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Event Notification Report for October 4, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/01/2004 - 10/04/2004

** EVENT NUMBERS **


41077 41078 41079 41082 41083 41084 41085 41086

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General Information or Other Event Number: 41077
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PORT TOWNSEND PAPER
Region: 4
City: PORT TOWNSEND State: WA
County:
License #: WN-I041-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL GOTT
Notification Date: 09/28/2004
Notification Time: 12:51 [ET]
Event Date: 05/17/2004
Event Time: [PDT]
Last Update Date: 09/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE LOST OHMART DENSITY GAUGE

"The licensee reported that an Ohmart density gauge (Model SH-F2, Serial Number 2479GK) had last been seen during an inventory and shutter check on November 17, 2003. The gauge contained a 1.85 GBq (50 mCi), Cs-137 sealed source. Facility records indicate the device's electrical signal was lost on December 12, 2003, at 4:30 pm. At that time, a physical investigation, to investigate the signal loss, was not performed. The next routine inventory was attempted on May 17, 2004. At this time the gauge was found to be missing.

"The missing gauge had measured 'weight rejects' at a remote part of the facility. Rejects are routinely sent to an eastern Washington landfill by truck. The gauge seems to have been dislodged from its angle-iron attachment, by large reject material, and then inadvertently taken to an eastern Washington landfill by the rejects truck.

"Gauge measurements were not vital to operations, so the loss of signal had gone ignored until the May 17th inventory attempt.

"CORRECTIVE ACTION TAKEN by licensee:

1. A special training session will be given, during the licensee's next monthly safety meeting, for those employees associated with fixed gauge operations. The training will emphasize the importance for employees to investigate when gauge process measurements are lost.

2. Special informational postings will be placed at key locations within the facility, near process control equipment receiving fixed gauge electrical signals, so facility employees shall be reminded to immediately investigate the loss of a gauging device's signal.

"Isotope and Activity Involved: Cs-137, 1.85 GBq (50 mCi)

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None likely.

"Lost, Stolen or Damaged? (mfg., model, serial number): Lost (or Stolen) Ohmart density gauge (Model SH-F2, Serial Number 2479GK)

"DISPOSITION/RECOVERY: Searches by licensee with the assistance of department staff were performed with Ludlum Model 19, Micro R meters and other detection instrumentation. These searches were unsuccessful.

"A search at the Licensee's facility in Port Townsend, Washington was conducted on May 25, 2004. A search at the landfill was performed on July 29, 2004."

Event Report Number: WA-04-028

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General Information or Other Event Number: 41078
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL GOTT
Notification Date: 09/28/2004
Notification Time: 15:08 [ET]
Event Date: 09/24/2004
Event Time: [PDT]
Last Update Date: 09/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT

"Per Swedish Medical Center policy, post thyroid treatment patients are prescribed 74 mBq (2mCi (milliCuries)) for the treatment follow-up scan, and 185 mBq (5 mCi) for subsequent treatment if necessary. On 24 September 2004 a patient was prescribed 74 mBq (2 mCi) of NaI (Iodine-131) for a post treatment scan. Instead, 191 mBq (5.16 mCi) of NaI (Iodine-131) were administered. The prescribing physician realized that a misadministration had occurred on 27 September 2004 when the patient underwent the scan. A viable follow-up scan was able to be performed even though the misadministration had occurred.

"There are multiple procedural checks in place to assure medical technicians administer the prescribed dose. Human error appears to have lead to checks not being performed prior to this event.

"The Radiation Safety Officer for Swedish Medical Center notified the State of Washington, of the misadministration, on 27 September 2004.

"The treating physician notified the patient on Monday, 27 September 2004, when the physician discovered the patient had been administered 191 mBq (5.16 mCi) of NaI (Iodine-131) instead of the prescribed 74 mBq (2 mCi) of NaI (Iodine-131)."

