United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2005 > May 6

Event Notification Report for May 6, 2005

U.S. Nuclear Regulatory Commission
Operations Center

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

** EVENT NUMBERS **


41238 41656 41661 41666 41667 41668 41670

To top of page
General Information or Other Event Number: 41238
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NUCLEAR SOURCES & SERVICES INC (NSSI)
Region: 4
City: HOUSTON State: TX
County:
License #: L-02991
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/02/2004
Notification Time: 16:00 [ET]
Event Date: 12/01/2004
Event Time: 11:00 [CST]
Last Update Date: 05/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
GARY JANOSKO (NMSS)

Event Text

PERSONNEL CONTAMINATION FROM SEALED SOURCE RUPTURE

The following information was received via facsimile from the Texas Department of State Health Services Radiation Branch:

"A contamination incident occurred at NSSI the morning of December 1, 2004. The incident involved the breaching of a sealed source as it was being removed from a device. The source involved was a 50 mCi Am-241Be source that was a part of a water salinity test device.

"The NSR-N source is inside an 8 inches long aluminum tube of about 1.5 inches diameter and is held in the center of the tube by two concentric tubes inserted from each end of the primary tube and pinned in place. The aluminum tube also contains a neutron detector to measure the backscatter neutrons when measuring the water in the device. In preparation for disposal of the source, the neutron tube is removed and discarded and the aluminum tube holding the source is removed from the water device.

"At the time of the incident, two persons were involved: The person operating the saw and the health physics monitor. A third person was in the machine shop area and about 4 feet away doing other work.

"The source rupture was noted immediately and health physics support was called to the area. Health physics personnel conducted initial surveys and removed the three personnel from the area. The involved personnel were surveyed out of the area, suited in PPE [personal protected equipment] and were escorted to the hot lab shower area. Nose wipes were collected for assay and each of the personnel showered to remove contamination and surveyed. (Water from this shower is captured in a tank for recovery and treatment.) After completing the release surveys, the involved personnel were released and sent home. "

The Texas Department of Health was contacted by the Headquarters Operations Center and added the following information. The source was apparently mispositioned in the tube and was cut by a band saw during the extraction process. Two of the individuals that were contaminated had nasal smears of 0.1 and 0.2 nanocuries. The third individual did not have any indication of contamination in the nasal smear. The contaminated individuals are scheduled to receive whole body counts.

*** UPDATE FROM K. VERSER TO J. KNOKE AT 15:03 ON 3/25/05 ***

The following was emailed as an update to Event 41238:

"Decontamination efforts are performed and coordinated by specialized team and monitored each week by DSHS staff. To date some 50 pallets of materials and equipment has been removed from the warehouse. These items were surveyed by agency staff with using alpha scintillation and taking random swipes. More than 90% of these items have been decontaminated with the remainder being shipped for disposal at appropriate facilities. An order impounding all sources of the model involved in the event have been impounded in place since December 10, 2004. All 50mCi Am/Be sources have been properly inventoried and ten of them were allowed to be sent to another licensee for removal and inventory. These were individually identified in the presence of agency staff. No contamination has been found outside of the warehouse and airborne activity inside is far below permissible levels and is being monitored with continuous air monitors (CAM)s. All that remains is a small, heavily contaminated area and that should be cleaned up in a couple of weeks. NSSI will survey and perform final decontamination of the building after which, Agency staff will perform a thorough survey to verify decontamination is adequate."

Notified R4DO (Pick) and NMSS (Gillen)

* * * UPDATE FROM K. VERSER TO P. SNYDER AT 12:48 ON 5/5/05 * * *

The State provided the following information via email:

"Additional information received from Licensee, indicates two of the employees involved in the initial event, received Committed Effective Dose Equivalent exposures exceeding the annual limit. One employee, designated HP received 5.82 Rem and the other, designated Operator, received 10.7 Rem. In the letter transmitting this information, the licensee indicated it would be 3-4 weeks before the personnel monitoring supplier would have dose data from personnel monitors for the employees. Texas has requested additional information from the licensee regarding methodology used to determine CEDE for the employees. The licensee is also being required to submit the estimated Total Effective Dose Equivalent for each of the employees involved in the incident.

"Texas is continuing its investigation of this incident and will send a final report when the investigation is complete."

