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Event Notification Report for November 30, 2001

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/29/2001 - 11/30/2001

                              ** EVENT NUMBERS **

38520  38522  38523  38524  38525  
.
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|General Information or Other                     |Event Number:   38520       |
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| REP ORG:  TENNESSEE DIV OF RAD HEALTH          |NOTIFICATION DATE: 11/28/2001|
|LICENSEE:  TRI-STATE TESTING AND DRILLING, INC. |NOTIFICATION TIME: 11:50[EST]|
|    CITY:  CHATTANOOGA              REGION:  2  |EVENT DATE:        11/28/2001|
|  COUNTY:                            STATE:  TN |EVENT TIME:        06:00[EST]|
|LICENSE#:  R-33105               AGREEMENT:  Y  |LAST UPDATE DATE:  11/28/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |EDWARD MCALPINE      R2      |
|                                                |FRED BROWN          NMSS     |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DEBRA SHULTS (fax)           |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                           
       
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| AGREEMENT STATE REPORT REGARDING A TRI-STATE TESTING AND DRILLING, IN C.  
  |
| TROXLER MOISTURE DENSITY GAUGE STOLEN IN CHATTANOOGA, TENNESSEE            
 |
|                                                                              |
| The following text is a portion of a facsimile received from the State of    |
| Tennessee, Department of Environment and Conservation, Division of           |
| Radiological Health:                                                         |
|                                                                              |
| "Event Report ID No.:  TN-01-217"                                            |
|                                                                              |
| "License Number:  R-33105"                                                   |
|                                                                              |
| "Licensee:  Tri-State Testing and Drilling, Inc."                            |
|                                                                              |
| "Event date and time:  November 28, 2001, approx. 0600 EST"                  |
|                                                                              |
| "Event location:  Chattanooga, TN"                                           |
|                                                                              |
| "Event type:  Stolen moisture density gauge"                                 |
|                                                                              |
| "Notifications:  Tennessee Emergency Management Agency, USNRC Region II,     |
| Alabama Office of Radiation Control, Georgia Radioactive Materials Program,  |
| Chattanooga Police Department"                                               |
|                                                                              |
| "Media interest:  None at this time.  A press release is being issued by     |
| TDEC."                                                                       |
|                                                                              |
| "Event description:  Tri-State Testing and Drilling. Inc. reported a Troxler |
| moisture density gauge, Model 3440, SN 17252, containing 8 millicuris of     |
| Cesium-137 and 40 millicuries of Americium-241:Beryllium, was stolen from    |
| the bed of a pickup truck early this morning.  The gauge was chained in the  |
| back of the truck parked at an employees residence.  Thieves cut the chain   |
| and removed the locked container.  State DRH inspectors are onsite           |
| investigating at this time."                                                 |
|                                                                              |
| (Call the NRC operations officer for contact information.)                   |
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|Other Nuclear Material                           |Event Number:   38522       |
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| REP ORG:  US GEOLOGICAL SURVEY                 |NOTIFICATION DATE: 11/29/2001|
|LICENSEE:  US GEOLOGICAL SURVEY                 |NOTIFICATION TIME: 11:00[EST]|
|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        11/19/2001|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MST]|
|LICENSE#:  05-01399-08           AGREEMENT:  Y  |LAST UPDATE DATE:  11/29/2001|
|  DOCKET:                                      |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |FRED BROWN          NMSS     |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DARRELL LILES                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                           
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| RADIOACTIVE SHIPMENT SHIPPED AS EXCEPTED PACKAGE - LIMITED
QUANTITYINSTEAD   |
| OF DOT 7A YELLOW II                                                          |
|                                                                              |
| The following text describes a mislabeled package shipped via FedEx:         |
|                                                                              |
| "Summary of Incident:                                                        |
|                                                                              |
