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Event Notification Report for February 4, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/03/2004 - 02/04/2004

** EVENT NUMBERS **


40488 40499 40500 40501 40502 40503 40504


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General Information or Other Event Number: 40488
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: J.K. DISPLAY INC.
Region: 3
City: MILWAUKEE State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PAUL CALEB
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/29/2004
Notification Time: 14:45 [ET]
Event Date: 01/28/2004
Event Time: [CST]
Last Update Date: 01/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)

Event Text

MISSING NDR, INC. STATIC ELIMINATOR GUN DEVICE.

On January 28, 2004 a letter was received by Wisconsin's Radioactive Materials Program, dated January 26, 2004 from state licensee J.K. Display, Inc., 8300 W. Parkland Court, Milwaukee, WI 53223. The letter informed the department that the company could not locate one of the two NDR, Inc., P-2021 Nuclecel-Ionizer air gun devices that it had in its possession..

The missing/loss P-2021 device, serial # A2CL456 was leased from NDR, November 2002 with an activity of 10.0 mCi of Po-210. The static eliminator gun was last used in July of 2003 because it was broken and unusable. Apparently, the connections between the air-hose and device leaked, reducing the gun's ability to produce ionized air. The device was placed in the shop on a shelf for return to NDR, Inc. at termination of the lease.

Polonium-210 has a half-life of 138 days, therefore, if the assay date of November 2003 is accurate, the source has gone through approximately three (3) half-lives. The Po-210 source at this point should have an activity of approximately 1.275 mCi.

The licensee has done an exhaustive search of the shop and offices for the device, but it cannot be located. The most likely possibility, according to the company, is an employee threw out the device.

Corrective actions taken by the company are to instruct their six employees to identify the device(s) and their location at all times and to isolate and store unused device(s) in a secure location.

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Fuel Cycle Facility Event Number: 40499
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: ERIC WALKER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/03/2004
Notification Time: 03:06 [ET]
Event Date: 02/02/2004
Event Time: 04:15 [CST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GEORGE KUZO (R2)
DANIEL GILLEN (NMSS)

Event Text

FAILURE OF C-360 #1 AUTOCLAVE HIGH PRESSURE ISOLATION SYSTEM.

At 0415 on 02-02-04 the Plant Shift Superintendent (PSS) was notified of a failure of the C-130 # 1 Autoclave High Pressure Isolation System. Water was observed leaking from the autoclave head-to-shell interface near the six o'clock position shortly after initiating a cylinder heat cycle. At the time of discovery, the autoclave was in TSR Mode 5 (heating) and the High Pressure Isolation System was required to be operable while in this mode. This system is designed to provide containment of the autoclave and prevent an external release of UF6 during a system breach while heating a UF6 cylinder. The PSS declared the system inoperable and TSR LCO 2.1.3.1.C.1 actions were implemented to remove the autoclave from service and place it in Mode 2, "Out of Service". The event is reportable as a 24 hour event, as required by 10 CFR76.120(c)(2)(i); An event in which equipment is disabled or fails to function as designed when the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specific limits, mitigate the consequences of an accident, or restore this facility to a preestablished safe condition after an accident. The equipment was required by TSR to be available and operable and no redundant equipment was available to perform the required safety function.

The Senior NRC Resident Inspector has been notified of this event.

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Power Reactor Event Number: 40500
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JAMES MILLIGAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/03/2004
Notification Time: 09:24 [ET]
Event Date: 02/03/2004
Event Time: 04:39 [CST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTHONY GODY (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO MAIN GENRATOR OUTPUT BREAKERS OPENING.

"AT 0439, 02/03/04, Callaway Plant experienced a reactor trip while operating transmission breakers located in the plant switchyard. Auxiliary feedwater actuated as expected to stabilize steam generator water levels. All other plant systems responded as expected. At present, the cause of the reactor trip is undetermined. Initial indications are that there were no voltage or frequency perturbations on the electrical grid. Plant staff is investigating potential areas in an effort to identify the cause of the trip."

The main generator output breakers opened when one of the transmission breakers in the switchyard was opened per the scheduled maintenance test. When the incoming Transmission line breaker was opened it should not have caused the main generator output breakers to open. All rods fully inserted into the core. Both Motor Driven Auxiliary Feedwater pumps automatically started on a loss of both main feedwater pumps and the Turbine Driven Auxiliary Feedwater pump started on low low steam generator water level. The "C" Steam Generator atmospheric steam dump valve opened for about 17 seconds before it closed (no leaking steam generator tubes in the "C" Steam Generator). All Emergency Core Cooling systems are fully operable except for the "A" Safety Injection System. It was declared inoperable when it failed a valve test last night at 0205 CST. All Emergency Diesel Generators are fully operable.
Turbine Driven Auxiliary Feedwater Pump discharge valves were closed after it had operator for about two hours. Approximately one hour after the valves were closed the Turbine Driven Auxiliary Feedwater pump tripped. This incident is being investigated.

