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Event Notification Report for August 22, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/19/2005 - 08/22/2005

** EVENT NUMBERS **


41897 41919 41920 41922 41925 41933 41934 41935

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41897
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ELLIS PFEFFER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/05/2005
Notification Time: 22:46 [ET]
Event Date: 08/05/2005
Event Time: 17:54 [CDT]
Last Update Date: 08/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (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

LOSS OF BOTH CONTROL ROOM EMERGENCY VENTILATION SYSTEMS DURING TESTING

During maintenance testing of the 'B' Control Room Emergency Ventilation system (CRV) the 'A' Air conditioning unit was running. The 'A' A/C unit (V-EAC-14A) tripped on a low service water flow condition while performing step 0255-11-III-4 which manipulated service water valves for the test. The 'B' loop of the CRV system was in a 30 day LCO due to the maintenance testing. When the 'A' A/C unit tripped and the 'B' unit inoperable due to testing, both CRV trains were inoperable and that placed the unit in a 24 hour Tech Spec LCO, 3.17.A.3.a. The compressor unit V-EAC-14A was reset following restart of the 13 Emergency Service Water pump 8 minutes after the trip and exited the 24 hour LCO.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM R. SCHREIFELS TO J. KNOKE AT 12:35 EDT ON 8/19/05 * * *

"The notification was initiated due to both trains of the Control Room Ventilation system being inoperable and was reported under 50.72 (b)(v)(D) as an event or condition that could have prevented fulfillment of a safety function.

"Monticello is retracting the event notification based on further investigation of the event. Successful completion of subsequent testing indicated that the 'B' train was still capable of performing its required safety function when the 'A' train tripped. Therefore Monticello has determined there was no loss of safety function as reported in Event Notification #41897. Additional investigation is ongoing and any identified issues will be entered into the station's corrective action program."

The licensee notified the NRC Resident Inspector. Notified R3DO(S. Burgess).

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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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General Information or Other Event Number: 41922
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: RIVER VALLEY TESTING
Region: 3
City: MENASHA State: WI
County:
License #: 139-1242-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: BILL GOTT
Notification Date: 08/17/2005
Notification Time: 12:47 [ET]
Event Date: 08/16/2005
Event Time: 14:30 [CDT]
Last Update Date: 08/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"A notification was made by the RSO on August 16, 2005, concerning a portable moisture density gauge that was run over at the Menasha coal plant, a temporary job site. The approximate time of the incident was 2:30 pm. The gauge was a Troxler 3440 containing 10 milliCuries of Cs-137 and 50 milliCuries of Am-241. The RSO reported that the radiation readings were verified as normal by comparing the reading at 1 meter to the Transportation Index. Visual observation confirmed that the source rod is in the normal position and the shielding is intact. Other individuals on the job site including the truck driver that ran over the gauge were surveyed. The area where the gauge was damaged was surveyed after the gauge was moved a few feet away and no radiation readings above background were noted. The gauge was transported back to the licensee's facility in Neenah [WI]. DHFS staff were dispatched to confirm that there was no contamination on August 17, 2005. The licensee has taken a wipe smear and is sending it to Troxler for counting. The gauge is locked in the transport case and has been placed in storage."

WI report number: 29

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General Information or Other Event Number: 41925
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT
Notification Date: 08/17/2005
Notification Time: 18:57 [ET]
Event Date: 08/04/2005
Event Time: 11:30 [MST]
Last Update Date: 08/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event."

Event Report ID Number: UT-05-0006

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Fuel Cycle Facility Event Number: 41933
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: RALPH WINIARSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2005
Notification Time: 18:48 [ET]
Event Date: 08/19/2005
Event Time: 15:30 [EDT]
Last Update Date: 08/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
CAUDLE JULIAN (R2)
JOSEPH HOLONICH (NMSS)

Event Text

NRC BULLETIN 91-01 VIOLATION OF CRITICALITY SPACING REQUIREMENTS

"Criticality spacing configuration requirements for Integrated Fuel Burnable Absorber (IFBA) rod caskets were violated in the IFBA loading dock (Dock 9). IFBA rod caskets are used for transport of IFBA rods from the IFBA loading dock to the Quality Control (QC) Inspection Area. Criticality spacing requirements for the caskets are posted on the lid of each container. The requirements state that loaded caskets are required to remain in the same horizontal array with 12-inch spacing between all other containers not in the same array. As such, stacking of loaded caskets is prohibited. Contrary to this requirement, Westinghouse operations personnel identified several caskets loaded with IFBA rods that were stacked in the IFBA loading dock (Dock 9). It is believed that this spacing condition was present for less than 24 hours, although this has not yet been confirmed.

