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Event Notification Report for April 6, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/05/2005 - 04/06/2005

** EVENT NUMBERS **


41442 41532 41554 41556 41557 41563 41564 41565 41567

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41442
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: RICHARD MEYERS
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/25/2005
Notification Time: 04:42 [ET]
Event Date: 02/24/2005
Event Time: 18:00 [PST]
Last Update Date: 04/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DALE POWERS (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

POTENTIAL BREACH OF SECONDARY CONTAINMENT DURING SEISMIC EVENT.

The licensee provided the following information:

"This event notification is being made to report an event that could have prevented fulfillment of the safety function to mitigate the consequences of an accident IAW 10CFR50.72(b)(3)(v)(D).

"The potential for creation of an actual hole through Secondary Containment (SC) via the Plant Service Water (TSW) system high point reactor building auto vents (TSW-AV-1A and TSW-AV-1 B) exists if a seismic event occurs and the Seismic Category 2 TSW loop-seal piping outside of Secondary Containment is breached (e.g., because of a pipe break) and has drained.

"Neither of the above conditions presently exists. However, a Secondary Containment breach could occur as a result of a single passive failure (i.e., pipe break in the TSW loop-seal piping described above). TSW-AV-1A and TSW-AV-1B are designed to open automatically when neither TSW system pump is operating to break the vacuum condition that would otherwise exist in the piping. When TSW-AV-1A and TSW-AV-1B are open in vacuum breaker mode, the resultant hole size into the TSW system piping would exceed the allowable Secondary Containment cumulative hole size [ of 32 square inches total], if the loop seal were also breached as described above. Due to this condition Secondary Containment was declared INOPERABLE at 1800 PST 2/24/05. As a compensatory measure to prevent exceeding the allowable Secondary Containment cumulative hole size, one of the two TSW reactor building auto vents (TSW-AV-1B) was isolated by closure of a manual valve (TSW-V-55B). This action was completed at 1828 PST 2/24/05 and the Secondary Containment was declared OPERABLE. One TSW auto vent is sufficient to perform the vacuum breaker function."

This condition was found by the licensee's System Engineer. The extent of condition and long term corrective action is under review by licensee.

Licensee will inform the NRC Resident Inspector.

* * * RETRACTION FROM FRED SCHILL TO HOWIE CROUCH @ 1535 EDT ON 04/05/05 * * *

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"On 2/25/05, Columbia Generating Station reported (ref: EN 41442) a condition that was discovered while reviewing service water (TSW) system design documents. During the review, it was determined that Seismic Category II TSW piping in the turbine (TG) and radwaste (RW) buildings could rupture and drain during a seismic event. This event would result in an inoperable secondary containment (SC) because TSW system high point vent valves located within the SC would automatically open when the piping drained after rupturing. Such an event would allow direct communication between the SC atmosphere and the TG/RW atmospheres and exceed the leakage rate assumed in Columbia's accident analysis. There are two principal accidents in Columbia's safety analysis for which SC is credited as a mitigating system. These are the Loss Of Coolant Accident (LOCA) and the Fuel Handling Accident (FHA). The SC performs no active function in response to either of these limiting events, however, its leak tightness is required to ensure that the release of radioactive materials from the primary containment is restricted to those leakage paths and associated leakage rates assumed in the accident analysis, and that fission products entrapped within the SC structure will be treated prior to discharge to the environment.

"Assuming a seismic event of the magnitude (0.25g) of the Safe Shutdown Earthquake (SSE) occurred and ruptured the TSW piping causing SC to become inoperable, it is beyond Columbia's safety analysis to postulate a release of radioactive material beyond Part 100 limits for that event. This is because analysis shows that the SSE will not in itself cause a LOCA or an FHA and Columbia's design and licensing bases do not assume a LOCA or FHA coincident with a seismic event. In the event that the SSE made SC inoperable, the Technical Specifications (LCO 3.6.4.1.B) require that the plant be in mode 3 in 12 hours and in mode 4 in 36 hours. Since this is achievable, it is reasonable to conclude that, in the event previously reported, plant shutdown can be accomplished without radiological release and within the completion time of the action required by the Technical Specifications.

