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Event Notification Report for November 3, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/02/2004 - 11/03/2004

** EVENT NUMBERS **


41159 41161 41162 41165 41166 41167 41168 41169

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General Information or Other Event Number: 41159
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: BARD BRACHYTHERAPY
Region: 3
City: CAROL STREAM State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 15:10 [ET]
Event Date: 10/29/2004
Event Time: [CDT]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD GARDNER (R3)
SANDRA WASSLER (NMSS)

Event Text

AGREEMENT STATE REPORT

"On October 29, the radiation safety officer (RSO) for Bard Brachytherapy, Mr. Ed Zduenk called the Division to report an excessive radiation level from a package that they had received. Federal Express had delivered a container that was shipped by Northwest Hospital, Randallstown, Maryland on October 26, 2004. The maximum measured radiation level on the surface of the package was 500 milliRem/h. At a distance of 3 feet, the measured radiation level was indistinguishable from background.

"After verifying that the package was intact and undamaged, the RSO proceeded to take measurements in the delivery vehicle. No elevated radiation levels were noted. With the package repositioned in the vehicle as described by the driver, additional measurements were made. There were no elevated readings detected on the exterior of the truck nor at the driver's position. As such, the RSO estimated the driver's exposure to be minimal from handling the package and briefly working at the rear of the delivery vehicle. The carrier was subsequently contacted with this information as well.

"After the package was accepted and moved to a safe location at the facility, additional measurements were taken. The maximum dose rate measured at 1 foot was 10 milliRem/h and at 2 feet was 2 milliRem/h. The container was expected to have 112 sealed sources of I-125 with an actual activity of 0.476 milliCurie each for a total of 53.3 milliCurie. After the package was opened and its contents inventoried, it was determined that all of the sources were accounted for. When the package was opened, the RSO observed that the lid of the interior primary shielded container was not in its expected position. Although some of the sources remained in the shielded container, the other sources were only in their shielded applicator. No sources were 'loose' in the box.

"Considering the shipper, the state of Maryland was notified of this event. This item is still open pending investigation to determine the cause of the event."

IL report number IL040068

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General Information or Other Event Number: 41161
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County: FAYETTE
License #: 20126696
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 16:52 [ET]
Event Date: 10/22/2004
Event Time: 14:00 [CDT]
Last Update Date: 10/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT

During the interlock check of a JL Shephard Model 1 Number 68-10 Irradiator, the source rod was lifted with the machine in the off position, indicating a failure of the interlock. Exposure determinations of the technicians present indicated an exposure less than reportable limits. An investigation is in progress.

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General Information or Other Event Number: 41162
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: LDS HOSPITAL
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800102
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 18:25 [ET]
Event Date: 10/26/2004
Event Time: 11:30 [MDT]
Last Update Date: 10/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"This event involved an HDR brachytherapy unit [Varian Medical Systems, Inc. Model GammaMed plus, serial number E159; with sealed source Model GammaMed 232, serial number 24-07-4445-004-082504-11622-71 (connector serial number D24E445)]. The female patients larynx cancer treatment plan called for four HDR brachytherapy treatments. On October 26, 2004, two HDR brachytherapy treatments were given. Before the third treatment was to be given, on October 27, 2004, an error was discovered. The prescribing physician stopped the treatment until dosimetry information was completed. The third treatment was not given. The error was caused because a circular tool was used to mark the treatment site. The diameter of the circle was used when the radius should have been applied. As a result, the area treated was 2 cm away from the defined locus instead of 1 cm. The total source length treated was 11 cm, (approximately 1 cm diameter cylinder surrounding the brachytherapy source placed inside a tracheotomy tube). The prescribed dose was 500 cGy (centiGray) to the entire 11 cm length. The worse case patient dose scenario was that the patient received 2,756 cGy at one dwell position out of 23 dwell positions along the 11 cm treatment length. The dose delivered would have been 551% greater than the prescribed dose at the position respective to the worst-case scenario. The licensee does not anticipate any adverse health affects to the patient. The Utah Division of Radiation Control is currently investigating this event."

