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Event Notification Report for August 15, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/12/2005 - 08/15/2005

** EVENT NUMBERS **


41799 41905 41908 41913 41914 41915 41916 41917 41918

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41799
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MIKE McDONNELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/26/2005
Notification Time: 15:30 [ET]
Event Date: 06/26/2005
Event Time: 10:55 [EDT]
Last Update Date: 08/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES DWYER (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

EMERGENCY DIESEL GENERATORS INOPERABLE DUE TO HIGH AMBIENT TEMPERATURE

"The report is being made in accordance with 10 CFR 50.72(b)(3) due to both Emergency Diesel Generators (EDGs) being declared inoperable. [This is a 24-hour LCO.] The EDGs were declared inoperable due to indicated outside air temperature exceeding the established operability limit of 95F for two short periods of time. Indicated outside air temperature went above 95F during the following time frames: 10:55 to 11:00 and 12:15 to 12:20. Indicated outside air temperature subsequently decreased to less than 95F following these spikes. Both EDGs are currently operable. Outside ambient temperatures are continuing to be monitored. Offsite power is available.

"Further evaluation of this event is ongoing."

The licensee notified the NRC Resident Inspector.

* * * EVENT RETRACTION FROM LICENSEE (NOYES) TO ABRAMOVITZ AT 12:06 ON 08/12/2005 * * *

"The initial report was made in accordance with 10 CFR 50.72(b)(3) due to both Emergency Diesel Generators (EDGs) being declared inoperable. The EDGs were declared inoperable due to indicated outside air temperature exceeding the established operability limit of 95F for short periods of time on 6/26/05. Outside indicated air temperature subsequently decreased to less than 95F following these short timeframes. Both EDGs were operable when the notification was made, and outside ambient temperatures continued to be monitored. Offsite power was available. Further evaluation of this event has been performed. The initial report used temperature indication that was conservative with respect to actual conditions. The evaluation determined that the air temperature outside the EDG Building was a maximum of 91 F on 6/26105. This evaluation was based on other temperature reading taken during the periods of interest. Additionally, further evaluation has determined that both EDGs were not inoperable even at the higher temperatures initially indicated. Therefore, the EDGs were not inoperable during the periods reported and event notification #41799 is retracted."

Notified the R1DO (Caruso).

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 41905
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: BILL GOTT
Notification Date: 08/09/2005
Notification Time: 15:57 [ET]
Event Date: 07/18/2005
Event Time: [EDT]
Last Update Date: 08/09/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
JOHN HICKEY (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"Treatment delivered to two (2) of seven (7) lesions on a patient on 18 July 2005, were discovered to be 50 percent less dose than that prescribed. (15 Gy (Grey) per lesion prescribed; two lesions received only 7.5 Gy each) This was discovered [on 3 August 2005], during an internal audit of treatments, conducted by medical physicist not originally involved with treatment. To date the investigation does not identify a problem with the equipment or the dose programs involved in planning. Initial indicators point to a potential communication problem between the original medical physicist and oncologist. At this time the investigation is pending due to the unavailability of the medical physicist due to vacation. Resumption of the investigation is to commence on or about 9 August 2005 when persons involved have returned from vacation."

RI Event Report ID: RI-05-003

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General Information or Other Event Number: 41908
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: PATRIOT ENGINEERING
Region: 3
City: DAYTON State: OH
County:
License #: OH31210580004
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/10/2005
Notification Time: 15:53 [ET]
Event Date: 08/01/2005
Event Time: 09:45 [EDT]
Last Update Date: 08/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
JOHN HICKEY (NMSS)
TAS (EMAIL) ()

Event Text

OHIO AGREEMENT STATE REPORT - STOLEN AND RECOVERED NUCLEAR GAUGE

The State provided the following information via email:

"At approximately 9:45 AM on Monday, 8/1/05, a Humbolt Model 5001, S/N 4634 portable gauge [10 milliCuries Cs-137 and 40 milliCuries Am-241] was stolen from a company vehicle while parked at a fast food restaurant in Dayton, Ohio. The gauge was discovered missing when the employee returned to the vehicle. The gauge was discovered in a roadside ditch about one mile from the restaurant approximately 45 minutes later by a line crew from a local power company. The gauge was intact with no apparent damage. The licensee's RSO responded to the scene and took area measurements which indicated that the integrity of the source had not been compromised. The gauge was taken back to the licensee's offices, where it was leak tested. A police report was filed. The Ohio Department of Health is inspecting the licensee to determine if proper security measures had been followed prior to the theft."