Event Report Number WA-04--57

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General Information or Other Event Number: 41079
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSAL ENGINEERING SCIENCES INC
Region: 1
City: CAPE CORAL State: FL
County: LEE COUNTY
License #: 2069-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: BILL GOTT
Notification Date: 09/29/2004
Notification Time: 14:23 [ET]
Event Date: 09/29/2004
Event Time: [EDT]
Last Update Date: 09/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
TRISH HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

"Licensee's case containing gauge [Troxler Moisture Density Gauge, Model 3411-B, Serial Number 18168, 8 millicuries Cs-137, 40 millicuries Am-241:Be] fell out of a truck while driving down the road. A fire truck just happened to be following the truck and secured the gauge. The technician noted loss and returned to the scene. Gauge and case were not damaged. The technician forgot to chain the gauge to the truck after finishing a job. The licensee will submit a written report on this incident."

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Power Reactor Event Number: 41082
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANNY WILLIAMSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2004
Notification Time: 12:00 [ET]
Event Date: 10/01/2004
Event Time: 07:30 [CDT]
Last Update Date: 10/01/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
LINDA HOWELL (R4)
BOB DENNIG (NREO)
HO NIEH (IRO)

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

Event Text

REACTOR TRIP DUE TO MAIN GENERATOR LOAD REJECTION

"At 7:30 a.m. [CDT] on October 1, 2004, an automatic reactor scram occurred as a result of an electrical fault on the main generator output lines that caused a main generator trip and turbine trip. All control rods inserted. Approximately 13 minutes prior to the fault, a loss of one station service transformer had occurred. This resulted in an automatic start of the Division 1 diesel generator and a loss of power to some plant auxiliaries, including the feedwater level regulation isolation valves.

"The loss of reserve station service no. 1, combined with the trip of the main generator, caused a loss of power to two condensate pumps and one main feedwater pump. The remaining two feedwater pumps tripped on low suction pressure. The reactor containment isolation cooling pump (RCIC) steam supply isolated during the scram transient, so the control room operators manually started the high-pressure core spray system (HPCS) pump for level control. The injection valve was closed as level had already reached the high water level isolation setpoint for that valve. It was later reopened manually as level approached the low level setpoint (level 2), which would have automatically opened the valve. The level 2 setpoint was reached briefly after the valve was already open.

"Reactor pressure is being controlled manually with safety relief valves (SRV's). The main steam isolation valves (MSIV's) were manually closed due to lowering pressure from steam loads in the plant that could not be immediately isolated because of loss of power to their valves. RCIC is also running in CST (condensate storage tank) to CST mode, to augment pressure control.

"The electrical load center which supplies power to the instrumentation and valves needed for feedwater operation was cross-tied to an alternate power source, and feedwater was restored to operation and is presently controlling reactor water level. During the event, standby service water also initiated.

"This is the presently known information. Further information will be provided as the investigation continues."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 41083
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: BARROW
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2004
Notification Time: 16:30 [ET]
Event Date: 10/01/2004
Event Time: 14:15 [EDT]
Last Update Date: 10/01/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ROBERT HAAG (R2)

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

Event Text

DEATH OF A CONTRACT EMPLOYEE FROM AN APPARENT HEART ATTACK

The following was received from the licensee via facsimile:

"A 56-year old male AREVA contractor died from a heart attack. A report of potential heart attack was made at 1242 [EDT] to the control room. Off-site medical assistance was used and the contractor was transported to South Miami-Homestead Hospital at 1340 [EDT]. [The] contractor was pronounced dead at 1415 [EDT]."

The licensee also reported that the individual was not contaminated and was stricken while working in a contractor trailer located near the facility administration building.

The licensee has notified the NRC Resident Inspector and will be notifying the Occupational Safety Health Administration (OSHA).

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Power Reactor Event Number: 41084
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT KIDDER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/02/2004
Notification Time: 15:22 [ET]
Event Date: 10/02/2004
Event Time: 13:00 [EDT]
Last Update Date: 10/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS KOZAK (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

Event Text

PLANT DECLARED THE EMERGENCY RECIRCULATION VENTILATION SYSTEM INOPERABLE.

