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Event Notification Report for October 20, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/19/2004 - 10/20/2004

** EVENT NUMBERS **


41123 41124 41125 41132 41133 41134 41137 41138 41139 41140

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General Information or Other Event Number: 41123
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIV. OF TEXAS AT AUSTIN
Region: 4
City: AUSTIN State: TX
County:
License #: L00485-000
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/15/2004
Notification Time: 09:45 [ET]
Event Date: 09/29/2004
Event Time: 12:00 [CDT]
Last Update Date: 10/15/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
SANDRA WASTLER (NMSS)

Event Text

TEXAS AGREEMENT STATE EVENT REPORT - LEAKING SOURCE

"The Licensee notified the Agency of a leaking source that was discovered on September 29, 2004 and confirmed by a second leak test on September 30, 2004. The source was for a Lagus Applied Technology, Inc. Model 101 AUTOTRAC Tracer Gas Monitor (SF6), Serial No. 177. The source was described as a Model 200-EC Electron Capture Detector, Serial No. 1271 with an activity of 300 millicuries, Tritium (3H) (October 3, 1998). The current activity is an estimated 214 millicuries. The leak test detected 18,178 dpm or 0.0082 microcuries of removable activity. The second leak test conducted September 30, 2004, confirmed the source was leaking with similar results. The gas monitor was taken out of service. After removing the SF6 compressed gas bottle, the monitor containing the leaking source was packaged for return to the manufacturer. The packaged source was shipped to the manufacturer on October 6, 2004. No violations were cited."

Texas Incident No: I-8172

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General Information or Other Event Number: 41124
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: BILL GOTT
Notification Date: 10/15/2004
Notification Time: 11:08 [ET]
Event Date: 10/01/2004
Event Time: [CDT]
Last Update Date: 10/15/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE - MEDICAL EVENT

"This incident took place on October 1, 2004. A patient from Room 5206 was administered 20 millicuries of Xe-133 gas resulting in a lung dose of 0.22 Rad and an Effective Dose Equivalent of 0.028 Rad. It was then found that the orders were written for a patient in Room 5213. The order form had the wrong patient name sticker attached. The nursing station supervisor stated that they had noticed incorrect patient name stickers in the Room 5213 patient chart. It is not known how these stickers and chart orders were switched. The patient was notified of the error and the correct patient later received the Xenon scan."

Event Report: LA040012

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General Information or Other Event Number: 41125
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NAPLES DIAGNOSTIC IMAGING CENTER
Region: 1
City: NAPLES State: FL
County:
License #: 2964-2
Agreement: Y
Docket:
NRC Notified By: JERRY EAKINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/15/2004
Notification Time: 12:21 [ET]
Event Date: 10/15/2004
Event Time: [EDT]
Last Update Date: 10/15/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRIAN MCDERMOTT (R1)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE - STOLEN RADIOACTIVE SOURCES

State of Florida Bureau of Radiation Control reported that licensee notified their agency of 3 missing Germanium 68 sources from their General Electric PET CT Hybrid Imaging device. The sources were discovered missing on 10/15/04. It has not been determined when the sources were last known to be in the possession of the licensee.

The sources were model number B3-693, serial Number 1004-09, 4.3 millicuries; model number B2-125, serial number 1004-02, 4.3 millicuries; model number A9-313, serial number 973-87, 0.58 millicuries. Specific activity of sources is corrected for decay as of 10/15/04. The Naples Police Department is investigating the possible theft. The Florida Bureau of Radiation Control also notified the Regional Terrorism Task Force in Fort Myers and the Florida State Warning Point.

Florida Incident # 04-137.

* * * UPDATE PROVIDED BY JERRY EAKINS TO JEFF ROTTON @ 1515 EDT ON 10/15/04 * * *

Florida Bureau of Radiation Control investigator found the sources on the licensee premises. The sources had been placed under the cushion of a supervisor's chair. Naples Police Department is continuing their investigation into any potential criminal activity. The estimated exposure to the supervisor was 60 mR based on 4 hours of exposure.