Ohio Report No. OH050003

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Power Reactor Event Number: 41913
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: BRAD EKLUND
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/12/2005
Notification Time: 03:26 [ET]
Event Date: 08/12/2005
Event Time: 00:19 [MST]
Last Update Date: 08/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
RUSSELL BYWATER (R4)
SUSAN FRANT (IRD)
CHRISTOPHER GRIMES (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation

Event Text

PLANT ENTERED LCO ACTION STATEMENT 3.8.1 TO BE IN MODE 5 DUE TO UNIT 1 "B" DIESEL GEN. BEING DECLARED INOPERABLE

"On August 12, 2005, at approximately 00:19 hours Mountain Standard Time (MST), Palo Verde Nuclear Generating Station (PVNGS) Unit 1 commenced a reactor shutdown required by Technical Specification 3.8.1.

"Limiting Condition for Operability (LCO) 3.8.1 requires two diesel generators (DGs) each capable of supplying one train of the onsite Class 1E AC Electrical Power Distribution System be available. On August 9, 2005, at approximately 04:20 MST, Unit 1 Diesel Generator 'B' failed to maintain the proper steady state output voltage (4080-4300 VAC) during monthly operability surveillance testing per '40ST-9DG02'. Diesel Generator 'B' was declared inoperable and the Unit entered LCO 3.8.1 action 'B'. An engineering action plan was initiated in an attempt to identify the cause of the generator output voltage fluctuation and correct the problem. To date, troubleshooting efforts have unable to isolate the problem. On August 12 at 0420 MST the 72 hour Completion Time associated with LCO 3.8.1 Action 'B' will expire and at 00:19 MST Unit 1 commenced a reactor shutdown in compliance with LCO 3.8.1 Action 'H'.

"The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public. The required offsite power sources are operable and the electrical grid is stable."

The NRC Resident Inspector will be notified.

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General Information or Other Event Number: 41914
Rep Org: DAIMLER - CHRYSLER
Licensee: DAIMLER - CHRYSLER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #:
Agreement: N
Docket:
NRC Notified By: JACK HARTWIG
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/10/2005
Notification Time: 18:18 [ET]
Event Date: 08/10/2005
Event Time: 12:00 [CST]
Last Update Date: 08/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
ROGER LANKSBURY (R3)
SCOTT FLANDERS (NMSS)

Event Text

GENERAL LICENSED SOURCE DAMAGED WHEN LEAD SHIELDING MELTED ON A NUCLEAR GAUGE

The RSO from a Daimler - Chrysler foundry reported that excessive heat inside the foundry had caused the lead shielding to partially melt. The device was a GN Technologies (now Thermo Electron Corp) model 5201 with source serial # GV8072 gauge serial # B3021. The gauge, which was on a foundry cuppola out of the area of any foot traffic, contained 100 millicuries of Cs-137. The radiation level on the top of the gauge measured 250 mr/hr at 1 ft from the source. The area near the gauge was roped off to isolate it from the public. They will shut the gauge off and the manufacturer's rep will remove it.

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Hospital Event Number: 41915
Rep Org: THOMAS JEFFERSON UNIVERSITY HOSP
Licensee: THOMAS JEFFERSON UNIVERSITY HOSP
Region: 1
City: PHILADELPHIA State: PA
County: PHILADELPHIA
License #: 37-955-7813
Agreement: N
Docket:
NRC Notified By: LARRY MARTINO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2005
Notification Time: 15:34 [ET]
Event Date: 08/12/2005
Event Time: 13:30 [EDT]
Last Update Date: 08/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
Person (Organization):
JOHN CARUSO (R1)
GEORGE PANGBURN (R1)
SCOTT FLANDERS (NMSS)

Event Text

PATIENT OVEREXPOSURE - I-131 CONTAMINATION FOUND UNDER THUMBNAIL

On 8/11/05 a patient was being treated with an I-131 (liquid) source for a hyperthyroid problem (148 milliCuries). Per procedure, the patient returned 24-hours later for a whole body count. A small (estimated 5 microCurie) I-131 fixed contamination site was found under the patient's right thumbnail. Initial estimates for the localized dose are 800 Rad. There was no other contamination nor did surveys show any contamination on individuals or equipment. The patient and doctor were notified. Decontamination is continuing.

