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Event Notification Report for June 13, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/10/2005 - 06/13/2005

** EVENT NUMBERS **


41749 41756 41757 41761 41762 41763 41765 41766

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General Information or Other Event Number: 41749
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MIAMI CHILDREN'S HOSPITAL
Region: 1
City: MIAMI State: FL
County: MIAMI-DADE
License #: 993-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/07/2005
Notification Time: 07:37 [ET]
Event Date: 06/06/2005
Event Time: [EDT]
Last Update Date: 06/07/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
TOM ESSIG (NMSS)

Event Text

FLORIDA AGREEMENT STATE REPORT - LOST AM-241 SOURCE

The following information was obtained from the State of Florida Bureau of Radiation Control via e-mail:

"Searle marker containing Am-241 source was reported missing from Children's Hospital Miami. Device was bought in early 1980's. This source is in a 'storage only' mode and was last seen during the May 2005 inventory. Florida is investigating."

The device description is a Searle marker, manufacturer and model unknown, serial number ACM-24, containing 14 milliCuries of Am-241.

Florida Incident Number FL05-088

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General Information or Other Event Number: 41756
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF FLORIDA SHANDS HOSPITAL
Region: 1
City: GAINSVILLE State: FL
County:
License #: 0031-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: BILL GOTT
Notification Date: 06/08/2005
Notification Time: 08:08 [ET]
Event Date: 05/25/2005
Event Time: [EDT]
Last Update Date: 06/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT

The State provided the following information via email:

"The patient was to receive 2 GigaBecquerel (GBq) (Yttrium-90) from siraspheres. Backpressure from the liver catheter popped the tubing off the 3-way stopcock; approximately 25% of the material was spilled before the tubing could be re-attached. A lower flow rate was used and no further problems were encountered. The spill was contained in the case around the stopcock. Patient received approximately 75% of the material/intended dose. The licensee will send a letter explaining the event. Determination of whether this qualifies as a medical event is the reason for the late NRC notification. Florida continues to investigate.

Florida event number: FL05-086

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General Information or Other Event Number: 41757
Rep Org: COLORADO DEPT OF HEALTH
Licensee: MARTEK BIOSCIENCES
Region: 4
City: BOULDER State: CO
County:
License #: 1080-01
Agreement: Y
Docket:
NRC Notified By: THOMAS PENTACOST
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/08/2005
Notification Time: 12:00 [ET]
Event Date: 06/03/2005
Event Time: [MDT]
Last Update Date: 06/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
RICHARD CORREIA (NMSS)

Event Text

COLORADO AGREEMENT STATE REPORT - INSTRUMENT SOURCE FAILURE AND SOURCE MATERIAL PLACED IN UNCONTROLLED STORAGE LOCATION

The State provided the following information via facsimile:

"On Monday, June 6, 2005, the Department received a call from the RSO for Martek Biosciences Boulder. He was reporting an incident that occurred at his facility on Friday, June 3, 2005.

"Martek Biosciences is a small research laboratory authorized to used milliCurie quantities of P-32, C-14, and H-3. Martek has a Beckman model 3801 liquid scintillation counter. The counter contains an internal 30 microCurie Cs-137 calibration source.

"The licensee's RSO reported that the liquid scintillation counter had been producing unusual results and a request for service was made to Beckman. A Beckman serviceman arrived at the facility on Friday to replace the 30 microCurie Cs-137 source. He came without survey equipment and did not have a lab coat. On disassembly of the device for source removal and replacement, it was determined that the source had disintegrated. The licensee RSO surveyed his facility and found contamination on the floor and the lab coat he had loaned to the Beckman serviceman. He decontaminated the areas where he found contamination.

"The Department contacted the Beckman serviceman by phone to discuss the incident. He indicated that the remains of the source and some of the contaminated lead shielding had been packaged and removed from the facility. This package was being stored in a rented storage facility pending return to Beckman. The Beckman serviceman did not know the exact address of the storage facility. At the time of the phone conversation, the Beckman serviceman was on vacation and was heading out of state. He was confident that there was no concern for contamination of the package or himself due to the surveys conducted by the licensee RSO.

"The Department contacted Beckman to obtain additional information on the 3801 liquid scintillation counter. He indicated that this device is generally licensed and is equivalent to the model 5801. The Beckman representative provided a copy of his California license and a copy of the request to amend the device registry sheet for the liquid scintillation counter. Apparently, Beckman is aware of other source failures for the liquid scintillation counter and has asked for a limited operational life of the source. The Beckman representative was not able to provide the actual address for the storage facility and he could not provide the names of any other service representatives in Colorado who might have access to the storage shed. He indicated that he would provide that information the next day.

"Tuesday, June 7, 2005: In phone messages from the Beckman representative the Department received the address of the storage facility and name of the regional service manager for Beckman.

