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Event Notification Report for April 27, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/26/2005 - 04/27/2005

** EVENT NUMBERS **


41619 41620 41626 41630 41639 41640 41641 41642

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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)
CANADA EPC (EMAIL) ()

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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General Information or Other Event Number: 41626
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: KENNECOTT UTAH COPPER CORPORATION
Region: 4
City: MAGNA State: UT
County:
License #: UT 1800289
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE(fax)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/22/2005
Notification Time: 18:56 [ET]
Event Date: 04/21/2005
Event Time: 14:50 [MST]
Last Update Date: 04/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
JOSEPH GIITTER (NMSS)

Event Text

EQUIPMENT FAILURE TO FUNCTION AS DESIGNED

"A licensee employee, trained by the device manufacturer, was performing a device inspection (inventory/shutter check/leak test) for one of the licensee's non-portable gauging devices (Ohmart Corporation Model SH-F2, serial number 2296CG) containing 7.4 gigabecquerels (200 millicuries) of cesium-137 (sealed source model number A-2102). A screw broke off while the employee was closing the device shutter. Because the screw broke off, the shutter could not be closed. The licensee plans to follow the manufacturer's procedures for this particular incident as per the manufacturer's training and instruction. This device will either be repaired by an individual specifically licensed by the Executive Secretary, the U.S. Nuclear Regulatory Commission, or an Agreement state to perform such service, or the licensee will return this device to the manufacturer."

Event date was March 2005 and reporting date was April 21,2005.
Utah event report # UT-05-0003

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General Information or Other Event Number: 41630
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: QORE INC.
Region: 1
City: WEST PALM BEACH State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/24/2005
Notification Time: 12:25 [ET]
Event Date: 04/23/2005
Event Time: 23:00 [EST]
Last Update Date: 04/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID SILK (R1)
JOSEPH GIITTER (NMSS)

Event Text

FLORIDA AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE


State of Florida Bureau of Radiation Control received the following information from the Radiation Safety Officer for Qore Inc., located in West Palm Beach, FL.

On 04/23/05 at 2300 EDT a Qore Inc. employee discovered that the Troxler Moisture Density gauge that had been cabled and locked to the bed of his truck was missing, cable had been cut Model number of the Troxler gauge is unknown at this time but usually a Troxler Moisture Density gauge contains 10 milliCuries of cesium-137 and 40 milliCuries of Am-241/Be. The gauge serial number is 22430, cesium-137 source serial number is 75-4160 and the americium-241 source serial number is 47-18251. The gauge was in its locked position and locked inside its case at the time it was stolen. The employee's truck was parked in front of a private residence at the time of the incident. West Palm Beach police were notified by the licensee of the stolen Troxler Moisture Density gauge and the report case number is 0S-9770.

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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.

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Power Reactor Event Number: 41640
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GRANT FERNSLER
HQ OPS Officer: PETE SNYDER
Notification Date: 04/26/2005
Notification Time: 07:41 [ET]
Event Date: 04/26/2005
Event Time: 07:31 [EDT]
Last Update Date: 04/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
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

SPDS (SAFETY PARAMETER DISPLAY SYSTEM) IS DOWN FOR PLANNED MAINTENANCE

"At 0731 hours [EDT] on 04/26/2005 the Unit 2 SPDS system was removed from service for planned maintenance. The duration of work is expected to be 48 hours (scheduled for completion at 0700 hours [EDT] on 04/28/2005).

"ERDS will remain operable during the work window but several points will not be available. For example 23 of 58 ERDS points will be unavailable while SPDS is out of service. However, the ERDS system will still be operable and transmit the remaining points.

"Loss of Emergency Assessment Capability - A review of the ability of the emergency organization to function without SPDS was performed. Alternate sources for many of the points in SPDS were identified and are contained on an Emergency Plan format in PICSY (plant integrated computer system). Those points not available from PICSY can be obtained from the control room. With these compensatory actions and the communications in place between the facilities, there will not be a major loss of emergency assessment capability.

"Since the Unit 2 SPDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 41641
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MIKE BALDARELLI
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/26/2005
Notification Time: 13:21 [ET]
Event Date: 04/26/2005
Event Time: 12:45 [EDT]
Last Update Date: 04/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD BARKLEY (R1)

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

Event Text

THE LICENSEE MADE AN OFFSITE NOTIFICATION DUE TO A FIRE

The licensee reported that there was a small fire lasting for 15-20 minutes in the wiring of a manlift on the charging floor of the Containment Building. It was a smoldering fire with lots of smoke. Offsite fire department was called for assistance. There were two minor injuries to licensee personnel due to smoke inhalation requiring them to be taken to a clinic. Damage was restricted to the manlift.

The NRC Resident Inspector along with State and Local Agencies were notified.

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Power Reactor Event Number: 41642
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MIKE BALDARELLI
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/26/2005
Notification Time: 13:21 [ET]
Event Date: 04/26/2005
Event Time: [EDT]
Last Update Date: 04/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD BARKLEY (R1)

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

Event Text

OIL SPILL OUTSIDE OF THE TURBINE BUILDING

There was an oil spill of between 10 - 25 gallons of 90 weight oil outside of the turbine building. Cleanup has begun and the State of Connecticut and Department of environmental protection were notified.

The NRC Resident Inspector, State and local agencies were notified.


* * * UPDATE on 04/26/05 by Mike Baldarelli to C Gould * * *

The source of the Hydraulic oil leak was a crane that had undergone maintenance the night before. The oil and soil have been removed.

Reg 1 RDO(Barkley) informed.

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