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Event Notification Report for December 24, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/23/2004 - 12/24/2004

** EVENT NUMBERS **


41249 41255 41266 41271 41272 41273 41285 41286 41288 41289 41290

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Hospital Event Number: 41249
Rep Org: HOSPITAL ALEJANDRO OTERO LOPEZ
Licensee: HOSPITAL ALEJANDRO OTERO LOPEZ
Region: 1
City: MANATI State: PR
County:
License #: 52-24916-01
Agreement: N
Docket:
NRC Notified By: DR EDUARDO PASCUAL FERRER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/08/2004
Notification Time: 12:36 [ET]
Event Date: 12/08/2004
Event Time: [EST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CLIFFORD ANDERSON (R1)
TOM ESSIG (NMSS)

Event Text

LOST BRACHYTHERAPY SEEDS

Licensee notified NRC that they have been performing an inventory of their I-125 brachytherapy seeds from 8/26/03 until 12/07/04. In September, the licensee discovered 4 seeds were missing along with a lead container. The licensee conducted a thorough search and interviewed hospital personnel that had access or used the brachytherapy seeds for patient treatment. Using a calculated activity range of 0.224 - 0.368 millicuries per seed with a possible decay factor of 4 half lives would give an estimated total remaining activity of 0.09 millicuries. As a preventive measure against future losses the licensee has placed a locked container in the Nuclear Medicine Hot Lab, and the licensee has restricted access to the locked container to only the lab physicist.

* * * UPDATE 1120 EST ON 12/9/04 FROM DR. FERRER TO S. SANDIN * * *

The following information was submitted by the licensee via fax:

"On the last quarter, we did an inventory for disposal of our Institution storage of brachytherapy seeds I-125 used for therapy in prostate carcinoma.

"All seeds that were not used we gathered for disposal. Upon taking a visual inventory of all the seeds, 4 seeds were missing.

"A thorough inventory of 32 seeds was done for the storage period, from August 26, 2003 to September 10, 2004. And immediately preventive measures were taken.

"Prevention of reoccurrence - Immediately a locked container was placed in the storage area - Nuclear Medicine Hot Lab. The personnel of brachytherapy were required to place seeds inside the locked container. Our physicist will be the only authorized individual allowed to remove the un-used seeds. This will minimized the number of people that will handle the seeds.

"We underwent a thorough search and interview the related personnel, from OR personnel, nurse staff, brachytherapy and nuclear medicine staff. This process took approximately 60 days. During the process we also found out that a lead container was missing and we re-started the searching process.

"We calculated the dose range of 0.224 mCi / seed to 0.368 mCi / seed and with a possible decay factor of 4 half lives - for an approximately total activity of 0.09 mCi.

"The incident was reported on December 08, 2004 ( 12:04 PM - EST)."

Notified R1DO (Anderson) and NMSS (Essig)

* * * UPDATE 0930 EST ON 12/23/04 FROM DR EDUARDO PASCUAL TO S.SANDIN * * *

During remodeling, the four (4) missing I-125 seeds were found in a lead container inside the hot lab.

Notified R1DO (Conte) and NMSS (Essig).

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General Information or Other Event Number: 41255
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: STORK SOUTHWESTERN LABS
Region: 4
City: HOUSTON State: TX
County:
License #: L05269-000
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/13/2004
Notification Time: 15:35 [ET]
Event Date: 12/10/2004
Event Time: 16:15 [CST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
TRISH HOLAHAN (NMSS)
AARON DANIS (TAS)
FAX TO CNSNS MEX ()

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

On December 10, 2004, (Friday), the Licensee had dispatched operator [deleted], for a job with a Troxler 3440, Serial No. 33733, containing two sealed Special Form sources: 8.0 mCi (nominal) Cs-137, Serial No 750-9391, and 40.0 mCi (nominal) Am-241/Be, Serial No 47-22867. Upon completion of the job the operator was returning to the company office, he decided to stop by the Wal Mart store in Harris County, Texas. Upon returning to his company truck, Ford F150 fleetside, License Plate No. [deleted], he determined that the gauge was missing from the tiedown location. Looking into the bed of the truck he noted that the cable securing the gauge to the truck had been cut and was laying in the bottom of the truck bed near the tailgate, still locked into place. The operator reported the incident to his supervisor and was advised to report the incident to the Harris County Constable's Office - Precinct #4. While he was making the report, Case No 0412101909, the company R.S.O. reported the incident to the Texas Department of State Health Services (DSHS) on-call duty officer. Due to the R.S.O. being at home, he did not have the source Serial Numbers. The source serial numbers were reported to the Agency on Monday afternoon at 1:15 p.m.

