Event Notification Report for August 30, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/27/2004 - 08/30/2004

** EVENT NUMBERS **


40908 40979 40989 40993 40994 40995 40996

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40908
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RAGER ORZELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 07/29/2004
Notification Time: 15:46 [ET]
Event Date: 07/29/2004
Event Time: 12:10 [EDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES TRAPP (R1)

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

Event Text

OFFSITE NOTIFICATION DUE TO RAW SEWAGE DISCHARGE TO LAKE ONTARIO

A report was received in the Unit 2 Control Room by Site personnel that raw sewage appeared to be seeping from a manhole inside the protected area. The Fire Department and Environmental Department were dispatched to the area. It was reported back to the Unit 2 Control Room that raw sewage was seeping from the manhole and filling nearby ditch and flowing to a storm sewer.

Due to the leakage, Nine Mile Point entered their HAZMAT response procedure. Initial investigation for the sewage release found the sewage lift station pumps' control switch in the "OFF" position preventing the pumps from operating. The lift station pumps were restarted and the discharge from the manhole stopped. Lift station pumps continue to function properly and cleanup efforts are underway. Investigation is underway on why the lift station pump control switches were in the off position. Based upon initial calculations, it was determined approximately 3000 gallons of raw sewage was released from manhole to a nearby storm sewer which discharges to Lake Ontario.

Nine Mile Point has notified the Oswego County Department of Health and New York State Department of Environmental Conservation. No hazards exist to offsite personnel and no wildlife has been adversely affected.


The Licensee notified the NRC Resident Inspector, Local and State agencies.

* * * UPDATE AT 1700 EDT ON 8/27/04 FROM CHRIS SKINNER TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"Subsequent investigation has determined that approximately 400 gallons of raw sewage was released into the storm drainage ditch. There was no active flow in the storm drainage ditch at the time of the event. Samples indicate that the raw sewage did not reach the lake. The event was reclassified as a State Pollutant Discharge Elimination System Permit Upset with minor impact to the environment. Therefore, the event notification from July 29, 2004 is retracted."

The licensee informed the NRC Resident Inspector. Notified R1DO (Cobey).

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General Information or Other Event Number: 40979
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NORTHEAST ALABAMA REGIONAL MEDICAL CENTER
Region: 1
City: Montgomery State: AL
County:
License #: 315
Agreement: Y
Docket:
NRC Notified By: DAVID TUBERVILLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2004
Notification Time: 08:52 [ET]
Event Date: 08/10/2004
Event Time: [CDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
GARY JANOSKO (NMSS)

Event Text

MEDICAL MISADMINISTRATION

The following information was received from the State of Alabama Department of Public Health via facsimile:

"SUBJECT: Licensee identification of I-131 Misadministration.

"By telefax notification on August 17, 2004, Northeast Alabama Regional Medical Center (Alabama Radioactive Material License No. 315) notified the State of Alabama of a misadministration involving Iodine-131.

"In the telefaxed report, the licensee indicated that the event occurred on August 10, 2004 and was discovered on August 12, 2004. The dose prescribed was 25 microcuries of I-131 and the dose administered was 3.0 millicuries. Based on the information supplied by the licensee, it appears that the imaging technologist misunderstood the referring physician's request and the dose was not approved by the authorized user. The licensee indicated in their report that there was no apparent effects to the patient. Corrective measures included reinstructing personnel and ensuring that all procedures are approved by the authorized user.

"At this time, the Office of Radiation Control is requesting additional information from the licensee. Once made available, the information will be supplied via the NMED database system."

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Hospital Event Number: 40989
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: VA MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: PAUL YURKO
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/27/2004
Notification Time: 09:12 [ET]
Event Date: 08/27/2004
Event Time: 08:15 [EDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
EUGENE COBEY (R1)
ERIC DUNCAN (R3)
TOM ESSIG (NMSS)

Event Text

THE LICENSEE REPORTED EXTERNAL RADIATION LEVELS ON A PACKAGE EXCEEDING THE LIMITS OF 10CFR 71.47.