Notified the R1DO (McDermott) and NMSS EO (Essig)

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Power Reactor Event Number: 41132
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WALLACE JUDD
HQ OPS Officer: BILL GOTT
Notification Date: 10/19/2004
Notification Time: 08:50 [ET]
Event Date: 08/22/2004
Event Time: 04:50 [EDT]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVID AYRES (R2)

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

60 DAY REPORT - INVALID ACTUATION OF SPECIFIED SYSTEM

"This 60-day optional report as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of a specified system, specifically the Nuclear Service Water System (NSWS).

"During TSM 158 work associated with W/O 98686671 a SPOC Relief Supervisor inadvertently caused a ground when disconnecting test meter leads from an energized circuit. This ground resulted in an unplanned RN [Nuclear Service Water] swap to the SNSWP [Standby Nuclear Service Water System].

"At 0450 on 8/22/04, a lo-lo level signal was received for B Train RN Pit and this initiated a swap to the SNSWP for both A and B trains. Prior to this event, both trains of RN had been aligned to the SNSWP on 8/16/04 for maintenance, and remained on the SNSWP due to 1RN-4B degraded condition (PIP C-04-3937)

"The lo-lo level signal did initiate a start of all four RN Pumps (1B and 2B started; 1A and 2A were already operating). RN crossover valves 1RN-53B and 1RN 54A closed as expected, separating RN trains A and B. Flow was manually initiated through all four NS Heat Exchangers to attempt to meet RN pump minimum flow demands. This was a complete actuation for Train B and the system performed as designed for existing plant conditions. This event was entered into the site corrective action program for resolution (PIP C04-04056).

"At 1629 on 8/22/04, a lo-lo level signal was received for B Train RN Pit and this initiated a swap to the SNSWP for both A and B trains. Prior to this event, both trains of RN had been aligned to the SNSWP on 8/16/04 for maintenance, and remained on the SNSWP due to 1RN-4B degraded condition (PIP C-04-3937). RN system response was as expected. The lo-lo level signal did initiate a start of all four RN Pumps (1B and 2A started; 1A and 2B were already operating). RN crossover valves 1RN-47A and 2RN-47A closed as expected, and return header isolation valves 1RN-53B and 1RN-54A closed as expected, separating RN trains A and B.

"Flow was manually initiated through all four NS heat exchangers to attempt to meet RN pump minimum flow demands. The reasons for the inadvertent actuation was a blown fuse. Performed Troubleshooting Plan to I/R Cause of Fuse HA-1 in 1EATC6 blowing under W/O #98686856-01 and 03. No cause for the fuse blowing on 2004-08-22 could be found. All data obtained under the plan were well within normal values.

"Thermography data indicate the fuse temperature was about 3 Deg F above ambient. The current through the fuse is 1.3 Amps. (Fuse HA-1 is a FLQ-3) Current alarm HF in 1EATC6 was calibrated, and was found in tolerance. No change in current through the fuse was noted during the calibration of the current alarm. The current alarm was cycled 5 times.

"This was a complete actuation for Train B and the system performed as designed for the existing plant conditions. This event has been entered into the site specific corrective action program for resolution. (C04-4060)."

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41133
Rep Org: ST. VINCENT HOSPITAL
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: ED WROBLEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2004
Notification Time: 12:05 [ET]
Event Date: 10/11/2004
Event Time: [CST]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
SANDRA WASTLER (NMSS)

Event Text

MEDICAL EVENT INVOLVING FRACTIONATED DOSE DELIVERY LESS THAN PRESCRIBED

On 10/11/04 a 49 year old female patient received the first of two treatments for endometrial cancer. A total dose of 700 centrigrays was prescribed to be delivered in two (2) 350 centigray fractions using a 1500 mm length catheter containing a 7.035 curies Ir-192 source (duration 189 seconds). Due to an error on the part of the Health Physicist, the 995 mm length catheter was used. This resulted in a calculated dose of less than 1 centigray to the thigh at a distance of 505 mm from the intended site. There are no expected adverse consequences.