Licensee is considering offering a reward and announcing the loss to local media.

Texas Incident No.: I-8191

* * * UPDATE FROM RAY JISHA TO W GOTT AT 1517 ON 12/23/04 * * *

A technician from another company was offered the gauge for sale. The technician consulted his supervisor who told him to purchase the gauge. The gauge was determined to be the stolen gauge from Stork. The gauge was intact and was returned to Stork. An update will be provided to the local law enforcement.

Notified NMSS (T Essig), R4DO (Spitzberg), TAS (J Foster) (email), and faxed to Mexico.

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General Information or Other Event Number: 41266
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: REED ENGINEERING GROUP, INC.
Region: 4
City: Cedar hill State: TX
County:
License #: L04343-000
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/15/2004
Notification Time: 13:55 [ET]
Event Date: 12/15/2004
Event Time: 00:00 [CST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
JOHN HICKEY (NMSS)
MEXICO NCNSS ()
AARON DANIS (TAS)

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via facsimile:

"The driver/operator of a company vehicle transported the nuclear moisture density gauge to his residence in Cedar Hill, Texas, rather than return it to permanent storage. The gauge was missing when the operator prepared to leave his residence this morning [12/15/04]. The stolen gauge is an older Troxler Model 3401B that was re-built into a Model 3411B, Serial No. 12990 containing two Special Form, sealed sources: Cs-137, nominal 8 millicuries, Serial No. 501337, and Am-241/Be, nominal 40 millicuries, Serial No. 47-8300. The gauge was removed from the company truck by cutting the security chain sometime during the hours of darkness. Both the gauge and the transport container were taken.

"The licensee is thinking of offering a reward and posting it both in the local newspaper and in advertising on a local news channel. Reward, if offered, will be no questions asked for return of the gauge."

Texas Incident No: I-8193

* * * UPDATE FROM RAY JISHA TO W GOTT AT 1517 ON 12/23/04 * * *

At 2300 on 12/21/04, Dallas Fire Department found the stolen gauge intact in a shopping cart in a shopping center parking lot. The gauge was returned to the Reed engineering group.

Notified NMSS (T Essig), R4DO (Spitzberg), TAS (J Foster) (email), and faxed to Mexico.

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General Information or Other Event Number: 41271
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: LAFAYETTE State: LA
County:
License #: LA-5115-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/21/2004
Notification Time: 09:45 [ET]
Event Date: 10/25/2004
Event Time: 14:00 [CST]
Last Update Date: 12/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE MEDICAL EVENT

The following information was received via facsimile:

"At 2:00PM on October 25, 2004, Saint Mary's Diagnostic Center reported that a Myoview dose was not showing the heart, but the sternum was viewable, indicating that the dose may have been MDP (bone agent). The syringe was retrieved from the customer and test confirmed the dose was MDP. The cause of the error was improper drug selection when filling the prescription. An in-service was conducted for the importance of detail when filling prescriptions and dispensing doses to correct the problem. The written notification was not received until December 13, 2004."

LA Event Report ID - LA040014

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General Information or Other Event Number: 41272
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAYOU TESTERS
Region: 4
City: AMEILA State: LA
County:
License #: LA-7112-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/21/2004
Notification Time: 09:45 [ET]
Event Date: 11/29/2004
Event Time: [CST]
Last Update Date: 12/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE EQUIPMENT FAILURE

The following report was received via facsimile:

"A INC IR-100 camera with serial number 4475 with 55 Curies of IR-192 was involved in an equipment failure. The exposure device locked before the pigtail was completely retracted into the locked position. The camera was surveyed and found no high or unusual readings. The radiographer was unable to unlock the camera to pull the source completely back so the device was sent to SPEC. SPEC removed and cleaned the lock assembly. SPEC stated that the malfunction was probably due to sand and dirt in the locking mechanism. The written notification was received on December 10, 2004."

LA Event Report ID- LA040015

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General Information or Other Event Number: 41273
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CENTRAL TESTING
Region: 4
City: SULPHUR State: LA
County:
License #: LA-2293-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/21/2004
Notification Time: 09:45 [ET]
Event Date: 11/17/2004
Event Time: [CST]
Last Update Date: 12/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE EQUIPMENT MALFUNCTION

The following report was received via facsimile:

"Central Testing Company had a camera malfunction on November 17, 2004. When the radiographer tried to crank out the source to make his first exposure he realized that the camera would not allow him to. He notified Central Testing of the problem. The camera was returned to SPEC and they replaced the locking mechanism on the camera. The camera is now functioning properly."

