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Event Notification Report for August 18, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/17/2004 - 08/18/2004

** EVENT NUMBERS **


40941 40943 40944 40947 40963 40964 40965

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 40941
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/11/2004
Notification Time: 12:06 [ET]
Event Date: 07/28/2004
Event Time: 09:20 [CDT]
Last Update Date: 08/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
MARK RING (R3)
RAYMOND LORSON (R1)
CAUDLE JULIAN (R2)
JOHN HICKEY (NMSS)

Event Text

MARINE CORP TRITIUM DEVICE INCIDENT

"On 28 July 2004, at approximately 0920 hours, the installed Tritium-in-Air monitor for the Tritium Instrument Repair Room (TIRR) at Maintenance Center Albany [(MCA), Georgia] abruptly alarmed.

"On 27 July 2004, the six counter sources (0.45 Curies each/2.7 Curie total) contained within the gear box of an M137 panoramic telescope had been replaced. The M137 unit was placed on an alignment fixture on the morning of 28 July.

"Upon alarm actuation, the TIRR and the Optics/Fire Control Shop were evacuated. Assembly of personnel was in a common area exterior to the shop. The MCA radiation protection assistant (RPA) and the Base radiation safety officer (BRSO) were summoned. Entry into the TIRR was made with the use of a Johnston Labs Model 111 portable tritium-in-air monitor. Suspicions were satisfied when the portable tritium-in-air monitor indicated 30-microCuries/m3 of tritium gas in the immediate vicinity of the test fixture and mounted M137 panoramic telescope. The TIRR utilizes a negative pressure ventilation system, which is directly ducted to the environment. The door to the TIRR was opened and within approximately one-half hour, the gaseous tritium levels had been reduced to background. The M137 was double bagged and placed within the TIRR vent hood.

"Two workers were present in the TIRR when the evacuation alarm sounded. The shop supervisor entered the area to assess the accuracy of the alarm condition. These three individuals were sent to the on-base medical clinic for urine collection. Samples were taken at time zero plus four hours, time zero plus eight hours, and for the-twenty-four hour period immediately following the time zero plus eight hour sample. The primary worker received a slight uptake of gaseous tritium. Dose calculations for that uptake proved the uptake to be [statistically] less than 0.0 milliRem. The other worker and the supervisor showed no evidence of any tritium uptake. Contamination wipes revealed no contamination of the test fixture or the wall."

* * * UPDATE 1120 EDT ON 8/17/04 FROM T. GIZICKI TO S. SANDIN VIA FAX * * *

The licensee is retracting this report based on the following:

"This note is to rescind the incident report number 40941. The event occurred at a Marine Corp Base in Albany, GA. The initial call into the NRC Operation Center on 10 August, 2004, stated that this was a potential incident under Part 30.5.

"After further review of the incident we have concluded and concurred with by Mr. Darrel Wiedeman, Region III, that the release of tritium was very minimal resulting in no closure of work areas, no surface contamination of work areas, or radiation dose to employees involved. The event therefore is determined to be non-reportable."

Notified R1DO(Jackson), R2DO(Julian), R3DO(Clayton) and NMSS (Essig).

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General Information or Other Event Number: 40943
Rep Org: NY STATE DEPARTMENT OF HEALTH
Licensee:
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/12/2004
Notification Time: 17:12 [ET]
Event Date: 08/10/2004
Event Time: [EDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED BRACHYTHERAPY SEEDS

"A New York State Department of Health licensee reported on 8/10/04 that prostate seed implant needles were found to be contaminated during a post implant radiological survey in the operating room. Two post implant urine samples from the patient were saved and were found to be contaminated as well. Radiograph of the prostate post implant indicated all seeds were implanted. Hospital staff believed that the contamination was attributable to the implant procedure as the patient had not received a diagnostic nuclear medicine procedure and there was no evidence of any other source for the contamination. The radiation oncologist contacted the patient and was able to administer KI [Potassium Iodide] later in the day, and he will evaluate the need for ongoing treatment with KI.

"New York State Department of Health staff went to the hospital on 8/11/04 to investigate this incident. Confirmatory measurements were made and the plastic needle packing tray, needles, lead pouch and urine samples were found to be contaminated. A third urine sample was obtained from the patient on 8/11/04, which also is contaminated. The radiation oncologist who performed the procedure stated that there were no problems with the needles or the implant procedure. The needles were examined and no bends, crimps or damage were observed. The hospital, has notified the pharmacy that had provided the preloaded sterile needles. NRC Region 1 staff were contacted by phone and were given the name of the pharmacy.

"The Radiation Safety Officer took the initial urine sample to another New York State Department of Health licensee on 8/11/04 for nuclide identification and rough quantification using a HPGe detector. The isotope in the urine was identified as I-125 and the activity was estimated to be 34 nanocuries per cc (volume of urine sample collected was 200 cc). The patient's urine samples will be sent to DOH Wadsworth Laboratories for analysis. Future samples are expected to be collected and analyzed.

