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Event Notification Report for April 7, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/06/2005 - 04/07/2005

** EVENT NUMBERS **


41557 41568 41570 41572 41573

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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: 41568
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: DON WALLS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/06/2005
Notification Time: 13:54 [ET]
Event Date: 04/06/2005
Event Time: 10:06 [CST]
Last Update Date: 04/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (R4)

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 N 0 Cold Shutdown 0 Cold Shutdown

Event Text

MAJOR LOSS OF COMMUNICATIONS CAPABILITY DUE TO OFFSITE FIBER OPTIC CABLE CUT

"On 4/6 at approximately 0900 Emergency Planning (EP) was notified by Arkansas Department of Health that they had lost communications with their Communications Center in Little Rock and asked ANO to perform tests to validate.

"Pope County 911 advised EP that there had been a major fiber optics cut east of Russellville. The NRC Resident also notified EP that their contact with Arlington and headquarters was out including commercial lines. Subsequent investigations revealed that ERDS, ENS, and Health Physics Network (HPN) lines are not functioning at ANO. Backup methods of communications are defined in the Emergency Plan procedures and are available.

"Establishment of communications are ongoing."

The licensee informed the State and NRC Resident Inspector.

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Other Nuclear Material Event Number: 41570
Rep Org: NATIONAL INSTITUTES OF HEALTH
Licensee: NATIONAL INSTITUTES OF HEALTH
Region: 1
City: BETHESDA State: MD
County: MONTGOMERY
License #: 19-00296-10
Agreement: Y
Docket:
NRC Notified By: BOB ZOON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/06/2005
Notification Time: 16:04 [ET]
Event Date: 03/10/2005
Event Time: [EST]
Last Update Date: 04/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES NOGGLE (R1)
MELVYN LEACH (NMSS)

Event Text

SOURCE VIAL OF GADOLINIUM-153 REPORTED MISSING

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

"This notification to the NRC Operations Center is in accordance with 10 CFR 20.2201(a)(ii) regarding the incident described below:

"On 3/10/05, we determined that 245 [microCurie] (9.1 MBq) of [Gd-153] (0.5N HCI) in a source vial was missing. The original activity was 1 [milliCurie] (37 MBq) on 4/12/2004, and the missing quantity, corrected for radioactive decay, represented the remaining activity after several labeling experiments.

"Following this discovery, the Authorized User interviewed all researchers who had access to her laboratory. None recalled disposing of the vial. In addition, a health physicist contacted a number of the researchers and performed an independent survey of this and adjacent laboratories with a photon-sensitive survey meter. The original lead pig was found in a box where other lead pigs were stored awaiting disposal. However, the source vial was not in the lead pig. In addition to searching the laboratory areas, we checked the records of both radioactive waste pick ups and other monitored waste from the building in which this laboratory is located. There was no indication of [Gd-153] in any of the records or surveys.

"At this time, the disposition of the material is unknown. Considering that the exposure rate for an unshielded point source of 245 [microCuries] of [Gd-153] is only 0.04 mR/hr, the missing material would not represent a significant external exposure risk. The approximately 69 nanograms of material missing would not represent a significant toxic hazard either.

"Corrective actions have been implemented by suspending the Authorized User's ability to order more radioactive material. With her pending departure from NIH, we do not feel any further actions will be warranted in this situation."

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Hospital Event Number: 41572
Rep Org: UNIVERSITY OF VIRGINIA
Licensee: UNIVERSITY OF VIRGINIA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-00034-26
Agreement: N
Docket: 03000329
NRC Notified By: RALPH ALLEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/06/2005
Notification Time: 16:59 [ET]
Event Date: 04/06/2005
Event Time: [EST]
Last Update Date: 04/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
JAMES NOGGLE (R1)
MELVYN LEACH (NMSS)

Event Text

MEDICAL EVENT INVOLVING ADMINISTRATION OF WRONG DIAGNOSTIC TEST

On the morning of 4/6, the Resident Physician reviewed the prescribing Physician's order for administration of a brain scan diagnostic test to image a tumor and instructed the technician to perform a "standard" brain scan which images blood flow. The Technician administered 30 mCi Tc-99m as instructed rather than the 3 mCi Thallium prescribed. The RSO noted that the test performed would result in a total dose of 3.22 mGy and a urinary bladder wall dose of 81 mGy (information from package insert). The RSO does not believe there will be any adverse consequences to the patient in that this was a diagnostic test. The error was identified by the Director of Nuclear Medicine during review. The patient had not been informed as of the time of this report. The patient will be rescheduled for the appropriate diagnostic test after elimination and decay of the Tc-99m.

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Power Reactor Event Number: 41573
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BOB LANCE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/06/2005
Notification Time: 22:56 [ET]
Event Date: 04/06/2005
Event Time: 16:55 [EST]
Last Update Date: 04/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES NOGGLE (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
2 N Y 100 Power Operation 95 Power Operation

Event Text

PARTIAL LOSS OF OFFSITE POWER RESULTING IN AUTOSTART OF EMERGENCY DIESEL GENERATORS

"At 1655 on April 6, 2005, a trip of the 4A/4B Transformer occurred at Limerick Generating Station in the 500 KV Substation. This de-energized one of the required off site sources and the associated 20 Start-up Bus and 201 Safeguard Bus, causing a valid actuation signal for the D12, D14, D21, and D23 Diesel Generators. All Diesels started and their associated 4 KV buses swapped to the 101 Safeguard Bus as required. Cause of the 4A/4B Transformer trip is under investigation. Power reduction on Unit 2 was performed in response to lowering Main Condenser vacuum during power supply transfers. Condition was stabilized and Unit 2 Reactor power restored to 100 %."

The cause of the lowering main condenser vacuum was that when the bus transfer occurred, several air valves on Unit 2 cycled which caused the lowering vacuum. Once power transferred, Unit 2 stabilized and was restored to 100% power. Unit 1 main condenser vacuum was not affected since power was not transferred on Unit 1.

Additionally, a Group 6A valve isolation signal was generated. This caused the purge valves to receive an isolation signal but the purge valves were not in operation nor were they required to be in operation at the time of the isolation signal. Both unit's Reactor Water Clean-up (RWCU) pumps tripped due to the isolation signal. At the time of this report, the isolation signal was reset, Unit 1 RWCU pump has been reset, and preparations are being made to restart Unit 2 RWCU pump.

The only other anomaly is that Unit 2 D22 diesel is in a maintenance outage and is scheduled to be returned to service tomorrow.

Currently, both units are in a 72-hour LCO action statement due to loss of one offsite power supply.

The licensee will inform the NRC resident inspector.

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