Event Notification Report for May 17, 2005

LOSS OF CONTROL OF RADIOGRAPHY CAMERA

A radiography crew had completed activities at a location at the Sun Refinery in Philadelphia Pennsylvania at approximately 1630 EDT on 5/17/05. The radiography camera used by the crew was an AEA Model 660B, containing a 32 Curie Ir-192 source (serial number B3762). The source was safely retracted and locked in its shielded position in the camera. The radiographer believed that the camera was in the possession of the assistant radiographer. The assistant radiographer believed the camera was in the possession of the radiographer. The camera was actually left unattended on a scaffolding at the Sun Refinery job site. At 2040 EDT on 5/17/05, Sun Refinery personnel discovered the camera while preparing to remove scaffolding at the job site. The licensee was immediately contacted and recovered the camera. The licensee stated that there is no indication that anyone had disturbed or worked in the vicinity of the camera while it was unattended.

OVEREXPOSURE DURING RADIOGRAPHY

A radiographer and his assistant were conducting a radiography exposure of a pipe weld. As the radiographer was picking up the crank handle to retract the source to the "safe shielded/locked" position, the radiographer was distracted when he heard someone yell "hey." The radiographer and his assistant investigated the sound on either side of the roped boundary. The radiographer left the survey meter back at the crank handle. Thinking the source was stowed, both approached the weld they were radiographing. They removed the source tube and collimator from the weld, and removed the film. The assistant walked back to the crank to place the film with the other exposed films and noticed the survey meter was pegged high. He immediately retracted the source to the "safe shielded/locked" position. Both men checked their pocket dosimeters and found them to be off scale.

Dose estimate calculations indicate that the RSO may have received up to 5.5 Rem and the assistant may have received up to 2.5 Rem. The film badges have been shipped via overnight express shipping for immediate processing and report.

Exposure Device: Amersham/Sentinel Model 660B S/N B-2790.
Source: AEA Technology Iridium-192, model 424-9, S/N 21852, 37.5 Curies.

FITNESS FOR DUTY

A non-licensed contract employee found a can of beer in his lunch box. The licensee's investigation determined that the introduction of alcohol into the Protected Area was not an intentional act. The contract employee's access was restored. The licensee notified the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

* * * UDATED ON 5/18/05 TO CORRECT UNIT 2 PLANT STATUS INFORMATION * * *

DAMAGED TROXLER MOISTURE DENSITY GAUGE

"On Tuesday, 5/17/05 at approximately 1530 hours, technician [DELETED] of our Crozet (Charlottesville), VA branch was performing a field density measurement with a Troxler Model 3411 moisture/density gauge (SN 5278) in an area of pipe backfill at the GEI project site in Charlottesville, Virginia. When finished with the test, he exited the trench and placed the Troxler nuclear density gauge at the corner of a fence line opposite the sediment pond behind him and was watching mixed fill being placed as backfill and compacted in the trench. A sheepsfoot roller backed up onto the bank near the fence because a rubber-tired roller was coming down the hill on the access road. [The roller driver] backed over and then pulled away from the gauge when he realized what he had done.

"The technician immediately conducted a visual examination and noted that the source rod base (with the Cesium 137 source) had remained inside the gauge, but the source rod itself was bent and the depth gauge rod broken. The site was roped off and the technician called the Crozet office RSO informing him of the incident. A survey meter was sent out to the site to check the gauge and area for radiation levels. Normal readings were noted with the source still in the rod in the gauge. The lock was still on the trigger; but, with the depth rod broken, the source rod could be extracted from the upper side of the gauge. Duct tape was used to wrap the bent source rod to prevent the rod coming out of the gauge during transit. The Corporate RSO was called and informed of the incident.

"The gauge was transported back to the Crozet nuclear storage room and marked out of service until repairs are made.

"Despite the fact that the technician was in close proximity to the gauge it was not in his direct line of sight or control. "

The sources were Cs-137 (8.4 milliCuries on 2/10/78) and Am/Be (40 milliCuries on 2/14/78). The RSO intends to transport the gauge to Troxler for disposal.

CALIFORNIA AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGE

A Troxler moisture density gauge was stolen from the back of a pickup truck parked at a licensee employee's residence sometime between 2000 PDT 05/17/05 and 0550 PDT on 05/18/05. The gauge was in its transportation case and the case was strapped down (vice chained) in the back of the truck. The employee delayed notification to the licensee until 5/26/05. The licensee notified the State at 1100 PDT on 05/27/05. The Los Angeles Police Department was notified and the licensee is offering a reward for return of the gauge. The licensee also notified the gauge manufacturer's local representative.

The Troxler was a model 3440, Serial Number 29792, with an 8 milliCuries Cs-137 and a 44 milliCuries Am-241/Be source.

PART 21 REPORT - MALFUNCTION OF NOVOSTE INTRAVASCULAR BRACHYTHERAPY BETA-CATH SYSTEM TRANSFER DEVICE

During a medical procedure on a patient, two individual coronary artery locations were being irradiated with Sr-90 (2.05 GBq, serial # ZA-494). The device being used, Novoste Intravascular Brachytherapy Beta-Cath System Transfer (S/N# 90556), hereinafter called "Device", failed to work properly.

The licensee noticed the source did not retract into the Device. At this point the licensee pulled the entire catheter out of the patient, and within one minute was able to return the sources safely into the Device. It was assumed the problem was with the catheter and it's connection to the Device.

The licensee continued to the next location on the patient. Upon attempting to return the source, the licensee noticed the sources were not moving from the patient. Within 5-10 seconds, the licensee pulled the entire catheter from the patient, and then placed the entire system into the "bailout" box for proper shielding from beta radiation. The next day the licensee called Novoste and explained the events. Novoste determined it was a faulty Device and sent the licensee a replacement.