The hospital is continuing to investigate the cause of the contamination.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41916
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: STEPHEN M. STRAUB
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2005
Notification Time: 17:22 [ET]
Event Date: 08/12/2005
Event Time: 15:50 [CDT]
Last Update Date: 08/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RUSSELL BYWATER (R4)
DAVID GRAVES (R4)
VICTOR DRICKS (R4)

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

OFFSITE NOTIFICATION MADE DUE TO EMERGENCY SIREN ACTUATION

"On 8/12/05 at 1550, Fort Calhoun Station was notified by an off-duty employee that an emergency siren was sounding in Washington County, Nebraska. No actual emergency exists and no testing is currently in progress. The siren's location is approximately 1/2 mile East of the P32/P35 county road intersections on county road P32.

"The local sheriff, radio station (KFAB), and NRC senior resident have been notified.

"The cause of the inadvertent siren activation is unknown at this time.

"This event is considered to be reportable per 10CFR50.72(b)(2)(xi)."

This siren is within 10 miles from the plant. The local sheriff will provide compensatory notifications if required.

The licensee notified the NRC Resident Inspector.

* * * RETRACTING EVENT BY LICENSEE (MARASCO) TO ABRAMOVITZ AT 2135 ON 8/12/2005 * * *

The licensee determined that their corporate communications department had been performing a test of the emergency sirens but had not notified the site.

Notified the R4DO (Bywater) and e-mailed R4 (Graves and Dricks).

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41917
Rep Org: BAYHEALTH MEDICAL CENTER
Licensee: BAYHEALTH MEDICAL CENTER
Region: 1
City: DOVER State: DE
County: KENT
License #: 07-14850-01
Agreement: N
Docket:
NRC Notified By: HEATHER JONES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/13/2005
Notification Time: 16:22 [ET]
Event Date: 08/13/2005
Event Time: 09:31 [EDT]
Last Update Date: 08/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JOHN CARUSO (R1)
SCOTT FLANDERS (NMSS)
JIM WHITNEY (E-MAIL) (TAS)
PENNY LANZISERA (R1)
PAMELA HENDERSON (R1)

Event Text

LOST/STOLEN CS-137 SOURCE

The Cs-137 source (116.4 microCuries) is kept in a lead container, in an unlocked lead-lined drawer, in a key coded cipher locked room. At 06:48 on 08/12/05, the daily quality control dose calibration was performed. At 09:31 on 8/13/05, the source and its lead container were discovered missing. Security personnel have reviewed video surveillance tapes for nearby corridors but the hall outside the source's room is not surveilled. The video tapes indicate that the only personnel within the area were Security personnel. Staff and technicians with access to the room were interviewed and none had knowledge of the incident.

Cardinal Health was contacted and verified that the source had not accidentally been returned to Cardinal Health.

The door to the source's room is labeled and locked.

The RSO has been notified and the Dover Police will be notified.

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Power Reactor Event Number: 41918
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM HUFFORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/14/2005
Notification Time: 20:42 [ET]
Event Date: 08/14/2005
Event Time: 19:10 [EDT]
Last Update Date: 08/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
JOHN CARUSO (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

FIRE ALARM IN TRAINING BUILDING DUE TO LOSS OF POWER

"This is a Voluntary Report based on a State Notification that does not meet the criteria of 10CFR50.72(b)(2)(xi).

"At approximately 19:10 hours, the Susquehanna Control Room was notified that offsite fire departments had responded to the Susquehanna Learning Center. This was due to a fire alarm received by the corporate office from the building due to a loss of power to the facility. Offsite fire department personnel along with our Training department inspected the building and found no indications of fire.

"The Susquehanna Learning Center is located outside of the protected area and approximately one eighth mile from the main access road on State Route 11.

"Pennsylvania Emergency Management Agency was advised."

The loss of power to the training building was the result from lightning in the area.

The licensee notified the NRC Resident Inspector.

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