Notified R4DO (Pruett) and NMSS (Hickey)

To top of page
General Information or Other Event Number: 41656
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: HDR CONSTRUCTION CONTROL CORPORATION
Region: 1
City: DAYTONA BEACH State: FL
County:
License #: 2763-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/02/2005
Notification Time: 09:55 [ET]
Event Date: 05/02/2005
Event Time: [EDT]
Last Update Date: 05/02/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1)
TOM ESSIG (NMSS)

Event Text

STOLEN HUMBOLT DENSITY GAUGE

Sometime between Friday afternoon (4/29/05) and 07:00 Monday morning (5/2/05), a Humbolt density gauge was stolen from the HDR job site. The gauge was stored in a shed located at 10 N Atlantic Ave, Daytona Beach, FL 32115. The Florida Bureau of Radiation Control is investigating the case.

Humbolt density gauge model: H-5001EZ
Serial number: 4360
Source activity: Cs-137 10 mCi, Am:Be-241 40 mCi
Police Report Number from Daytona Beach Police: 2005-05-0073
Florida Report: FL05-69

To top of page
General Information or Other Event Number: 41661
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TESTMASTERS INC.
Region: 4
City: HOUSTON State: TX
County: HARRIS
License #: 03651-001
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/03/2005
Notification Time: 08:53 [ET]
Event Date: 05/02/2005
Event Time: 15:30 [CDT]
Last Update Date: 05/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
JOHN HICKEY (NMSS)

Event Text

AGREEMENT STATE - PERSONNEL OVEREXPOSURE

"On 5/2/2005 at 4:00 p.m., Texas Department of State Health Services was notified by [the] Radiation Safety Officer [RSO] with Testmasters, Inc. in Houston. [The RSO] stated that he had just received the Occupational Radiation Exposure Report for Testmasters during the period of 3/20/05 through 4/19/05 with a monthly whole body exposure of 4.665 Rem to one of his radiographers. This puts the radiographer's annual exposure at 6.395 Rem. He stated that this radiographer works the night shift and usually works in the dark room where there is no source. There is however one portable gage that is used on night shift at Testmasters for radiography. It is an Amersham 660B with an Ir-192 source. The source activity is 140 Ci. The radiographer thinks he left his badge in his tool box which is located in the radiography bay area. Testmasters plans to make a badge storage area in the front office where all employees can keep their badges when not in use. An investigation will follow."

The employee's badge has been rescinded until this investigation is completed.

State report number: I-8228

* * * UPDATE FROM STATE (K. VERSER) TO P. SNYDER 1200 EDT 5/5/05 * * *

The State provided the following information via email:

The fourth sentence of the original text above should read as follows: "There is however one industrial radiography camera that is used on night shift at Testmasters for radiography."

Notified NMSS (Hickey) and R4DO (Pruett).

To top of page
Hospital Event Number: 41666
Rep Org: UNION HOSPITAL
Licensee: UNION HOSPITAL
Region: 3
City: TERRE HAUTE State: IN
County:
License #: 13-16457-01
Agreement: N
Docket:
NRC Notified By: GARY ADLER
HQ OPS Officer: PETE SNYDER
Notification Date: 05/05/2005
Notification Time: 14:25 [ET]
Event Date: 05/02/2005
Event Time: 16:20 [CST]
Last Update Date: 05/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVE PASSEHL (R3)
THOMAS ESSIG (NMSS)

Event Text

MEDICAL EVENT: BRACHYTHERAPY UNDER DOSE ADMINISTRATION

On May 2, 2005 to May 3, 2005 during a planned 1 day 5 hour 22 minute brachytherapy vaginal dose a calculated 27% under dose of 1825 cGy dose was administered in a 2.5 cm solid vaginal cylinder. Two 19.56 mg Ra equivalent Cs-137 sources were used. This event was discovered on May 4, 2005 at 10 am, during a summary review, when the licensee discovered that the wrong size applicator cylinder was used. A 1.93 cm cylinder was planned to have been used to apply a 2500 cGy total dose.

The licensee contacted the patient about the under dose and plans to administer the rest of the dose on May 5, 2005. The licensee is formulating a plan to administer additional training to the hospital staff to prevent future events of this type.