On May 19, 2005 the replacement arrived and the faulty device was sent back to the company.

INVALID SYSTEM ACTUATION - AUXILIARY FEEDWATER PUMP STARTED DURING SURVEILLANCE

"Per 10 CFR 50.73(a)(1), this telephone notification is made under 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation. The train D steam-driven Auxiliary Feedwater Pump was inadvertently started while performing post-maintenance testing on another component.

"The test was conducted using applicable steps in a surveillance procedure for the solid state protection system. A procedure step for isolating the auxiliary feedwater pump steam turbine was incorrectly performed so that the steam turbine was not isolated, as intended, and started when the test actuation signal was initiated. The steam-driven turbine and pump functioned successfully as a result of the invalid signal.

"The signal was determined to be invalid in that it was not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the safety function of the system. The pump start was not an intentional manual initiation. The invalid actuation is reportable in that it did not occur while the system was properly removed from service and did not occur after the safety function had already been completed"

The licensee notified the NRC Resident Inspector.

INVALID ACTUATION OF THE "B" RESIDUAL HEAT REMOVAL (RHR) PUMP.

"July 12, 2005 Telephone Report in Accordance with 10 CFR 50.73(a)(2)(iv)(A) Invalid Actuation of the "B" Residual Heat Removal (RHR) Pump.

"SPECIFIC TRAINS AND SYSTEMS THAT WERE ACTUATED

"During a maintenance activity involving replacement of a safeguards relay, "B" Train RHR Pump 2P-10B was started inadvertently. The RHR pump is part of the emergency core cooling system (ECCS).

"DESCRIPTION OF WHETHER EACH TRAIN ACTUATION WAS COMPLETE OR PARTIAL

"On May 17, 2005, Unit 2 was in a shutdown condition (MODE 6) for routine refueling outage. At approximately 0042, Unit 2 RHR Pump 2P-10B was inadvertently started. Since RHR Pump 2P-10A had already been running for normal shutdown decay heat removal, the inadvertent start of the B RHR pump resulted in both RHR pumps running. Operations observed an increase in RHR flow but initially attributed the flow change to the RHR Heat Exchanger (HX) Bypass Flow Control Valve, which was operating in automatic.

"At the time of the inadvertent pump start, technicians were landing a wire as part of performance of a procedure to replace a safeguards relay. During this activity, the technicians heard a breaker close in the 480 VAC safeguards bus. Primary Plant Computer System (PPCS) computer data indicates that this breaker closure corresponded to the 2P-10B RHR Pump start. The technicians were not aware that this breaker closure was caused by their activity. The inadvertent RHR pump start was identified at 0525.

"The investigation of this event determined that a current path was created during the relay replacement, which caused starting of 2P-10B. No other ECCS components were actuated during this event. A review of the activity could not determine the specific wire that was lifted landed to cause the pump start. Rather several wire combinations were noted, each of which could have caused what is commonly referred to as a 'sneak' current path. These current paths can result in the RHR pump starting circuit being energized.

"DESCRIPTION OF WHETHER OR NOT THE SYSTEM STARTED AND FUNCTIONED SUCCESSFULLY

"This event was not safety significant. The RHR pump started and functioned successfully. The RHR pump was the only ECCS component in the system affected. Since the pump was aligned in the standby mode to provide normal decay heat removal cooling, its start appropriately resulted in additional cooling flow being pumped to the reactor core. The RHR pump was secured and returned to standby mode following discovery of this condition.

"As corrective action, a procedure change was initiated to add a precaution statement to ensure the associated safeguards relay cabinet is deenergized to the extent possible prior to similar maintenance activities to prevent inadvertent safeguards actuations. This item is documented in the PBNP corrective action process system (CAP 064616)."


The NRC Resident Inspector was notified of this event report by the licensee.

LOST M88 ACADA CHEMICAL DETECTOR

The following information was discussed with the U.S. Army (Gizicki), and faxed to HOC:

"On 23 Dec 04 a Stryker vehicle (sn CV007-01) containing one ea M88 ACADA detector (NSN 6665-01-438-3673 with possible s/n Y14-D-19158 ) was shipped from Ft. Lewis, WA to General Dynamics Land System (GSLS) in Sterling Hts, MI. The M88 ACADA is hard mounted in the Stryker vehicle. The M88 ACADA contains 30 millicuries of Ni-63 in sealed source form. The particular vehicle with the M88 was to be retrofitted and tested for shipment to Iraq.

"The stryker vehicle was received at GDLS Sterling Hts. on 28 Feb 2005. The Stryker vehicle with the M88 was driven from GDLS, Sterling Hts, MI to GDLS Shelby, MI on 28 Feb 05 in order to be equipped with other components and inspected. On 25 March 2005 the Stryker was shipped to Fort Huachuca, AZ where the vehicle was to be further tested. The Stryker vehicle was shipped from EPG Ft. Huachuca, AZ to Yuma Proving Grounds, AZ on 25 March 2005 for additional testing. The vehicle was then shipped from Yuma PG to Ft. Lewis, WA where it was received on 4 April 05.

"On 13 April 05 the M88 ACADA was discovered missing at Ft. Lewis WA. The Licensee was notified on 17 May 05 of the missing M88 detector. Between May 17 and 11 July 2005 an extensive search for the missing M88 occurred at GDLS (Sterling Hts., MI, Shelby MI and Auburn, WA sites), Yuma PG, AZ, Ft. Huachuca, AZ, and Ft. Lewis, WA. The missing M88 could not be found and presumed lost or stolen. The Army is currently conducting their own investigation of the lost device through the Army CID office."