United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > June 27

Event Notification Report for June 27, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/26/2003 - 06/27/2003



                              ** EVENT NUMBERS **



39631  39922  39957  39961  



+------------------------------------------------------------------------------+

|Power Reactor                                    |Event Number:   39631       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 03/02/2003|

|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 16:00[EST]|

|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        03/02/2003|

+------------------------------------------------+EVENT TIME:        14:30[EST]|

| NRC NOTIFIED BY:  CHARLES PIKE                 |LAST UPDATE DATE:  06/26/2003|

|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |WALTER RODGERS       R2      |

|10 CFR SECTION:                                 |DAVID AYRES          R2      |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|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                                   

+------------------------------------------------------------------------------+

| OFFSITE NOTIFICATION TO STATE AGENCY OF EXPIRED GREEN SEA TURTLE FOUND AT    |

| BARRIER NET                                                                  |

|                                                                              |

| "NRC notification [is] being made due to state notification to [the] Florida |

| Wildlife Commission regarding a Green Sea Turtle found dead at barrier net   |

| pursuant to 10 CFR 50.72(b)(2)(xi)."                                         |

|                                                                              |

| The turtle was found on the surface at the barrier net with no injuries or   |

| abnormalities except for fresh cuts common for turtles coming through pipes. |

| The cause of death is unknown at this time. A necropsy is planned.           |

|                                                                              |

| The NRC Resident Inspector will be notified by the licensee.                 |

|                                                                              |

| * * * UPDATE ON 3/15/03 @ 1033 EST FROM TEREZAKIS TO CROUCH * * *            |

|                                                                              |

| "On 3-15-03, a green sea turtle was retrieved from the plant's intake canal. |

| The turtle was determined to be in need of rehabilitation.  The injuries to  |

| the turtle are not causal to plant operation. Per the plant's turtle permit, |

| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified at |

| 0920 EST.  This non-emergency notification is being made pursuant to 10 CFR  |

| 50.72(b)(2)(xi) due to the notification of FWCC."                            |

|                                                                              |

| The NRC Resident Inspector will be notified by the licensee.                 |

|                                                                              |

| * * * UPDATE ON 3/19/03 AT 1222 EST FROM E. SUMNER TO RIPLEY  * * *          |

|                                                                              |

| "On 03/19/03 @ 1105 hrs., one loggerhead turtle was retrieved from the       |

| plant's intake canal.  The turtle was determined to be in need of            |

| rehabilitation.  The injury to the turtle is not causal to plant operation.  |

| Per the plant's turtle permit, the Florida Fish and Wildlife Conservation    |

| Commission (FWCC) was notified at 1115 EST."                                 |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

|                                                                              |

| * * * UPDATED ON 3/31/03 AT 1159 EST FROM W.L. PARK TO A. COSTA * * *        |

|                                                                              |

| "On 3-31-03 [1105 EST], a loggerhead sea turtle was retrieved from the       |

| plant's intake canal. The turtle was determined to be in need of             |

| rehabilitation. The injuries to the turtle are not causal to plant           |

| operation. Per the plant's turtle permit, the Florida Fish and Wildlife      |

| Conservation Commission (FWCC) was notified at 1105 EST. This non-emergency  |

| notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to the     |

| notification of FWCC."                                                       |

|                                                                              |

| The NRC Resident Inspector will be notified.                                 |

|                                                                              |

| * * * UPDATE 1235EST ON 4/9/03 FROM ANDY TEREZAKIS TO S.SANDIN * * *         |

|                                                                              |

| "On 4-9-03, a loggerhead sea turtle was retrieved from the plant's Intake    |

| canal. The turtle was determined to be in need of rehabilitation. The        |

| injuries to the turtle are not causal to plant operation. Per the plant's    |

| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC)  |

| was notified at 1100 EST. This non-emergency notification is being made      |

| pursuant to 10CFR50.72(b)(2)(xi) due to the notification of FWCC."           |

|                                                                              |

| The licensee informed the NRC resident inspector.  Notified R2DO(Landis).    |

|                                                                              |

| *** UPDATE ON 5/2/03 AT 1826 FROM S. OEHRLE TO A. COSTA ***                  |

|                                                                              |

| "On 5/2/03, a green sea turtle was retrieved from the intake canal.  The     |

| turtle  required rehabilitation.  The injuries were not causal to plant      |

| operation.  Per the plant's turtle permit, the Florida Fish and Wildlife     |

| Conservation Commission was notified at 1445 EDT.  This non-emergency        |

| notification is being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to        |