| 11/19/2001:  Samples were irradiated for McCrone & Associates Inc. by the US |
| Geological Survey TRIGA Reactor staff. (Facility license R-1 13, docket      |
| 50-274).  After irradiation, the samples were surveyed with an ion chamber   |
| and analyzed with a germanium detector for nuclide determination. The ion    |
| chamber had been response checked that morning. The samples were packaged in |
| Type A shipping container (juice can) that was placed inside a cardboard     |
| box.  Radiation surveys on the package were conducted using the same ion     |
| chamber as before, and contamination surveys were also conducted.  All       |
| radiation/contamination surveys and isotope activities indicated an excepted |
| package-limited quantity radioactive shipment. These readings were           |
| consistent with prior sample irradiations performed for McCrone &            |
| Associates. The package, reading 0.42 mr/hr on the surface was sent from     |
| Denver, CO to McCrone and Associates Inc (in a Chicago suburb) via FedEx     |
| overnight.                                                                   |
|                                                                              |
| 11/20/2001:  McCrone's Radiation Safety Officer notified USGS Reactor staff  |
| that the package containing the samples had been received and the surface of |
| the box read 4 mr/hr with their Geiger-Mueller pancake detector.  No         |
| contamination was found on the package. The package was opened only to       |
| remove the paperwork and then was placed behind lead shielding.              |
|                                                                              |
| The calibration of the USGS meter that was used to survey the outgoing       |
| package was checked and the meter was found to be defective.  A good USGS    |
| ion chamber was sent via FedEx overnight to McCrone to get comparison        |
| readings.                                                                    |
|                                                                              |
| 11/21/2001:   Radiation readings were taken on top of the Type A container   |
| (inner package) with McCrone's detector (3.0 mr/hr) and with USGS detector   |
| (1.8 mr/hr).                                                                 |
|                                                                              |
| Calculations were performed to estimate the radiation levels on the surface  |
| of the package and the transport index when it was shipped. These            |
| calculations were based on the half-life of Na-24, the predominant isotope,  |
| and the readings taken by McCrone & Associates approximately 19 hours after  |
| the package was shipped by USGS. These calculations indicate the package     |
| read approximately 5.8 mr/hr on the surface and had a transport index of 0.1 |
| at the time of shipment. With a transport index of 0.1 and shipment time of  |
| 19 hours (allowing 5 hours for flight) a person at one meter from the        |
| package the total 14 hours would receive 1.4 mrem. We believe this           |
| calculation represents a very conservative maximum exposure received from    |
| the package by any one individual during the shipment.                       |
|                                                                              |
| FedEx was notified of the mislabeled package (Harold Brooks with the         |
| Dangerous Goods Department). The State of Illinois has also been notified by |
| McCrone and Associates personnel. The shipping department of the USGS at the |
| Denver Federal Center has also been notified of the incident.                |
|                                                                              |
| Conclusions:                                                                 |
|                                                                              |
| No radioactivity was released from the package. FedEx workers received an    |
| estimated 1.4 person-mrems during shipment of this package.                  |
|                                                                              |
| Follow-up:                                                                   |
|                                                                              |
| Further investigations will be performed to determine actions that can be    |
| taken to prevent similar incidents from occurring in the future. A           |
| comprehensive written report will be submitted by December 3, 2001."         |
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|General Information or Other                     |Event Number:   38523       |
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| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 11/29/2001|
|LICENSEE:  ROMAGOSA ONCOLOGY                    |NOTIFICATION TIME: 16:45[EST]|
|    CITY:  NEW IBERIA               REGION:  4  |EVENT DATE:        11/28/2001|
|  COUNTY:                            STATE:  LA |EVENT TIME:             [CST]|
|LICENSE#:  LA-0978-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  11/29/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON       R4     |
|                                                |LARRY CAMPER        NMSS     |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BLACKWELL (FAX)              |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                           
       
