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Event Notification Report for April 26, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/23/2004 - 04/26/2004

** EVENT NUMBERS **


40687 40692 40693 40699 40700 40701 40702 40703

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General Information or Other Event Number: 40687
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-01302-001
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/20/2004
Notification Time: 11:55 [ET]
Event Date: 04/13/2004
Event Time: 15:30 [CDT]
Last Update Date: 04/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - ACCIDENTAL SHIPMENT OF RADIOACTIVE MATERIAL

On 4/13/04, at approximately 3:30 PM CDT, the Wisconsin Radiation Protection section received a telephone call from the New York State Labor Department, Radiological Health Department.

New York State Radiological Health Dept. had just been informed by one of their licensees, Mick Radio-Nuclear Instruments, Inc., that a package had been received from St. Nicholas Hospital, Sheboygan, WI. The company had found 2 radioactive brachytherapy seeds within a Mick applicator which had been returned to their company for repairs. The radioactive seeds were stuck in the Mick applicator. Mick Radio-Nuclear Instruments contacted the shipper of the device, St. Nicholas Hospital, to obtain details identifying the radionuclide. The 2 seeds have been identified as containing I-125, 0.370 milli Curies each on 3/12/04. Mick Radio-Nuclear is not licensed to receive this radioactive material which was inadvertently sent by St. Nicholas Hospital. The package was shipped on 4/8/04 and received on 4/13/04.

The Wisconsin Department of Health and Family Services (DHFS) is reporting this item as a "loss of control of radioactive material to an unlicensed entity" and "potential exposure to the general public." DHFS staff are being dispatched on 4/20/04 to investigate.

The radioactive material is now in the possession of the Radiological Health Department for the state of New York. St. Nicholas Hospital is working on identifying a company in New York that can take possession of the radioactive brachytherapy seeds and return them to the manufacturer.

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General Information or Other Event Number: 40692
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: CONAGRA FOODS
Region: 1
City: NEWPORT State: TN
County:
License #: 337
Agreement: Y
Docket:
NRC Notified By: BILLY FREEMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/21/2004
Notification Time: 13:45 [ET]
Event Date: 04/21/2004
Event Time: [EDT]
Last Update Date: 04/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID SILK (R1)
JOSEPH GIITTER (NMSS)
TOM DECKER (R2)
JIM WHITNEY (TAS)

Event Text

AGREEMENT STATE REPORT INVOLVING LOST GENERAL LICENSE SOURCE MATERIAL

"The licensee called to report that a Filtec FT-50 fill level gauge, serial number, 112082, containing 100 millicuries of Am-241 in sealed source, serial number 4473, could not be located during inventory. The unit was removed from a manufacturing line in June, 1995 and stored in a building along with other idle equipment. During a recent project to clean this building and dispose of old equipment, the licensee was unable to locate this unit. An extensive search was conducted throughout the facility and the gauge could not be located. Personnel who may have had knowledge of the unit were interviewed. The last documented time that the gauge was seen in storage was in January 1998. The licensee believes that the unit was discarded with other idle equipment. The manufacturer's records indicate the source was not returned to them. Inspectors [Tennessee Division of Radiological Health] are enroute to the facility to investigate."

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Other Nuclear Material Event Number: 40693
Rep Org: BAXTER HEALTH CARE
Licensee: BAXTER HEALTH CARE
Region: 1
City: AIBONITO State: PR
County:
License #: 52-21175-01
Agreement: N
Docket:
NRC Notified By: ANGEL ALICEA
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/21/2004
Notification Time: 16:54 [ET]
Event Date: 04/21/2004
Event Time: 12:00 [EDT]
Last Update Date: 04/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
36.83(a)(1) - UNSHIELD STUCK SOURCE
Person (Organization):
DAVID SILK (R1)
TOM DECKER (R2)
CHARLIE MILLER (NMSS)
JOSEPH GIITTER (NMSS)

Event Text

IRRADIATOR SOURCE RACK JAMMED IN THE UP POSITION

At 1200 EDT operators were lowering a source rack when it jammed due to a maintenance ladder. The licensee entered their emergency procedure and contacted the manufacturer, i.e., MDS Nordion, for assistance. MDS Nordion is expected onsite at 1040 EDT tomorrow 4/22 to help the licensee develop a recovery plan. The stuck source rack contains approximately 2,030 curies of Co-60. The maze is closed restricting personnel access. There were no personnel exposures associated with this occurrence.

