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Event Notification Report for September 1, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/31/2004 - 09/01/2004

** EVENT NUMBERS **


40986 40987 40988 40990 40991 40992 40998 41001 41002

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General Information or Other Event Number: 40986
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: AEA TECHNOLOGY QSA INC
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/26/2004
Notification Time: 11:21 [ET]
Event Date: 08/20/2004
Event Time: 16:00 [EDT]
Last Update Date: 08/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
ERIC DUNCAN (R3)
TOM ESSIG (NMSS)

Event Text

AEA TECHNOLOGY REPORTED RECEIVING A LEAKING SOURCE FROM ONE OF THEIR CUSTOMERS

AEA reports that an AEA Model PDM.1002.Hn Series static eliminator device, containing approximately 3 millicuries of polonium-210 was returned from a customer and found to be leaking. A wipe survey of the NRD, Inc. Model P-001 foil sealed source contained in the device measured 0.008 microcuries of polonium-210. Wipe survey of the outside package detected no contamination. The device was received from AEA's customer, Hank Graff Chevrolet in Davidson, MI. on August 19, 2004. AEA contacted the sealed source manufacturer, NRD, Inc.

AEA Technology QSA, Inc. (AEA) sealed the source in a plastic bag and the immediate area was checked for further contamination. No contamination other than what was on the source was found. AEA contacted the source manufacturer, NRD, Inc. An investigation is pending. The Agency will notify the U.S. NRC and the State of New York as applicable to the device customer site and source manufacturer site jurisdiction.

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General Information or Other Event Number: 40987
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TULANE UNIVERSITY
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0004-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/26/2004
Notification Time: 15:20 [ET]
Event Date: 04/20/2004
Event Time: [CDT]
Last Update Date: 08/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT - INCORRECT MEDICAL TREATMENT SITE

The following information was received via facsimile:

"The incident occurred on April 20, 2004 at the Tulane Cancer Center. The patient was being treated for cervical cancer. The Nucletron Source Position Simulator had previously been repaired by the service technician by providing a replacement screw. During measurement of correct catheter position with the device, the simulator cable became stuck resulting in underestimation of the required distance. This erroneous number was entered into the Nucletron HDR unit. The 9050 milliCurie source of Ir-192 did not extend to the desired location but remained outside the patient for approximately 2 minutes at 2.6 centimeters from the skin. The dose estimate for this was 270 R. The patient was notified and the treatment plan modified. As of July 21, 2004 there is no effect on the patient. To prevent reoccurrence the procedure was modified to test for looseness in the Source Position Simulator prior to use."

Louisiana Report # LA040007

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General Information or Other Event Number: 40988
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NORTHROP GRUMMAN SHIP SYSTEMS
Region: 4
City: AVONDALE State: LA
County:
License #: LA-0711-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/26/2004
Notification Time: 15:28 [ET]
Event Date: 07/21/2004
Event Time: [CDT]
Last Update Date: 08/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
SANDRA WASTLER (NMSS)
JIM WHITNEY (TAS)

Event Text

AGREEMENT STATE REPORT - LOST OR STOLEN GAUGE

The following information was received via facsimile:

"On July 21, 2004 a Niton Analyzer with serial number 6067 with 40 milliCuries of Fe-55 and 30 milliCuries of Am-241 came up missing. The security department was notified immediately. Every effort was made to locate the analyzer but it could not be found. Signs were posted at all clock stations and exit gates. Security also checked the employees when they were leaving the yard."

Louisiana Report # LA040008

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General Information or Other Event Number: 40990
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CHILDREN'S HOSPITAL
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-1448-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL (fax)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/27/2004
Notification Time: 09:35 [ET]
Event Date: 08/05/2004
Event Time: [CDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
TOM ESSIG (NMSS)

Event Text

INCORRECT DOSE ADMINISTERED TO A PATIENT

A misadministration occurred on August 5, 2004. The patient was an uncooperative 20 year old Down's Syndrome who was to be injected with 20 mCi of Tc-99m MDP for a bone scan. While attempting to restrain the patient the technologist mistakenly reached for and injected a 4.2 mCi DMSA renal scan dose. The patient was notified of the error and subsequently injected with the correct dose. The misadministration did not exceed the 5 rems effective dose equivalent or the 50 rems dose equivalent to any organ. The technologist was been counseled to obtain assistance when performing such administrations in the future.

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General Information or Other Event Number: 40991
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAYOU TESTERS
Region: 4
City: AMEILA State: LA
County:
License #: LA-7112-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL (fax)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/27/2004
Notification Time: 10:01 [ET]
Event Date: 07/01/2004
Event Time: [CDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
TOM ESSIG (NMSS)

Event Text

LICENSEE REPORTED FAILURE OF A RADIOGRAPHY CAMERA

On July 1, 2004 while Bayou Testers was performing quarterly inspections, they noticed that the case on a INC-100 industrial radiography camera was split open. The exposure devise was taken out of operation and sent to Source Production and Equipment (SPEC). The devise contained approximately 10 Ci of Ir-192. SPEC informed the licensee that the cause of the case splitting was corrosion of the depleted uranium shield, which caused it to swell and tear the weld. SPEC informed the licensee that this occurrence was not unusual.

