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Event Notification Report for February 23, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/22/2005 - 02/23/2005

** EVENT NUMBERS **


41419 41420 41428 41430

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General Information or Other Event Number: 41419
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: EQUITABLE PRODUCTION CO.
Region: 1
City:  State: KY
County:
License #: KY 201-027-56
Agreement: Y
Docket:
NRC Notified By: ROBERT GRESHAM
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/18/2005
Notification Time: 15:34 [ET]
Event Date: 02/18/2005
Event Time: 14:20 [CST]
Last Update Date: 02/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE

Today at 1520 EST Schlumberger out of Houston office notified Kentucky Dept. of Radiation Control of the following event.

Equitable Production Co. (main office located somewhere in Kentucky) has a stuck well logging source tool. Sometime in the last week the well logging source became stuck at which time the State of Kentucky should have been notified. When trying to retrieve the well logging source the well logging source was broken in half (located in Knott County, Eastern Kentucky). The upper portion of the well logging source containing the americium-241 portion of the well logging was retrieved, no contamination. The top of the stuck well logging tool is at an estimated depth of 3454 feet and the top the cesium-137, 1.7 curies, is at a depth of 3460 feet. According to the State of Kentucky Radiation Control Officer, the 3454 foot depth is vertical depth and there is no contamination or ruptured sources.

Plugging well: Will do a 500 foot pour on top the of the stuck well logging source and then place a wipstock on top of the plug.

A State of Kentucky Dept. of Radiation Control person will be present when the well is plugged.

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General Information or Other Event Number: 41420
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MARSHFIELD CLINIC
Region: 3
City: MARSHFIELD State: WI
County:
License #: 141-01162-001
Agreement: Y
Docket:
NRC Notified By: PAUL SCHMIDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/18/2005
Notification Time: 17:04 [ET]
Event Date: 02/16/2005
Event Time: [CST]
Last Update Date: 02/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICK LOUDEN (R3)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE MEDICAL EVENT

The following information was provided by the State of Wisconsin via facsimile:

"On Thursday, February 17, 2005 at approximately 3:45p.m. [CST], the Wisconsin Radiation Protection Section (RPS) received a telephone call from the Marshfield Clinic, Marshfield, WI (license number 141-01162-001) informing the section of a medical event involving a therapeutic radiation dose from a gamma knife exposing a site outside the intended treatment volume to a level greater than 50% of the expected dose. (HFS 157.72 (1) (a) 3.)

"Preliminary Information From the Licensee:

"On Wednesday, February 16, 2005, the Marshfield Clinic had scheduled a therapeutic radiation treatment of 18 Gray (1800 Rads) using a gamma knife. During the process of manually programming the positioning system, the y and z coordinates were transposed. The error was not noticed during a double check of the treatment coordinates. As a result, a site outside the intended treatment volume received an estimated dose of 5.06 Gray (506 Rads) instead of the originally estimated 0.4 Gray (40 Rads). The volume of the unintended treatment site was 0.7 cubic centimeters. The treatment duration was 2.42 minutes. The prescribed dose of 18 Gray was delivered and the patient treatment was completed.

"The attending neurosurgeon and radiation oncologist believe there will be no medical consequences to the patient from the unintended exposure. The referring physician has been notified.

"[State of Wisconsin] is reporting this event under:

"HFS 157.72 (1) (a) 3. requires a licensee to report an event where there is 'A dose to an organ outside the intended treatment volume that exceeds the expected dose to that organ by 0.5 Sv (50 Rem) where the excess dose is greater than 50% of the expected dose to that organ. . . '

"DHFS, RPS staff have been dispatched on Friday, February 18, 2005 to investigate.