To top of page
Power Reactor Event Number: 41667
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK CRIM
HQ OPS Officer: PETE SNYDER
Notification Date: 05/05/2005
Notification Time: 15:44 [ET]
Event Date: 03/06/2005
Event Time: 15:07 [EDT]
Last Update Date: 05/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BRIAN MCDERMOTT (R1)

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

Event Text

INVALID SAFETY SYSTEM ACTUATION DURING AN OUTAGE

"This 60-day ENS report is being made per 10CFR 50.73(a)(2)(iv)(A) to report an invalid automatic actuation of systems listed in paragraph (a)(2)(iv)(B), namely ECCS, emergency diesel generator (EDG), and emergency service water (ESW).

"On March 6, 2005 at 15:07 hours a Unit 2 Division 3 LOCA signal was inadvertently initiated during replacement of a power supply on ECCS. Continuity on the 24 VDC power distribution signal common was lost while lifting leads on the power supply. One terminal on the power supply was part of a daisy chain circuit connection. This resulted in an unplanned actuation of the high drywell pressure relays.

"Two 24 VDC power supplies are connected in parallel to supply power to Division 3 ECCS trip units and relays. It was planned to replace one of these power supplies while the power distribution network remained energized by the redundant power supply. However, the continuity of the power distribution network relied on the connection of two leads on one terminal on the out-of-service power supply. When the two leads were separated several relays lost their normal connection to the signal common. Reverse currents caused the false actuation of the Division 3 high drywell pressure relays.

"D23 EDG automatically started and ran unloaded. The C ESW pump automatically started due to the EDG start. The 2A Core Spray (CS) loop received a partial actuation in that the Division 3 signal was initiated but the Division 1 signal was not initiated. 2C CS pump started as designed and 2A CS pump did not start which was expected. The 2A CS loop automatic valve alignment is initiated by the Division 1 signal; therefore, no automatic 2A CS loop valve alignment occurred. All systems functioned as designed during the event.

"The cause of the event was that the work package planner for the power supply replacement failed to recognize the impact on plant systems and as a result applied less than adequate technical rigor. The maintenance planning procedure will be revised to ensure the appropriate level of technical rigor is applied for work packages that lift or manipulate a signal common lead.

"This event Is reportable per 10CFR50.73(a)(2)(iv)(A) since 2C Core Spray pump, D23 EDG and C ESW pump automatically actuated on an invalid signal."

The NRC Resident Inspector has been notified.

To top of page
Power Reactor Event Number: 41668
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: RICHARD SADLER
HQ OPS Officer: GERRY WAIG
Notification Date: 05/05/2005
Notification Time: 16:06 [ET]
Event Date: 05/05/2005
Event Time: 07:30 [EDT]
Last Update Date: 05/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
BRIAN MCDERMOTT (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY- ALCOHOL

A licensed employee was determined to be under the influence of alcohol during a for-cause test. The employee's access to the site has been restricted. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the State of Connecticut, local officials, and the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 41670
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SAUER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 05/06/2005
Notification Time: 00:32 [ET]
Event Date: 05/05/2005
Event Time: 23:05 [EDT]
Last Update Date: 05/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
BRIAN MCDERMOTT (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

TECHNICAL SPECIFICATIONS REQUIRED PLANT SHUTDOWN BEGAN AND THEN TERMINATED

"Unit shutdown was commenced at 2305 to comply with requirements of technical specification 3.0.3. 14 and 15 Containment Fan Coil Units (CFCU'S), 2 of 5 total CFCU's, had been removed from service to remove silt buildup in their emergency supply piping. While in this configuration, a tubing line supplying service water pressure for control of the 13SW223 (outlet flow control valve) for 13 CFCU developed a leak that rendered that valve and associated CFCU inoperable. With 3 CFCU's inoperable entry into technical specification 3.0.3 was required. A turbine load reduction was commenced at 2305 at 1% per hour. The 15 CFCU was restored to operable status at 2320 and the technical specification 3.0.3 and the load reduction were terminated. 14 CFCU was returned to operable at 2323. Repairs were made on the tubing for 13 CFCU and that was returned to operable status at 0009 on 5/6/05. 11 and 12 CFCU's were operable and in service for the duration of the event. The unit has been returned to 100% rated power.

"The only other safety related equipment removed from service at the time of the event was the 13 service water pump for investigation of a reduced flow condition, and had no impact on this event.

The licensee notified the NRC Resident Inspector.

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