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Event Notification Report for May 13, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/12/2005 - 05/13/2005

** EVENT NUMBERS **


41684 41685 41692 41693

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Other Nuclear Material Event Number: 41684
Rep Org: MN STATE UNIV AT MANKATO
Licensee: MN STATE UNIV AT MANKATO
Region: 3
City:  State: MN
County:
License #: SNM-397
Agreement: N
Docket:
NRC Notified By: MIKE PETERS
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/10/2005
Notification Time: 09:44 [ET]
Event Date: 05/04/2005
Event Time: [CDT]
Last Update Date: 05/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ANNE MARIE STONE (R3)
JOHN HICKEY (NMSS)
MELVYN LEACH (IRD)
DONNA-MARIE PEREZ (TAS)

Event Text

LOSS OF 100 MG OF PLUTONIUM/BERYLLIUM SEALED SOURCE

The Minnesota State University provided notification of a lost sealed source from the radiation facility. The source was a 100mg Pu/Be (6 milliCuries) (Serial # M-1202), and used primarily in the State University laboratory for teaching purposes. In 1962 an inventory was taken and documented that 2 sources (10 gram and 100 mg) were stored in a barrel and shielded in paraffin. Somewhere over the years it was understood that only one 10.1 gram source was in the barrel. When the licensee moved from one facility to another in 1973, no detailed inventory was taken of the contents in the barrel.

On 05/04/05 the sealed sources were being reclaimed by Los Alamos and when the paperwork was checked against the actual contents it was noted that the 100mg sealed source was missing. A thorough search by licensee of their facility did not find any evidence of the missing source.

The source dimension is 1.75 " long and 1.25 " in diameter.

**** UPDATE FROM ANN MARIE STONE, NRC REGION 3 ON 05/12/05 AT 1750 EDT TO PETE SNYDER ****

Changed Reporting Organization and Licensee field from the University of Minnesota to Minnesota State University at Mankato. R3DO (A. Marie Stone) notified.

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General Information or Other Event Number: 41685
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: THOMAS WOOD PRESERVING
Region: 1
City:  State: MS
County:
License #: GL-266
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/10/2005
Notification Time: 14:38 [ET]
Event Date: 04/07/2005
Event Time: [CDT]
Last Update Date: 05/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KINNEMAN (R1)
THOMAS ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST FLUORESCENCE ANALYZER

The State provided the following information via email:

"During an inspection at Thomas Wood Preserving on April 7, 2005, it was determined that a generally licensed device, Asoma Model LCA x-ray fluorescence analyzer, Serial No. 466, containing 30 millicuries of Curium-244, was missing. The plant manager of the treatment plant stated that the device had been returned to Spectro Analytical, the device distributor, several years ago. [The Division of Radiation Health] DRH contacted Spectro Analytical on May 2, 2005, and learned that they had never received the device from the company. The plant manager stated that he would continue looking for the device and inform DRH if it was located. It is assumed that the treatment plant purchased a new fluorescence analyzer and the other device was put in storage and/or misplaced. Thomas Wood Preserving, holder of General License No. GL-266 was cited violations for failure to secure radioactive material from authorized removal and failure to report the lost device to the Agency. The licensee is also required to provide a written report to DRH in accordance with State Regulations. It is not known when the device was lost or the event occurred."

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Power Reactor Event Number: 41692
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: WESLEY HELD
Notification Date: 05/12/2005
Notification Time: 11:22 [ET]
Event Date: 05/12/2005
Event Time: 04:11 [EDT]
Last Update Date: 05/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES MOORMAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWNDUE TO LOSS OF EMERGENCY BUS E1

"On May 12, 2005, at 0411 hours, electrical power was lost to the 4160 VAC Emergency Bus E1. Emergency Diesel Generator 1 was inoperable for maintenance at the time of the electrical power loss. This power loss to Emergency Bus E1 affected both Units 1 and 2.