"The discussion in the guidance document (NUREG 1022) for reporting under Part 50.72(b)(3)(v) states the level of judgment for reporting under these criteria is a reasonable expectation of preventing fulfillment of a safety function. It also states that the intent of the criteria is to capture those events where there would have been a failure of a safety system to properly complete a safety function regardless of whether there was an actual demand. This discussion however, as the Part 50.72(b)(3)(v) and Part 50.73(a)(2)(v) criteria state, apply to safety functions of systems or structures that are needed to control the release of radioactive material, because safe shutdown of the plant without radiological release is assured post SSE (sans SC), as described in Columbia's design and licensing bases, SC would not be needed to control the release of radioactive material and therefore the reporting criteria is not met."

The licensee will be voluntarily submitting a Licensee Event Report as a method of information sharing with the rest of the industry.

The licensee has notified the NRC Resident Inspector. Headquarters Operations Officer notified R4DO (Howell).

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Hospital Event Number: 41532
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 3
City: SOUTH BEND State: IN
County:
License #: 13-02650-02
Agreement: N
Docket:
NRC Notified By: JOHN SCHEU
HQ OPS Officer: BILL GOTT
Notification Date: 03/28/2005
Notification Time: 11:13 [ET]
Event Date: 02/23/2004
Event Time: [CST]
Last Update Date: 04/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
KENNETH RIEMER (R3)
TOM ESSIG (NMSS)

Event Text

MEDICAL EVENT

The following information was supplied by the licensee:

"Two patients involved in what we now think to be reportable events.

1. A.M. 2-23-04 to 2-24-04
2. R.M. 3-01-04 to 3-02-04

"In both cases the patients were being treated for endometrial cancer with brachytherapy. A new Wang vaginal applicator was used. The tandem was loaded with incorrect size sources (of Cs-137) which then had the ability to slide out of the intended treatment position through the placement spring when the patient would sit in a more up-right position. With the sources out of position they would irradiate the patients inner thigh. The dose to the thigh had to be estimated based on estimated time the patient was in an up-right position and the effect seen on the skin.

"At the time these incidents took place it was not felt that reportable events had taken place because of the calculated exposure to the thigh, patient symptoms, and the interpretation of 35.3045 (a) (1)(2), (3).

"One of the patients (A.M.) returned recently (1/05) with an ulcer at the area of thigh exposure. This has caused the radiation therapy staff to reevaluate their dose estimation to the patients. After review, it is believed that reportable events my have occurred based on 35.3045 (A) (3).

"This conclusion was formulated on 3-25-05 after a staff meeting and 1 received the final letter from the physician today 3-28-05."


The tandem manufacturer recommends 3M seeds and the facility used Amersham seeds which resulted in the seeds shifting. A total of 5 patients were treated. The initial estimates determined that the exposure was less than the reportable limit. All the patients were notified of the exposure.

One of the two overexposed patients is responding well to treatment. The other patient may have received the higher dose. The remaining three patients appear to have received less than the reportable dose.

* * * UPDATE FROM JOHN SCHEU TO JEFF ROTTON ON 4/1/2005 AT 1608 * * *

Discussion between the licensee and NRC Region 3 inspectors determined that a third patient should be added to this event:

3. K.B. 3-19-04 to 3-22-04

Notified R3DO (Riemer) and NMSSEO (Collins).

* * * UPDATE FROM JOHN SCHEU TO HOWIE CROUCH ON 4/5/05 AT 1833 EDT * * *

Discussion between the licensee and NRC Region 3 inspectors determined that a fourth and fifth patient should be added to this event:

4. D. T. 1/26/04 to 1/27/04
5. M. S. 2/18/04 to 4/21/04

Notified R3DO (O'Brien) and NMSS EO (Leach).

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General Information or Other Event Number: 41554
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS
Region: 4
City: PASADENA State: TX
County:
License #: L04322
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/31/2005
Notification Time: 16:21 [ET]
Event Date: 01/18/2005
Event Time: [CST]
Last Update Date: 03/31/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)

Event Text

AGREEMENT STATE - OVEREXPOSURE

The following information was provided by the Texas Department of State Health Services via E-mail (state text in quotes):

"Radiography was conducted at both field and fixed locations during the December [2004] monitoring period. The badge of [the radiographer trainee] was the only high badge for the Licensee during the monitoring period. The Radiography Trainer claims that his pocket dosimeter and alarming rate meter showed no unusual activity during the monitoring period. All exposure devices were leak tested December 30, 2004, with no leakage in excess of applicable limits being exceeded - no leakage. The Radiographer Trainer was on two crews during the monitoring period. Both other crew members had normal exposures for the monitoring period. No explanation for a possible source of exposure to the badge was offered by the Licensee or the wearer of the badge. The Licensee was cited for violating the Deep dose annual exposure limits for calendar year 2004."

