United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2005 > November 2

Event Notification Report for November 2, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/01/2005 - 11/02/2005

** EVENT NUMBERS **


42085 42086 42090 42091 42092 42095 42104 42105 42109

To top of page
General Information or Other Event Number: 42085
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: COLUMBIA IRON AND METAL
Region: 3
City: GIRARD State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/27/2005
Notification Time: 11:04 [ET]
Event Date: 10/26/2005
Event Time: [EDT]
Last Update Date: 10/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
MICHELE BURGESS (NMSS)

Event Text

SOURCE DISCOVERED AT METAL SCRAP YARD

The State provided the following information via facsimile:

Gauge containing a Sr-90 sealed source was discovered at a metal scrap yard in Girard, Ohio. The gauge is a Betamike model manufactured by Taylor Instruments (Model 015020; Serial 781-35). The activity as of 8/70 was 100 mCi (millicuries). The activity as of 10/27/05 was calculated to be 44 mCi (millicuries). The Ohio Department of Health dispatched an inspector to the scrap yard on October 26. The gauge is secure and a leak test of the source showed no removable contamination. Radiation levels are 5 mR/hr (milliRem per hour) on contact and 1 mR/hr at 30 cm. Disposal options for the device are being investigated.

Ohio Report OH05-134

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. 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.

To top of page
General Information or Other Event Number: 42086
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: PHARMACY SERVICES OF PEORIA
Region: 3
City: PEORIA State: IL
County:
License #: IL-01874-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL GOTT
Notification Date: 10/27/2005
Notification Time: 13:46 [ET]
Event Date: 10/26/2005
Event Time: 14:00 [CDT]
Last Update Date: 10/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - LOOSE SURFACE CONTAMINATION AND CONTAMINATED PERSONNEL

"At 6:40 PM, October 26, 2005, the Agency's Duty Officer received a call from the dispatch center to contact Pharmacy Services of Peoria (IL-01874-01) at their Peoria facility regarding a contaminated package they had transported back from Proctor Hospital, Peoria, IL (IL-01188-01) earlier that afternoon. Pharmacy Services of Peoria reported that the package was contaminated on the surface with Tc-99m. Direct measurements yielded 3 milliR/hr and 4.9 million DPM. The package was immediately set aside in their waste area and secured. The driver was surveyed and contamination was found on one hand. His hand was decontaminated until readings were approximately 0.04 milliR/hr and no removable contamination remained. The pharmacy vehicle was subsequently surveyed and decontaminated to the extent practicable below releasable limits. Pharmacy Services of Peoria went on to state that he had contacted the hospital as well when the contamination was discovered that afternoon.

"The Duty Office then contacted, a technician of Proctor Hospital who indicated that a syringe of Tc-99m had partially vented which resulted in the contamination of her glove and the exterior of the retrieved pharmacy container. She stated that following notification from the pharmacy around 2 pm that afternoon, she had surveyed the hot lab for contamination and discovered loose radioactive contamination on the counter, the floor and the gloves she had been using at the time. She successfully decontaminated the floor and changed the counter absorbent covering. No other contamination had been found in the Department.

"On October 27, 2005 a Division representative called both individuals to follow-up and discuss reporting requirements. Pharmacy Services of Peoria advised that the courier had visited one other facility that afternoon following the collection of the briefcase containing empty lead containers at Proctor Hospital. Representatives from the pharmacy had called the second facility the previous afternoon to advise them of the potential for contamination. The second facility investigated and then reported back that their monitoring had revealed no contamination of the items dropped off. The pharmacy subsequently visited the site themselves later that same day to retrieve some empty containers and confirmed no contamination was present on any of the packages involved. He went on to report that the driver involved was monitored when he reported for work on the morning of the 27th and no additional removable contamination was discovered on his hands and as a further precaution the vehicle that had been used was set aside for the day and would not be driven.

"When the technician of Proctor Hospital was contacted she reported that she believed the contamination on the package resulted from a procedure where she was preparing a diagnostic tracer from a kit. Based on the initial amount involved and the subsequent diagnostic procedure she believed that no more than 0.5 milliCi of Tc-99m could have been involved. Circumstances in the hot lab and with available personnel lead to an uncommon situation where the package to be retrieved by the pharmacy courier was in the dose preparation area leading to its eventual contamination. Although routine procedure is to monitor all items removed from the radioactive work area of the hot lab, this was not performed on this occasion as it was unusual for the package to be in the dose preparation area. The licensee indicated that similar circumstances are very unlikely to be repeated so the potential for second occurrence is negligible."

