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Event Notification Report for April 26, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/25/2005 - 04/26/2005

** EVENT NUMBERS **


41619 41620 41632 41635 41636 41638 41639

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General Information or Other Event Number: 41619
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KING COUNTY WASHINGTON
Region: 4
City: Seattle State: WA
County: King
License #: WN-R0593
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/21/2005
Notification Time: 11:22 [ET]
Event Date: 05/26/2000
Event Time: [PST]
Last Update Date: 04/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
RICH CARREIA (NMSS)
DUTY OFFICER/EMAIL (EPC)

Event Text

AGREEMENT STATE - LOST KAY-RAY/SENSALL MOISTURE ANALYZER

The following information was received from the Washington State via E-mail:

"Location of Event: The former Pendleton Flour Mills / Fisher Flour Mills site (located on Harbor Island, at 13th Avenue Southwest and Klickitat Avenue Southwest, Seattle, Washington).

"This is to report a missing [Generally Licensed] GL radioactive material device and its radioactive source (one Kay-Ray/Sensall moisture analyzer, device model 7062P, housing serial number 9954, source serial number 9310V, containing 50 millicuries cesium-137 (as of May 31, 1979). The last known location of the device / radioactive source is the former Pendleton Flour Mills / Fisher Flour Mills site (located on Harbor Island, at 13th Avenue Southwest and Klickitat Avenue Southwest, Seattle, Washington). Presumed missing after May 26, 2000 (date of last apparently reliable inventory confirmation from Fisher).

"The apparent cause is loss of physical control of general license material during sale of mill site; or possibly inadequate documentation of proper disposal / transfer of the device / radioactive source. Since 1979 the device / radioactive source was reportedly located at that site. Washington State sales records indicate that Pendleton bought the mill site from Fisher on April 24, 2001, and that King County bought the mill site from Pendleton on July 28, 2003. [Office of Radiation Protection] ORP discovered the discrepancy during GL registration for material indicated to be on site. After an extensive investigation, ORP can not determine the status of the material.

"Corrective Actions:
Pendleton and Fisher replied to ORP March 18, 2005, notice of noncompliance letter for potential loss of control of the device. The replies were unacceptable since they are inconsistent and do not confirm the location of the material. Fisher reported they transferred said device / source to Pendleton; and Pendleton reported that Fisher removed said device / source). The ORP April 18, 2005, noncompliance letter directs Pendleton and Fisher to jointly conduct a thorough and exhaustive physical search of the entire mill site, since both still have spaces there, and for Pendleton and Fisher to perform additional interviews of current and former company employees who may know more about the status of the device. Pendleton and Fisher must cooperate with ORP to provide ORP with a written and acceptable reply identifying the disposition of the missing device.

"Event Number WA-05-014, missing Generally Licensed (GL) device."

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General Information or Other Event Number: 41620
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/21/2005
Notification Time: 15:05 [ET]
Event Date: 04/19/2005
Event Time: [CST]
Last Update Date: 04/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)

Event Text

EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following information was provided by the State via facsimile:


"On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital.

"The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing.

"The licensee has developed, an action plan for this event based on possible causes:
1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule.
2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician.
3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education.

"A voluntary MedWatch form was sent in to the FDA.

"Wisconsin Radiation Protection Section plans on investigating this event."

State Event Report ID # 24.

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Power Reactor Event Number: 41632
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK GORLEY
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/25/2005
Notification Time: 12:30 [ET]
Event Date: 04/25/2005
Event Time: 12:00 [EST]
Last Update Date: 04/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOEL MUNDAY (R2)

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

THE PLANT'S TSC (TECHNICAL SUPPORT CENTER) HAS BEEN TAKEN OUT OF SERVICE DUE TO PLANNED MAINTENANCE WORK

"On 4/2512005 at 12:00 p.m., EDT the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned maintenance and equipment modifications. The maintenance activities require relocation of the control panel (1X75-C001) which contains the HVAC controls and annunciators as well as the radiation monitoring meter and annunciator. The loss of this equipment requires taking the TSC out of service. The maintenance activities are scheduled to take five weeks. The alternate TSC will remain operable and available, so no loss of TSC function will occur due to the maintenance activity.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity results in a loss of an emergency response facility for the duration of the evolution."


The NRC Resident Inspector was notified and state and local notifications will be made.

