Event Notification Report for July 17, 2007

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The State provided the following information via email:

"At approximately 9:00 AM July 17, 2007, the Agency was informed that the Licensee had a gauge in a pickup truck traveling north from 67 Avenue and Lower Buckeye to I-10 noticed at the I-10 ramp the gauge was missing. He began the trip at approximately 7:00 AM. The Gauge case was secured in the truck as required. He did not put the gauge in the case however. The gauge is a Troxler Model 3430, Serial Number 39005 and contains 8 mCi of Cesium-137 and 40 mCi Am:Be-241. The Company plans a press release and will offer a reward for the gauge.

"Phoenix PD is investigating.

"The Agency continues to investigate this event.

"The states of CA, NV, CO, UT, and NM and Mexico and U.S. NRC and FBI are being notified of this event."

Arizona report number: 07-010

* * * UPDATE PROVIDED BY AUBREY V. GODWIN TO JASON KOZAL ON 07/27/07 AT 1306 EDT * * *

"The gauge has been recovered. It was found by a street sweeper. It was not opened and no radiation exposures appear to have occurred.

"The states of CA, NV, CO, UT, and NM and Mexico and U.S. NRC and FBI are being notified of this event."

Notified the R4DO (Smith), FSME (Thorp), ILTAB (via e-mail) , Mexico (e-mail).

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.

UNANALYZED CONDITION - VENT SPACE LESS THAN DESIGN BASIS

"During a review of the temporary repair of the steam line drain bypass line in the Unit 1 Reactor Building Steam Chase, two storage gangboxes were noted to be on the grated opening in the floor of the Steam Chase (elevation 129 ft). These grated openings are designed to be open to provide pressure and temperature relief between the steam chase and the torus room for high energy steam line breaks.

"Appendix N to the Unit 1 FSAR credits the openings for venting the steam chase to the torus room through the openings for a main steam line break, and for venting the torus room to the steam chase for a HPCI steam line break in the torus room. The most limiting event is the HPCI steam line break in the torus room and the vent path associated with that event. Original assumptions used in the calculation for the vent opening did not adequately account for the grating itself and for louvers installed in a previous plant modification. As a result the vent area was further reduced.

"Upon further review of the above condition, it has been determined that a non-conforming and unanalyzed condition exists In that the vent area between the torus room and main steam chase in the reactor building is less than the area assumed in the analysis, even without gangboxes covering a portion of the grating.

"As such, for a HPCI steam line break in the torus room, the short term pressure between the torus room and the corner rooms (diagonals) is greater than 2 psid, which is the stated limit in Appendix N of the Unit 1 FSAR. The corner rooms contain ECCS components in the RHR and core spray systems. Based on engineering judgment there is reasonable assurance that the present nonconforming condition does not prevent safety systems and structures from fulfilling their safety function. This is based on the following information:

"Structural Steel floor elevation platforms do not appear to have been credited in the structural design capability of the walls. These platforms should act to help maintain the wall intact with increased pressure. The increased pressure transient is a very short term transient, approximately 2-3 seconds in duration, after which the pressure will return to within 2 psid. It is expected that the wall would withstand this transient without degrading the performance of the low pressure ECCS systems or other structures and components. Lastly, the probability of occurrence of a steam leak leading to an instantaneous line break is very small. There is currently no report of steam leaks from the HPCI line, and although a probability evaluation has not been performed, it is likely that the probability of occurrence of such a break is very small. Thus, there is no known immediate threat that would prevent safety systems from performing their safety function. More detailed review is continuing at this point.

"Short term corrective action will be required to increase the open 'vent' area between the torus room and the reactor building 130 ft elevation and restore at least the assumed vent path from the torus room. This can be accomplished by removing the gangboxes over the vent area in the steam chase and/or completing a floor plug evaluation of vent area needed between the torus room and the reactor building 130 ft elevation which will restore compliance with the 2 psid criteria. Analysis is currently underway to assess the pressure and temperature effects on the safety related structures and equipment by these short term actions.

"Regarding reportability, based on engineering judgment as previously discussed, the unanalyzed condition does not represent a condition that significantly degraded plant safety; however, additional information is needed in order to more conclusively determine this. For this reason this condition is being conservatively reported under 10CFR50.72(b)(3)(ii)(B) until such time as more conclusive information is provided to make the final determination."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM GORLEY TO HUFFMAN AT 1435 EDT ON 8/30/07 * * *

"Upon further review of the above 'as found' conditions, it has been determined that there are existing conservatisms in the current analysis which bound the flow restriction caused by the gang boxes on the grating. The evaluation concluded that the gang boxes found on the grated opening in the floor of the steam chase would not increase the pressures in the Unit 1 reactor building as a result of HELB conditions. Thus the pressure between the torus room and the corner rooms (diagonals) which is limited to 2 psid as stated limit in Appendix N of the Unit 1 FSAR is not affected. In addition, an additional open floor plug (the 3 ft by 3 ft floor plugs between Elevation 130 and the torus room below found to be covered by a hinged metal plate) is acceptable since it causes less differential pressure across reactor building compartments during the HELB's evaluated.