"Notification is being made based on the loss of spacing of the caskets in conjunction with the failure to limit the potential pathway for moderator introduction into the caskets (see discussion below for more detail).

"Double Contingency Protection
The criticality safety analysis considers criticality not credible for normal and credible process upset conditions. However, the criticality safety analysis (ISA-12) also establishes that criticality is possible if large quantities of rods were stacked and interstitial moderation was provided and retained among the stacked fuel rods.

"Introduction of interstitial moderation is limited by the casket covers and through limitation of available sources. While no liquid moderator was present in any of the caskets, the potential pathway for moderator introduction was not addressed by either the criticality safety posting (deficiency in the criticality safety analysis) or operating procedures. In addition (as discussed under the Reason for Notification), the caskets were improperly spaced in a stacked configuration.

"It was determined that the criticality safety analysis is deficient and that less than two unlikely, independent, and concurrent changes in process conditions would be required before a criticality accident would be possible. A criticality is judged to be credible through the introduction of moderation and the incorrect configuration of the caskets.

"In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.3), this event satisfies the criteria for a 4-hour notification.

"Summary of Activity:
IFBA casket loading operations were discontinued.
Operations Management reviewed the procedural requirements prohibiting stacking of caskets with all of the operations personnel.
The program to train and re-certify all Operations personnel is continuing, per schedule.
The program to assess and reconstitute the plant's criticality safety basis is continuing, per schedule.

"Conclusions:
Problem was self identified by Westinghouse Operations personnel. As stated previously it is believed that the improper spacing configuration was present for less than 24 hours.
Less than double contingency protection remained.
No liquid moderator was present in any of the caskets.
At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved.
The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures.
A causal analysis will be performed.
The plant programs for training and recertification of operations personnel and for assessment and reconstitution of the plant's criticality safety basis are appropriate corrective actions for this type of event and are continuing according to plan."

There is no NRC Resident Inspector at the site. The loading operations are estimated to be discontinued for 3 to 7 days.

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Power Reactor Event Number: 41934
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID VINEYARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2005
Notification Time: 20:32 [ET]
Event Date: 08/19/2005
Event Time: [EDT]
Last Update Date: 08/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
CAUDLE JULIAN (R2)

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

VIOLATION OF MAXIMUM CORE POWER LEVEL PER OPERATING LICENSE REQUIREMENTS

"Pursuant to the reporting requirements of Item 2.H of the [Vogtle Electric Generating Plant] VEGP Unit 1 and Unit 2 operating licenses, [Southern Nuclear Company] SNC is notifying the NRC of overpower events in violation of the maximum core power level of 3565 MWt authorized by Item 2.C.(1) of the licenses.

"Based on a review of operating data dating back to January 2, 2002, SNC has identified occurrences where the daily average core power exceeded 3565 MWt by as much as 0.4 MWt for Unit 1 and 0.9 MWt for Unit 2."

The temperature signal from the steam generator blowdown, used as input into the computer calorimetric, was determined to be out of calibration in each unit. The licensee is evaluating this situation for a causal effect.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41935
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CLAY WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/20/2005
Notification Time: 19:16 [ET]
Event Date: 08/19/2005
Event Time: [PDT]
Last Update Date: 08/20/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
GARY SANBORN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LICENSE REQUIRED 24 HOUR NOTIFICATION OF UNUSUAL FISH KILL

"Section 4.1 of Appendix B of the Operating License for Units 2 and 3 requires Southern California Edison (SCE) to report to the NRC within 24 hours any unusual or important environmental events, which includes unusual fish kills.

"Between August 19 and August 20, 2005, SCE removed an unusually large number of fish from the Units 2 and 3 intake structure. At approximately 1000 PDT on August 20, 2005, SCE estimated the quantity to be approximately 11,070 pounds (approximately 6420 pounds from Unit 2 and 4650 pounds from Unit 3). While the NRC has not specified a reporting limit for an unusual fish kill, SCE has internally defined this quantity as 4500 pounds. This unusual influx of fish is unrelated to plant operation and a heat treat of the intake structure was not being performed. However, there is a heat treat of the San Onofre Unit 2 intake structure scheduled for later today."

The licensee stated that the fish kill was apparently the result of a large school of anchovies that swam to close to the intake.

The licensee notified the NRC Resident Inspector.

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