Both the patient and prescribing physician were informed. A new treatment plan has been developed and the patient rescheduled. Corrective actions are to be determined. The licensee informed Region 3 (Mike Lafranzo).

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Power Reactor Event Number: 41134
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: EUGENE SKELTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2004
Notification Time: 12:35 [ET]
Event Date: 10/19/2004
Event Time: 05:28 [CDT]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JACK WHITTEN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 98 Power Operation

Event Text

LOSS OF NORMAL POWER SUPPLY TO "2E" SWITCHGEAR RESULTED IN AFW AUTOSTART

"Unit 2 experienced an autostart of Auxiliary Feedwater System (AFW) and Emergency Diesel Generator 'B' following transfer of the '2E' Switchgear to Alternate Power Supply.

"Normal Power Supply (XST1) experienced a loss of power, causing the '2E' Switchgear to slow transfer to the -2 Breakers from the Alternate Power Supply (XST2).

"The AFW (MDAFWP [Motor-driven Auxiliary Feedwater Pumps] 'A' and 'B' and TDAFWP [Turbine-driven Auxiliary Feedwater Pump]) autostarted due to Sequencer Operations.

"The EDG 'B' autostarted on low voltage condition but did not supply power to the affected '2E' bus. The EDG 'B' cooling water was provided by the service water system.

"Power was restored to XST1 at 0606 CDT. The cause of the EDG 'B' autostart is under investigation. The cause of the loss of power to XST1 is under investigation. Power was reduced to 98.2% to ensure Nuclear Power <100%. All other systems functioned as required. Local NRC Resident was informed."

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Power Reactor Event Number: 41137
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [ ] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: STEVE GODFREY
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2004
Notification Time: 23:03 [ET]
Event Date: 10/19/2004
Event Time: 22:10 [EDT]
Last Update Date: 10/19/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MIKE ERNSTES (R2)
TAD MARSH (NRR)
HO NIEH (IRD)
CARDWELL (FEMA)
WELLER (DHS)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO UNEXPLAINED DECREASE IN SPENT FUEL POOL WATER LEVEL

"An uncontrollable decrease in water level in the spent fuel pool occurred. All fuel assemblies remained covered. Current plant conditions DO NOT threaten public safety. Level decrease is secure. Valve lineup caused level decrease to BWST. Approximately 24 feet above fuel maintained. Secured fuel transfer canal drain lineup."

Unit 3 is currently defueled. The licensee was attempting to perform a spent fuel pool makeup while there was another valve lineup in progress which drained the deep end of the fuel transfer canal. This exposed some piping that allowed a flow path from the spent fuel pool to the BWST and resulted in the transfer of slightly less than 1 ft. level in the spent fuel pool, or approximately 10,000 gallons. Operators immediately recognized the decrease in spent fuel pool level and took appropriate steps to secure other activities in order to identify the drain path. This included securing the RCB wash downs in progress inside containment to eliminate a source for the observed increase in RB sump levels and secured equipment drain downs in progress in the Aux Building to eliminate these as a source for the observed increase in the high activity waste tank level.

Spent fuel pool level decreased from 0.3 ft above to about 0.7 ft below the normal. During the transient, a 24 ft. level was maintained above the spent fuel. No increase in radiation levels following the decreasing in water level was observed.

The licensee had recently started three spent fuel pool cooling pumps and due to a decrease in spent fuel pool temperature some shrinkage had occurred. The drain down to the BWST was initiated at approximately 2115 hours. At 2130 hours, Operators recognized the problem and entered the applicable Abnormal Procedure. At 2210 hours the Licensee declared an Unusual Event and took actions to secure the valve lineup which allowed the drain down. These actions were completed by 2215 hours at which time the Unusual Event was terminated. By 2224 hours a level increase due to makeup was observed.

Current spent fuel pool level is - 0.15 ft and increasing. The Licensee will continue makeup until the level reaches + 0.5 which is estimated to occur at approximately 0100 hours on 10/20/04. No offsite radioactive release occurred.

The licensee will inform the NRC resident inspector.