The trainee was seen by a physician however, the blood work results are not yet available. As corrective action, the licensee has notified all radiographers to carefully monitor their pocket dosimeters and alarming rate meters, and to keep their personal monitoring badges away from sources of radiation.

The four cameras used contained Ir-192 (72.4 Ci, 81.5 Ci, 34.1 Ci, and 39.4 Ci). Total dose received by the radiographer trainee was 11.885 REM DDE for December 2004 and 12.771 REM DDE for the annual monitoring period.

Texas Incident # I-8199.

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General Information or Other Event Number: 41556
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEAM COOPERHEAT - MQS
Region: 4
City: ALVIN State: TX
County:
License #: L00087
Agreement: Y
Docket:
NRC Notified By: GLENN CORBIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/31/2005
Notification Time: 16:33 [ET]
Event Date: 02/21/2005
Event Time: 18:55 [CST]
Last Update Date: 03/31/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)

Event Text

AGREEMENT STATE - RADIOGRAPHIC SOURCE PARTIALLY DISCONNECTED FROM CAMERA

The following information was provided via E-mail by the Texas Department of State Health Services (DSHS) (state text in quotes):

"On February 21,2005 at the Motiva Enterprise facility located in Port Arthur, Texas an event took place that prevented the return of a radiography source to the shielded position via normal operations. The unauthorized retrieval of the source was done without proper license condition authorization. All dosimeters have been processed and no overexposures have occurred as a result of the retrieval. Additionally, a verbal notification was made to DSHS, and followed by written report received 03/21/05.

"The Operating and Emergency procedures to be employed in an incident of this type were reviewed for full understanding by all staff involved in Radiographic operations."

The source was Ir-192 (150 Ci) from a SPEC Model G-60; AEA Model 969.

Texas Incident # I-8224

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General Information or Other Event Number: 41557
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: MIRIAM HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/01/2005
Notification Time: 13:56 [ET]
Event Date: 03/30/2005
Event Time: [EST]
Last Update Date: 04/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
ELMO COLLINS (NMSS)

Event Text

AGREEMENT STATE - LOST Am-241 SOURCE

An Am-241 sealed source (Serial #: NM-129 received in January 1978) was last inventoried in February 2005.

On the afternoon of March 30, 2005, it was concluded that a wand marker containing 2 mCi of Am-241 was missing. The marker had not been in use and was secured "in storage" in the Nuclear Medicine Hot Lab at the Miriam Hospital. Initially the source was considered to be misplaced. However, on March 30, 2005, the hospital's preliminary investigations had not recovered the source and it was reported as lost. The source is identified as an Am-241 (2mCi) wand formerly used as a marker for an ELCINT camera. The source is in a steel wand and is shielded until a window is opened when used as a marker. It was described as a steel rod with wires out the back end approximately 8 inches long and approximately 0.75 inches in diameter.

The Rhode Island RCA was notified of the incident on March 30, 2005 via a voice message and retrieved by RCA personnel on April 1, 2005 after returning from training out of state. The licensee is continuing a search of each campus in an attempt to retrieve or account for the source.

Event Report ID: RI-05-002

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Power Reactor Event Number: 41563
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/05/2005
Notification Time: 14:00 [ET]
Event Date: 04/04/2005
Event Time: 20:36 [EST]
Last Update Date: 04/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
JAMES NOGGLE (R1)

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

Event Text

FITNESS FOR DUTY REPORT

A non-licensed contract supervisor was determined to be under the influence of alcohol during for-cause testing. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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General Information or Other Event Number: 41564
Rep Org: DAVID BLACKMORE AND ASSOCIATES
Licensee: DAVID BLACKMORE AND ASSOCIATES
Region: 1
City: POTTSTOWN State: PA
County:
License #: 37-28297-01
Agreement: N
Docket:
NRC Notified By: JOE HUGHES
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/05/2005
Notification Time: 15:25 [ET]
Event Date: 04/05/2005
Event Time: 11:00 [EST]
Last Update Date: 04/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES NOGGLE (R1)
MELVYN LEACH (NMSS)