"The brachytherapy seeds were manufactured by Mills Biopharmarmaceuticals, Inc., sold by Mentor MBI (Oklahoma City, OK) and loaded into needles by the pharmacy. Brachytherapy seed specifics are:
Model: 125SL
Lot Number: 042814
Batch Number: IB040142N
Seed activity on 8/10/04: 0.405 millicuries"

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General Information or Other Event Number: 40944
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WYATT ENGINEERING - USKH
Region: 4
City: SPOKANE State: WA
County:
License #: WN-I0409-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/12/2004
Notification Time: 18:13 [ET]
Event Date: 07/27/2004
Event Time: [PDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

Taken in part from email sent from Washington Department of Health

"The licensee reported that a Troxler moisture/density gauge, Model 3430, Serial Number 19736 was damaged while in use. The gauge was backed over by a water truck while the source rod was extended into the road surface. The gauge contained two sealed sources, (Cs-137, 0.296 GBq [8 milliCuries] and Am-241:Be 1.48 GBq [40 milliCuries]). The licensee stated the gauge had been placed on the surface with the source rod in a test hole. The licensee was looking for a new test location when the truck damaged the gauge.

"The licensee attempted to retract the Cs-137 source into its shielded position but could not. The operator placed the end of the probe back in the test hole and waited for help. A manufacturer's representative arrived at about 10:30 a.m. to assist the licensee. He surveyed the area and found that the highest reading was 50 mR/hr directly beside the gauge with the rod in the ground. A second attempt was made to retract the source rod into the shielded position. This resulted in moving all but the last inch inside the shield. At this point the source rod with shield was placed in a five gallon bucket and filled with dirt and rock while the transport box was made ready.

"Both the Cs-137 and Am-241:Be sources appeared to be intact and undamaged. The representative attempted again to move the Cs-137 source into the shielded position. This attempt was successful. The Cs-137 source rod/shield assembly and Am-241:Be source were placed into the transport box and more dirt and rock were added. The box was then locked and chained inside the licensee's truck.

"Dose-rate measurements were taken and noted to be 10 mR/hr at 6 inches from the box. The driver's side of the cab measured about 2 mR/hr. The licensee was instructed to park the vehicle, not to leave it unattended and not to drive it until additional shielding could be located. The representative took possession and transported the gauge to a storage area where it was secured. A leak test was performed and found to be negative. The representative will ship the gauge for disposal."

Washington State event report #WA 04-044.

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General Information or Other Event Number: 40947
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE (HOSPITAL)
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: MATT MCKINLEY
HQ OPS Officer: ARLON COSTA
Notification Date: 08/13/2004
Notification Time: 11:03 [ET]
Event Date: 08/11/2004
Event Time: 10:45 [CDT]
Last Update Date: 08/13/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
TOM ESSIG (NMSS)

Event Text

KENTUCKY AGREEMENT STATE NOTIFICATION

University of Louisville Hospital physicians were injecting a prescribed treatment of Yttrium-90 (Therasphere) 3.32 GBq (GigaBecquerel) into a patient's liver and only 0.72 Gbq was actually administered (22%). The licensee is investigating the cause of the misadministration. Initial investigation points to a tubing extension modification made to carry the dose to the targeted organ since the majority of the flow remained in the tubing. Hospital physicians have used the equipment 5 to 6 times without any incident. The licensee will send the tubing back to the manufacturer for further investigation. The physician notified the patient.

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Power Reactor Event Number: 40963
Facility: HUMBOLDT BAY
Region: 4 State: CA
Unit: [3] [ ] [ ]
RX Type: [3] GE-1
NRC Notified By: LARRY PARKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/17/2004
Notification Time: 11:40 [ET]
Event Date: 08/17/2004
Event Time: 08:30 [PDT]
Last Update Date: 08/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM JONES (R4)
TOM ESSIG (NMSS)
ELIOT BRENNER (PAO)
PETER WILSON (IRD)

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

Event Text

"REPORT OF MISSING SPECIAL NUCLEAR MATERIAL

"This is a non-emergency Event Notification in accordance with 10 CFR 74.11 to inform the NRC of missing special nuclear material of low strategic significance. On July 16, 2004, Pacific Gas, and Electric (PG&E) notified the NRC of a material accountability discrepancy involving a portion of a spent fuel rod used at the Humboldt Bay Power Plant (HBPP) Unit 3 (reference NRC Event Notification 40877). The discrepancy in plant records called into question the location of three approximately 18-inch segments that were cut from a single spent fuel rod in a used fuel assembly (A-49) in 1968. PG&E initiated a comprehensive search of the on-site HBPP spent fuel pool (SFP), a review of plant and nuclear materials shipping records, and interviews with present and former employees and contractors to resolve the material accountability discrepancy and locate the unaccounted for fuel segments.

"On August 17, 2004, at 08:30 PDT, the HBPP Plant Staff Review Committee (PSRC) reviewed the results of the search of the SFP to-date and concluded that the search of the most likely locations for the unaccounted for fuel segments (storage containers within the SFP) and all easily accessible spaces in the SFP was thorough and complete and that the search had not located the unaccounted for fuel segments in the SFP. The PSRC also reviewed the results to-date of the in-progress review of plant records, interviews, and nuclear material shipping records and concluded that the relevant information obtained did not definitively identify the on-site or off-site location of the unaccounted for fuel segments. Though it remains probable that the unaccounted for fuel segments will ultimately be found in the SFP or shown to have been shipped to a facility licensed to reprocess or store nuclear materials, PG&E is conservatively considering these segments as missing and making this 1-hour non-emergency event notification in accordance with 10 CFR 74.11.

