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Event Notification Report for February 18, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/17/2005 - 02/18/2005

** EVENT NUMBERS **


41409 41411 41412 41413 41414 41415 41416 41417

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General Information or Other Event Number: 41409
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: SHAW INDUSTRIES
Region: 1
City: DALTON State: GA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: LIZ SEALE
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/14/2005
Notification Time: 15:13 [ET]
Event Date: 12/27/2004
Event Time: [EST]
Last Update Date: 02/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
TOM ESSIG (NMSS)

Event Text

GEORGIA AGREEMENT STATE REPORT - MISSING RADIOACTIVE SOURCE

The following information was received from the State via facsimile:

"Description of Event: On December 27, 2004, Shaw Industries, a general licensee, contracted with Graves & Phillips Engineering & Maintenance (Alabama License Number 1291) to have four sources removed and returned to the supplier, Omhart. Upon arrival at Omhart on February 4, 2005, the package contained only three sources and one detector. Shaw Industries reported that the fourth source was possibly left on the line where it was used to measure thickness of carpet and that line was sent to a scrap metal yard on January 11, 2005. However, it is still undetermined what has happened to the missing source.

"The Environmental Radiation Staff and representatives from Shaw Industries have been dispatched to the scrap metal yard to investigate the incident. The source holder was Omhart Vega Model BAL and serial number 3781 BC. Isotope: Sr-90. Amount of activity: 25 milliCuries."

Georgia Event Report ID GA-05-05.

* * * UPDATE FROM C. SANDERS TO J. ROTTON AT 1549 ON 02/15/05 * * *

2 personnel from the Georgia Environmental Radiation Staff, 5 representatives from Shaw Industries, and 5 representatives from Regional Recycle are scheduled to physically dismantle the trash pile on 02/16/05 where the missing source is believed to be located and conduct a thorough search for the source. The pile is approximately 40' high, 35 yards wide, and 85 yards long.

Notified R1DO (Cobey) and NMSS EO (Moore).

* * * UPDATE FROM L. SEALE TO J. KNOKE AT 11:18 ON 02/16/05 * * *

"February 14, 2005
The Radioactive Materials Program notified the NRC Operations Center of the event. Attempts to find the source by Shaw Industries' representatives and Environmental Radiation Staff were unsuccessful. The scrap pile that may contain the source is approximately 75-100 yards long, 30-40 yards wide, and 40' to 50' high. Regional Recycling stated that there was a 99% chance that the material was destined for the steel mill across the street from their facility, that is, a 1% chance that the material would be sent to a scrap yard in Kentucky.

"February 15, 2005
Environmental Radiation Staff notified the state of Alabama of the event and ongoing investigation due to Graves & Phillips Engineering & Maintenance, an Alabama licensee. Shaw Industries forwarded to the Environmental Radiation Program dose profiles and pictures of the source device received from Ohmart. Regional Recycling reviewed its records and no shipments had been sent to the Kentucky facility since November 2004. All facilities were notified of the event and pictures and descriptions of the device were sent to the facilities that may receive scrap metal from Shaw Industries.

"Shaw Industries and the Radiation Program were informed by Regional Recycling (scrap yard) that they wanted to dismantle the scrap pile to try to locate the source. Shaw Industries, Regional Recycling and the Environmental Program will provide staff to facilitate the search. The search is to begin on February 16, 2005. Regional Recycling has halted their operations until the search is completed. The Radioactive Materials Program updated the NRC Operation Center on the status of the event.

"February 16, 2005
Shaw Industries and the Environmental Program are currently at Regional Recycling and are visually inspecting the scrap as it is sorted by a crane. The Radioactive Materials Program updated the NRC Operation Center on the status of the event."

Notified R1DO (Cobey) and NMSS EO (Essig).

