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Event Notification Report for December 17, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/16/2003 - 12/17/2003

** EVENT NUMBERS **


40385 40387 40390 40393 40394

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General Information or Other Event Number: 40385
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: WASTE CONTROL SPECIALIST
Region: 4
City: Andrews State: TX
County:
License #: L04971
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/11/2003
Notification Time: 11:30 [ET]
Event Date: 12/09/2003
Event Time: [CST]
Last Update Date: 12/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ROBERTO TORRES (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT INVOLVING FIRE WITH RADIOACTIVE MATERIAL

"On December 10, 2003, [the licensee's RSO at] Waste Control Specialist reported a fire involving radioactive material that occurred on December 9, 2003. There was no excessive exposure to individuals nor was there any off-site airborne release.

"The waste processing company believes reactive metals (lithium, sodium, potassium) oxidized in water to start the fire. Packing materials were placed in a shredder that feeds into a hopper containing mixed waste. The system is closed with HEPA filters in place. Vibrations from the hopper may have resulted in the ignition. The material burned for about 20 seconds and was extinguished. When more materials were poured into a mix pan, the fire reignited and again was quickly extinguished.

"According to the Licensee's preliminary calculations, the affected or burned radioactive material exceeded the reportable quantity of five times an ALI [annual limit on intake]. The total radioactive material in the mix pan was under 50 microcuries. The shredder contained about 2.4 microcuries. There were 12 to 14 radionuclides involved. The Licensee will send a detailed written report within 30 days to include specifics on radionuclides and activities.

"The most serious consequence was the unplanned fire. The building is pressurized and the smoke from the fire was pulled through HEPA filters and a monitored exhaust system. The workers wear PPE [personal protective equipment) and airlines with protection factors of 1000."

Texas Incident # I-8024.

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General Information or Other Event Number: 40387
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: LEXINGTON CLINIC
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-016-26
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/11/2003
Notification Time: 14:06 [ET]
Event Date: 11/24/2003
Event Time: [CST]
Last Update Date: 12/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANIELLO DELLA GRECA (R1)
TOM ESSIG (NMSS)

Event Text

KENTUCKY AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

On 11/24/03 a patient was administered a thyroid uptake dose of 0.98 millicuries. The prescribed dose was 0.015 millicuries. The misadministration apparently occurred due to the prescription order being made incorrectly with no subsequent verification. The patient and the patient's physician were notified on 11/26/03. No adverse effect to the patient occurred as a result of the misadministration.

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General Information or Other Event Number: 40390
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GALLETT AND ASSOCIATES
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1316-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/12/2003
Notification Time: 14:36 [ET]
Event Date: 12/12/2003
Event Time: 11:00 [EST]
Last Update Date: 12/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANIELLO DELLA GRECA (R1)
PATRICIA HOLAHAN (NMSS)

Event Text

GEORGIA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

On 12/12/03 at 1100 ET, a licensee's pickup truck was stolen with a moisture density gauge locked in the bed of the truck. The truck was parked at a construction site on Northside Drive in downtown Atlanta, GA. The gauge is a CPN Model MC Porta-Probe, Serial Number MD60703301. The gauge contained two sources: 50 milliCuries Am241/Be and 10 milliCuries Cs-137. The licensee has reported the theft to the Atlanta Police Dept. and the Atlanta Field Office of the FBI.

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General Information or Other Event Number: 40393
Rep Org: AUTOMATIC VALVE
Licensee: AUTOMATIC VALVE
Region: 3
City: NOVI State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: TODD HUTCHINS (EMAIL)
HQ OPS Officer: GERRY WAIG
Notification Date: 12/16/2003
Notification Time: 15:01 [ET]
Event Date: 10/16/2003
Event Time: [EST]
Last Update Date: 12/16/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
THOMAS KOZAK (R3)
PHIL HARRELL (R4)
CHRISTOPHER CAHILL (R1)
SUSIE BLACK (NRR)

Event Text

10 CFR 21.21 POTENTIAL FAILURE OF SOLENOID OPERATED VALVE TO CLOSE AT ELEVATED AIR PRESSURE

The following is taken from a facsimile from Automatic Valve:

"Describe Problem (Initial Concern and Symptoms):
On 10/16/2003 Paul Chenell of Dresden reported that a B7122-145, serial number 64065 shipped on 12/11/2002, valve failed to exhaust air with both solenoids de-energized causing the CRD valve to remain in the open position.

"On 10/17/2003 the valve was delivered to Automatic Valve for analysis of the problem. Contain Symptom (Action):
Re-inspect all existing 6910-001 plungers to verify the correct overall length (Done 10-17-03). Rebuild, retest, and return the B7122-145 valves to Dresden (Shipped 11-26-03).
Notify customers potentially impacted, by Fax, to inspect plunger lengths (10/24/03).
Inspect all units installed at Dresden station (completed 10-30-03, 15 of 274 plungers found out of specification)
Inspect all units installed at Cooper station (completed 10-29-03, 0 of 64 plungers found out of specification)
Hold shipment for all 6910-001 plungers from suspect lot.

