1249-01
Agreement: Y
Docket:
NRC Notified By: JASON HUNT
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ROOFING CONSULTANTS LTD
Region: 3
City: CRETE State: IL
County:
License #: 133-1249-01
Agreement: Y
Docket:
NRC Notified By: JASON HUNT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/24/2007
Notification Time: 17:11 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [CDT]
Last Update Date: 04/24/2007
Notification Time: 17:11 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [CDT]
Last Update Date: 04/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LAURA KOZAK (R3)
KEITH McCONNELL (FSME)
ILTAB (E-MAIL)
LAURA KOZAK (R3)
KEITH McCONNELL (FSME)
ILTAB (E-MAIL)
MOISTURE DENSITY GAUGE STOLEN
The State provided the following information via email:
"On Tuesday, April 24, 2007, the State of Wisconsin, Department of Health and Family Services, Radiation Protection Section was notified that a CPN Model MCM-2 roofing gauge, containing 50 mCi of Am-241 had been reported stolen near Crete, Illinois. The Department was notified because the gauge is under ownership of a State of Wisconsin company. The gauge appears to have been in the State of Illinois under the control of a company employee that resides in Illinois and is performing work at a client's location in Illinois. The owner did not file for reciprocity with the State of Illinois.
"Upon further investigation by the Department, the Department learned that the owner of the gauge does not have a proper Wisconsin Radioactive Material License. The owner received the gauge in a transfer of ownership when the past owner (a Wisconsin Radioactive Material License, #133-1249-01, Roofing Consultants LTD) sold the company to the current owner. The name of the company did not change when the ownership changed occurred, so the company is still operating under the name of Roofing Consultants LTD. The State of Wisconsin is currently investigating this transfer of ownership.
"The State of Illinois has been contacted concerning this incident and is in contact with the Will County Sheriff Department. The State of Illinois and the State of Wisconsin will continue to investigate this incident."
Wisconsin Event Number: 07-009
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.
The State provided the following information via email:
"On Tuesday, April 24, 2007, the State of Wisconsin, Department of Health and Family Services, Radiation Protection Section was notified that a CPN Model MCM-2 roofing gauge, containing 50 mCi of Am-241 had been reported stolen near Crete, Illinois. The Department was notified because the gauge is under ownership of a State of Wisconsin company. The gauge appears to have been in the State of Illinois under the control of a company employee that resides in Illinois and is performing work at a client's location in Illinois. The owner did not file for reciprocity with the State of Illinois.
"Upon further investigation by the Department, the Department learned that the owner of the gauge does not have a proper Wisconsin Radioactive Material License. The owner received the gauge in a transfer of ownership when the past owner (a Wisconsin Radioactive Material License, #133-1249-01, Roofing Consultants LTD) sold the company to the current owner. The name of the company did not change when the ownership changed occurred, so the company is still operating under the name of Roofing Consultants LTD. The State of Wisconsin is currently investigating this transfer of ownership.
"The State of Illinois has been contacted concerning this incident and is in contact with the Will County Sheriff Department. The State of Illinois and the State of Wisconsin will continue to investigate this incident."
Wisconsin Event Number: 07-009
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.
Power Reactor
Event Number: 43317
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN OSBORNE
HQ OPS Officer: JOHN KNOKE
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN OSBORNE
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/25/2007
Notification Time: 01:33 [ET]
Event Date: 04/24/2007
Event Time: 22:48 [EDT]
Last Update Date: 04/25/2007
Notification Time: 01:33 [ET]
Event Date: 04/24/2007
Event Time: 22:48 [EDT]
Last Update Date: 04/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JAMES TRAPP (R1)
JAMES TRAPP (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 100 | Power Operation | 0 | Hot Standby |
MANUAL TRIP DUE TO LOSS OF CIRCULATORS
"A manual trip of Salem Unit 1 was initiated due to a loss of circulators from heavy grassing at the circulating water intake. All rods fully inserted on the trip and all systems responded as designed with decay heat being removed via the steam dump system. All Auxiliary Feedwater pumps automatically started as expected on low steam generator levels from the trip.