| offsite notification."                                                       |

|                                                                              |

| The Licensee will notify the NRC Resident Inspector.  Notified R2DO          |

| (Munday).                                                                    |

|                                                                              |

| **** update on 05/24/03 at 1417 EDT FROM JOE HESSLING TO JOHN MACKINNON      |

| ****                                                                         |

|                                                                              |

| "On 5-24-03, a loggerhead sea turtle was retrieved from the plant's intake   |

| canal.  The turtle was determined to be in need of rehabilitation.  The      |

| turtle was very underweight and lethargic, no injuries or anomalies noted.   |

| Turtle's condition is not causal to plant operation.  Per the plant's turtle |

| permit the Florida Fish and Wildlife Conservation Commission (FWCC) was      |

| notified at 1345 EDT.  This non-emergency notification is being made         |

| pursuant to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC. NRC R2DO |

| (TOM DECKER) notified.                                                       |

|                                                                              |

| The NRC Resident Inspector was by notified of this event by the licensee.    |

|                                                                              |

| ****UPDATE ON 5/27/03 AT 10:49 FROM HESSLING TO LAURA****                    |

|                                                                              |

| "On 5-27-03, a loggerhead sea turtle was retrieved from the plant's intake   |

| canal. The turtle was determined to be in need of rehabilitation. The turtle |

| was underweight, and missing lower posterior marginals on left side.         |

| Turtle's injuries are not causal to plant operation. Per the plant's turtle  |

| permit, the Florida Fish and Wildlife Conservation Commission (FWCC) was     |

| notified at 0850 EDT. This non-emergency notification is being made pursuant |

| to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC."                  |

|                                                                              |

| Notified R2DO (T. Decker)                                                    |

|                                                                              |

| * * * UPDATE ON 06/17/03 AT 12:45 EDT FROM CALVIN WARD TO ARLON COSTA * * *  |

|                                                                              |

| "At approximately 12:45 p.m. on 6/17/03 a loggerhead turtle was rescued from |

| the St. Lucie Plant intake canal. The turtle was injured and will be         |

| transported to the State authorized sea turtle rehabilitation facility. The  |

| Florida Dept. of Environmental Protection (FDEP) was notified at 1:09 p.m.   |

| as required by the St. Lucie Plant Sea Turtle Permit - see the attached sea  |

| turtle stranding report (1 page).                                            |

|                                                                              |

| "Notification to the state government agency requires a four (4) Hr.         |

| Non-Emergency Notification to the NRC per 10 CFR 50.72(b)(2)(xi). There were |

| no unusual plant evolutions in progress which may have contributed to this   |

| event."                                                                      |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

|                                                                              |

| Notified R2DO (L. Wert).                                                     |

|                                                                              |

| * * * UPDATE 0605 EDT ON 6/26/03 FROM STEVE MERRILL TO S. SANDIN * * *       |

|                                                                              |

| The licensee was informed by the FWCC that the green sea turtle requiring    |

| rehabilitation which was retrieved from the plant's intake canal on 3/15/03  |

| had expired within 10 days of removal.  Consequently, the licensee is        |

| updating their 3/15/03 report to include this additional information.  The   |

| licensee will inform the NRC Resident Inspector.  Notified R2DO(C. Ogle).    |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Other Nuclear Material                           |Event Number:   39922       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  CONSOLE ENERGY INC                   |NOTIFICATION DATE: 06/11/2003|

|LICENSEE:  BUCHANAN MINE CONSOLIDATION COMPANY  |NOTIFICATION TIME: 15:12[EDT]|

|    CITY:  MAVISDALE                REGION:  2  |EVENT DATE:        06/04/2003|

|  COUNTY:                            STATE:  VA |EVENT TIME:             [EDT]|

|LICENSE#:  GENERAL               AGREEMENT:  N  |LAST UPDATE DATE:  06/26/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |MARK LESSER          R2      |