A surveillance test was being performed on the Emergency Recirc vent System and all six dampers on both trains failed to stroke in the required Tech. Spec. times. Therefore, both trains of the Emergency Recirc Vent System were declared inoperable and the plant entered T.S. 3.0.3. The LCO action statement requires the plant to be in mode 2 in 7 hours and mode 3 in the following six hours and mode 4 in the following 24 hours. They are currently troubleshooting the problem.

The NRC resident Inspector was notified

HOO Note: see event 41085

* * * UPDATE ON 10/02/04 AT 1940 EDT FROM FREDERICK SMITH TO GERRY WAIG * * *

"Update to [Event] Notifications 41084 and 41085:
At 1840 [EDT] on 10/02/04 it was determined that the apparent slow response times of the Control Room Emergency Recirculation [CRER] dampers was due to a malfunctioning relay in the initiation circuit, not due to failure of the dampers. The LCO actions associated with the CRER system were exited and the actions associated with the initiation instrument were entered. Therefore the plant is no longer required to shutdown per T.S. 3.0.3. The plant shutdown has been terminated. Plant power will be returned to 100%."

The licensee has notified the NRC resident Inspector.

Notified R3DO (Thomas Kozak).

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Power Reactor Event Number: 41085
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT KIDDER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/02/2004
Notification Time: 15:22 [ET]
Event Date: 10/02/2004
Event Time: 15:00 [EDT]
Last Update Date: 10/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 83 Power Operation

Event Text

REACTOR POWER BEING REDUCED DUE TO ENTERING TS 3.0.3 BECAUSE OF INOPEABLE RECIRC VENT SYSTEM

At 1500 hours the plant commenced reactor shutdown from 100% power for entering T.S. 3.0.3 due to both trains of the Emergency Recirc Vent System being declared inoperable. The reactor will be in mode 2 by 2000 hours, mode 3 by 0200 hours on 10/03 and mode 4 by 0200 hours on 10/04. If the problem is corrected, they will terminate the shutdown.

The NRC Resident Inspector was notified.

HOO Note: see event 41084

* * * UPDATE ON 10/02/04 AT 1940 EDT FROM FREDERICK SMITH TO GERRY WAIG * * *

"Update to [Event] Notifications 41084 and 41085:
At 1840 [EDT] on 10/02/04 it was determined that the apparent slow response times of the Control Room Emergency Recirculation [CRER] dampers was due to a malfunctioning relay in the initiation circuit, not due to failure of the dampers. The LCO actions associated with the CRER system were exited and the actions associated with the initiation instrument were entered. Therefore the plant is no longer required to shutdown per T.S. 3.0.3. The plant shutdown has been terminated. Plant power will be returned to 100%."

The licensee has notified the NRC resident Inspector.

Notified R3DO (Thomas Kozak).

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Power Reactor Event Number: 41086
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY D. COLEMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/03/2004
Notification Time: 10:46 [ET]
Event Date: 10/03/2004
Event Time: 05:30 [EDT]
Last Update Date: 10/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ROBERT HAAG (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 20 Power Operation 20 Power Operation

Event Text

PRIMARY CONTAINMENT PENETRATION ISOLATION VALVES INOPERABLE

"During a review of outage clearances, it was discovered that a Caution tag out for Service Air to the Drywell was active and the valves were open. This rendered the valves inoperable and Technical Specification 3.6.1.3 action B for one penetration with two inoperable PCIVs was entered. The action was to isolate the penetration by closing one valve within one hour. The event was discovered at 0530 and the outboard valve was closed at 0655 . Since the one hour time limit was exceeded, Technical Specification 3.6.1.3 action E (Mode 3 in 12 hours and Mode 4 in 36 hours) was entered at 0630 and exited at 0655. Technical Specification 3.6.1.3 action A, which is the Tech. Spec. for one inoperable isolation valve will remain in effect. The plant entered Mode 3 at 1530 on 10/01/04. Mode 3 requires primary containment and all PCIVs to be operable. This condition of non-compliance existed from 1530 on 10/01/04 until 0655 on 10/03/04.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012