"The unit had previously entered the abnormal operating procedure for circulating water due to two circulators being out of service; one had previously emergency tripped due to high traveling water screen differential pressure and a second had been out of service for condenser waterbox cleaning. Alarms were received indicating rapid rising differential pressure on the remaining four in-service circulators' traveling water screens.
"In accordance with the abnormal procedure, the Control Room Supervisor directed the tripping of the circulators and the reactor. There were no complications encountered as a result of the trip and all equipment operated as expected. The operating crew stabilized the plant at no load conditions. Salem Unit 1 is currently in Mode 3 with RCS at normal operating temperature and pressure. Actions are being taken to return the circulators to service."
Unit 2 was not affected at this time and is operating at 100% power.
The licensee notified the NRC Resident Inspector and the local township Licensee will be issuing a press release.
*** UPDATE FROM LICENSEE(MEEKINS) TO KNOKE AT 0853 EDT ON 04/25/07 ***
The power level was at 40% when the manual trip occurred and not 100% as previously reported.
Notified R1DO (Trapp)
"A manual trip of Salem Unit 1 was initiated due to a loss of circulators from heavy grassing at the circulating water intake. All rods fully inserted on the trip and all systems responded as designed with decay heat being removed via the steam dump system. All Auxiliary Feedwater pumps automatically started as expected on low steam generator levels from the trip.
"The unit had previously entered the abnormal operating procedure for circulating water due to two circulators being out of service; one had previously emergency tripped due to high traveling water screen differential pressure and a second had been out of service for condenser waterbox cleaning. Alarms were received indicating rapid rising differential pressure on the remaining four in-service circulators' traveling water screens.
"In accordance with the abnormal procedure, the Control Room Supervisor directed the tripping of the circulators and the reactor. There were no complications encountered as a result of the trip and all equipment operated as expected. The operating crew stabilized the plant at no load conditions. Salem Unit 1 is currently in Mode 3 with RCS at normal operating temperature and pressure. Actions are being taken to return the circulators to service."
Unit 2 was not affected at this time and is operating at 100% power.
The licensee notified the NRC Resident Inspector and the local township Licensee will be issuing a press release.
*** UPDATE FROM LICENSEE(MEEKINS) TO KNOKE AT 0853 EDT ON 04/25/07 ***
The power level was at 40% when the manual trip occurred and not 100% as previously reported.
Notified R1DO (Trapp)
Other Nuclear Material
Event Number: 43327
Rep Org: PLASTECH
Licensee: PLASTECH
Region: 3
City: FOWLERVILLE State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: PATRICIA DIETZEN
HQ OPS Officer: JOE O'HARA
Licensee: PLASTECH
Region: 3
City: FOWLERVILLE State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: PATRICIA DIETZEN
HQ OPS Officer: JOE O'HARA
Notification Date: 04/30/2007
Notification Time: 11:43 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 04/30/2007
Notification Time: 11:43 [ET]
Event Date: 04/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 04/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DAVE PASSEHL (R3)
GREG MORELL (FSME)
ILTAB (e-mail)
DAVE PASSEHL (R3)
GREG MORELL (FSME)
ILTAB (e-mail)
LOST STATIC ELIMINATOR
Plastech contacted the NRC Operations Center to inform us that they performed an inventory on 4/24/07 and identified that an Amstat Industries, Inc. static eliminator S/N A2DF555, Model - P2021-8101 was missing and presumed lost. The static eliminator has not been seen since November of 2006. The person providing the report said that the initial activity of the static eliminator was 10 milli Curies but did not know what isotope was used in the device. Typically Amstat Industries static eliminators use Polonium-210. The company recognized the loss during an inventory required to renew their lease.
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.
Plastech contacted the NRC Operations Center to inform us that they performed an inventory on 4/24/07 and identified that an Amstat Industries, Inc. static eliminator S/N A2DF555, Model - P2021-8101 was missing and presumed lost. The static eliminator has not been seen since November of 2006. The person providing the report said that the initial activity of the static eliminator was 10 milli Curies but did not know what isotope was used in the device. Typically Amstat Industries static eliminators use Polonium-210. The company recognized the loss during an inventory required to renew their lease.
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.