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Other Nuclear Material Event Number: 41138
Rep Org: COMPUTALOG WIRELINE
Licensee: COMPUTALOG WIRELINE
Region: 4
City: FORT WORTH State: TX
County:
License #: 42-26891-01
Agreement: Y
Docket:
NRC Notified By: JEFF PETTIGREW
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/19/2004
Notification Time: 23:10 [ET]
Event Date: 10/19/2004
Event Time: 21:30 [CDT]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JACK WHITTEN (R4)
ELMO COLLINS (NMSS)

Event Text

LOSS OF WELL LOGGING SOURCE OFF SHORE

During well logging operations on a fixed platform in the Gulf of Mexico, the well logging tool separated from the wireline and fell overboard in approximately 40 feet of water. The well logging tool has a 45 millicurie Cs-137 source attached. Licensee is going to coordinate with NRC Region 4 and State of Louisiana personnel to identify a source/tool recovery team to search for the radioactive source. There is a slight possibility that the tool could be caught on the platform substructure that is normally inaccessible by personnel.

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Power Reactor Event Number: 41139
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: KEN HILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/19/2004
Notification Time: 23:37 [ET]
Event Date: 10/19/2004
Event Time: 18:30 [CDT]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE DUE TO CONTROLLER SIGNAL CONVERTER TROUBLE.

"On October 19, 2004 at approximately 1830 hours CDT, Unit One was performing QCOS 2300-05, Quarterly HPCI Pump Operability Test. This was being performed to prove operability following maintenance work on various valves and the turning motor gear unit. At this time when the HPCI turbine was rolled, the HPCI Signal Converter Trouble alarm was received. The HPCI Flow Controller demand controlled at approximately 7250 gpm instead of controlling at the desired 5600 gpm. HPCI was determined not to be operable and was shutdown per procedure. Due to the unexpected behavior of the HPCI Flow Controller, at this time it is not certain if the HPCI will meet its safety function. Therefore, we are reporting this event under 10 CFR 50.72 (b)(3)(v)."

Licensee entered Tech Spec 3.5.1.(f) 14 day Limiting Condition of Operation (LCO) for HPCI. Reactor Core Isolation Cooling (RICI) is operable. All other Emergency Core Cooling Systems (ECCS) and the Emergency Diesel Generators (EDG) are fully operable if needed.

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

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Power Reactor Event Number: 41140
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: DAVID YOUNGE
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/20/2004
Notification Time: 01:35 [ET]
Event Date: 10/19/2004
Event Time: 17:30 [EDT]
Last Update Date: 10/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MIKE ERNSTES (R2)

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
3 N Y 0 Refueling 0 Refueling

Event Text

STANDBY EMERGENCY ELECTRICAL POWER PATHS INOPERABLE FOR 41 MINUTES

"The Keowee Hydro Units provide the emergency power source for the Oconee Units. At 0357 on 10/19/04, Keowee Unit 1 (and the overhead emergency power path) was declared inoperable in order to perform scheduled maintenance. At 1730, Keowee Unit 2 (and the underground emergency power path) was declared inoperable due to the loss of breaker control power associated with Keowee Unit 2 auxiliaries. At 1811, as required by Technical Specification 3.8.1 condition I, both standby buses were energized from a Lee Combustion Turbine via an isolated power path. At 1828, a Operability Verification of Keowee Unit 2 to the overhead emergency power path was performed with all acceptance criteria met. At 1904, Keowee Unit 2 to the overhead emergency power path was declared operable. Technical Specification 3.8.1 condition I was exited.

"Initial Safety Significance: Between times 1730 to 1811, both on site emergency power paths were inoperable. During this time period a condition existed that could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.

"Corrective Action(s): At 1828, an Operability Verification of Keowee Unit 2 to the overhead emergency power path was performed with all acceptance criteria met. At 1904, Keowee Unit 2 to the overhead emergency power path was declared operable. Technical Specification 3.8.1. condition I was exited. A team is established to investigate the loss of breaker control power associated with Keowee Unit 2 auxiliaries."

The licensee will notify the NRC Resident Inspector.

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