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Event Notification Report for August 17, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/16/2005 - 08/17/2005

** EVENT NUMBERS **


41844 41869 41915 41921

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41844
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JEFFREY WILLIAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/14/2005
Notification Time: 20:43 [ET]
Event Date: 07/14/2005
Event Time: 16:10 [CDT]
Last Update Date: 08/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PATTY PELKE (R3)

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

STATION BLACKOUT TEMPERATURE ANALYSIS HIGHER THAN RCIC GOVERNOR DOCUMENTATION

"During fact gathering in response to an NRC inspection inquiry, it was determined that documentation does not exist that demonstrates that the Reactor Core Isolation Cooling (RCIC) Electronic Governor Module (EGM) would be able to operate during the required Station Blackout (SBO) coping mission time at the postulated post SBO RCIC room temperature of 206.4F. Current documentation supports operation up to 150F.

"The EGM is a skid-mounted module that provides speed control signals for the RCIC Woodward Governor. Failure of the EGM would result in a loss of speed control for the RCIC turbine. This could result in an overspeed, underspeed or no change condition. Overspeed of the turbine would result in a mechanical overspeed trip. This device is not in the EQ program but is Augmented Quality.

"RCIC continues to perform its Technical Specification required functions as defined in the Bases of Technical Specification (TS) 3.5.3. The TS function is to respond to transient events by providing makeup coolant to the reactor. The RCIC Room temperatures for the postulated TS transient events is less than the currently documented component qualification temperature. The RCIC is not an ESF system and no credit is taken in the safety analysis for RCIC system operation but is retained in the TS based on its contribution to the reduction of overall plant risk per Criterion 4 of 10 CFR 50.36. The RCIC system design requirements ensure that the criteria of 10CFR50 Appendix A, GDC 33, are satisfied.

"Due to the lack of supporting documentation for the EGM, the beyond design basis regulatory SBO rule requirements of 10 CFR 50.63 may not be met. This condition could potentially result in an unanalyzed condition that could significantly degrade plant safety and is therefore reportable under 10 CFR 50.72(b)(3)(ii).

"An analysis of the RCIC Room Heat Up Rate calculation is being performed as there are conservatisms built into the calculation that when removed will result in a lower temperature than 206.4F. Additional actions in progress include, establishing appropriate protected pathways to minimize the potential for a Loss Of Off-Site Power which could result in a SBO, performance of temperature qualification testing at SBO temperatures for the EGM, and performance of an extent of condition review for remaining RCIC components to ensure temperature qualification is met for the SBO rule. In parallel with temperature qualification testing, a modification to relocate the EGM to an area outside the RCIC room that has a lower SBO profile temperature is being pursued in the event that temperature qualification is not successful."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM D. COVEYOU TO W. GOTT AT 1427 EDT ON 8/16/05 * * *

"A 8-hour notification was made on July 14, 2005, in accordance with 10 50.72(b)(3)(ii)(B), Unanalyzed condition. The report was made because documentation did not support the continued operation of Reactor Core Isolation Cooling (RCIC) Electronic Governor Module (EGM) during the required Station Blackout (SBO) coping mission.

"Since the initial report, the post SBO room heatup calculation was evaluated and determined that the decay heat removal function during the SBO coping mission was met. The decay heat removal function during SBO coping period is achieved by either High Pressure Core Spray (HPCS) or RCIC systems. In addition, the other RCIC functions (i.e., Remote Shutdown, and Safe Shutdown Fire) were evaluated and determined to be met. Since the RCIC functions and the decay heat removal and vessel inventory functions during the SBO coping mission were maintained, the plant was not in an unanalyzed condition and this issue is not reportable.

"Since the condition is not reportable EN 41844 is retracted.

"The licensee notified the NRC Resident "

Notified R3DO (K. O'Brien)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41869
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: CHAUNCEY GOULD
Notification Date: 07/25/2005
Notification Time: 18:38 [ET]
Event Date: 07/25/2005
Event Time: 18:15 [EDT]
Last Update Date: 08/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
Person (Organization):
MIKE ERNSTES (R2)
PETER WILSON (IRD)
ELMO COLLINS (NMSS)

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

SPECIAL NUCLEAR MATERIALS INVENTORY DISCOVERS A FUEL PIN MISSING

" As a result of NRC Bulletin 2005-01 "Material Control and Accounting at Reactors and Wet Spent Fuel Storage Facilities", Oconee has been conducting an inventory of Special Nuclear Materials (SNM), other than complete fuel assemblies, stored in the spent fuel pools at Oconee. One canister, documented as containing 383 fuel pins, was found to actually contain 382 fuel pins. At this time it is uncertain if this is a record keeping error or an actual "lost" pin.