"The results of this additional review confirmed the original engineering judgment that there was reasonable assurance that the as found nonconforming condition did not prevent safety systems and structures from fulfilling their safety function. Short term corrective actions were completed upon discovery of he 'as found' condition to further increase the open 'vent' area between the torus room and the reactor building 130 ft elevation and restore at least the assumed vent path from the torus room. This was accomplished by removing the gang boxes over the vent area in the steam chase.

"Based on this review of the design calculations white taking the 'as found' conditions into consideration, the conclusion reached is that the nonconforming 'as found' conditions did not represent a condition that significantly degraded plant safety. For this reason this condition that was initially reported under 10CFR50.72(b)(3)(ii)(B) is being retracted."

The licensee will notify the NRC Resident Inspector. R2DO (Shaeffer) notified.

FIRE INSIDE OF OWNER CONTROL AREA

"A small fire was discovered in an office building outside the protected area. The fire was extinguished using a hand held water fire extinguisher. The office building was evacuated as a precaution. One individual received a minor burn and was tended to by an onsite EMT. Local fire department responded to assist in smoke removal. EAL classification did not apply since the fire was outside the protected area. Fire was reported to be a trash can fire with fire damage being limited to the trash can, adjacent wall, and ceiling tile. Courtesy notifications to state and local government agencies have been made."


The licensee notified the NRC Resident Inspector.

AUTOMATIC REACTOR SCRAM ON LOW REACTOR VESSEL WATER LEVEL (RVWL)

"An automatic reactor scram occurred at 0522 on 07/17/07 due to a low reactor water level, following a trip of the 'C' Reactor Feed Pump. Reactor water level lowered to the low-low level setpoint and a reactor isolation occurred. Reactor level has been returned to the normal band and a reactor cooldown has been initiated using isolation condensers."

The cause of the "C" RFP trip is attributed to an electrical fault as sensed on ground sensing and differential sensing instrumentation. No flames or smoke was observed, however, operators reported an acrid smell of insulation. Following the automatic scram on low reactor water level [138" above top of active fuel (TAF)], level continued to decrease to the low-low setpoint of 86" TAF resulting in a reactor isolation signal. The reactor isolation signal initiates closure of the Main Steam Isolation Valves (MSIVs), trip of the Recirc Pumps and actuation of the Isolation Condensers. Current reactor pressure is 520 psig with a cooldown rate of 82F/hr. The licensee plans to issue a press release and will take the Unit to cold shutdown for repairs.

The licensee informed the NRC Resident Inspector.

* * * UPDATE AT 1000 EDT ON 07/17/07 FROM STEVE FULLER TO S. SANDIN * * *

The following information reported under 10CFR50.72(b)(3)(iv)(A) was provided as an update:

"The following systems actuated upon receipt of a lo-lo reactor water level signal, subsequent to the reactor scram, reported under EN #43495, which occurred at 0522 on 07/17/07:

MSIVs - Isolation
Isolation Condensers - Initiation
Standby Gas Treatment - Initiation
Recirc Pumps - Trip
Containment Valves - Isolation
Core Spray - Start, but no injection
Containment Spray - Manual initiation only, following use of EMRVs to control Rx pressure, causing elevated Torus water temperature."

The licensee informed the NRC Resident Inspector. Notified R1DO (Krafty).

* * * UPDATE AT 1122 EDT ON 7/17/07 FROM STEVE FULLER TO S. SANDIN * * *

The following information reported under 10CFR50.72(b)(2)(xi) was provided as an update:

"Notified the New Jersey D.E.P. of an unplanned plant shutdown which occurred at 0522 07/17/07. There was no environmental impact from the plant shutdown.

"This notification is required to be made within 12 hours of an unplanned plant shutdown."

The licensee informed the NRC Resident Inspector. Notified R1DO (Krafty).

TECHNICAL SUPPORT CENTER INOPERABLE DUE TO PLANNED RELOCATION

"On 07/17/07 at 0700 hours CDT the Monticello Nuclear Generating Plant's (MNGP) Technical Support Center (TSC) will begin relocation to a new facility. The relocation activities include implementation of compensatory measures to maintain the TSC functions during the transition. The compensatory measures include having the Emergency Director report to the Control Room and co-locating the remaining TSC staff at the EOF should an event declared requiring Emergency Response Organization (ERO) activation. The ERO has previously successfully demonstrated the ability to implement these compensatory measures. The relocation and testing of equipment in the new TSC are scheduled to be complete[d] on or before 07/23/07.

