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Event Notification Report for July 13, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/12/2005 - 07/13/2005

** EVENT NUMBERS **


41767 41827 41836

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 41767
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-000712-06
Agreement: Y
Docket:
NRC Notified By: JEFF HAVENNER
HQ OPS Officer: BILL GOTT
Notification Date: 06/13/2005
Notification Time: 09:39 [ET]
Event Date: 06/10/2005
Event Time: [CDT]
Last Update Date: 07/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
TODD JACKSON (R1)
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)
TAS (email) ()

Event Text

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).

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General Information or Other Event Number: 41827
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS - WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: PAUL J. CALEB
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/08/2005
Notification Time: 15:45 [ET]
Event Date: 07/06/2005
Event Time: [CDT]
Last Update Date: 07/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3)
GARY JANOSKO (NMSS)

Event Text

WISCONSIN AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via email:

"On July 6, 2005, a brachytherapy procedure to treat a bile duct carcinoma using 22 iridium-192 sources totaling 53.9 milliCuries in a ribbon with spacing of 0.5 centimeter between each source was performed. The ribbon was routed through the nasal gastric system to the treatment site (bile duct). A radiograph was taken of the source placement in the bile duct before releasing the patient to a hospital room. The radiograph verified the sources to be in the prescribed location.

"On July 7, 2005, a verification image was taken at 0850 and found that the radioactive sources had moved approximately 5 centimeters toward the gastrointestinal tract. The location of the sources was outside of the intended site. An attempt to reposition the source ribbon by the authorized user was unsuccessful. The authorized user amended the written directive and removed the sources at approximately 1300. The sources were placed in storage.

"The licensee notified the department on July 8, 2005. The Wisconsin Radiation Protection Section will investigate the medical event."

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Power Reactor Event Number: 41836
Facility: POINT BEACH
Region: 3 State: WI
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JACK GADZALA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/12/2005
Notification Time: 16:42 [ET]
Event Date: 05/17/2005
Event Time: 00:42 [CDT]
Last Update Date: 07/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
PATTY PELKE (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

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.

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