| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
02/15/2005 - 02/16/2005 ** EVENT NUMBERS ** |
 | Other Nuclear Material | Event Number: 41387 | Rep Org: HALLIBURTON ENERGY SERVICES
Licensee: HALLIBURTON ENERGY SERVICES
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DWAINE BROWN
HQ OPS Officer: CHAUNCEY GOULD | Notification Date: 02/08/2005
Notification Time: 16:42 [ET]
Event Date: 02/08/2005
Event Time: 11:30 [CST]
Last Update Date: 02/15/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
BLAIR SPITZBERG (R4)
JAMES TRAPP (R1)
GEORGE PANGBORN (R1)
LONNIE LACEY (DHS)
CHUCK CAIN (R4)
MR CREWS (DOT)
THOMAS YATES (DOE)
JOSEPHINE PICCONE (STP)
JACK RAMSEY (IP)
JACK CRLENJAK (IRD)
| Event Text LICENSEE REPORTED A SHIPMENT THEY WERE TO RECEIVE IS UNACCOUNTED FOR
Halliburton Energy Services had shipped a well logging source and calibrating source containing 18.5 curies of Am-241 Be and .5 curies of Am-241 from Nizhnevartovsk, Russia to Houston TX. Both sources were in a 18" dia 23" long cylindrical type "A" container which weighed 83kg. The sources went through Amsterdam to JFK in New York and cleared customs in New York on 10/09/04. After clearing customs they have not been able to track the package to any of the transport companies that were scheduled to handle it. An ongoing search is still being conducted.
* * * UPDATE ON 02/09/05 @ 1751 FROM RICHARD ARSENAULT TO CHAUNCEY GOULD * * *
The licensee was notified at 1621 CT that the unaccounted for sources were located at the Forward Freight facilities in Boston, MA. It appears that they were trucked to Boston after a Boston label was inadvertently placed on the package at the Newark facility of Forward Freight. The licensee stated the package appears to be intact and the are sending a rep to Boston on 2/10/05.
Notified Regs 1 & 4, NMSS, PAO, DHS, DOT, DOE, IP, TAS, STP
* * * UPDATE ON 02/10/05 @ 1358 HRS. EST FROM ARSENAULT TO CROUCH * * *
A representative from Halliburton Energy Services has verified that the sources and packaging are intact and all source material is accounted for. Forward Air Freight is scheduled to ship the package to Halliburton in Houston, TX.
Notified R1DO (Cobey), R4DO(Whitten), R4 (Cain) and NMSS (Essig).
* * * UPDATE ON 2/13/05 @ 2348 EST BY S. SANDIN * * *
During administrative review of this report, two (2) corrections were made; the previously shown notification time of 1921 EST was corrected to read 1642 EST, and the 10 CFR Section citation of 20.2201(a)(1)(ii) was corrected to read to show 20.2201(a)(1)(i).
* * * UPDATE FROM HALLIBURTON (BROWN) TO NRC (HUFFMAN) AT 10:33 EST ON 02/14/05 * * *
The licensee reported that the source has arrived in Houston and is currently enroute to the Halliburton facility and is scheduled to arrive at 1100 CST. R1DO( Lorson), R4DO (Whitten), and NMSS (Moore).
* * * UPDATE FROM HALLIBURTON (BROWN) TO JEFF ROTTON AT 1601 EST ON 02/15/05 * * *
The licensee reported that the source was delivered to the Halliburton facility at 1100 CST on 02/14/05 and has been satisfactorily inspected and leak tested with no problems. Notified R1DO (Cobey), R4DO (Whitten), and NMSS (Moore). |
| General Information or Other | Event Number: 41395 | Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CAPITOL ULTRASONICS
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-5838-L01
Agreement: Y
Docket:
NRC Notified By: S. BLACKWELL (VIA FAX)
HQ OPS Officer: BILL HUFFMAN | Notification Date: 02/10/2005
Notification Time: 09:30 [ET]
Event Date: 01/07/2005
Event Time: [CST]
Last Update Date: 02/10/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JACK WHITTEN (R4)
SANDRA WASTLER (NMSS)
| Event Text AGREEMENT STATE REPORT OF RADIOGRAPHY CAMERA MALFUNCTION
"Radiography operations were being performed with an AEA Technologies Model 741 camera with a 33 Ci source of Cobalt-60. The radiographers could not get the source to return to the shielded position. It was determined that a mechanical failure had occurred in the connector to the drive cable which transports the source from its shielded position into the exposure position and back again. The mechanical failure is being analyzed by the equipment manufacturer. "
The Louisiana Department of Environmental Quality stated that one of the individuals involved in the event received a film badge dose of 2552 mRem.
