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Event Notification Report for May 25, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/24/2005 - 05/25/2005

** EVENT NUMBERS **


41718 41719 41721 41726 41728

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General Information or Other Event Number: 41718
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERN MEDICAL CENTER
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/19/2005
Notification Time: 12:34 [ET]
Event Date: 05/18/2005
Event Time: [CDT]
Last Update Date: 05/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
RICHARD CORREIA (NMSS)

Event Text

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION WITH BROKEN PD-103 SEED (1.7 MILLICURIES)

The State provided the following information via facsimile:

"On May 18, 2005, during a prostate brachytherapy procedure, a pre-loaded cartridge containing Pd-103 seeds jammed in a Mick applicator. The jam occurred during a cartridge change, and when the authorized user attempted to remove the stuck cartridge from the applicator, the end of one seed was sheared off. After the authorized user reattached the applicator to the needle, he determined a seed had broken. Pieces of the broken seed were found in a needle and in the cartridge. This needle was removed from the patient and a new needle was inserted. The cartridge was removed from the Mick applicator and no contamination was detected on the applicator itself. The patient treatment was completed without further incident. Contamination was detected on several pieces of equipment as well as on the floor of the operating room. All personnel were surveyed before they were permitted to leave the operating room. Access to the operating room was restricted until the room was decontaminated by the radiation safety officer and the medical physicist. The seed fragments and cartridge were placed in a lead pig and secured in the radioactive waste storage area, where they will be held for decay-in-storage. The activity of the broken Pd-103 seed was 1.7 mCi.

"The licensee notified DHFS on May 18, 2005. The Wisconsin Radiation Protection Section will investigate this event."

The State event report number is 26.

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General Information or Other Event Number: 41719
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: WESTERN MEDICAL CENTER
Region: 4
City: SANTA ANA State: CA
County: ORANGE
License #: 0231-30
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/19/2005
Notification Time: 13:42 [ET]
Event Date: 03/21/2005
Event Time: [PDT]
Last Update Date: 05/20/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
RICHARD CORREIA (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST 12 UNUSED I-125 THERAPY SEEDS TOTALING 4.8 MILLICURIES

The State provided the following information via facsimile:

"On March 21, 2005, the licensee, Western Medical Center, shipped 12 unused I-125 therapy seeds of 0.4 mCi/seed (4.8 mCi total) to GE Healthcare via Fed-Ex. On April 19, 2005, Fed-Ex notified the licensee by letter that the shipment had apparently been lost in transit. The shipment has not yet been located. [The State] will update NMED as more information becomes available."

The Fed Ex shipment information will be forthcoming from the State as they receive it.

The State report number is 051905.

* * * UPDATE ON 05/19/05 AT 14:58 EDT FROM HAMRICK TO KNOKE * * *

"The number of seeds should be 14 at 0.391 mCi/seed for a total of 5.474 mCi (as of 2/26/05; activity is now about 2.12 mCi).

"The shipment left the licensee's facility on 3/21/05 via FedEx to GE Healthcare in Arlington, IL.

"On 3/24/05, the licensee was first notified by GE Healthcare that they had received the package, but that it did not contain the seeds, but some type of brackets. The licensee notified FedEx, who initiated a tracking operation. On 4/19/05, the licensee received written notice from FedEx that the package still had not been found. The records internal to FedEx indicated the package had apparently been damaged during the shipment, and FedEx speculates the shipping papers were switched with the other shipment. [The State] will provide additional information at the close of the investigation into this matter."

Notifications were given to R4DO (Nease) and NMSS (Moore & Correia)

* * * UPDATE ON 05/20/05 AT 15:30 EDT FROM THE STATE ( HAMRICK) VIA E-MAIL * * *

"This is a follow up to the reported lost shipment of I-125 seeds, which are now found. The seeds were delivered to the shippee, GE Healthcare, on March 24, 2005. The contact from GE Healthcare to the licensee in California indicated they had received an unexpected package from them (containing some type of brackets), but was not intended to indicate they had not received the package containing the seeds. The California licensee interpreted the information from GE Healthcare to mean that the seeds they had shipped had not arrived, however this apparently was not the case. Receipts of non-radioactive and radioactive shipments are handled separately at GE Healthcare, so the call to the California licensee was only to report the receipt of the unexpected non-radioactive shipment.