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Power Reactor Event Number: 41635
Facility: MCGUIRE
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PHIL THOMPSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 04/25/2005
Notification Time: 15:57 [ET]
Event Date: 04/09/2005
Event Time: 10:39 [EDT]
Last Update Date: 04/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOEL MUNDAY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 0

Event Text

INVALID SPECIFIED SYSTEM ACTUATION

"This report is being made under 10CFR50.73(a)(2)(iv)(A) - Invalid Safety System Actuation.

"At 10:39:06 on April 9, 2005, the steam supply valve to Unit 2 turbine-driven auxiliary feedwater pump, 25A-48ABC, was manually failed open during a maintenance activity causing the pump to start. There was no valid actuation signal. The train of auxiliary feedwater started and functioned successfully. The actuation was complete and lasted for 1 minute and 25 seconds."

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 41636
Rep Org: CRAIG TESTING LABORATORY
Licensee: CRAIG TESTING LABORATORY
Region: 1
City: POCOPSON State: PA
County:
License #: 29-18018-01
Agreement: N
Docket:
NRC Notified By: IAN CREIG
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/25/2005
Notification Time: 15:57 [ET]
Event Date: 04/25/2005
Event Time: 13:30 [EDT]
Last Update Date: 04/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RICHARD BARKLEY (R1)
TOM ESSIG (NMSS)
TAS fax ()

Event Text

LICENSEE REPORTED A LOST TROXLER GAUGE MODEL 3430

A technician for the Craig Testing Laboratory placed a Troxler gauge model 3430 and its transportation box into the back of his pickup securing it with a chain, however he did not latch the top of the box or close his truck's tailgate. When he drove from the job site in Pocoson, PA., he heard a noise but he did not stop until he reached a stop light (approx 2 miles away). He got out of the truck and noticed the transport box was dangling from the back of the truck still attached to the chain, but without the Troxler gauge inside. He retraced his route, but there was no Troxler gauge. The Troxler gauge (SN # 25540) contained 8 millicuries of Cs-137 and 40 millicuries of Am/Be-241. The local police Department was notified.

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Power Reactor Event Number: 41638
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BILL DALTON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/25/2005
Notification Time: 20:41 [ET]
Event Date: 04/25/2005
Event Time: 16:55 [EDT]
Last Update Date: 04/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RICHARD BARKLEY (R1)

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

HPCI DECLARED INOPERABLE

"On 4/25/05 @1655, Engineering completed an evaluation and notified Operations that leakage at the packing leak off plug on the bonnet of MO-2-23-014, the Unit 2 HPCI Turbine Steam Supply Valve, is part of the ASME Class 2 piping boundary. Per station procedures, upon discovery of leakage from a Class 2 component pressure boundary, the component is declared inoperable. Therefore MO-2-23-014 and the Unit 2 HPCI system was inoperable. Reactor operation is unaffected and Unit 2 remains at 100% power. The inoperability of the HPCI system places the Unit in a 14-day shutdown Tech Spec action statement. Further investigation of the cause and the ASME Code requirements is in progress."

The NRC Resident Inspector was notified

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Power Reactor Event Number: 41639
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRADDOCK D. LEWIS
HQ OPS Officer: PETE SNYDER
Notification Date: 04/26/2005
Notification Time: 02:12 [ET]
Event Date: 04/26/2005
Event Time: 00:02 [EDT]
Last Update Date: 04/26/2005
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):
ERIC DUNCAN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 8 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP WITH AFW ACTUATION

"The DC Cook Unit 1 Reactor automatically tripped during normal plant startup preparations to synchronize the Main Generator with the offsite electrical GRID. Indicated Reactor power at the time of trip was 8 % power and stable. Preliminary review indicates the trip was caused by an Intermediate Range high flux reactor trip signal. The Intermediate Range High Flux Reactor trip occurred below the Reactor Protection System actuation setpoint. This is a one-out-of-two logic and the trip is active below interlock Permissive P-10 (10% reactor power). The cause of the Reactor Trip is under investigation. This event is reportable under 10CFR50.72(b)(2)(iv)(B), RPS actuation, as a four (4) hour report and under 10CFR50,72(b)(3)(iv)(A), Specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event. The DC Cook Senior Resident NRC Inspector was notified 04/26/05 at approximately 00:30 [hrs. EDT]."

The electrical grid is stable and Unit 1 is being supplied by offsite power. Unit 2 is not affected. All control rods fully inserted. Decay heat is being removed via steam dumps to the main condenser.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012