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Event Notification Report for November 15, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/12/2004 - 11/15/2004

** EVENT NUMBERS **


41182 41189 41192 41193 41194 41195

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General Information or Other Event Number: 41182
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City: SEATTLE State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/09/2004
Notification Time: 11:10 [ET]
Event Date: 11/05/2004
Event Time: [PST]
Last Update Date: 11/09/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT DUE TO LOSS OF IODINE-125 CALIBRATION SEEDS

"On Monday morning, 8 November 2004, the licensee reported a loss of 16 Iodine-125 calibration seeds, Amersham Model 6711, total of 193 mega Becquerel (5.216 milliCi), packaged in 2 vials. The vials contained 6 and 10 seeds respectively. Each vial was inside a lead shield.

"The missing calibration seeds had been received on 5 November. They arrived in the same package as medical therapy seeds. The licensee's medical physicist removed the therapy seeds and placed them into secured storage assuming that the calibration and therapy seeds were all contained in the vials the physicist was removing. However, the calibration seeds were reported by the vendor to have been in additional vials associated with the foam packing material. The cardboard package and packing foam is routinely sent to the licensee's recycle center once the licensed material has been removed. This probably happened (including the calibration seeds) some time shortly after the physicist opened the package on 5 November.

"On 8 November, the medical physicist realized the calibration seeds were not with the therapy seeds. The physicist reported their loss to the licensee's Radiation Safety Officer. Licensee staff surveyed the receipt area, the recycle center as well as the corridors connecting the areas and other likely spots. The lost material has not been located. The waste material had apparently been removed from the facility on 7 November. It is likely the lost material went to the landfill on 7 November. The licensee is still investigating. The licensee will send the department a formal report when their investigation is complete.

"Contributing factor: The licensee failed to perform an acceptable package receipt survey.
"Corrective actions: Will be addressed during the department's investigation.

"No media contact: None yet. "

WA Event Report # WA-04-066

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General Information or Other Event Number: 41189
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HARRIS METHODIST FORT WORTH
Region: 4
City: FORT WORTH State: TX
County:
License #: L01837-000
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/10/2004
Notification Time: 14:21 [ET]
Event Date: 05/16/2004
Event Time: 12:00 [CST]
Last Update Date: 11/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT FROM TEXAS: EQUIPMENT FAILURE THERAPY DEVICE AT HOSPITAL

"On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. ... The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device."

Texas Incident No.: I-8179

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Power Reactor Event Number: 41192
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: DAVID FOSS
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/12/2004
Notification Time: 10:58 [ET]
Event Date: 09/18/2004
Event Time: 03:57 [EST]
Last Update Date: 11/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOHN ROGGE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

INVALID SPECIFIED SYSTEM ACTUATION DUE TO OFF SITE POWER SOURCE FAST TRANSFER

"This 60-day optional report, as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of specified systems, specifically the Units 2 and 3 Primary Containment Isolation Systems (PCIS).

"On 9/18/04, at approximately 0357 hours [EDT], the 343SU offsite-power source tripped resulting in a fast transfer of expected 4 kV emergency busses to the alternate offsite power source. The fast transfer resulted in system isolations on both units due to the affect on the PCIS instrumentation logic. The system isolations are an expected occurrence for a fast transfer. The isolations involved various process lines such as Reactor Water Cleanup (RWCU) and Containment Atmospheric Control (CAC) / Containment Atmospheric Dilution (CAD). The Units 2 and 3 PCIS isolations were reset by approximately 0420 hours in accordance with procedures. All required isolation valves operated as designed.

"The offsite power source (343SU) was lost as a result of a momentary deenergization of the 220-34 Newlinville Transmission Line to clear a ground fault. The fault was approximately 29 miles from the PBAPS site and was caused by a lightning strike to a transmission tower near the Newlinville substation. Field inspections of the 220-34 Transmission Lines and Towers were performed and it was identified that there was a flash mark on the tower insulator confirming the lightning strike. It was determined that the protective relaying for the 220-34 Newlinville Transmission Line operated as designed. The 343SU offsite power source was returned to service by approximately 2115 hours on 9/18/04. This issue has been entered into the site Corrective Action Program (CR 254392) for evaluation and implementation of further corrective actions.

"The NRC Resident Inspector has been informed of this notification."