State report ID is LA050001 |
| General Information or Other | Event Number: 41399 | Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: RICK HORKY
HQ OPS Officer: STEVE SANDIN | Notification Date: 02/10/2005
Notification Time: 15:53 [ET]
Event Date: 01/18/2005
Event Time: [CST]
Last Update Date: 02/10/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
EUGENE COBEY (R1)
C.W. (BILL) REAMER (NMSS)
| Event Text AGREEMENT STATE REPORT INVOLVING LESS THAN PLANNED DOSE FRACTION FOR CERVICAL CANCER
The following is excerpted from a transmittal sent by the licensee and received on 2/3 by the State of KY concerning a medical event:
"1. Licensee's name: Brown Cancer Center, University of Louisville Hospital
"2. Prescribing physician's name: [Attending Physician]
"3. A brief description of the event: On Tuesday, January 18, 2005 a patient was scheduled to undergo a vaginal cylinder HDR procedure using a 3.0 cm cylinder. The catheter was placed in position [under the supervision of the Attending Physician]. When the setup was complete, and upon leaving the room [the Resident Physician] noticed that the catheter was 'draped' around the patient's foot as it ran from the cylinder to the HDR machine. [The Resident Physician] 'undraped' the catheter from her foot, then all staff left the room. The treatment then ran for it's scheduled 5.5 minutes.
"After the treatment was completed, the Medical Physicist removed the catheter. He noticed that the catheter appeared to not be fully inserted into the cylinder as required and estimates that it may have been withdrawn from the desired location by approximately 15 cm. He promptly informed [the Attending and Resident Physicians] and together informed [the] Chairman of Radiation Oncology.
"4. Effect on the individual: This treatment was the second of three treatments prescribed. The patient is being monitored and no adverse effects to the patient are expected nor did any occur.
"5. Why the event occurred: The event occurred due to the lack of a positive mechanical 'lock' of the HDR catheter to metal guide insert tube. The system uses a moveable nylon collar surrounding the catheter, which is slid into position once the catheter is placed into the metal guide insert tube. A nut is then screwed over the nylon collar forming a 'compression' fitting much like that used for compression fittings on copper-tubing.
The event may have occurred when [the Resident Physician] 'undraped' the catheter which was 'draped' around the patient's foot. The nylon collar-nut compression fitting may have allowed the catheter to be pulled partially out of the metal guide tube.
"6. What improvements are needed to prevent recurrence The manufacturer also offers a different type of collar-nut compression fitting utilizing a stainless steel collar that is glued onto the catheter at the appropriate distance. This constitutes a 'positive' mechanically locked position for the catheter. This alternate system is being readied for use henceforth.
"7. Action taken to prevent recurrence: The catheter is now length/position marked and is checked by both the physician and the physicist prior to leaving and upon re-entering the HDR suite. A soon as the parts are assembled for the stainless steel type of collar, the HDR catheters will be switched over to the new equipment. This will provide a 'positive' lock on catheter length into the metal guide tube assembly.
"8. If licensee informed the individual or individual's responsible relative or guardian, and if not, why: The patient and referring physician were informed of the situation by [the Attending Physician].
"9. Information provided to the individual or individual's responsible relative or guardian: The patient was informed that she may have received a dose lower than that prescribed to the area of intended treatment. She was informed that the treatment would not be repeated (this was the second of three treatments planned) as it was not absolutely clear if an under dose occurred. She was told that she would be carefully monitored for progress."
A followup transmittal from the licensee received on 2/9 by the state of KY provided estimated dose data:
"As the report described, during the treatment the source for the HDR may have been withdrawn from the desired treatment site by 15 cm. The dose desired for the 5.5 minute treatment was seven hundred and fifty (750) cGy to the site of interest. With the source offset by 15 cm, the delivered dose would have been four (4) cGy. Assuming that the source was in fact approximately 2 cm exterior to the vagina, the dose at the labia would have been one hundred (100) cGy." |
| Power Reactor | Event Number: 41410 | Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CLAY WILLIAMS
HQ OPS Officer: BILL GOTT | Notification Date: 02/15/2005
Notification Time: 01:13 [ET]
Event Date: 02/14/2005
Event Time: 21:55 [PST]
Last Update Date: 02/15/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
| 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 | 100 | Power Operation | Event Text TECH SPEC REQUIRED SHUTDOWN
The following information was provided by the licensee via e-mail:
"On February 10, 2005, plant operators observed an abnormal flow condition on Unit 2 Train 'B' Component Cooling Water (CCW) from the Shutdown Cooling Heat (SDC) exchanger and, at about 2315 PST, declared Train 'B' of Containment Spray inoperable. This caused Unit 2 to enter a seven-day action statement (TS 3.6.6.1).
"Although it may have been possible to correct the abnormal flow condition on-line, SCE has elected to shutdown Unit 2. Plant Operators initiated the shutdown at about 2155 PST on February 14, 2005. SCE in reporting this occurrence in accordance with 10CFR50.72(b)(2)(i).
"At the time the shutdown was initiated, Unit 2 was operating at about 100% power. Unit 3 continues to operate at about 100 % power. The NRC Resident Inspectors have been briefed on the shutdown plans and will be provided with a copy of this report." | |