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Event Notification Report for June 18, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/17/2004 - 06/18/2004

** EVENT NUMBERS **


40812 40823 40824 40825 40826

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General Information or Other Event Number: 40812
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ADCO SERVICES
Region: 3
City: TINLEY PARK State: IL
County:
License #: IL-0134701
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/14/2004
Notification Time: 10:13 [ET]
Event Date: 06/14/2004
Event Time: [CDT]
Last Update Date: 06/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICK LOUDEN (R3)
ROBERTO TORRES (NMSS)
JIM WHITNEY (TAS)

Event Text

ILLINOIS AGREEMENT STATE REPORT - SOURCE MISSING IN SHIPMENT

One of five packages being shipped on 6/3/04 from Honeywell Corporation in Phoenix, AZ did not arrive at the licensee's facility as scheduled on 6/4/04. The package consisted of a 7-10 gallon steel drum containing 10 Curies of Pm-147 as sealed sources. The sources were removed from industrial gauging devices being disposed of.

* * * UPDATE ON 6/14/04 AT 1542 EDT FROM D. PERRERO TO A. COSTA * * *

Fed-Ex located the missing shipment in Pittsburgh and arrangements are being made to forward it to ADCO Services Inc, at Tinley Park, IL. Notified NMSS (Essig), R3DO(Louden) and TAS (Whitney).

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Power Reactor Event Number: 40823
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD DeSANCTIS
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 06/17/2004
Notification Time: 03:38 [ET]
Event Date: 06/17/2004
Event Time: 00:22 [EDT]
Last Update Date: 06/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
ANTHONY DIMITRIADIS (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 48 Power Operation

Event Text

TECH SPEC REQUIRED PLANT SHUTDOWN DUE TO EMERGENCY CORE COOLING SYSTEM INOPERABLE

At 0338 EDT on 06/17/04, the licensee reported that at 0321 EDT on 06/14/04, the licensee identified that the Salem Unit 1 #12 charging pump was declared inoperable due to an inoperable discharge check valve. Repairs to the check valve are not expected to be completed by 0321 EDT on 06/17/04. At 0022 EDT on 06/17/04, the licensee commenced a shutdown of Salem Unit 1 from 100% power to comply with Tech Spec 3.5.2, Emergency Core Cooling System Inoperable (72 hour LCO). #15 service water pump and #11 auxiliary building exhaust fan have been declared inoperable for scheduled maintenance.

There were no personnel injuries or radiological occurrences associated with this event.

This event has no effect on Salem Unit 2 which is at 100% power.

The licensee notified the NRC Resident Inspector and plans to notify State and Local officials.

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Power Reactor Event Number: 40824
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/17/2004
Notification Time: 06:17 [ET]
Event Date: 06/17/2004
Event Time: 05:21 [EDT]
Last Update Date: 06/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT HAAG (R2)

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

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) DECLARED INOPERABLE

While changing out a light bulb in the Unit 1 HPCI room, the surveillance operator noticed that the bolts for the HPCI pump discharge check valve, 1E41-F005, bonnet on pressure seal were loose. All six bolts could be turned by hand. HPCI was declared inoperable until an investigation is performed. The bolts were properly torqued and HPCI pump run is complete and sat. Licensee entered Technical Specification 3.5.1 (14 day Limiting Condition of Operation). All other Emergency Core Cooling Systems are fully operable including the Reactor Core Isolation Cooling System.

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

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Hospital Event Number: 40825
Rep Org: RUTLAND REGIONAL MEDICAL CENTER
Licensee: RUTLAND REGIONAL MEDICAL CENTER
Region: 1
City: RUTLAND State: VT
County:
License #: 44-14121-01
Agreement: N
Docket:
NRC Notified By: PAUL WAITE
HQ OPS Officer: JEFF HIXON
Notification Date: 06/17/2004
Notification Time: 13:47 [ET]
Event Date: 06/07/2004
Event Time: [EDT]
Last Update Date: 06/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
LINDA PSYK-GERSEY (NMSS)

Event Text

MEDICAL EVENT

A 19 year old female was diagnosed with Grave's Disease of the thyroid. Consultation with an authorized user (a physician) was requested for consideration of Iodine-131 ablation of her thyroid gland.

After this consultation, the patient wished to undergo radioactive iodine ablation of her thyroid gland. The physician completed a prescription in which his written directive was an order for 12 microCuries of Iodine-131. The word "micro" was written using the Greek alphabet letter. The technologist ordered 12 milliCuries of Iodine-131. The technologist received 12.5 milliCuries and this amount was administered orally on 4/7/04. The licensee became aware of this misadministration on 6/7/04 during their quarterly quality maintenance review.

The licensee's review of this case with the physician revealed that his intent was to have ordered a 12 milliCurie dose. The physician wrote microCurie by mistake, as a microCurie dose would have been inappropriate for the clinical indication.

There were no untoward affects from this administration. At this time, it is not known if the patient has been notified. Licensee RSO will provide that information at a later time.

The licensee has reviewed this case and the sequence of events. The following action has been taken. The preprinted prescription form was modified such that after the blank where the authorized user enters the name of the isotope and the dose, the words "microCurie" and "milliCurie" will be written next to each other. The authorized user will need to circle one of the choices.

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Power Reactor Event Number: 40826
Facility: YANKEE ROWE
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: NEIL OLESON
HQ OPS Officer: JEFF HIXON
Notification Date: 06/17/2004
Notification Time: 15:53 [ET]
Event Date: 06/17/2004
Event Time: 12:40 [EDT]
Last Update Date: 06/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)
CHARLIE MILLER (NMSS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned

Event Text

OFFSITE NOTIFICATION TO VERMONT DEPARTMENT OF PUBLIC SAFETY


Three 55 gallon drums of sand, each impregnated with 1.73 microCuries Cs-137, were shipped to Yankee Rowe from Atlanta, Georgia via Federal Express. The specific activity of the material is 32 picoCuries per gram. Upon arrival at Yankee Rowe, a hole in one of the drums was noticed and about 70 pounds of sand was determined to be missing. About 3 pounds of material was recovered from the shipping truck. The hole appeared to be caused by a fork lift puncture.

The specific activity of the material is less than the Department of Transportation reportable quantity.

Yankee Rowe contacted state of Vermont and notified the NRC Resident Inspector.

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Friday, March 30, 2012