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General Information or Other Event Number: 40992
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: DOW CHEMICAL
Region: 4
City: PLAQUEMINE State: LA
County:
License #: LA-2002-L02
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL (fax)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/27/2004
Notification Time: 11:09 [ET]
Event Date: 07/20/2004
Event Time: [CDT]
Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
TOM ESSIG (NMSS)

Event Text

POSSIBLE RADIATION EXPOSURE FROM A LEVEL DETECTION DEVICE

It has been determined that during a painting and insulation replacement: job on the exterior of the D-15 vessel at the Solvents Plant at Dow's Plaquemine manufacturing complex, a radiation shield was not locked out on a 500 mCi Cs-137 radiation source used for level detection. The zone of potential exposure was approximately 3 inches wide by 14 inches long on the external top of the tank. The work that was being performed was in such a manner that there could have been a possibility of hand or arm exposure. During the six day period it was determined that up to 16 persons had the potential to be exposed while completing the insulation replacement. A conservative estimate of 5 minutes total continuous exposure time over this period at a distance of 5 inches from the source yield a potential exposure of 421 mrems. A two minute total continuous exposure at a distance of 14 inches would yield a potential exposure of 31 mrems. The cause of the incident was failure to lock out a radiation shield prior to commencement of work. Lock out procedures for the facility have been reviewed and strengthened to prevent reoccurrence. Medical screening was performed on all potentially exposed personnel and the results were reviewed with the personnel. No effects were observed.

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Power Reactor Event Number: 40998
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: DON SHEEHAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2004
Notification Time: 11:42 [ET]
Event Date: 08/30/2004
Event Time: 08:35 [EDT]
Last Update Date: 08/31/2004
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):
PAMELA HENDERSON (R1)

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

Event Text

UNIT 1 MANUALLY SCRAMMED DUE TO OSCILLATING REACTOR VESSEL WATER LEVEL

"Nine Mile Point, Unit One is initiating a 10 CFR 50.72 (b) (2) (iv) (B) 4-Hour Non-Emergency notification based upon insertion of a 'MANUAL' scram that occurred at 08:35 on Monday, August 30, 2004.

"At time of transient, plant was operating in Mode 1, Power Operating Condition, at 99.7% of rated power.

"At 08:25 on Monday, August 30, 2004, Operators noted oscillations on 13 Feedwater flow control valve (FCV) while in 'AUTOMATIC' mode of operation (normal mode of operation for this equipment). Operators took "MANUAL" control of 13 FCV per Plant Operating Procedures. 13 FCV oscillations continued while in the 'MANUAL' mode, and a decision was made to insert a 'MANUAL' scram at 08:35. All control rods fully inserted and the plant responded as designed to the scram.

"At 08:44, the scram signal was reset per procedure.

"Currently, plant is in Mode 2, Hot Shutdown Condition with cooldown in progress. Plant is transitioning to Mode 3, Cold Shutdown Condition, per Plant Operating Procedures."

At the time the manual scram was inserted, Reactor Vessel Water Level (RVWL) was 67 inches and decreasing (automatic scram setpoint is 53 inches). The 13 FCV is on the discharge of the turbine-driven feedwater pump. Decay heat is currently being removed by the main condenser via the steam bypass valves. All ECCS and safety-related equipment is available, if needed. At the time of the transient there was no plant maintenance on-going which could have been a contributing factor.

The licensee informed the NRC Resident Inspector.

* * * UPDATE ON 8/30/04 AT 2358 EDT FROM M. MINNICK TO J. ROTTON * * *

"The notification sent to the NRC on 8/30/04 at 11:42 was found to be incomplete. As a normal and expected response to a manual scram at high power, the High Pressure Coolant Injection System (feedwater) automatically initiated during the transient following the manual scram. This should have been reported as an 8 hour Non-Emergency 10CFR50. 72 (b) (3) (iv) (A) notification."

The licensee notified the NRC Resident Inspector.

Notified R1DO (Henderson).

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Other Nuclear Material Event Number: 41001
Rep Org: C. W. THOMAS INC
Licensee: C. W. THOMAS INC
Region: 1
City: PHILADELPHIA State: PA
County:
License #:
Agreement: N
Docket:
NRC Notified By: JOHN BECKER
HQ OPS Officer: BILL GOTT
Notification Date: 08/31/2004
Notification Time: 08:46 [ET]
Event Date: 08/09/2004
Event Time: 07:00 [EDT]
Last Update Date: 08/31/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
PAMELA HENDERSON (R1)
SANDRA WASTLER (NMSS)

Event Text

LOST GENERAL LICENSED POLONIUM SOURCE

The Ionizing Static Tip of a General Purpose Air Gun (Model number P-201-001, Serial number A2DH072) was discovered missing on 8/9/04. A thorough search of the work area was conducted, but the tip could not be found. It is speculated that the gun was dropped and the tip was dislodged from the gun and was subsequently swept up and disposed of in the trash. The tip is a Polonium-210 source with approximately 1.6 milliCuries. The gun was leased from NRD Advanced Static Control Systems.

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Power Reactor Event Number: 41002
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: DANIEL MALONE
HQ OPS Officer: BILL GOTT
Notification Date: 08/31/2004
Notification Time: 09:38 [ET]
Event Date: 08/31/2004
Event Time: 07:18 [EDT]
Last Update Date: 08/31/2004
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):
JULIO LARA (R3)
RICHARD WESSMAN (IRD)
TERRY REIS (NRR)
MICHAEL CASE (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 95 Power Operation 0 Hot Standby

Event Text

RPS ACTUATION DUE TO FIRE IN 2B CONDENSATE PUMP

"At 0718 EDT, the reactor was manually tripped from approximately 95% power following notification to the control room of a fire associated with condensate pump 2B. Initially, upon notification of smoke at the condensate pump, a rapid down power had been commenced, wherein reactor power was reduced from 100% to approximately 95% power.

"An automatic actuation of the auxiliary feedwater system also occurred as designed to maintain steam generator water level following the reactor trip.

"The fire was extinguished in less than 10 minutes. The local fire department was notified, responded to the site as a precautionary measure, but was not used in extinguishing the fire. All systems functioned as designed. The reactor is stable in mode 3."

Decay heat is being removed with the steam generators discharging steam to the main condenser.

The licensee notified the NRC Resident Inspector.

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