The event occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-OIVA. The permittee is VA Medical Center, Durham, North Carolina.
The event occurred on August 27, 2004, and was discovered at 8:15 AM EDT on the same day. The basis for the event is under 10 CFR 20.1906(d)(2) in that a package received in the nuclear medicine service of the: VA Medical Center, Durham, North Carolina measured 250 mrem/hr at a point on the external surface of the package. Photon Imaging Corporation (a commercial radiopharmacy located in Raleigh, North Carolina) delivered the package containing a Tc-99m baulk vial to the nuclear medicine service of the VA Medical Center, Durham, North Carolina. .A survey of the surface of the delivery container indicated a point on its external surface that measured 250 mrem/hr and 4 mrem/hr @) 1 meter. Wipe surveys, however, did not indicate any removable contamination. Upon inspection of the package, it was discovered that the cap of the shield containing a baulk dose of Tc-99m of 137.6 mCi had inadvertently fallen loose and was no longer shielding the vial. There was no indication that the vial itself was damaged or that any of the Tc-99m had leaked into the package. The permittee user does not anticipate any adverse medical effects to patients, staff or members of the public. The permittee immediately notified the commercial vendor.

The Department of Veterans Affairs will evaluate the circumstances related to the event and submit a written report to NRC Region 3, within 15 days.

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Power Reactor Event Number: 40993
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JEFF WILLIAMS
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/27/2004
Notification Time: 12:20 [ET]
Event Date: 08/27/2004
Event Time: 06:58 [CDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
ERIC DUNCAN (R3)

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

Event Text

CONTRACT SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A contract supervisor tested positive for alcohol during a for-cause test. The individual's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 40994
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARK VERBECK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/27/2004
Notification Time: 12:36 [ET]
Event Date: 08/27/2004
Event Time: 08:50 [CDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM JOHNSON (R4)

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

Event Text

OFFSITE NOTIFICATIONS MADE TO SPILLAGE OF PHOSPHONIC ACID

15 gallon spill of blulab 7016 acid anti-scalant (used for Circulating Water System) of which 5 gallons was caught in a bucket and approximately 10 gallons spilled of which 1 or 2 gallons ended up into the lake. Licensee notified the National Response Center and the Texas Commission of Environmental Quality.

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

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Power Reactor Event Number: 40995
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: EDWARD HARRISON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/28/2004
Notification Time: 07:38 [ET]
Event Date: 08/28/2004
Event Time: 01:46 [CDT]
Last Update Date: 08/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

FAILURE OF THE PLANT PROCESS COMPUTER DUE TO LOSS OF POWER SUPPLY

At approximately 01:46 (CDT) on August 28, 2004, the Duane Arnold Energy Center plant process computer (PPC) failed due to a lost power supply. This computer system provides the control room with its Safety Parameter Display System (SPDS), the Emergency Response Data System (ERDS) and MIDAS. With the loss of the PPC, and specifically the subsequent loss of SPDS, ERDS, and MIDAS representing a major loss of emergency assessment capability, the reportability criteria of 10CFR50.72(b)(3)(xiii) was met. No other control room indications, or communication systems were affected by this computer outage. They expect to have a new power supply at the site by noon today and installed within two hours after arrival.


The NRC Resident Inspector will be notified.

* * * UPDATE PROVIDED BY DICK FOWLER TO JEFF ROTTON AT 1302 ON 08/28/04 * * *

The Duane Arnold Energy Center plant process computer (PPC) power supply has been replaced and operation of the PPC has been restored.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40996
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ART BREADY
HQ OPS Officer: ARLON COSTA
Notification Date: 08/30/2004
Notification Time: 02:54 [ET]
Event Date: 08/29/2004
Event Time: 19:28 [EDT]
Last Update Date: 08/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
EUGENE COBEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

ALARM INDICATION OF INOPERABLE REACTOR WATER CLEANUP SUPPLY ISOLATION VALVE

"On 08/29/04 at 1928 hours [EDT], an alarm was received in the control room indicating the reactor water cleanup (RWCU) high differential flow isolation channel for the outboard RWCU supply isolation valve was inoperable. At the time, the channel functional test for the inboard RWCU high differential flow isolation channel was being performed. During the channel functional test, power to the inboard isolation valve is removed to permit continued RWCU system operation while the isolation function is tested. With the outboard isolation actuation instrumentation channel inoperable and the inboard isolation valve deenergized, in the event of a break in the RWCU system, the required isolation function may not be completed.

"This event is being reported in accordance with 10CFR50.72(b)(3)(v)(C) as a condition that could have prevented the fulfillment of a safety function.

"In accordance with Technical Specification requirements, the RWCU system was removed from service and the inboard and outboard supply Isolation valves were closed."

There is no immediate impact on water chemistry and the licensee is investigating the cause of the original failure as well as possible long term degradation of the reactor water chemistry.

The licensee notified the NRC Resident Inspector and will notify the local township authorities of this incident.

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