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Power Reactor Event Number: 41193
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: DAVID FOSS
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/12/2004
Notification Time: 10:58 [ET]
Event Date: 09/28/2004
Event Time: 01:00 [EST]
Last Update Date: 11/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOHN ROGGE (R1)

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

Event Text

INVALID SPECIFIED SYSTEM ACTUATION DUE TO BUS VOLTAGE DIP DURING RECIRC MG START

"This 60-day optional report, as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of specified systems, specifically the Unit 2 Primary Containment Isolation System (PCIS).

"On 9/28/04, at approximately 0100 hours [EDT], a Group III Outboard PCIS isolation occurred during the start of the 2B Recirculation Motor / Generator (M/G) Set. The Recirculation M/G Set was being started to perform post-maintenance testing during the refueling outage subsequent to work involving the Recirculation M/G Set. This outboard isolation resulted in the closure of various valves associated with the Reactor Building / Refueling Floor Ventilation Systems and the start of the 'B' Standby Gas Treatment Fan. All equipment operated as designed. The isolation occurred as a result of a voltage dip on the 2B Reactor Protection System (RPS) / PCIS power supply while on its alternate feed at the time that the 2B Recirculation M/G Set was started. The 2B RPS / PCIS power supply was on the alternate feed in preparation for planned testing of the Emergency Diesel Generators (LOCA-LOOP testing). This RPS / PCIS power supply alternate feed was fed from the same startup transformer that the 2B Recirculation MG Set is fed from. The voltage dip from the start of the large Recirculation M/G Set was sufficient to cause the protective relaying on the 2B RPS /PCIS alternate feed power supply to shed the power supply from the 2B RPS / PCIS bus. Deenergization of the bus caused the Group III Outboard PCIS isolation. A RPS scram signal was also generated. Just prior to the start of the 2B Recirculation M/G set, Operations personnel were briefed on the probability of the isolation and were prepared to take prompt action to reset the isolation and Scram. The 2B RPS / PCIS power supply was returned to its normal power supply (i.e. 2B RPS M/G Set) and the Group III PCIS and the Scram was promptly reset by 0105 hours. This issue has been entered into the Corrective Action Program (CR 257503).

"The NRC Resident Inspector has been informed of this notification."

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Power Reactor Event Number: 41194
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DALE TURINETTI
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/12/2004
Notification Time: 14:59 [ET]
Event Date: 11/12/2004
Event Time: 11:18 [EST]
Last Update Date: 11/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
MARK RING (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
2 N Y 63 Power Operation 63 Power Operation

Event Text

FITNESS FOR DUTY

A non-licensed contract supervisor tested positive for drugs during a followup test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41195
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KELLY PAUL
HQ OPS Officer: BILL GOTT
Notification Date: 11/12/2004
Notification Time: 15:20 [ET]
Event Date: 11/12/2004
Event Time: 15:00 [EST]
Last Update Date: 11/12/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MARK RING (R3)
JIM CALDWELL (R3)
TERRY REIS (NRR)
RICHARD WESSMAN (IRD)
TAD MARSH (NRR)
REED (DHS)
BISCOE (FEMA)

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

UNUSUAL EVENT

The licensee had carbon dioxide release in the turbine lube oil bay affecting normal access. There was no unplanned radioactive release. There was no indication of a fire. There were no personnel injuries or equipment damage.

At 1540 11/12/04, the NRC made the decision to remain in the Normal Mode.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM J BITONTI TO W GOTT AT 1556 ON 11/12/04 * * *

At 1540 Perry remains in an unusual event. The carbon dioxide release was not due to a fire. The licensee is ventilating the area to restore normal access. The fire department has been requested and is currently on site. There are no abnormal elevated radiation levels detected out the plant vents requiring consideration of offsite protective actions.

Notified R3 (Lipa).

* * * UPDATE AT 1651 ON 11/12/04 FROM J BITONTI TO M RIPLEY * * *

At 1636 EST the licensee secured from the Unusual Event. Normal access has been restored to the area and a fire watch established until the fire suppression system is restored to normal.

The licensee notified the NRC Resident Inspector.

Notified R3DO (Ring), IRD (Wessman), NRR (Reis), NSIR (Weber), DHS (Reed), and FEMA (Biscoe)

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