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General Information or Other Event Number: 41411
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NUCOR STEEL
Region: 4
City: NORFOLK State: NE
County:
License #: 07-04-01
Agreement: Y
Docket:
NRC Notified By: JULIA SCHMITT
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/15/2005
Notification Time: 18:00 [ET]
Event Date: 02/04/2005
Event Time: [CST]
Last Update Date: 02/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
SCOTT MOORE (NMSS)

Event Text

FAILURE OF SAFETY EQUIPMENT - FIXED GAUGE

The following information (Report # NE050003) was provided by the State of Nebraska (Julia Schmitt) via facsimile:

"Operators noticed that strand line #2 was showing erratic readings that were not consistent with the other three operating molds. Operations were suspended to investigate the cause. The assistant RSOs responded and observed that the gauge had separated between the top actuator flange and the shield housing. It was determined that the gauge's lead housing had separated from the flange, leaving approximately seven inches of the source rod unshielded. There was no visible exterior damage to the flange or housing. Leak tests and surveys were performed that verified that the gauge's actuator was locked-out. The device was removed from service and placed in an onsite storage vault awaiting analysis as to the cause of the failure."

The licensee reporting this malfunction is Nucor Corporation, located in Norfolk, NE 68702.

The source of radiation is a fixed gauge, model number P2608-100, manufactured by Berthold, and contained 0.003 curies of Co-60. The malfunctioned equipment is a fixed gauge, model number LB300 ML, also manufactured by Berthold.

Ms. Schmitt believed the radiation exposure to personnel was < 2mrem/hr, however, this has not been determined as fact.

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Other Nuclear Material Event Number: 41412
Rep Org: ALCO CORPORATION
Licensee: ALCO CORPORATION
Region: 1
City: GUAYNABO State: PR
County:
License #: 52-24843-01
Agreement: N
Docket: 030-2920
NRC Notified By: DAVID ROHE
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/16/2005
Notification Time: 14:59 [ET]
Event Date: 02/16/2005
Event Time: 14:55 [EST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
EUGENE COBEY (R1)
SANDRA WASTLER (NMSS)
DONNA-MARIE PEREZ (TAS)

Event Text

CPN NUCLEAR GAUGE STOLEN FROM THE JOBSITE

An employee of the ALCO Corporation was working at a jobsite on Highway PR837 in Guaynabo, Puerto Rico with a CPN nuclear gauge. About 14:55 on 2/16/05 he had walked 40 feet away from the nuclear gauge and when he returned to the area he noticed the gauge missing. The gauge contain two sources, 50 millicuries Am-241and 10 millicuries of Cs-137. A police report was being taken and that information will be provided as a later update.

No reward for the return of the gauge is being offered at this time.

* * * UPDATE ON 02/17/05 AT 0742 FROM DAVID RHOE TO GERRY WAIG * * *

The following information was received via facsimile from Mr. Rhoe:

"RE: Stolen CPN Nuclear Gauge [Serial number] MD20801021

"On February 16, 2005 the above nuclear gauge was stolen from a Ramon E. Ruiz Toledo vehicle. The nuclear gauge was located inside the carrying case and the case was secured by chains/padlock to the vehicle. The chain was cut and the nuclear gauge/case/chains were removed. Mr. Ruiz Toledo was inspecting the asphalt and the vehicle was temporarily out of sight due to the blind spots around the corner of the road. The handle of the nuclear gauge inside the case was not locked. The incident occurred between 3:30 to 4:00 pm on RP 837 in Guaynabo at the Barrio Camarones site. The police and NRC were immediately notified. The police report number is 05-7-132-02011.

"The following media stations were notified:
Channel 2 WKAQ TV
Channel 4 WAPA TV
University of Puerto Rico TV

"Today the radio stations and newspaper will be notified. There will be a reward offered for the return of the gauge."

Notified TAS DO, R1DO (Eugene Cobey), NMSS (Sandra Wastler)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41413
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: PHILIP NORTH
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/16/2005
Notification Time: 21:20 [ET]
Event Date: 02/16/2005
Event Time: 13:31 [EST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RUDOLPH BERNHARD (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 18 Power Operation

Event Text

DEGRADED CONDITION - REACTOR BUILDING NORMAL SUMP LEVEL INCREASING

The licensee provided the following information via facsimile:

"Event:
"On February 16, 2005 at 1331 hours EST, Operations discovered that the Oconee Unit 3 Reactor Building Normal Sump (RBNS) level was increasing. Chemistry sampled the containment normal sump to determine the water source and could not conclusively rule out Low Pressure Service Water (LPSW). The leak rate into the sump is approximately 1.9 gpm. LPSW is the cooling medium used for the Reactor Cooling Pump (RCP) motor coolers, the Reactor Building Cooling Units (RBCU), and the Reactor Building Auxiliary Cooling Units (RBACU).