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Power Reactor Event Number: 41165
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: J. M. CLARK
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/01/2004
Notification Time: 23:44 [ET]
Event Date: 11/01/2004
Event Time: 16:44 [CST]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHUCK CAIN (R4)
TONY VEGEL (R4)

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

Event Text

EMERGENCY DIESEL GENERATOR AUTOMATIC START

"At 1644 [11/01/04], with River Bend Station in Mode 5 (Refueling), voltage on offsite power line Reserve Station Service (RSS) No. 2 was lost. This offsite power line is the 230 KV power supply to the Division 2, 4160 volt safety related electrical bus. The Division 2 emergency diesel generator (EDG) automatically started and loaded on a loss of voltage to the 4160 volt safety bus.

"At the time of the event, Division 2 Residual Heat Removal (RHR) was in the fuel pool cooling assist mode and the pump secured due to the loss of power. It was subsequently restarted and continues to provide the shutdown cooling function.

"The following systems were isolated as a result of this event: Reactor Water Clean-up, Alternate Decay Heat Removal, and Floor Drains.

"Investigation of the cause of the event is ongoing."

There was no impact on spent fuel pool level or temperature. At the event reporting time, power to the bus was still being provided by the Division 2 EDG with plans to restore normal power shortly. The licensee informed the NRC Resident Inspector. See also similar event EN # 41164 of 10/31/04.

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Other Nuclear Material Event Number: 41166
Rep Org: MALLINCKRODT
Licensee: MALLINCKRODT
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: ROLAND SAWYER
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/02/2004
Notification Time: 09:45 [ET]
Event Date: 11/02/2003
Event Time: [CST]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PATRICK LOUDEN (R3)
STEPHEN CAHILL (R2)
JOHN HICKEY (NMSS)
DAVID SILK (R1)

Event Text

MISSING DEPLETED URANIUM SHIPPING SHIELD

"The licensee reported that an empty 18kg depleted uranium shipping shield could not be located. The shield was supposedly shipped from North Carolina Pharmacy in Greensboro, NC to Mallinckrodt (NRC Materials License #24-04206-01 Docket Number 030-00001), however, no record of delivery was found. After one year of searching, Mallinckrodt has declared the material "lost" as of 11/02/04.

"Description of the lost source of licensed material Radionuclide: Depleted Uranium shield
Physical Form: Solid (Mo-99 generator shielding encased in stainless steel housing)
Activity: 18 kilograms
Manufacturer: Manufacturing Science Corporation (Oakridge, TN)
Model Number: L33200, Serial Number: 002771

"The depleted Uranium shield described above was incorporated into a Mo-99 DTE generator and subsequently distributed to the North Carolina Nuclear Pharmacy located in Greensboro, North Carolina (North Carolina Department of Environment and Natural Resources Radioactive Materials license #041-0780-1). As of the date of this letter the shield containing the depleted Uranium has not been located. All efforts, including contacting couriers and searches at both Maryland Heights and the Greensboro pharmacy have been unsuccessful.

"With the tracking system that is currently in place at Maryland Heights as well as the delinquency notification program, we are able to track the shield when assigned to a shipment and upon its return. Based on these facts, the shield receipt by the customer has been verified, however the shipment from the pharmacy to Maryland Heights could not be verified. The in house tracking system at Maryland Heights shows that the shield was not returned and its disposition at this time is unknown with any degree of certainty.

"Exposure of individuals and the possible Total Effective Dose Equivalent to persons within unrestricted areas, as a result of the loss of the licensed material, is deemed minimal due to the relatively low activity, and physical nature of the source (i.e., solid, steel-encased source).

"Site personnel will continue searching for the missing depleted Uranium shield by conducting additional search exercises. In the spirit of ALARA, searching through containers of long-lived radioactive waste materials is not being considered at this time. Additionally, the VP of regulatory affairs for Cardinal Health was contacted concerning this issue. His efforts were also unsuccessful in locating the shield.

"A full evaluation of the Depleted Uranium accountability and tracking program is in progress through a team approach. This six sigma approach will result in corrective actions that will strengthen the return process and prevent reoccurrence. The scheduled completion of this six sigma project is March 2005."

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Power Reactor Event Number: 41167
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PAT LEARY
HQ OPS Officer: BILL GOTT
Notification Date: 11/02/2004
Notification Time: 17:36 [ET]
Event Date: 11/02/2004
Event Time: 14:00 [EST]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID SILK (R1)

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

UNANALYSED CONDITION - INADEQUATE CABLE SEPARATION

"On 11/2/04 at 1400, Seabrook Station determined that a potential scenario involving a fire could result in the loss of the Train A and Train B centrifugal charging pumps (CCP). During a fire, inadequate cable separation could result in the spurious closure of one of two series volume control tank (VCT) outlet valves. This would result in a loss of suction to the operating CCP and eventual loss of the pump. The second CCP is assumed to be lost as a result of the same fire. This condition was concluded to be reportable pursuant to 10CFR50.72(b)(3)(ii)(B) as a condition that resulted in the plant being in an unanalyzed condition that significantly degrades plant safety.