LA Event Report ID - LA040013

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Power Reactor Event Number: 41285
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/23/2004
Notification Time: 09:46 [ET]
Event Date: 12/22/2004
Event Time: 12:15 [EST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
RICHARD CONTE (R1)
TERRY REIS (NRR)

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

CONFIRMED POSITIVE FITNESS FOR DUTY TEST OF A LICENSED SUPERVISOR

"The licensee reported a confirmed positive [random] fitness for duty test of a licensed supervisor. The individual has been removed from licensed duties and denied access to the facility. A work performance investigation has been completed. Worked performed by the individual has been verified to meet all standards and compliances."

The licensee will notify the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 41286
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: DAN HARTNETT
HQ OPS Officer: BILL GOTT
Notification Date: 12/23/2004
Notification Time: 13:45 [ET]
Event Date: 12/23/2004
Event Time: 06:14 [EST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (R3)
ERIC LEEDS (NSIR)

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

LOSS OF RESPONSE CAPABILITY

"At 0614 hours on December 23, 2004, Davis-Besse activated station isolation procedures due to heavy snow and blowing snow. This is being reported as a loss of response capability under 10CFR 50.72 (b)(3)(xiii) due to the potential inability of local authorities to perform an evacuation. Minimum Emergency Response staffing is being maintained at the site. The state of Ohio and Ottawa and Lucas Counties have confirmed that they are currently capable of performing their emergency plan responsibilities."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41288
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: FRED KIRK
HQ OPS Officer: BILL GOTT
Notification Date: 12/23/2004
Notification Time: 17:46 [ET]
Event Date: 12/23/2004
Event Time: 14:10 [EST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CAUDLE JULIAN (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

LOSS OF COMMUNICATIONS

"Test results for the 12/23/04 weekly McGuire Nuclear Station silent siren test performed by the counties located in the McGuire EPZ indicated a failure of 50 out of the 67 sirens. This failure involved all of the sirens located in 2 of the 4 counties located in the EPZ who have the capability to activate these sirens. This failure occurred at 1410 on 12/23/04 and is believed to be due to 'Tropospheric Ducting (TD) radio frequency interference (RFI). A strong weather front was moving through the area at the time of the testing and is believed to be the cause of the TD RFI. Interference cleared at 1425 and subsequent retest by all four affected counties were completed with a 100% success rate with all siren test indications normal. Due to the short period of time of the unavailability and the prompt restoration of function, backup route alerting was not established. Long-term resolution of this RFI problem is being developed."

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 41289
Facility: FRAMATOME ANP
RX Type: URANIUM FUEL FABRICATION
Comments: LEU FABRICATION
                   COMMERCIAL LWR FUEL
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-1168
Agreement: N
Docket: 07001201
NRC Notified By: CHARLES HOLMAN
HQ OPS Officer: JANELLE BATTISTE
Notification Date: 12/23/2004
Notification Time: 20:03 [ET]
Event Date: 12/23/2004
Event Time: [EST]
Last Update Date: 12/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
CAUDLE JULIAN (R2)
RICHARD CONTE (R1)
SCOTT FLANDERS (NMSS)

Event Text

EXTERNAL RADIATION LEVELS GREATER THAN LIMITS

On a shipment received from Hope Creek, one of eight packages had a high radiation level on the bottom of the package. The radiation level was 236 millirem/hour. The packages contained nuclear service equipment. Packages were offloaded and placed in a secure area of the plant. The package has not been opened. Framatome has notified Hope Creek and will notify the shipper.

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Power Reactor Event Number: 41290
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JIM CASE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/24/2004
Notification Time: 03:07 [ET]
Event Date: 12/23/2004
Event Time: 23:54 [EST]
Last Update Date: 12/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 44 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM FOLLOWING DOWN SHIFT OF BOTH RECIRC PUMPS FROM FAST TO SLOW SPEED

"At 2345 on 12/23/04 both reactor recirc pumps down shifted from fast to slow speed which resulted in reactor power reducing from 100% to 44%. At 2354 an automatic scram occurred from the activation of the Oscillation Power Range Monitor (OPRM) instrumentation. After the scram all safety systems responded as designed. Cause of the reactor recirc pump downshift is still under discovery."

All rods fully inserted. No safety relief valves lifted during the transient. The licensee was in no major LCO at the time. Pressure control is via the steam bypass valves.

The licensee has notified the NRC Resident Inspector.

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