"Unit 3 entered Technical Specification 3.6.1.A at 1331. This requires restoring containment to Operable status within 1 hour. The approximately 1.9 gpm leakage is above the leakage allowed in calculation OSC-7005 "LPSW Allowable Leakage Inside Containment". At 1431 Unit 3 entered Technical Specification 3.6.1 B which requires being in mode 3 in 12 hours.

"Initial Safety Significance:
"By limiting the amount of LPSW leakage inside containment then containment operability is ensured. Above the calculated LPSW leakage as stated in OSC-7005, containment operability is in question. The LPSW system pressure could be less than containment LOCA peak pressure. Therefore containment atmosphere has the potential to leak through the LPSW system, during a LOCA, and out the return line resulting in a containment leak path.

"Collective Action(s):
"Additional sampling and process indications suggest that the cause of the Reactor Building Normal Sump rate increase is feedwater or main steam. A power reduction to 18% has been completed and a reactor building entry is in progress to confirm the source of the leakage. If the source is confirmed to be feedwater or main steam, Technical Specification 3.6.1 will be exited."

The turbine is still loaded and the electrical grid was not affected by the power decrease to 18%. All systems functioned as required and other units at Oconee were not affected by this event.

NRC Resident Inspector was notified.


* * * UPDATE ON 2/17/05 @ 0018 BY JOHN COLLINS TO CHAUNCEY GOULD * * * UPDATE

They entered the containment and verified a steam leak off the impulse line for the "3B" steam generator main steam pressure transmitters. They are currently at 18% power and making a decisions on repair options.

The NRC Resident Inspector will be informed. The Reg 2 RDO(Bernhard) was notified.


* * * UPDATE ON 2/17/05 @ 0139 BY JOHN COLLINS TO CHAUNCEY GOULD * * * RETRACTION

At 0012 on February 17, 2005 entry into the Unit 3 reactor building confirmed that the source of leakage into the reactor building normal sump was the Main Steam system. Specifically, the location of the leak appears to be a fitting downstream of an instrument root valve off the 3B Main Steam line. Based on this information, Technical Specification 3.6.1 was exited and this event is not reportable per 10CFR50.72. and therefore being retracted.

A shutdown to MODE 3 will be conducted to facilitate repairing the leak.

The NRC Resident Inspector will be informed. Reg 2 RDO(Bernhard) was notified.

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Power Reactor Event Number: 41414
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: PETER BRAMFORD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/17/2005
Notification Time: 00:18 [ET]
Event Date: 02/16/2005
Event Time: 21:12 [EST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EUGENE COBEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DUE TO TURBINE TRIP AS A RESULT OF FAILED POWER SUPPLY

"Ginna Station received a reactor trip from Turbine Trip at 2112 hrs on 02/16/05. The Turbine Trip signal was generated from the ATWS Mitigation System Actuation Circuitry (AMSAC) related to a failed power supply in the Advanced Digital Feedwater Control System. All control rods inserted on the reactor trip. The plant is currently stable in Mode 3, RCS Pressure 2235 psig, Temperature 540 deg F. AFW [Auxiliary Feed Water] did actuate as designed after the trip.

"For the transient, min & max Temperatures, Pressures & Levels are:
RCS Temperature: Max - 561 deg F Min - 538 deg F
RCS Pressure: Max - 2250 psig Min - 2218 psig
Pressurizer Level: Max - 50% Min - 28%"

The electrical grid is stable. Decay heat is being rejected to the Main Condenser. The licensee notified the NRC Resident Inspector and the State Public Service Commission.

