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Event Notification Report for September 8, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/07/2004 - 09/08/2004

** EVENT NUMBERS **


41008 41014 41015 41022 41024

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General Information or Other Event Number: 41008
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: AURORA State: WI
County:
License #: 09-1017-01
Agreement: Y
Docket:
NRC Notified By: PAUL CALEB
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/02/2004
Notification Time: 11:20 [ET]
Event Date: 08/31/2004
Event Time: 14:00 [CDT]
Last Update Date: 09/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
LINDA GERSEY (NMSS)

Event Text

WISCONSIN AGREEMENT STATE REPORT: SOURCE FAILED TO RETRACT

"On the evening of August 31, 2004 during a mammosite treatment utilizing a Varian HDR unit, the source failed to retract upon completion of the treatment time. The licensee's RSO/AMP had to enter the treatment room and retract the source manually.

"The licensee subsequently contacted Varian for assistance. A service representative from Varian arrived at Aurora Baycare Medical Center on Wednesday, Sept. 1, 2004. The Varian service representative found nothing wrong with the HDR unit. However, approximately 2 cm of the connecting catheter had 'buckled' (appeared melted and twisted), possibly restricting source movement. The licensee has contacted the catheter manufacturer for assistance in analyzing the catheter to determine what may have caused it to buckle.

"Preliminary dose indications by the licensee indicate that the patient received an additional amount of dose to the skin while the source was being retracted. The licensee reported that the most probable estimate of the additional skin dose is 1.0 Gy."

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General Information or Other Event Number: 41014
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: KING ASPHALT INC
Region: 1
City: LIBERTY State: SC
County:
License #: 436
Agreement: Y
Docket:
NRC Notified By: JEREMY HANNA
HQ OPS Officer: ARLON COSTA
Notification Date: 09/03/2004
Notification Time: 15:47 [ET]
Event Date: 09/03/2004
Event Time: 12:50 [EDT]
Last Update Date: 09/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
PATRICIA HOLAHAN (NMSS)
DONNA-MARIE PEREZ (TAS)

Event Text

SC AGREEMENT STATE REPORT: STOLEN MOISTURE DENSITY GAUGE

Upon returning from lunch, the King Asphalt Inc. technician noticed that the moisture density gauge had been missing from the storage box casing. The gauge was previously secured in the box casing stored on the pickup truck bed. The box locking mechanism appears to have been pried open in order to retrieve the gauge. The moisture density gauge is a Humboldt Model No.5001EZ, S/N 670, containing 11 milliCuries of Cs-137 and 44 milliCuries of Am-241:Be. A report of the stole gauge was filed with the Greenville, SC police.

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General Information or Other Event Number: 41015
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN
Region: 3
City: MADISON State: WI
County:
License #: 25-1323-01
Agreement: Y
Docket:
NRC Notified By: PAUL SCHMIDT
HQ OPS Officer: ARLON COSTA
Notification Date: 09/03/2004
Notification Time: 15:41 [ET]
Event Date: 09/03/2004
Event Time: 13:30 [CDT]
Last Update Date: 09/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
SCOTT FLANDERS (NMSS)

Event Text

WI AGREEMENT STATE: LOSS OF CONTROL OF RADIOACTIVE MATERIAL

"On Friday, September 3, 2004 at approximately 1:30 p.m., the Wisconsin Radiation Protection Section (RPS) received a telephone call from the University of Wisconsin - Madison (license number 25-1323-01) informing the section of a lost Ir-192 source that had been inadvertently shipped to the University of Arizona Medical Center, Tucson, AZ.

"Preliminary Information From the Licensee

"On Monday, August 30, 2004, the University of Wisconsin - Madison calibration lab had completed calibration of a Standard Imaging, Model 1000+ reentrant well chamber (ion chamber used to determine brachytherapy seed dose) and shipped it back to the chamber owner, the University of Arizona Medical Center. Shortly after arrival, the U.A. Medical Center discovered that the chamber contained a 0.4 mCi [milliCurie] Iridium-192 brachytherapy seed that had been used during calibration. The U.A. Medical Center subsequently notified the U.W. Madison of the incident on Friday, September 3, 2004.

"The licensee estimates that the dose rate from an unshielded 0.4 mCi Ir-192 seed source would be approximately 0.192 mR/hr at 1 meter. The licensee believes that the chamber shielded the source so the dose rate on the surface of the shipping container was negligible."

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Power Reactor Event Number: 41022
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: RICK VIRGIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/05/2004
Notification Time: 17:35 [ET]
Event Date: 09/05/2004
Event Time: 17:10 [EDT]
Last Update Date: 09/07/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
SCOTT SHAFFER (R2)
RICHARD WESSMAN (IRD)
JOEL MUNDAY (R2)
MICHAEL CASE (NRR)
LIVINGSTON (DHS)
KUZIA (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 97 Power Operation 97 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO HURRICANE WARNING

Crystal River declared a Notification of Unusual Event due to hurricane warning in effect for the plant and surrounding areas. All safety systems are operable.

The licensee notified the NRC Resident Inspector and the State emergency response organization.

* * * UPDATE AT 1027 ON 9/7/04 R TYRIE TO W GOTT * * *

The licensee terminated the Notification of Unusual Event at 1017 today, 9/7/04. The basis of the termination is that the hurricane warning was lifted yesterday 9/6/04 and offsite power has been restored.

Notified R2 (Pribish), NRR (Reis), IRD (Wessman), DHS (Akers), FEMA (Kuzia).

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Power Reactor Event Number: 41024
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: LARRY MOFFATT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/08/2004
Notification Time: 03:11 [ET]
Event Date: 09/08/2004
Event Time: 01:00 [EDT]
Last Update Date: 09/08/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CAROLYN EVANS (R2)

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

Event Text

POTENTIAL REACTOR COOLANT SYSTEM PRESSURE BOUNDARY LEAK LOCATED

"At 0100 on September 8, 2004, while in Mode 3 conducting a Reactor Building walkdown after an unplanned reactor trip during Tropical Storm Frances, Crystal River Unit 3 identified a potential Reactor Coolant System pressure boundary leak located on a weld associated with a pressurizer level sensing line (upstream of reactor coolant isolation valve RCV-75). The cause of the leak is not known at this time, and the leak did not have a significant effect on plant operation. The last unidentified leak rates that were completed prior to the plant shutdown were 0.10 - 0.13 gpm. This defect in the primary coolant system is unacceptable per ASME Section XI. The condition is 8-Hour reportable per 10CFR 50.72 (b)(3)(ii)(A). The plant will be cooled down to Mode 5 and additional inspections and necessary repairs implemented.

Dry boron crystal deposit are on the sensing line upstream of RCV-75 . See similar event reported by Crystal River Unit 3 on 10/04/03 (event # 40222)

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

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