Event Text

DAMAGED MOISTURE DENSITY GAGE DURING CONSTRUCTION

During construction at the Providence Regency residential construction site in Lower Providence Township, a CPN MCMDR moisture density gage was damaged when run over by a bulldozer. The gage was a model MC3, Serial number 300405564, containing 10 millicuries of Cs-137 and 50 millicuries of Am-241: Be. The external case of the gage was damaged and the rod snapped off. The radioactive sources were intact and stored in the locked position of the gage and not damaged. No leakage was detected. The gage will be shipped to the manufacturer for repair.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41565
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MIKE FERRY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/05/2005
Notification Time: 19:59 [ET]
Event Date: 04/05/2005
Event Time: 16:12 [PST]
Last Update Date: 04/05/2005
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
LINDA HOWELL (R4)
JAMES LYONS (NRR)
KRISS KENNEDY (IRD)
CHRIS LIGGETT (FEMA)
ED HOISINGTON (DHS)
ELIOT BRENNER (PAO)

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

UNUSUAL EVENT DECLARED UNDER E.A.L. 9-3.U.1

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"Columbia Generating Station has declared an unusual event ([EAL] 9-3.U.1) due to an unintentional vehicle crash into the Radwaste Building (Safe-Shutdown Bldg) roll-up door during the normal course of plant activities. Damage to the door has prevented normal closure of the door. Efforts to close the door are on-going.

"Terminated the event @ 1655 [PDT] due to determination that an unusual event did not exist."

A plant employee was using a plant-owned vehicle to move a sea-land container into the Radwaste Building when he struck the bottom of the roll-up door. There were no injuries to plant personnel and no other damage to plant equipment.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM PAM ANKRUM TO HOWIE CROUCH @ 2133 EDT ON 4/5/05 * * *

The following retraction was obtained from the licensee via facsimile (licensee text in quotes):

"At 1912 EDT on April 5, 2005, NRC was notified of an Unusual Event at Columbia Generating Station (EN #41565). This notification also informed the NRC that the event was terminated at 1955 EDT (1655 PDT) on April 5, 2005.

"This is a follow-up to inform the NRC that Columbia Generating Station is retracting its Unusual Event Declaration due to the following reason. Columbia Generating Station Procedure 13.1.1A requires entry into Unusual Event EAL 9.3.U.1 if 'the impact is of such force that damage to structures or equipment inside a Safe Shutdown Building may have occurred.' Upon further evaluation, the impact was not of sufficient force to have caused damage to structures or equipment inside a Safe Shutdown Building. Based on this information, the Unusual Event criteria was not met.

"The licensee notified the NRC Resident Inspector and local, State, and other Government Agencies of this update."

Notified IRD (Kennedy), R4DO (Howell), NRR EO (Lyons), FEMA (Liggett) and DHS (Frost) and HQPAO (Brenner).

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Power Reactor Event Number: 41567
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ROBERT SCHREIFELS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/05/2005
Notification Time: 22:26 [ET]
Event Date: 04/05/2005
Event Time: 16:00 [CST]
Last Update Date: 04/05/2005
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):
KENNETH O'BRIEN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

POTENTIAL VULNERABILITY WITH ALTERNATE SHUTDOWN SYSTEM (ASDS) ISOLATION DESIGN

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"On April 5, 2005 at 1600 [hrs. CDT], Monticello Nuclear Generating Plant during a review of the Alternate Shutdown System (ASDS) as part of the corrective actions for LER 2005-01, submitted on April 4, 2005 (Event Notification #41436) discovered a second breaker affected by a similar cause as identified in the LER. The Bus 16 source (Breaker 152-609) to Load Center #104 has a similar potential vulnerability with the ASDS isolation design that could result in Load Center #104 being locked out in the event of a Control Room or Cable Spreading Room fire. The Monticello Appendix R Safe Shutdown Analysis for Control Room/Cable Spreading [Room] fire assumes a loss of control of Division I and II equipment from the Control room, however safe shutdown is achieved remotely from the ASDS panel. ASDS design is such that a Control Room/Cable Spreading Room fire would not impede the ability to safely shutdown and maintain the plant in a shutdown condition.

"Contrary to the ASDS design, it was discovered that an unisolated metering circuit could result in Load Center #104 being locked out in the event of a Control Room/Cable Spreading Room fire. The bus lockout is not isolated by the ASDS transfer switches, therefore, this condition could result in failure of Load Center #104 to re-energize during the implementation of the Shutdown Outside Control Room procedure. ASDS is not required to be operable at this time.

"As a result of this determination, MNGP will issue a revision to LER 2005-01 to the NRC to reflect the new information.

"This event is being reported as a potential loss of safety function (10CFR50.72(b)(3)(v)(A,B, and D) and as a degraded or unanalyzed condition (10CFR50.72(b)(3)(ii)(B). The NRC [Resident Inspector] has been notified."

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