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| STATE LICENSEE REPORTED A MEDICAL MISADMINISTRATION                          |
|                                                                              |
| A patient was being treated with a brachytherapy dose of Ir-192. The Ir-192  |
| was 6.6 Ci.  The facility was performing multiple fractions.  Each fraction  |
| was supposed to be 440 centigray.  Fraction 5 of 6 was 269 centigray, which  |
| is more than a 20% difference.   The individual making the notification      |
| stated that another directive would be written for the sixth fraction so     |
| that the patient receives the full 2640 centigray dose.                      |
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|General Information or Other                     |Event Number:   38524       |
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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 11/29/2001|
|LICENSEE:  COMPUTALOG WIRELINE PRODUCTS INC     |NOTIFICATION TIME:
16:48[EST]|
|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        11/29/2001|
|  COUNTY:                            STATE:  TX |EVENT TIME:        06:50[CST]|
|LICENSE#:  L00747                AGREEMENT:  Y  |LAST UPDATE DATE:  11/29/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON       R4     |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  OGDEN                        |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                  EVENT TEXT                           
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| TRANSPORTATION INCIDENT INVOLVING A TEXAS STATE LICENSEE                     |
|                                                                              |
| Ice on bridge caused car in left lane to loose control.  Car following       |
| swerved into right lane in front of wireline truck traveling approximately   |
| 30 mph. Truck could have hit car or move to edge of road, which it did and   |
| ended up in the ditch.   The truck laid over on it's right side with minor   |
| damage to right side of the vehicle - mirror and glass.   No damage to       |
| sources which were secured in Pigs welded to the floor and wall of the       |
| vehicle.  The vehicle is to be up-righted and towed to Houston for repairs.  |
| RSO for Licensee is on-site and has assessed sources as un-damaged and       |
| secure in their storage Pigs.  The sources carried by the truck are a Well   |
| logging calibration stick(Ra-226), calibration bar(Am-241/Be/Cs-137), a      |
| Cs-137 well logging source and a Am-241/Be well logging source.  Only minor  |
| injuries were received by the two occupants of the truck.  Activity readings |
| were normal for the truck.                                                   |
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|Power Reactor                                    |Event Number:   38525       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 11/29/2001|
|    UNIT:  [1] [2] []                STATE:  WI |NOTIFICATION TIME: 18:07[EST]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        11/29/2001|
+------------------------------------------------+EVENT TIME:        15:38[CST]|
| NRC NOTIFIED BY:  MEYER                        |LAST UPDATE DATE:  11/29/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON         ORGANIZATION  |
|EMERGENCY CLASS:          NON EMERGENCY         |BRUCE JORGENSEN      R3      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                  
+------------------------------------------------------------------------------+
| A LOSS OF INSTRUMENT AIR MAY CAUSE A POTENTIAL COMMON MODE FAILURE FOR
ALL   |
| AUXILIARY FEEDWATER PUMPS.                                                   |
|                                                                              |
| Instrument Air (IA) can be lost primarily by two failure mechanisms. The     |
| first, and most likely, is a loss of off-site power where the IA and Service |
| Air (SA) compressors are stripped from the bus and not automatically         |
| re-loaded.  The second less likely scenario is a random loss of the          |
| instrument air system due to equipment failure without potential for short   |
| term recovery. When IA is lost, the minimum flow recirculation valves for    |
| AFW fail closed.                                                             |
|                                                                              |
| During these two transients, the AFW pumps will start injecting into the     |
| steam generators.  Early in the EOP's, the operator is directed to control   |
| flow to the steam generators to maintain desired level.  This may include    |
| shutting off flow to one or both steam generators if level is above the      |
| desired band.  If flow from any auxiliary feed pump is reduced too low (as   |
| would occur if the auxiliary feed regulating valves are closed) without      |
| functional recirculation valves, the pump will fail in a very short period   |
| of time.  This common mode of failure (common loss of instrument air and     |
| common response to high steam generator level) could result in simultaneous  |
| failure of all AFW pumps.                                                    |
|                                                                              |
| The Auxiliary Feedwater system has passed all required testing and is        |
| currently fully operable and capable of performing its safety function.  It  |
| is only under the specific circumstances outlined above that a failure of    |
| Auxiliary Feedwater may occur.  The licensee is taking interim corrective    |
| actions in the form of Operating Crew briefs to ensure Auxiliary Feedwater   |
| is not damaged under Loss of Air conditions and is evaluating procedural and |
| equipment design changes to provide a permanent correction to Aux.           |
| Feedwater.                                                                   |
|                                                                              |
| The NRC Resident Inspector will be notified.                                 |
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