Event Notification Report for June 10, 2005

STOLEN M-22 AUTOMATIC CHEMICAL DETECTORS

Five M-22 Automatic Chemical Detectors were stolen from the NBC Room (locked secure storage) at Fort Campbell, KY. The theft was discovered on June 10, 2005. Each device contains 20 milliCuries of Nickel - 63. The Army Criminal Investigative Service and the Fort Campbell Military police are conducting an investigation. The Device serial number/source serial numbers are: Y14M0989/Y14C0989, Y14M08283/Y14D08283, Y14M08429/Y14D08429, Y14M08075/Y14D08075, Y14M08548/Y14D08548.

The licensee notified R3 (D. Wiedeman)

* * * UPDATE AT 10:00 AM ON 7/8/05 FROM T. GIZICKI TO P. SNYDER * * *

U. S. Army TACOM Command Rock Island, IL called to update the event. It was discovered that the detectors reported as stolen on 10 June 2005 were not stolen but inappropriately removed from a storage room. The Army found the material in another room on 20 June 2005.

Notified R3 (L. Kozak), R1 (G. Bowman), and NMSS EO (J. Hickey)

*** RETRACTION AT 09:10 ON 07/12/05 FROM J. HAVENNER TO J. KNOKE ***

U. S. Army TACOM Command Rock Island, IL (Havenner) stated that upon further investigation of the incident it was concluded the radioactive material was never lost and no criminal act was involved, therefore the Event Notification is retracted.

Notified R1 (Henderson), R3 (Pelke), and NMSS EO (Essig).

LOST SEALED TRITIUM SOURCE

The licensee reported they discovered one missing gaseous tritium light source from a total of 892 at the site (550 had previously been shipped to their Mexico plant). The missing light source, which measured 27 millicuries, was to be part of a shipment of 700 to be returned to the manufacturer, SRB Technologies, since they are being replaced by LED light sources. These lights, which are mounted in blocks of Lucite, are used in the production of photomultipliers which are used in equipment produced for the medical industry.

MANUAL REACTOR TRIP DUE TO SERVICE WATER LEAK IN EXCITER CABINET

At 0924 on 06/10/05, Indian Point 3 was manually tripped due to a service water leak in the main generator exciter. All control rods fully inserted. Plant response was as designed. Unit 3 is stable in Mode 3. Investigation is ongoing. Unit 2 [was not affected and] remains at 100% power."

The steam generators are discharging steam to the main condenser to remove decay heat.

The licensee notified the NRC resident inspector.

FRACTIONAL DOSE DELIVERED DIFFERED FROM THE PRESCRIBED DOSE

"A hyperthyroid therapy patient received one of the intended two Nal-131 capsules sent by the radio pharmacy for the therapy. The patient received 10.2 mCi in one capsule instead of the intended 20.6 mCi in two capsules. Both capsules were received in one plastic vial inside of a lead shield. The entire vial was assayed and the assay of 20.6 mCi was within 10% of the prescribed dose of 20.0 mCi. The technologist failed to notice that there were two capsules in the vial because a desiccant inside the vial blocked the view of the second capsule and prevented the second capsule from leaving the vial. Normally, hyperthyroid therapy doses are received in one capsule. Therefore, the technologist was not expecting a second capsule.

"The radio pharmacy discovered the second capsule when the package was returned to the pharmacy the next day, June 10, 2005. They called the Nuclear Medicine department at 8:30 am on June 10, 2005. The prescribing physician was called and he requested that the patient receive the second capsule. The patient returned to the Nuclear Medicine department at 10:00 am on June 10, 2005 and received the second capsule, which assayed at 9.74 mCi at that time. The total dose the patient received was 19.94 mCi.

"Why the event occurred: Hyperthyroid therapy doses are normally received in one capsule. The technologist was not expecting a second capsule. The desiccant placed in the vial by the radio pharmacy obscured the second capsule from the technologist's sight. The desiccant also prevented the second capsule from coming out of the vial when the first capsule came out of the vial.

"Effect on the patient: The prescribing physician does not believe this event will have a negative effect on the patient as she received the remainder of the dose within 24 hours.

"To prevent recurrence of this action the licensee will assay all applicable capsule vials after the patient has received their dose, but before the patient leaves the department. This will ensure that no capsules remain in the vial.

"Certification that the licensee notified the individual: The patient was notified by telephone on June 10, 2005 and the patient returned to the hospital to receive the second capsule of 9.74 mCi Nal-131."

* * * RETRACTION ON 06/13/05 AT 1720 BY MARTY JOHNSON TO CHAUNCEY GOULD * * *

Based on a re-reading of Part 35 and a conversation with Region 3 Materials Inspection and Materials Licensing Branches it was determined that this is not a medical event and should be retracted.

Notified Reg 3 RDO (Patrick Louden) and NMSS (Patricia Holahan)


* * * UNRETRACTION ON 06/22/05 AT 0945 EDT BY MARTY JOHNSON TO HOWIE CROUCH * * *

Through discussions with Region 3, the licensee was informed that the NRC has determined this event is, in fact, a medical event therefore should not be retracted.

Notified R3DO (Burgess) and NMSS (Michelle Burgess).

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The State of Florida reported that a Troxler gauge, Model # 3411B, Serial # 8280, was found in the trunk of a vehicle in which the occupants were being investigated for attempted robbery. The incident location was at a Wal-Mart store in Lake City, Florida. The gauge, which was impounded and placed in Florida's DOT District Office, was found undamaged. The Soil Moisture Density Gauge will remain in a licensed storage area until picked up by the owner. The isotopes used in the gauge are 10 mCi of Cs-137 and 40 mCi of Am-241/Be.

Incident Number FL05-093

LOSS OF OFFSITE BUS DUE TO A LIGHTING STRIKE WITH ACTUATION OF EMERGENCY DIESEL GENERATOR

"At 1351 hours, a lightning strike resulted in a loss of Offsite Circuit #751. Loss of Circuit #751 resulted in a momentary loss of Bus 16 until its re-energization by Emergency Diesel Generator B. Safeguards Bus 17 remained de-energized as its Supply Breaker from Emergency Diesel Generator B failed to close as expected.

"Additionally, while responding per applicable Abnormal Procedures, Service Water Pump A was manually started. Service Water Pump A tripped approximately 2 minutes later with a report of smoke and sparks emanating from the Service Water Pump A motor. Due to the loss of Safeguards Bus 17 and Service Water Pump A, the plant ran on Service Water Pump C only. Emergency Diesel Generator B was transferred to alternate cooling during the event.

"The plant remained stable in Mode 1, 100% power, Tavg at 561°F, and RCS pressure at 2235 psig during the entire event. Emergency Buses 16 and 17 are now powered by Offsite Circuit #767. Service Water Pumps B and C are now operating. Offsite Circuit #751 has been restored to operable status.

"Emergency Diesel Generator B is secure and remains inoperable per Technical Specifications while work continues on the Emergency Diesel Generator B Supply Breaker to Bus 17.

"Service Water Pump A remains inoperable while work continues on it's motor."

Licensee stated that they are in a 7 day LCO for restoring the equipment.

The licensee notified the NRC Resident Inspector.