"Wisconsin Incident No: 20"

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Power Reactor Event Number: 41428
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MIKE TAYLOR
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/22/2005
Notification Time: 06:20 [ET]
Event Date: 02/22/2005
Event Time: 03:08 [EST]
Last Update Date: 02/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAYMOND LORSON (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

EMERGENCY DIESEL GENERATOR AND EMERGENCY FEEDWATER AUTO START ON VITAL BUS FAILURE TO TRANSFER

"To support routine preventative maintenance on the 4160V Unit Auxiliary Transformer breaker, 4160V Vital Bus 5 did not successfully transfer to the Reserve Auxiliary Transformer. Bus 5 momentarily de-energized and the Emergency Diesel Generator started and loaded as expected supplying Bus 5. The Emergency Feedwater System actuated as expected on momentary undervoltage to Bus 5. The plant remains stable at 100% power. A station troubleshooting team has been established.

"The reason that Bus 5 did not transfer to the Reserve Auxiliary Transformer is not known at this time."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41430
Facility: HUMBOLDT BAY
Region: 4 State: CA
Unit: [3] [ ] [ ]
RX Type: [3] GE-1
NRC Notified By: DAVID SOKOLSKY
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2005
Notification Time: 17:25 [ET]
Event Date: 02/22/2005
Event Time: 14:25 [PST]
Last Update Date: 02/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DALE POWERS (R4)
SCOTT MOORE (NMSS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Decommissioned 0 Decommissioned

Event Text

REPORT OF MISSING SPECIAL NUCLEAR MATERIAL

The following details were provided by the licensee via email after the telephonic notification:

"This is a non-emergency Event Notification in accordance with 10 CFR 20.2201(a)(1)(ii) to inform the NRC of missing special nuclear material (SNM) (up to approximately 0.15 grams of U235). The missing SNM consists of one complete and three partial in-core detectors.

"Since June 2004, Pacific Gas and Electric (PG&E) has been performing an investigation and search for three missing 18-inch rod segments at the Humboldt Bay Power Plant (HBPP) (reference NRC Event Notifications 40877 and 40963). The investigation also included a verification of the inventory of all SNM, including fuel and non-fuel SNM. As a result of the investigation, plant personnel identified HBPP records that indicate 54 in-core detectors should be in the spent fuel pool (SFP).

"In-core detectors were used inside in-core assemblies during plant operations to measure reactor power level. There were three in-core detectors contained inside each in-core assembly. The in-core assemblies were segmented for storage, and the in-core detectors from a total of 18 in-core assemblies (containing 54 in-core detectors) should be onsite. Each in-core detector is approximately 2-1/2 inches long. Depending on design, an in-core detector contains as much as 0.04 grams of U235, to slightly less than 0.002 grams of U235.

"PG&E personnel performed a search in the SFP for the in-core detectors from December 2004 through February 2005. On February 4, 2005, PG&E determined that not all 54 in-core detectors could be located and informed the NRC. PG&E is submitting this Event Notification in accordance with 10 CFR 20.2201(a)(1)(ii) that requires a telephonic report and an Event Notification to be made within 30 days from February 4, 2005.

"PG&E will be issuing a press release tomorrow that includes this issue.

"PG&E's search for in-core detectors is complete. PG&E has determined that 50 complete and three partial in-core detectors are in the SFP. Therefore, one complete and three partial in-core detectors are missing. The partial in-core detectors appear to have been cut when the in-core assemblies were cut to be shortened for SFP storage in the mid-1970s or mid-1980s.

"Most probable locations for the missing in-core detectors are licensed, monitored and restricted radiological control areas, therefore the public health and safety has not been adversely affected.

"PG&E will issue licensee event report (LER) 2005-001-00, 'Missing In-core Detectors,' dated February 22, 2005, to be submitted in accordance with 10 CFR 20.2201(b)(2)(ii) (Reference PG&E Letter HBL-05-002). Information pertaining to the missing in-core detectors is also included in the HBPP SNM Control and Accountability Project Interim Reports, to be submitted February 22, 2005 (Reference PG&E Letter HBL-05-001).

"NRC personnel at headquarters and in Region IV have been notified of the status of this issue."

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