"Compensatory measures include establishing a roving fire watch in the affected fire zones, operator briefings, and limiting combustible material in the affected fire zones."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41168
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF KINISLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/02/2004
Notification Time: 20:22 [ET]
Event Date: 11/02/2004
Event Time: 11:05 [PST]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHUCK CAIN (R4)

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

Event Text

UNPLANNED DIESEL GENERATOR START ON A VALID BUS UNDERVOLTAGE SIGNAL

"On November 2, 2004, at 11:05 PST, with Diablo Canyon Unit 2 in Mode 6 (Refueling), Emergency Diesel Generator (EDG) 2-1 auto started on an unplanned actuation signal from a valid 4160 volt Bus G undervoltage signal. All equipment responded as designed. After the EDG started, the auxiliary feeder breaker opened, and loads were automatically sequenced onto the EDG. At the time of the event, test equipment was being connected in preparation for an instrumented manual test start of EDG 2-1 prior to maintenance.

"On November 2, 2004, at 1708 PST, operators transferred Bus G to auxiliary power and shutdown DG 2-1.

"Prior to the event, Bus G was being supplied by auxiliary power, with startup power cleared for planned maintenance. Bus G was being prepared to be cleared for maintenance, therefore, required equipment was in-service on the other buses. Buses F and H were unaffected by this event and remain operable on auxiliary power, with EDG 2-2 (Bus H) and 2-3 (Bus F) operable. The following decay heat removal trains are powered from Bus G: Residual Heat Removal Pump 2-1 remained in standby, Component Cooling Water Pump 2-2 started on the transfer to EDG, and Auxiliary Saltwater Pump 2-2 re-started.

"Unit 2 is in day 9 of a refueling outage, with the reactor head removed, the refueling cavity filled, and the upper internals installed with rods latched.


"Unit 1 was unaffected and continues to operate in Mode 1 (Power Operation) at 100 percent power.

"The cause of the Bus G undervoltage signal is being investigated."

The licensee stated that no undervoltage was seen on any other equipment but the undervoltage relays on Bus G did sense an undervoltage. Residual Heat Removal was unaffected by the event. Bus G has been returned to its pre-event configuration and is considered operable. The other EDGs were fully operable at the time of the event and there were no significant LCOs at the time. All systems functioned as required.

The licensee has notified the NRC Resident Inspector

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Power Reactor Event Number: 41169
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUANE GARTNER
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/03/2004
Notification Time: 05:15 [ET]
Event Date: 11/03/2004
Event Time: 03:10 [EST]
Last Update Date: 11/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
DAVID SILK (R1)

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

Event Text

OFFSITE MEDICAL TREATMENT FOR INJURED CONTAMINATED WORKER

"On 11/03/04 at approximately 0256 hrs, a refueling bridge operator was injured when his gloved right hand became entangled in the refuel bridge mast during the performance of core alterations. The moving mast sections crushed two of the operator's fingers, and the bridge was immediately shutdown by the spotter. An irradiated fuel bundle had just been removed from the reactor core at the time of the incident, and was being raised to the full up position for transport to the spent fuel pool. The refueling SRO directed the bridge power be turned on to lower the mast slightly and release the operator's hand. The bridge operator was escorted off of the refuel floor by radiation protection and site medical personnel. A bridge relief crew completed the movement of the irradiated fuel bundle to its target location in the spent fuel pool, and core alterations were stopped pending completion of an accident investigation.

"The injured bridge operator was contaminated with approximately 5000 counts per minute on the injured hand, and was transported offsite by radiation protection and site medical personnel at approximately 0310 hrs. The operator was subsequently de-contaminated inside of the ambulance under the care of the emergency room physician, and the contaminated material was returned to site inside the ambulance. Once decontaminated, the operator was admitted to the Salem Memorial Hospital emergency room in Salem, New Jersey."

The licensee informed the Lower Alloways Creek Township and the NRC Resident Inspector and does not plan a press release.

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