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Event Notification Report for August 19, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/18/2005 - 08/19/2005

** EVENT NUMBERS **


41908 41919 41920 41927 41928 41929 41931

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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: 08/18/2005
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

* * * UPDATE FROM THE STATE OF OHIO TO NRC (HUFFMAN) AT 12:19 EDT ON 8/18/05 * * *

The State provided the following information via email:

"Inspection by Bureau determined that licensee's employee failed to follow procedures for securing device in vehicle. Gauge was only secured in vehicle by bungee cords, with no locking mechanism or fixed restraint system. In addition, vehicle was left unattended and unobserved while employee was in fast food restaurant for prolonged period."

R3DO (Riemer) and NMSS (Hickey) notified. TAS informed via email.

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General Information or Other Event Number: 41919
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HTS INC CONSULTANTS
Region: 4
City: HOUSTON State: TX
County:
License #: L-02757
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: BILL GOTT
Notification Date: 08/16/2005
Notification Time: 15:00 [ET]
Event Date: 08/16/2005
Event Time: 07:00 [CDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
MICHELE BURGESS (NMSS)
JIM WHITNEY email (TAS)
Mexico fax ()

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

An employee parked the truck containing the Troxler Moisture Density Gauge (Model 3411B, s/n 7573, Am/Be 40 milli Curies, Cs-137 8 milli Curies) overnight at his apartment complex. The gauge was secured by a lock and chain. The truck was parked at 2200 CDT on 08/15/05. When the employee returned to the truck at 0700 on 08/16/05 the chain was cut and the gauge was gone. The theft was reported to the police.

TX report number: TX-I-8252.

Less than the quantity of an IAEA Category 3 source.

Sources that are "Less than IAEA 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.

* * * UPDATE FROM D. HUNTSMAN TO J. KNOKE AT 16:46 EDT ON 08/18/05 * * *

An individual called the owner of the lost Troxler gauge, indicating it was discarded on her property. The gauge was initially picked up by the local fire department, and then by the owner. The gauge was surveyed and had readings of less than 1 mr/hr. The gauge was found to have no damage, however, all the associated paperwork was missing.

Notified the R4DO (Sanborn), NMSS (Holonich) and TAS (Perez) of the update. Faxed Mexico the update.

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General Information or Other Event Number: 41920
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLAGLER HOSPITAL, INC
Region: 1
City: ST. AUGUSTINE State: FL
County:
License #: 1203-1
Agreement: Y
Docket:
NRC Notified By: CHARLES E. ADAMS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/16/2005
Notification Time: 16:30 [ET]
Event Date: 08/09/2005
Event Time: 12:00 [EDT]
Last Update Date: 08/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
MICHELE BURGESS (NMSS)

Event Text

FLORIDA AGREEMENT STATE REPORT

"Licensee reports that a doctor wrote the prescription for I-131 thyroid scan when he meant it to be a I-123 scan.. Event occurred on 8/09/05 and was discovered on 8/11/05. This office was notified 8/15/05. The doctor and patient have been notified. No adverse medical consequences for the patient are expected. Any further action is referred to Radioactive Materials. "

Total Activity of the Iodine-131 was 6.05 millicuries.

Florida Incident Number FL05-113

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Power Reactor Event Number: 41927
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: QUENTIN HICKS
HQ OPS Officer: PETE SNYDER
Notification Date: 08/18/2005
Notification Time: 11:10 [ET]
Event Date: 08/18/2005
Event Time: 09:49 [EDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAYMOND LORSON (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC SCRAM DUE TO LOSS OF A POWER BOARD

"Unit 1 scrammed from 100% power due to a loss of power board 11 coincident with 1/2 scram present already on RPS channel 12 due to [instrumentation and control] (I&C) testing. A loss of power board 11 causes a loss of 11 RPS trip bus which in turn produces a 1/2 scram. Loss of power board 11 is currently under investigation. In addition during the scram, HPCI injected into the reactor vessel on a turbine trip signal to maintain reactor water level.

"Currently, the reactor is in hot shutdown with reactor water levels being maintained in the normal level band at 74 inches with feedwater in automatic. Reactor pressure is currently 920 psig and being maintained in automatic with turbine bypass valves.

"Plan is to stay in hot shutdown and complete scram recovery procedures."