A conference call with the Baxter Plant Manager and NRC staff was established to discuss the details of this report.

* * * UPDATE ON 04/24/04 @ 1424 BY ANGEL ALICEA TO CHAUNCEY GOULD * * *

The licensee reported that at 2000 on 04/23/04 the source was placed in the shielded position submerged in 25 ft of water in the pool. They are terminating this event.

Notified Tom Decker, George Pangburn, Frank Costello, Cathy Modes, and Betsey Ullrich

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General Information or Other Event Number: 40699
Rep Org: FAIRBANKS MORSE ENGINE
Licensee: FAIRBANKS MORSE ENGINE
Region: 3
City: BELOIT State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TODD COLLINS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/23/2004
Notification Time: 12:41 [ET]
Event Date: 04/21/2004
Event Time: [CDT]
Last Update Date: 04/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID HILLS (R3)
DAVID SILK (R1)
RUSSELL BYWATER (R4)
VERN HODGE (NRR)

Event Text

FAIRBANKS MORSE ENGINE HAS DETERMINED A POTENTIAL SAFETY HAZARD WITH THE WOODWARD DIGITAL REFERENCE UNIT (DRU)

On April 21, 2004, Fairbanks Morse Engine evaluation determined a potential safety hazard exists for Woodward DRU's. The FM P/N is 12998236 and the Woodward P/N is 9903-439.

The defect exhibits erratic ramp up of speed and hence the inability to reach rated RPM and inability to apply load to the engine. The cause has been traced to a random contamination problem of an integrated circuit (IC) in DRU's manufactured by Woodward between November 2000, and January 2002.

The rate of occurrence is less than 10 in the US and approx 20 worldwide. There are approx 38,000 Woodward units worldwide that use this IC. Only one US nuclear utility has experienced this failure and the failure occurred during testing prior to declaration of operability. In all cases, the failure occurs within a very few hours of operation. Therefore, if a DRU has been installed and has been operating for many hours/years, it is not at risk for this failure.

The utilities that FM has supplied DRU's to in the timeframe identified that may be affected include the following:

Utility Site Year Shipped
FP&L Seabrook 2001
WCNOC Wolf Creek 2001

The above utilities are also being notified and affected DRU's will have IC's replaced as necessary.

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Fuel Cycle Facility Event Number: 40700
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: STEVE SKAGGS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/24/2004
Notification Time: 04:46 [ET]
Event Date: 04/23/2004
Event Time: 08:45 [CDT]
Last Update Date: 04/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
CAUDLE JULIAN (R2)
JOSEPH GIITTER (NMSS)

Event Text

CRITICALITY CONTROL 24-HOUR (BULLETIN 91-01) REPORT

The following information was obtained from the regulatee via facsimile:

"At 0845, on 04-23-04, the Plant Shift Superintendent was notified of a violation of Nuclear Criticality Safety (NCS) controls associated with storage of waste drums in the C-335 building. Two Spacing Exempt waste drums were identified to have been characterized utilizing erroneous results from the Q2 drum monitor in violation of Nuclear Criticality Safety Evaluation (NCSE) 091. The characterization is based on it being unlikely that the drum monitor will give an erroneous result. The purpose of the requirements is to ensure the mass in an NCS Spacing Exempt waste drum is below the [DELETED] 235U limit.

"The waste drums have been independently sampled and demonstrated to be below the [DELETED] 235U limit.

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

"SAFETY SIGNIFICANCE OF EVENTS:
While the [DELETED] 235U limit was not exceeded for these two drums, both legs of double contingency were lost and the potential exists for waste drums to be non-conservatively characterized using the Q2 drum monitor.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S)) OF HOW CRITICALITY COULD OCCUR:
In order for a criticality to occur, two or more waste drums containing above the [DELETED] 235U limit would have to be accumulated to exceed a critical mass with no spacing and be moderated.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):
Double contingency is maintained by implementing two controls on mass.

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
Each drum contains less than [DELETED] 235U at an enrichment of less than 1.5 wt% 235U.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
The first leg of double contingency relies on it being unlikely for the Q2 drum monitor to provide an erroneous result. The drum monitor measurement gave a non-conservative erroneous result, which was used to characterize the drum. Therefore, the unlikely statement was violated. However, the drums were subsequently sampled with the result being below the [DELETED] 235U limit for each drum. Therefore, the parameter was maintained.