|                                                |CHRISTOPHER CAHILL   R1      |

+------------------------------------------------+FRED BROWN           NMSS    |

| NRC NOTIFIED BY:  JOE RICHARD                  |ROBERTA WARREN       IAT     |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| MISSING OR LOST GAUGE CONTAINING A RADIOACTIVE SOURCE                        |

|                                                                              |

| A Texas Nuclear Product pipe mounted fixed gauge device, model 5202, Series  |

| SG, serial number B174 containing a Cesium 137 (Cs-137), 500 millicuries     |

| source (assay date of November 1984) could not be located in storage.  The   |

| gauge was removed from a pipe on the evening of  1/28/03 by an independent   |

| contractor who placed the gauge in a temporary storage on the morning of     |

| 1/29/03 at the Buchanan Mine Preparation Plant located in Mavisdale,         |

| Virginia.  The gauge was closed and pad locked before it was placed in the   |

| small building storage room.  The independent contractor and the plant       |

| foreman looked for the gauge on 6/2/03 and could not locate it.  They        |

| continued looking for the gauge until 6/4/02 when they declared that it was  |

| missing.  The licensee has no reason to believe that the gauge left the      |

| property, is retracing the steps of the gauge movement and  is interviewing  |

| their employees in an attempt to locate the gauge.                           |

|                                                                              |

| * * * UPDATE AT 0951 EDT ON 06/26/03 FROM REGION II IAT (BOLAND) to NRC HOC  |

| (GOTT) * * *                                                                 |

|                                                                              |

| The following was emailed from Region II:                                    |

|                                                                              |

| "The licensee searched their site for the gauge and interviewed employees    |

| who had access to the floc [floculant] building with negative results.       |

|                                                                              |

| "There are two waste streams in which the gauge may have left the plant:     |

|                                                                              |

| "The first is in scrap metal.  Scrap metal waste goes to Mansbauch Metal in  |

| Ashland, Virginia.  Incoming waste at Mansbauch must pass through an         |

| Exploranium portal monitor.  The alarm set point for this type of monitor is |

| normally set at twice background so they are very sensitive.  The scrap      |

| metal is then put on a conveyor for further processing.  Three Ludlum        |

| detectors monitor the loose scrap on the conveyor.  The processed scrap must |

| then pass through the portal monitor leaving the facility.  The smelter      |

| accepting the scrap will also have a portal monitor.  There were no alarms   |

| in the time period under consideration and there is no backlog of scrap at   |

| the facility.  This does not seem to be a credible scenario for the loss of  |

| the gauge.                                                                   |

|                                                                              |

| "The second waste stream is for normal industrial waste.  The local sanitary |

| landfill is not used and, according to the licensee,  all waste other than   |

| scrap metal is supposed to be sent to the industrial waste stream.  The      |

| waste is transferred by H&K Trucking Co. to the Cumberland Plateau Regional  |

| Waste Management Authority in Lebanon, Virginia for waste consolidation      |

| prior to being sent to the BFI Carter Valley Landfill in Hawkins Co.         |

| Tennessee.  Waste coming into the Cumberland facility is dumped on the floor |

| and then loaded into a larger container for shipment to the landfill.        |

| Periodically, individuals at this facility remove metal such as soft drink   |

| cans for further sale to a scrap dealer.  The BFI Landfill has a portal      |

| monitor and was sensitive enough to recently detect in a large waste         |

| shipment, a facial tissue used by an individual that had been administered   |

| Tc-99m.                                                                      |

|                                                                              |

| "On June 17, NRC inspectors discussed the issue with licensee                |

| representatives and surveyed areas of the site where the gauge might         |

| logically have been moved.  The radiation detection instruments the          |

| inspectors used were sensitive enough to detect the gauge radiation unless   |

| it was significantly shielded above and beyond the shielding inherent in the |

| gauge.  The inspectors demonstrated that their survey instruments could      |

| easily detect the radiation from a similar gauge that was in place at the    |

| facility.  The inspectors also traveled to the BFI landfill and discussed    |

| the issue with landfill operators.                                           |

|                                                                              |

| "The operators of the Cumberland Plateau facility issued a memorandum to     |

| staff describing the gauge and stating the importance of its recovery.  The  |

| Buchanan facility management was to also issue a similar memorandum and      |

| claims to still be looking for the gauge."                                   |

|                                                                              |

| Notified NMSS (Broaddus), R2DO (Ogle), NRC IAT (Hahn).                       |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   39957       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 06/23/2003|