All control rods fully inserted. No safety relief valves actuated. Electrical busses were being supplied by normal offsite power. Emergency diesel generators are available. The decay heat removal path is currently normal feedwater to the reactor vessel through the turbine bypass valves to the condenser. There was no impact on Unit 2. The licensee is going to suspend any high risk maintenance activities on Unit 2.

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41928
Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: 37-11866-04
Agreement: N
Docket:
NRC Notified By: TONY MONTAGNESE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/18/2005
Notification Time: 14:08 [ET]
Event Date: 08/18/2005
Event Time: 10:00 [EDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAYMOND LORSON (R1)
TOM ESSIG (NMSS)

Event Text

MEDICAL EVENT

The licensee reports that a patient was scheduled to receive five Gamma Knife treatments to a single tumor in the head. Two treatments were successfully administered. Prior to the third treatment, it was determined that the shield "jaws' on the Gamma Knife were stuck closed and the Knife was considered inoperable. Consequently, the patient did not receive the final three prescribed treatments.

The licensee has requested repairs on the Gamma Knife from an authorized service representative. The licensee believes that a microphone clip, used to communicate with the patient while under treatment, may have fallen into the Gamma Knife and jammed the "jaws."

The licensee plans to continue treatment of the patient pending repair to the Gamma Knife.

The licensee also planned to notify the State of Pennsylvania.

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Other Nuclear Material Event Number: 41929
Rep Org: SCHLUMBERGER INC.
Licensee: SCHLUMBERGER INC.
Region: 1
City: TRENTON State: NJ
County:
License #: 29-08636-02
Agreement: N
Docket:
NRC Notified By: TOM BRACKE
HQ OPS Officer: PETE SNYDER
Notification Date: 08/18/2005
Notification Time: 14:25 [ET]
Event Date: 08/17/2005
Event Time: 12:00 [EDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RAYMOND LORSON (R1)
GARY SANBORN (R4)
GREG MORELL (NMSS)

Event Text

MATERIAL EVENT - LOST TRITIUM SOURCE

A shipment of a pulse neutron generator containing a 1.5 curie tritium source was determined to be lost by the shipper (Federal Express) and reported to the licensee on 8/17/05. The neutron generator originated in New Jersey and was shipped to Texas where it was used under a well logging source license. Upon completion of use, the generator was to be returned to New Jersey from Texas. The shipment in question originated in Webster, Texas, and was destined for the licensee's Princeton Technology Center in Princeton Junction, New Jersey. The shipping date was 7/12/05. The licensee stated that the neutron generator failed to arrive as scheduled and that on or about 7/15/05 the shipper initiated an internal incident report to investigate the shipment. The neutron generator was tracked to the shipper's Trenton, New Jersey site. The licensee also reported that the shipper reported finding packaging related to the neutron generator shipment but that the contents were missing.

The tritium source in the neutron generator is less than the quantity of an IAEA Category 3 source.

Sources that are "Less than IAEA 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 IAEA 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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Power Reactor Event Number: 41931
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MICHAEL FITZPATRICK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/18/2005
Notification Time: 19:03 [ET]
Event Date: 08/18/2005
Event Time: 14:40 [CDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KENNETH RIEMER (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

Event Text

HIGH PRESSURE CORE SPRAY SYSTEM INOPERABLE

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to mitigate the consequences of an accident. During a scheduled 24 hour surveillance run of the 1B diesel generator, with the diesel generator paralleled to its associated Bus 143, an electrical fault occurred in the Division 3 AC system. This resulted in a trip of the normal System Auxiliary Feed breaker ACB 1432 to the bus. The diesel generator was manually tripped when it was subsequently identified that its associated cooling water pump was not running. With the 1B diesel generator tripped, the Division 3 AC system is de-energized. The consequence is a loss of the Unit 1 High Pressure Core Spray System. High Pressure Core Spray is a single train system that performs a safety function, and therefore, loss of the system is reportable as an 8 hour ENS notification under SAF 1.8.

"The required actions of Technical Specification 3.5.1 for the High Pressure Core Spray System were entered on 8/18/05 at 14:40 when the system was made inoperable. All other Emergency Core Cooling Systems are operable at this time. The High Pressure Core Spray system is also unavailable, and On Line Risk for Unit 1 is Yellow. The system has been quarantined, and an investigation is currently in progress to determine the cause of the electrical fault."

Unit 2 is not affected by this event, and Unit 1 is in a 14 day LCO to repair the EDG.

The licensee notified the NRC Resident Inspector.

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Friday, March 30, 2012