"Initial Safety Significance:
"The inventory process for other canisters is not complete, and it is possible that the pin may be in another container. These containers being inventoried have been stored underwater in the spent fuel pool for years. The affected canister was filled in 1982. Oconee has no reason to believe that this pin or any other SNM has been stolen or unlawfully diverted. For reference, one fuel assembly contains 208 fuel pins.

"Corrective Action(s):
"The inventory process is continuing. This notification is being trade per 10 CFR 74.11."

The NRC Resident Inspector will be notified.


****** RETRACTION on 08/16/05 at 1537 EDT by Stephen C. Newman to MacKinnon *****

"On July 17, 2005 at 1838 [ET] Oconee reported that during an inventory of Special Nuclear Material (SNM), other than complete fuel assemblies stored in the spend fuel pools at Oconee, one canister, documented as containing 383 fuel pins, was found to actually contain 382 fuel pins. At that time it was uncertain if this is a record keeping error or an actual "lost" pin. Further investigation has located the suspect fuel pin in a different canister; consequently, this issue no longer meets the reporting requirements as previously stated and this report is being retracted.

"Initial Safety Significance: There is no initial safety significance.

"Corrective Action(s): No additional corrective actions planned at this time."

R2DO (C. Julian), NMSS EO (M. Burgess) and IRD Manger (M. Leach) notified.

NRC resident Inspector was notified of this retraction by the licensee.

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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 #: 37-00148-06
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: 08/16/2005
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.


* * * UPDATE ON 08/15/05 @ 1114 BY LARRY MARTINO TO CHAUNCEY GOULD * * *

The initial report was incorrect and the correct version is as follows:

THE NUCLEAR MEDICAL TECHNICIAN HAD AN 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 . Per procedure, the patient returned 24-hours later for a whole body count. After completing this treatment, a small (estimated 5 microCurie) I-131 fixed contamination site was found under the nuclear medicine technician'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 technician and treating physician were notified. Decontamination is continuing. This report was made under 10CFR20.2202(a)(1)(iii) a shallow-dose equivalent to the skin or extremities of 250 rads or more.

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

Notified Reg 1 RDO (Ray Lorson), RI (George Pangburn) and NMSS EO(Michele Burgess)

*****Update on 08/16/05 at 1455EDT by John Keklak to MacKinnon ****


"License number 37-00148-06

"On 08/12/05, a Nuclear Medicine Technologist underwent a thyroid count (as per procedure) the day after administering a therapy dosage of I-131 sodium iodide (liquid) to a patient. The thyroid count results prompted a skin contamination survey that located I-131 skin contamination under the edge of the Technologist's right thumbnail. Following decontamination, some I-131 remained fixed. Initial conservative dose estimates indicated localized skin dose in the range of 800 Rad, current (8/16/05) best estimates indicate dose of about 130 Rad. No other contamination was found on this technologist, other personnel, equipment, or room surfaces. Most likely cause was a loss of integrity of the protective glove the technologist was wearing while handling the sodium iodide.

"The hospital is continuing to investigate the event"

R1DO (R. Lorson), R1 (Penny Lanzisera) and NMSS EO (M. Burgess) notified.

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Other Nuclear Material Event Number: 41921
Rep Org: GEO-EXPLOR INC
Licensee: GEO-EXPLOR INC
Region: 1
City: DORADO State: PR
County:
License #: 52-25-580-01
Agreement: N
Docket: 03035886
NRC Notified By: REYNALDO RODRIGUEZ
HQ OPS Officer: BILL GOTT
Notification Date: 08/16/2005
Notification Time: 16:18 [ET]
Event Date: 08/16/2005
Event Time: [EDT]
Last Update Date: 08/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RAYMOND LORSON (R1)
MICHELE BURGESS (NMSS)
JIM WHITNEY email (TAS)

Event Text

LOST/MISSING MOISTURE DENSITY GAUGE

The employee placed the CPN Moisture Density Gauge (s/n: 18098458 Am/Be, Cs-137) into its case and placed the case in the back of the pickup truck. Before the employee chained the case to the truck he was required to move away from the back of the truck. He later drove away without chaining the case to the truck or closing the back gate. About 0.3 miles down the road he noticed that the gate was open and the gauge was missing. He returned to the work site but did not see the gauge along the way and could not find the gauge at the work site. The incident was reported to the local police. The company is notifying the local news media and is offering a reward.

Less than the quantity of a Category 3 source.

Sources that are "Less than Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury.

For some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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