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Power Reactor Event Number: 41415
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK CRIM
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/17/2005
Notification Time: 10:28 [ET]
Event Date: 02/17/2005
Event Time: [EST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
RAYMOND LORSON (R1)
JOHN HICKEY (NMSS)
AARON DANIS (TAS)

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

MISSING CALIBRATION SOURCE

"On January 22, 2005 a radiation protection technician discovered that a radiation detector calibration source was missing from its locked storage cabinet. An investigation was initiated and efforts to locate the source continue but the source has not been located. The source is approximately 2 inches in diameter in the form of a metal disc containing 0.0154 micro-curies of Thorium-230 that is used to calibrate SAC-4 alpha counters. The source is labeled and poses no radiological hazard to individuals that could unknowingly be in close proximity to it. The source was last used to calibrate a SAC-4 alpha counter on 1/20/2005.

"10CFR20.2201(a)(1)(ii) requires a telephone report to the Operations Center in accordance with 10CFR50.72 within 30 days of the loss of licensed material in a quantity greater than 10 times the quantity specified in Appendix C to Part 20. The quantity specified in Appendix C for Thorium-230 is 0.001 micro-curies; therefore, this report is required."

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41416
Rep Org: PORTER MEMORIAL HOSPITAL
Licensee: PORTER MEMORIAL HOSPITAL
Region: 3
City: VALPARAISO State: IN
County:
License #: 13-170-73-01
Agreement: N
Docket:
NRC Notified By: APPAREO DEVATA
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/17/2005
Notification Time: 14:48 [ET]
Event Date: 02/17/2005
Event Time: 13:40 [CST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATRICK LOUDEN (R3)
SCOTT MOORE (NMSS)

Event Text

MEDICAL EVENT - TOTAL DOSE DELIVERED DIFFERS FROM PRESCRIBED DOSE

Licensee called to report that on 02/16/05, the hospital performed a prostate seed implant. It was discovered after the implants were performed that the activity content for the first set of seeds (63 seeds) was incorrect. The hospital had ordered 0.27 millicuries per seed of I-125 and received 0.37 millicuries per seed. The order had been placed and confirmed with the seed manufacturing company, but the incorrect activity per seed was sent for the first of three implants for this patient. The documentation that was supplied with the order did identify the first set of seeds containing 0.37 millicuries per seed. Both the patient and the referring physician have been notified of the error. A post implant CT was performed to attempt to accurately calculate the dose overage, but the licensee determined that process would be difficult to verify. Licensee is evaluating methods to prevent reoccurrence (such as - perform own source calibration, verify documentation prior to implantation). Licensee did state that there was no unintended permanent functional damage to an organ or physiological system.

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Power Reactor Event Number: 41417
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: FREDERICK SMITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/17/2005
Notification Time: 22:05 [ET]
Event Date: 02/17/2005
Event Time: 17:30 [EST]
Last Update Date: 02/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PATRICK LOUDEN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE DUE TO UNANALYZED CONDITION

The following information was provided by the licensee via facsimile:

"During testing of the Division 2 Diesel Generator Testable Rupture Disc (TRD), it was discovered that excessive force was needed to open its damper. The function of the TRD is to open to relieve exhaust pressure should the diesel generator's non-safety exhaust silencer become blocked. Upon inspection of the TRD, some deformation was noted on the TRD damper. Since the possibility that the condition might exist on the other two divisional diesel generators could not be ruled out, they were also declared inoperable and LCO 3.0.3 entered. An unanalyzed condition potentially exists because a change in engineering design potentially affected multiple trains. Since all three diesel generators are inoperable, a loss of off-site power would challenge safe shutdown capability, the ability to remove decay heat and accident mitigation.

"A plant shutdown required by Technical Specifications (LCO 3.0.3) was required due to declaring all 3 divisional diesel generators inoperable. LCO 3.0.3 was entered at 1730 hrs on 2/17/05. No power reduction was required as the Division 2 Diesel Generator was declared operable at 2011 after unlatching its Testable Rupture Disc (TRD) [and LCO 3.0.3 was exited].

"The resident NRC inspector was informed of the LCO 3.0.3 entry and exit [and this event notification]. No other notifications of governmental agencies or the press are planned."

At the time of the notification to NRC Headquarters, the Division 1 EDG TRD had been unlatched and declared operable. The Division 3 EDG TRD was expected to be unlatched within the next hour.

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