|LICENSEE:  GOOD SHEPHERD HOSPITAL               |NOTIFICATION TIME: 17:26[EDT]|

|    CITY:  BARRINGTON               REGION:  3  |EVENT DATE:        06/17/2003|

|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|

|LICENSE#:  IL-01620-01           AGREEMENT:  Y  |LAST UPDATE DATE:  06/23/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |PATRICK LOUDEN       R3      |

|                                                |C.W. (BILL) REAMER   NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  DAREN PERRERO                |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| AGREEMENT STATE REPORT- WRONG PATIENT SELECTED                               |

|                                                                              |

| "Today, June 23, 2003, a consultant to Good Shepherd Hospital (IL-01620-01)  |

| in Barrington, IL called concerning a reportable medical event [discovery    |

| date 06/20/2003].  On June 17th the licensee was scheduled to provide a      |

| therapeutic dose of 15 milliCi [milliCuries] of I-131 to a patient by        |

| capsule.  Instead, the patient received a capsule with an assayed dose of    |

| 10.8 milliCi.  Apparently, two treatments were scheduled for the day and a   |

| second patient was prescribed a dose of 11 milliCi and the technician failed |

| to administer the correct dose to the patient.  The second patient did not   |

| receive any treatment that day and was rescheduled for last Friday.  (A      |

| separate call to the pharmacy confirmed two doses were delivered on Tuesday, |

| one of 15 milliCi and a second [dose] of 11 milliCi and another dose of 10   |

| milliCi was provided on Friday.)                                             |

|                                                                              |

| "At this time, the radiation oncologist does not believe there will be any   |

| appreciable effect to the patient, but will continue to follow through with  |

| the evaluation to determine if an additional dose is necessary to achieve    |

| the optimal results.  The licensee has advised the referring physician       |

| verbally and in writing.  They have determined it would not be appropriate   |

| to notify the patient[s] given their condition and medical situation.        |

|                                                                              |

| "The licensee has spoken with the responsible technician about ensuring the  |

| correct dose is administered to the correct patient.  The licensee is in the |

| process of changes procedures at the site so that two individuals must       |

| independently confirm the correct patient identification and dosage          |

| information immediately prior to administration.                             |

|                                                                              |

| "The licensee was advised as the need for timely reporting or these events   |

| and that a formal report must be filed within 15 days as per 32 Ill. Adm.    |

| Code 335.1080."                                                              |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Other Nuclear Material                           |Event Number:   39961       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  HAENGEL & ASSOCIATES ENGINEERING     |NOTIFICATION DATE: 06/26/2003|

|LICENSEE:  HAENGEL & ASSOCIATES ENGINEERING     |NOTIFICATION TIME: 13:21[EDT]|

|    CITY:  NEWPORT                  REGION:  3  |EVENT DATE:        06/26/2003|

|  COUNTY:                            STATE:  MI |EVENT TIME:             [EDT]|

|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  06/26/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |PATRICK LOUDEN       R3      |

|                                                |THOMAS ESSIG         NMSS    |

+------------------------------------------------+ROBERTA WARREN       NSIR    |

| NRC NOTIFIED BY:  GUSTAVO HAENGEL              |                             |

|  HQ OPS OFFICER:  JAMES DODSON                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| STOLEN TROXLER GAUGE IN NEWPORT, MICHIGAN                                    |

|                                                                              |

| The licensee reported that on 6/26/03 at 1200 pm a technician noticed that   |

| his parked van, containing a Troxler gauge model 3430, had broken windows    |

| and had been vandalized. The chain was cut which was holding a Troxler gauge |

| model 3430 and the gauge was missing. The gauge contains 8 millicuries       |

| Cs-137 and 40 millicuries Am-241. Local Police, Troxler and RIII Cassandra   |

| Frasier were notified by the licensee.                                       |

+------------------------------------------------------------------------------+