Thus, GE Healthcare received the seeds on March 24, 2005, and knew they had received them on that date. There was simply a misunderstanding in the communication with the California licensee."

Notifications were given to R4DO (Nease) and NMSS (Correia)

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General Information or Other Event Number: 41721
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: KELLOGG USA INC
Region: 4
City: OMAHA State: NE
County:
License #: GL0552
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/20/2005
Notification Time: 11:20 [ET]
Event Date: 03/31/2005
Event Time: [CDT]
Last Update Date: 05/20/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
RICHARD CORREIA (NMSS)

Event Text

THE LICENSEE REPORTED LOST/STOLEN TRITIUM SOURCE EXIT LIGHTS

"Kellogg's did an extensive inventory of the exit signs at their facility in the past couple months. They determined that nine exit signs are missing, that were listed on a previous inventory. They believe that the signs are now in the local landfill because a number of remodeling projects have been done at Kellogg's. They have communicated with staff and contractors the importance of maintaining control of these devices. Kellogg's is also looking into alternative methods for providing exit signage".

Type of sign - Radioluminescent sign

Manufacturer - SRB Technologies Inc

Model # BXU20SW

Serial Numbers - 217791, 217808, 217845, 217897, 217903, 217949, 217950, 217951, 218307

Each sign measured 17.51 Ci tritium

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Power Reactor Event Number: 41726
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PHIL CHASE
HQ OPS Officer: BILL GOTT
Notification Date: 05/24/2005
Notification Time: 15:33 [ET]
Event Date: 05/24/2005
Event Time: 09:14 [EDT]
Last Update Date: 05/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
CLIFFORD ANDERSON (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41728
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: WESLEY HELD
Notification Date: 05/24/2005
Notification Time: 20:00 [ET]
Event Date: 05/24/2005
Event Time: 13:50 [EDT]
Last Update Date: 05/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID AYRES (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION INVOLVING EMERGENCY BACKUP POWER GENERATORS

"Event: On 5-19-05, Oconee discovered that an electrical contactor had failed at Keowee Hydro Station. This contactor normally can provide auxiliary power from one Keowee Hydro Unit (KHU) to cooling fans on the Keowee Main Transformer, which is part of the Overhead power path (one train of emergency power to the three Oconee units). At the time, power to the cooling fans was being provided by an alternate power source. A problem report (PIP) was written and an Operability Assessment concluded that the Overhead power path was fully operable. On 5-24-05 at 1350 hours, it was recognized that the alternate power source supplying the cooling fans was supplied from the auxiliary power bus associated with the KHU then aligned to the Underground power path (the redundant train of emergency power to the three Oconee units).

"It was recognized that this alignment presented a single failure vulnerability in that loss of the auxiliary power bus for the KHU aligned to the Underground path could also result in loss of Main Transformer cooling on the Overhead power path. As a result, Operations declared entry at 1350 hours into Technical Specification (TS) 3.8.1 condition C for the Overhead power path being inoperable (a 72 hour allowed completion time). A review of available information indicates that the electrical contactor actually failed on or before 5-2-05. Therefore the period of vulnerability to this potential single failure was approximately 22 days. This condition is being reported as an unanalyzed condition per guidance in NUREG 1022 section 3.2.4.

"Initial Safety Significance: If the postulated single failure occurred during a design basis event, it is expected that, without credit for Operator intervention, both KHUs would fail, but the failure is not expected until a minimum of one hour after the loss of auxiliary power. During this time Operations would have been able to realign the KHU with auxiliary power to the Underground path and/or to have started and aligned a combustion turbine at Lee Steam Station. Therefore, the condition being reported is not expected to result in a loss of safety function.

"Corrective Action(s): The immediate corrective action was to realign the Keowee units to the opposite power paths. This aligned the KHU capable of supplying power to the Main Transformer cooling fans to the Overhead path. The KHU associated with the failed contactor was aligned to the Underground path. The TS condition was exited at 1540 hours when this realignment was complete."

The licensee notified the NRC Resident Inspector.

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