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

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Hospital Event Number: 40501
Rep Org: ST. JOSEPHS WAYNE HOSPITAL
Licensee: ST. JOSEPHS WAYNE HOSPITAL
Region: 1
City: WAYNE State: NJ
County:
License #: 29-18334-01
Agreement: N
Docket:
NRC Notified By: DR. MARSDEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/03/2004
Notification Time: 11:26 [ET]
Event Date: 01/13/2004
Event Time: [EST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JOHN KINNEMAN (R1)
TOM ESSIG (NMSS)

Event Text

TWO I-125 SEEDS UNACCOUNTED FOR FOLLOWING SURGERY

On 1/13/04 a male patient received I-125 implants. Following the operation, the physician did not properly inventory the residual I-125 seeds. Two (2) seeds were missing (0.36 millicuries/ea). St. Josephs Wayne Hospital was informed of the discrepancy by the physician performing the operation and conducted extensive surveys with negative results. Corrective action includes an administrative requirement to have either a dosimetrist or physicist present during all future implant operations to ensure adequate inventory control.

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Hospital Event Number: 40502
Rep Org: MERCY HEALTH SYSTEM
Licensee: MERCY HEALTH SYSTEM
Region: 1
City: DARBY State: PA
County:
License #: 37-00993-05
Agreement: N
Docket:
NRC Notified By: JOHN BABU
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/03/2004
Notification Time: 14:05 [ET]
Event Date: 01/23/2004
Event Time: [EST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
JOHN KINNEMAN (R1)
JONH HICKEY (NMSS)

Event Text

HIGH BACKGROUND READINGS FOUND IN STERILIZATION WATER USED TO STERILIZE THE SEEDS AND CARTRIDGE PRIOR TO USAGE.

The licensee reported that during the completion of a prostate implant a higher than background reading was measured in the sterilization water used to sterilize the seeds and the cartridge prior to the implant. The licensee had two extra seeds left over after the implant, so they returned them to the manufacturer along with a sample of the sterilization water to be analyzed. The manufacturer suspects that one of the seeds may have been a leaking, but that has not yet been verified. A bioassay was also performed on the staff involved with the implant and only the physicist had a higher than background reading. The patient was also given a bioassay, but since they have never done this to a patient, there was no data to compare with.

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Power Reactor Event Number: 40503
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAN AUTALA
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/03/2004
Notification Time: 18:52 [ET]
Event Date: 02/03/2004
Event Time: 15:35 [MST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
ANTHONY GODY (R4)
GENE IMBRO (NRR)
RICHARD WESSMAN (IRO)
MICHAEL WEBER (NSIR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 45 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO RCS PRESSURE BOUNDARY LEAKAGE

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On February 3, 2004 at approximately 14:18 MST, Palo Verde Nuclear Generating Station (PVNGS) Unit 1 identified reactor coolant system (RCS) pressure boundary leakage. PVNGS Unit 1 was in Mode 1 (Power Operation) at 99% power with normal RCS temperature and pressure at the time of discovery. A normal reactor shutdown was commenced at 15:35. Technical Specification Limiting Condition for Operation 3.4.14 (RCS Operational Leakage) allows no pressure boundary leakage and requires the plant to be in Mode 3 (Hot Shutdown) within 6 hours and Mode 5 (Cold Shutdown) within 36 hours and TLCO 3.14.103 (Structural Integrity).

"The leakage was discovered on a High Pressure Safety Injection Drain Valve (SIA-V056) with is connected to the RCS loop 1 hot leg and is non isolable. The location of the leak is at a weld on the valve socket weld and is estimated at 10 drops per second.

"No automatic or manual reactor protection system or engineered safety features actuations occurred and none were required. There were no other component failures, testing or work in progress that contributed to the leak. The leak is located within the containment building, therefore there is no release of radioactivity to the environment and no impact to the health and safety of the public. There is no elevated RCS activity and heat removal is via normal steaming to the main turbine condenser, The electric grid is stable."

The licensee has notified the NRC resident Inspector.

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Power Reactor Event Number: 40504
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CLAY WILLIAMS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/03/2004
Notification Time: 19:05 [ET]
Event Date: 02/03/2004
Event Time: 11:30 [PST]
Last Update Date: 02/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
ANTHONY GODY (R4)

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

Event Text

LICENSEE REPORTED A FISH KILL INVOLVING APPROXIMATELY 13,590 POUNDS OF SARDINES


Section 4.1 of Appendix B of the Operating License for Units 2 and 3 requires Southern California Edison (SCE) to report to the NRC within 24 hours any unusual or important environmental events, which includes unusual fish kills.

Between February 2 and February 3, 2004, SCE removed an unusually large number of sardines from the Units 2 and 3 intake structure. At approximately 1100 on February 3, 2004, SCE determined the quantity to be approximately 13,590 pounds (approximately 6940 pounds from Unit 2 and 6650 pounds from Unit 3). While the NRC has not specified a reporting limit for an unusual fish kill, SCE has internally defined this quantity as 4500 pounds. SCE believes the unusual
influx of sardines may be related to current winter storm conditions.

The NRC Resident Inspectors have been notified

The licensee will also give a courtesy call to the San Diego Regional Water Quality Control Board

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