Unit 1

"The loss of power to E1 resulted in Division 1 Primary Containment Isolation Valve (PCIV) actuations. The actuations included the Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Traversing In-core Probe, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 3 (i.e., Reactor Water Cleanup), and Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems) valves, as well as the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation) and the automatic start of Standby Gas Treatment (SGT) System train B. The actuations of PCIVs and Reactor Building Ventilation System isolation were complete and the affected equipment responded as designed to the invalid signal (i.e., the valves and dampers that were open, at the time of the event, closed). Additionally, SGT System train B started and functioned successfully.

"Loss of power to E1 also resulted in entry into LCO 3.0.3 (i.e., be in Mode 2 within 7 hours, Mode 3 within 13 hours, and Mode 4 within 37 hours) due to all required reactor coolant leakage detection instrumentation/systems being inoperable.

"At 0440 hours, it was discovered that all three Control Room Air Conditioning (AC) subsystems became inoperable due to failure of the control building air compressors and Technical Specification LCO 3.0.3 was entered. At 0515 hours, it was determined that both Control Room Emergency Ventilation (CREV) subsystems became inoperable when the dampers drifted shut. At 0546 hours, a control building air compressor was started and the control room air conditioning and CREV subsystems were returned to operable status.

"Operators initiated a plant shutdown for Unit 1, as required by Technical Specifications at 0948 hours.

Unit 2

"Conditions and activities associated with the Control Room AC and CREV systems apply to Unit 2 as well as Unit 1.

Reporting Requirements Met by this Notification

"10 CFR 50.72(b)(2)(1), the initiation of any nuclear plant shutdown required by the plant's Technical Specifications, applies to Unit 1.

"10 CFR 50.72(b)(3)(v)(D), a condition that, at the time of discovery, could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident (i.e., Control Room AC and CREV), applies to both Units 1 and 2.

"10 CFR 50.73(a)(i), invalid actuation of general containment isolation signals affecting containment isolation valves in more than one system, applies to Unit 1.

INITIAL SAFETY SIGNIFICANCE EVALUATION

"Currently Unit 2 is operating at steady state with Unit 1 being shut down. Specified systems actuated as designed. No adverse impact to the control room environment occurred during the period (i.e., one hour and 35 minutes) the affected ventilation system was inoperable. The other redundant emergency busses are operable. Prior to the event reactor coolant leakage level for Unit 1 was well within operating limits. The actions as required by the applicable Technical Specifications have been established.

CORRECTIVE ACTIONS

"Activities are currently under way to determine the cause of the E1 power loss and restore electrical power to Emergency Bus E1. Causes and actions to preclude recurrence will be addressed in accordance with the corrective action program and provided to the NRC in the associated licensee event report."

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41693
Rep Org: SHORE MEMORIAL HOSPITAL
Licensee: SHORE MEMORIAL HOSPITAL
Region: 1
City: SOMMERS POINT State: NJ
County:
License #: 29-11642-01
Agreement: N
Docket:
NRC Notified By: JOHNATHAN LAW
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/12/2005
Notification Time: 14:33 [ET]
Event Date: 05/11/2005
Event Time: [EDT]
Last Update Date: 05/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN KINNEMAN (R1)
RICHARD CORREIA (NMSS)

Event Text

MEDICAL EVENT - ACTUAL DOSE GREATER THAN PRESCRIBED DOSE

On 05/11/05, a patient in the hospital was scheduled to receive an I-131 dose of 12 millicuries to the thyroid. Due to an error by the nuclear medical technician, a dose of 14.8 millicuries of I-131 was measured and delivered. There were two doses for different patients being measured in the lab at the time and the prescribing physician typically would write nuclear medicine directives with a range, such as 12-14 millicuries. In this specific instance, the physician wrote the directive for exactly 12 millicuries. The physician stated that there would be no unintended damage to the patient. The hospital RSO stated that the prescribing physician would be notifying the patient. The RSO intends to reinforce following proper lab procedures and exercising caution when working with multiple doses to all physicians and lab personnel.

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