"The second leg of double contingency relies on it being independently unlikely for the Q2 drum monitor to provide an erroneous result. The independent drum monitor measurement gave a non-conservative erroneous result, which was independently used to characterize the drum. Therefore, the independent unlikely statement was violated. However, the drums were subsequently independently sampled with the independent result being below the [DELETED] 235U limit for each drum. Therefore, the parameter was maintained.

"Although the parameter was maintained, double contingency is based on two controls on one parameter. Therefore, double contingency was not maintained.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
1. Characterize waste drums (PF-04-7258 and PF-03-5051) using the independent sample results. Completed 04/23/04.
2. Complete the 'extent of condition' examination prior to making a determination for removal of the ropes and postings."

The Q2 drum monitor requires a density of material input to properly characterize drum material. Sodium fluoride (NaF) density was used instead of uranyl fluoride (UO2F2) which resulted in a non-conservative characterization. The drum contained both materials.

Plant personnel have imposed spacing requirements on all other drums in the immediate area that have questionable characterizations until they can be properly analyzed.

To prevent re-occurrence, plant management has issued orders and mandates to verify drum contents utilizing two different and distinct sampling methods (i.e. monitoring and laboratory sampling).

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Power Reactor Event Number: 40701
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: CHARLES HOLLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/24/2004
Notification Time: 06:59 [ET]
Event Date: 04/24/2004
Event Time: 04:04 [EDT]
Last Update Date: 04/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
CAUDLE JULIAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

TRANSPORT OF POTENTIALLY CONTAMINATED INJURED PERSONNEL TO OFFSITE MEDICAL FACILITY

The following information was obtained from the licensee via facsimile:

"Individual transported to the hospital as potentially contaminated due to injury received in Unit 2 Reactor Containment Building. At 0430 on 4-24-04 EDT, individual left site by ambulance.

"RP [Radiation Protection] technician escorted injured person to hospital. RP has notified site that the injured person was not contaminated. (0500 EDT on 4-24-04)"

Injured person was transported to the Oconee Memorial Hospital using the hospital ambulance.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40702
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DENNIS FRANCIS
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/24/2004
Notification Time: 09:00 [ET]
Event Date: 04/24/2004
Event Time: 06:03 [CDT]
Last Update Date: 04/24/2004
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):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 20 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO MSIV CLOSURE

"This report is being made in accordance with 10 CFR 50.72 (b)(2)(iv)(B) .

"On 04/24/2004 at 06:03 [CDT], Dresden Unit 2 experienced an automatic Scram from 20% Reactor power
due to Main Steam Isolation Valve closure, cause is under investigation. There were no Electromatic Relief or Safety Relief Valve actuations and the Isolation Condenser was initiated manually for pressure control. There were no ECCS initiations. PCIS Group 2 and Group 3 Isolations occurred as expected due to normal reactor water level
decrease following the scram. All other systems responded as expected."

All control rods fully inserted on the automatic scram. The electric plant is in a normal lineup and being supplied from offsite power.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40703
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DENNIS FRANCIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/24/2004
Notification Time: 15:30 [ET]
Event Date: 04/24/2004
Event Time: 10:50 [CDT]
Last Update Date: 04/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

ISOLATION CONDENSER DECLARED INOPERABLE

"This report is being made in accordance with 10 CFR 50.72(b)(3)(v)(B).

"On 04/24/2004 at 06:03 [CDT], Dresden Unit 2 was using the Isolation Condenser to control reactor pressure following a Unit Scram. The isolation condenser operated properly until 10:50 [CDT] when the Isolation Condenser 2-1301-3 valve could not be opened to the full open position. ISO Condenser was declared INOPERABLE and Technical Specification Limiting Condition of Operation 3.5.3. Condition 'A' was ENTERED. High Pressure Coolant Injection has been administratively verified OPERABLE.

"Reactor Pressure is being maintained 550-1000 psig and being maintained with Reactor Water Clean Up Flow and Gland Seal System.

"Investigation into the cause of the valve failure is in-progress."

Unit 2 had been operating approximately 30 days prior to the scram reported previously in EN #40702. The licensee informed the NRC Resident Inspector.

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