"PG&E will be issuing a press release later today describing the current status of this issue.

"PG&E has embarked upon a 'phase II' search of the remaining less-accessible SFP areas and will continue its review of plant records, nuclear materials shipping records (plant and waste repository records), and interviews of plant personnel to definitively locate the missing fuel segments. A supplemental LER will be provided to the NRC when the segments are located or when the phase II search is concluded.

"No evidence has been uncovered to support the possibility of theft or diversion of the unaccounted for fuel segments. Due to the high radioactivity of the material, to be handled safely, the segments would have to be encased in a heavy shielded container that would have to be moved with special handling equipment designed for this purpose, precluding an abrupt loss. Since plant start-up, HBPP has been equipped with a system of radiation monitors for the refueling building (where the SFP is located) with alarm setpoints that are capable of alerting plant personnel of the movement of highly radioactive material should the fuel segments have been removed from the SFP without being in a shielded container. This could not have occurred casually without plant staff or security personnel observing the movement.

"Because the three approximately 18-inch segments are not readily identifiable in the SFP, three possible scenarios exist. The highest probability is that the fuel segments are in a SFP area that is not readily accessible, and will be located during a more detailed search of these locations. The second highest probability is that the fuel segments were shipped offsite to an appropriately controlled and restricted facility for either analysis or reprocessing. The least probable location, but not yet capable of being ruled out, is that the fuel segments were inadvertently included in a shipment to a licensed, monitored, and restricted LLRW facility. Since these possible locations are licensed, monitored and restricted radiological control areas, the public health and safety has not been adversely affected.

"For additional information, refer to licensee event report (LER) 2004-001-00,'Three Missing Fuel Rod Segments,' dated August 16, 2004, and submitted in accordance with 10 CFR 20.2201(b)(2)(ii), (Reference H BL-04-020).

"NRC personnel at headquarters and in Region IV have been notified of the status of this issue."

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Power Reactor Event Number: 40964
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: STEPHEN MAGILL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/17/2004
Notification Time: 11:46 [ET]
Event Date: 08/17/2004
Event Time: 05:28 [PDT]
Last Update Date: 08/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
WILLIAM JONES (R4)

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

Event Text

MANUAL REACTOR SCRAM DUE TO TRIP OF REACTOR FEEDWATER PUMP "A" ON LOW SUCTION PRESSURE.


"With a reactor startup in progress at 0528 PDT, operators at Columbia Generating Station inserted a manual reactor scram when the operating Reactor Feed Water (RFW) pump RFW-P-1A tripped. Reactor power was approximately 20% at the time of RFW pump trip. The cause of the RFW pump trip was due to low suction pressure; the cause of the low suction pressure is currently under investigation. The Reactor Core Isolation Cooling (RCIC) system [was manually started and] was used to maintain reactor vessel water level until reactor pressure was reduced to within the capacity of the condensate booster pumps (500 to 600 psi). The RCIC system has been returned to a standby lineup. The reactor is in Mode 3 (Hot Shutdown) with both reactor recirculation pumps running at minimum speed (15 Hertz). Decay heat is being rejected to the main condenser via auxiliary steam loads. All ECCS systems are operable. All emergency diesel generators are operable. No Safety Relief valves lifted during the scram."

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

See similar event number 40959 that occurred on 08/15/04.

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Power Reactor Event Number: 40965
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: GLENN HUTTON
HQ OPS Officer: BILL GOTT
Notification Date: 08/17/2004
Notification Time: 15:30 [ET]
Event Date: 08/17/2004
Event Time: 13:15 [EDT]
Last Update Date: 08/17/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TODD JACKSON (R1)

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

OFFSITE NOTIFICATION - POSSIBLE DISCHARGE PERMIT VIOLATION

At 1145 EDT the Chemistry Tech sampled the Rad Waste Service water overboard line. The sample showed less than 0.02 milligrams per liter (mg/l) residual chloride. The Chemistry Tech adjusted up the chlorination rate.

At 1315 a second sample yielded a result of 0.29 mg/l residual chloride. The tech immediately secured the Chloride system, and sampled the intake canal. The results were less than 0.02 mg/l residual chloride.

Oyster Creek is monitoring for any environmental impact. The change in residual chloride may not correlate to the increase in chlorination rate, therefore sample error is possible and is under review.

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 08/17/04 AT 2123 EDT BY JEFF DOFTAL TAKNE BY MACKINNON * * *

"This is a follow-up to an earlier notification made at 15:30 today. Based upon further investigation the Potential NJPES Violation was found to be valid. The residual intake Cl - (Chloride) concentrations were found to be 0.29 mg/l. This is in excess of the 0.2 mg/l limit. The over chlorination event lasted for approximately 2 hours." R1DO (Todd Jackson) notified.

The NRC Resident Inspector will be notified of this update by the licensee.

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