"The site Emergency Response Organization has been notified of the relocation and instructed on the planned compensatory measures to be implemented during the move. MNGP will notify the NRC upon completion of the relocation and declaration of TSC operability in the new location. This event is considered reportable per 10 CFR 50.72 (b)(3)(xiii). The licensee has notified the NRC Resident Inspector."


* * * UPDATE ON 07/19/07 AT 1546 EDT FROM GERALD HOLTHAUS TO MACKINNON * * *

"On 07/19/07 at 1400 hours CDT the Monticello Nuclear Generating Plant's Technical Support Center (TSC) was declared operable after its relocation to a new facility. Relocation and testing activities have been completed and the Emergency Response Organization has been notified of the cessation of compensatory measures.

NRC R3DO (Eric Duncan) notified.

"The licensee has notified the NRC Resident Inspector."

AGREEMENT STATE REPORT - SIX LOST PALLADIUM - 103 SEEDS

The following information was received via e-mail:

"This is notification of an event in Washington State as reported to the WA Department of Health, Office of Radiation Protection.

"STATUS: Update/Closed
"Licensee: Swedish Medical Center
"City and State: Seattle, Washington
"License Number: WN-M008-1
"Type of License: Broad, Medical
"Date and time of Event: July 17, 2007, about 10 am.
"Location of Event: First Hill Campus, Operating Room, Seattle WA.

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"The licensee reported that beginning at 7:30 am on July 17, 2007; they administered 96 of 102 Palladium-103, prostate cancer therapy seeds. The 6 remaining seeds were counted and placed in a glass storage vial. The vial was labeled and put into a leaded storage container and then placed in the procedure room source storage area.

"At 10 am, it was noted that only a single storage vial was present where two were expected since two cases had been completed by that time. The rooms, waste containers and other items and adjacent areas were searched and surveyed. A survey of the biohazard storage room was also conducted with no readings above background detected at any of the locations. Others involved with the implants searched and were also unable to find the seeds.

"At 2:30 pm the RSO was notified. Another search and survey with a Ludlum Model 2221 scaler/rate meter using a model 44-3 probe was conducted at that time. An on site search through the trash compactor of approximately ¼ of the total waste in the compactor was also unsuccessful at finding them. The staff reviewed the implant records and determined that 6 seeds were still missing. At 8:50 pm, the RSO stopped the search and declared the seeds lost. At approximately 9:20 pm, the RSO transmitted an electronic notification to Washington DOH regarding the 6 missing prostate seeds.

"On July 18, 2007, at 8:30 am, the RSO learned the majority of the linens from the previous day's procedure were still on the loading dock. The RSO had the linen carts segregated and conducted a search and survey. The RSO completed this search and did not find the seeds in the linens. The off site laundry facility was contacted. The laundry facility manager indicated that no containers were found and they would be on the lookout for such a container.

"After reviewing the timeline and interviewing staff regarding the events, the RSO has determined the cause of the event was inattention to detail and human error on the part of the staff responsible for seed count and reconciliation.

"An analysis of the seed count and reconciliation process indicates that keeping the unused seeds in the procedure room until all cases for the day have been completed may have contributed to this event. The RSO has immediately required that at the completion of each individual procedure the unused seeds are removed from the procedure room and an independent count of the seeds conducted. This is to be performed before the next case occurs to allow immediate survey of the procedure room in the event the seed count cannot be reconciled. The RSO also has stipulated that trained staff must be present for all procedures while seeds are in use.

"The RSO has scheduled training for July 26, 2007 to review this event with all operating room staff involved with this procedure. The RSO will also review the procedural changes that have occurred as a consequence of this event. Immediately contacting the RSO will also be emphasized to other users of radioactive material at their periodic radiation safety training and to new users during their orientation.

"The department considered the licensee to have made every reasonable effort to locate the seeds. Therefore the department did not conduct an on-site investigation.

"Notification Reporting Criteria: WAC 246-221-240 Reports of Stolen, Lost, or Missing Radiation Sources .
"Isotope and Activity involved: Palladium-103 seeds (six), 1.08 mCi/seed average.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): No
"Lost, Stolen or Damaged? (mfg., model, serial number): LOST: Six Palladium-103 therapy seeds (no SN's), TheraSeed model 200 , manufactured by TheraGenics, 1.08 mCi/seed average, total of 6.48 mCi.
"Disposition/recovery: Irretrievably lost, no recovery expected.
"Leak test? N/A
"Vehicle: N/A.
"Release of activity? Other than the loss of the 6 seeds, none.
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual): consequences: None expected.
"Was patient or responsible relative notified? No.
"Was written report provided to patient? No.
"Was referring physician notified? Yes, on July 18, 2007.
"Consultant used? No.

Washington Report: WA-07-068

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.

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