"Wednesday, June 8, 2005: The Department received a call from the Beckman service manager. He indicated that there are two service representatives who have the key to the storage shed. The two Colorado service representatives are the only persons with the keys to the storage shed. One of the Beckman service representatives is out of state and a second is currently in Albuquerque, NM.

"The Beckman service manager indicated that the Beckman serviceman should not have removed the source from the Martek facility. He also indicated that the shed did not contain any other sources and that it was only used for the storage of parts. One of the Beckman service representative is expected to return to Denver on Thursday morning. He will open the shed for inspection by the Department.

"Additional data to be provided to complete this report pending the inspection at Martek and the storage facility."

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General Information or Other Event Number: 41761
Rep Org: AMETEK SOLID STATE CONTROLS
Licensee: AMETEK SOLID STATE CONTROLS
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB GEORGE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/10/2005
Notification Time: 09:07 [ET]
Event Date: 06/07/2005
Event Time: [EDT]
Last Update Date: 06/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JULIO LARA (R3)
O.TABATABAI (E-MAIL) (NRR)
J. FOSTER (E-MAIL) (NRR)

Event Text

PART 21 REPORT INVOLVING A POTENTIAL FOR PREMATURE FAILURE OF CONTROL ROD INSTRUMENTATION POWER SUPPLY

Ametek Solid State Controls produces AC-DC power supplies that are used at several nuclear power plants. Ametek states that its Series AC-DC power supplies may have a problem with premature failure. The specific Model Numbers affected are as follows:

85-RP1510-00
85-RP4804-00
85-RP4808-00
85-RP DUAL-4807\1

Ametek states that an intermittent loss of continuity in a magnet wire connector may cause overheating in a lug and transformer which could eventually result in a premature failure of the power supply ( within approximately two years of initial service). The problem was discovered during testing of a power supplies by Ametek. No nuclear power plants have reported any problems with the power supplies.

Ametek states that its records indicate that these power supplies were supplied to Braidwood, Byron, and DC Cook.

Ametek believes that the power supplies are used for control rod instrumentation. A total of 33 power supplies have been sold but Ametek believes that most of these are not in service. Ametek recommends that these power supplies either be returned to Ametek for rework or that the affected sites request a service by an Ametek representative onsite.

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Power Reactor Event Number: 41762
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: TIM BUCHAL
HQ OPS Officer: BILL GOTT
Notification Date: 06/10/2005
Notification Time: 09:55 [ET]
Event Date: 06/10/2005
Event Time: 09:24 [EDT]
Last Update Date: 06/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
TODD JACKSON (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 100 Power Operation 0 Hot Standby

Event Text

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.

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Hospital Event Number: 41763
Rep Org: EDWARD W. SPARROW REGIONAL CENTER
Licensee: EDWARD W. SPARROW REGIONAL CENTER
Region: 3
City: LANSING State: MI
County:
License #: 21-01430-01
Agreement: N
Docket:
NRC Notified By: TRACY MAUDRIE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/10/2005
Notification Time: 14:07 [ET]
Event Date: 06/10/2005
Event Time: [EDT]
Last Update Date: 06/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
TOM ESSIG (NMSS)

Event Text

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."

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Power Reactor Event Number: 41765
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: DANIEL W. DEAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/10/2005
Notification Time: 20:55 [ET]
Event Date: 06/10/2005
Event Time: 13:51 [EDT]
Last Update Date: 06/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
TODD JACKSON (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

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 561F, 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.

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Power Reactor Event Number: 41766
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RON RUSTICK
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/11/2005
Notification Time: 15:30 [ET]
Event Date: 06/11/2005
Event Time: 13:10 [CDT]
Last Update Date: 06/11/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation
2 N Y 95 Power Operation 95 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

"At 1310 on June 11, 2005 Quad Cities Station was notified that the calculated post-LOCA switchyard voltage is below the minimum acceptable value required to ensure offsite power will remain available following a design basis accident. The appropriate Technical Specification Actions have been taken for both Units. The ability of the Emergency Diesel Generators to fulfill their design function is not affected by this condition. This event is being reported in accordance with 10CFR50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"Actual Switchyard voltage at the time of this notification is 356 Kv. The required minimum post-accident switchyard voltage for current conditions is 352.9 Kv for U-1 and 351 Kv for U-2, while the projected post-accident voltage which prompted this notification is 347.4 Kv.

"This notification is similar to the condition reported on March 24, 2005 (EN #41524), April 4, 2005 (EN #41562) and April 11, 2005 (EN #41587)."

Both Units entered T.S. 3.8.1 which requires verification of EDG operability (completed) and continued monitoring of line voltages with restoration of at least one offsite-line to the required minimum within 24-hours.

The licensee informed the NRC Resident Inspector.

* * * UPDATE 1610 EDT ON 6/11/05 FROM RON RUSTICK TO S. SANDIN * * *

At 1505 CDT both Units exited T.S. 3.8.1 when projected post-accident line voltage reached 353.8 kV. Notified R3DO (Lara).

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Friday, March 30, 2012