"Root Cause/s of Problem: 10 CFR Part 21 Report Required: Yes
The valve was first functionally tested in the normal manner- that is at 35 psig low pressure & at 145 psig high pressure. The valve functioned without problems at low pressure but failed to return to its normally closed position at 145 psig when both solenoids were de-energized. Further functional testing revealed that at an inlet pressure of approximately 100 psig the valve would fail to return when de-energized.

"When the valve was disassembled, the plunger in the number 2 solenoid, the left hand solenoid when facing the exhaust port, was found to be approximately .020 too long - 1.315" compared to the specified length of 1.290 +.005/-.003. Because the plunger only has a total stroke of less than .030, the natural expansion of the seal material in the plunger, due to a combination of heat and pressure, combined with the out of specification length created a situation where the plunger had no room to move and thus exhaust pilot air when the solenoid was deenergized.

"The root cause of the failure is the out of spec plunger. Procedures require the lengths of all plungers to be inspected prior to use.

"Analysis of the results of measurement testing revealed an unexpected degree of variation In recorded lengths.
Variation was traced to the use of different types of equipment and the inherent difficulty in measuring compressible material with pressure sensitive measurement devices. This may have lead to some units being categorized as In specification initially and out of specification at subsequent inspection. (Refer to corrective action 5.1).

"Notwithstanding measurement variation, the primary root cause of the observed plunger dimensions is changes to the length of the fluorocarbon insert after it is pressed into the plunger body. This variation is detectable and beyond measurement uncertainty.

"Dissection of returned plungers revealed abnormal compression set among all plungers which were beyond specification limits and normal compression set among plungers which were within specification limits.

"Chemical analysis and durometer testing did not show any significant differences In the chemical properties or material hardness of the lot or in previous lots of identical insert material.

"However, the following results were obtained when plunger insert samples were compressed by 23 for 24 hours at 230 degrees F:

"Scenario [Average Set %, # tested]
Unused insert, suspect lot, visible set, as received [92%, 3]
Unused insert, suspect lot, visible set, post cured at 260 F [11%, 2]
Unused insert, previous lot no visible set, as received [10%, 3]
Unused insert, suspect lot no visible set, as received [9%,, 2]
Field return Insert, suspect lot, visible set [36%, 4]
Field return Insert, suspect lot, no visible set [10%, 2]

"From this we concluded that there is a cure problem with a portion of the suspect lot and that post cure takes place when the solenoid is continuously energized. Based on the test results, we believe that a portion of the lot was not properly post cured.

"The degree of growth of the plunger insert due to compression set is observed to be variable. This depends on exact dimensions of the molded insert when installed, the ID of the plunger retaining the insert and the exact cure duration variation of the bad plunger inserts.

"The degree of growth also seems to be terminal. Returned plungers (field failure) and other samples from the suspect lot on hand) at Automatic Valve have not changed dimensions during the period of study. Five plungers tested at 200 degrees F for five days exhibited thermal expansion and did not detectably change size when cooled down. Ten plungers subjected to 230 degrees F for ten days exhibited thermal expansion and did not detectably change size when cooled down. (Refer to corrective action 5.2, 5.3)

5. Corrective Action:
5.1) Specific individual measurement equipment is specified for plunger measurement.
5.2) Specific lot definition based on curing process (as opposed to pre-vulcanized rubber lot) to define lot homogeneity for all plunger inserts
5.3) A sample of each homogeneous processed sample to be tested for compression set as part of dedication process.
Test Conducted to Verify It: Test samples to be placed under worst case temperature and pressure characteristics for a period of 10 months.

"6. Implementation (Describe: Include Applicable CN Numbers):
CN 8897 defines lot and compression set and measurement characteristics for 6910-001 plungers..

"7. Corrective Action to System to Prevent Recurrence: To be determined.

"The following plants have components containing the suspected lots as follows:

Nebraska Public Power - Cooper Station
Exelon - Limerick, Peach Bottom, Quad Cities, Dresden"

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Power Reactor Event Number: 40394
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [ ] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: DAN FORRY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/16/2003
Notification Time: 19:11 [ET]
Event Date: 12/16/2003
Event Time: 15:40 [EST]
Last Update Date: 12/16/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER CAHILL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

"During the performance of planned Unit 3 "High Pressure Coolant Injection (HPCI) Pump, Valve, Flow and Unit Cooler Functional and In-Service Testing" the HPCI turbine exhaust line drain valve remained open for longer than expected. The test was aborted and troubleshooting was initiated to determine the cause of this unexpected result. The HPCI system is being maintained in an available status but maintained Tech. Spec. inoperable pending additional evaluation."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012