State Report: IL050052

To top of page
General Information or Other Event Number: 42090
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GEORGIA PACIFIC
Region: 4
City: CROSSETT State: AR
County:
License #: ARK-321-BP-11
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2005
Notification Time: 15:56 [ET]
Event Date: 10/18/2005
Event Time: [CDT]
Last Update Date: 10/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SCOTT MOORE (NMSS)
LANCE ENGLISH email (TAS)

Event Text

AGREEMENT STATE REPORT - MISSING PAPER THICKNESS GAUGE

On 10/18/05 while conducting leak checks of their equipment, the licensee discovered a NDC Model 104F Paper Thickness Gauge (80 millicuries Am-241 s/n 11480) missing. The device was not located in a search of the facility. The device was part of the production line. The licensee notified the Arkansas Department of Health at 1430 CDT on 10/28/05.

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. 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.

To top of page
General Information or Other Event Number: 42091
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UT SOUTHWESTERN MEDICAL CENTER
Region: 4
City: FORT WORTH State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2005
Notification Time: 17:50 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 10/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT

The licensee provided the following information via email:

"The written prescribed dose for this treatment was 550 cGy with the plan of repeating another procedure one week afterwards for a total prescribed dose of 1100 cGy. This dose, to be given in 2 fractions, was to be delivered to the vaginal cavity using High Dose Rate (HDR) afterloader device. The first fractionation of 550 cGy was delivered incorrectly, approximately 4.5 cm anterior to the correct position. This resulted in the intended target area receiving 1451 cGy in one treatment.

"The medical physicist discovered the error in the brachytherapy vision software (planning system). When digitizing the calculation point of the coronal plane, the sagittal plane viewing plane was in an incorrect position that resulted in the calculation point being entered incorrectly. There was no other medical physicist to second check the plan at that time due to personnel shortage issues.

"The prescribing physician determined that the clinical effect of the dose is negligible and there is no impact to the patient's well being."

Texas Incident number: I-8253
Event Report ID No: TX-05-41932

To top of page
General Information or Other Event Number: 42092
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS HI TEMP ALLOY PROCESSORS AND BROKERS
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2005
Notification Time: 17:50 [ET]
Event Date: 09/21/2005
Event Time: [CDT]
Last Update Date: 10/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
DANIEL GILLEN (NMSS)
LANCE ENGLISH email (TAS)
MEXICO fax ()

Event Text

AGREEMENT STATE REPORT - MISSING PORTABLE ALLOY ANALYZER

The licensee provided the following information via email:

"On 09/21/05 while preparing for Hurricane Rita, the owner's truck was stolen from in front of his office in Houston, Texas, 77087. Since his office is a trailer, the owner thought it best to put his Niton Alloy Analyzer [6 millicuries Cd-109 s/n U1238 NR5498] in his truck to bring home in case his office was destroyed by the hurricane. Houston law enforcement was notified as soon as owner discovered the truck missing. His truck was recovered 10/13/05, but the analyzer was not."

Texas Incident No: I-8273

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. 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.

To top of page
General Information or Other Event Number: 42095
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ATLANTIC GEO TECH ENVIRONMENTAL SERVICES
Region: 1
City: JACKSONVILLE State: FL
County:
License #: FL-2725-1
Agreement: Y
Docket:
NRC Notified By: DAVID FERGUSON
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2005
Notification Time: 13:54 [ET]
Event Date: 10/29/2005
Event Time: 09:30 [EDT]
Last Update Date: 10/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID SILK (R1)
DANIEL GILLEN (NMSS)
LANCE ENGLISH email (TAS)

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

On 10/29/05, a Troxler Moisture Density Gauge (model 3440, s/n 032146, 8 millicuries Cs-137, 40 millicuries Am-241: Be) was stolen from the back of the operators truck at the job site on Four Acre Road in Jacksonville, FL. The gauge was chained and locked to the operator's truck. The operator left the truck at the job site while she reviewed the job site. She returned to the truck and drove back to the office. At the office she noted that the gauge was gone. The Jacksonville Police Department was notified. The company intends on placing an ad in the local newspaper.

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. 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.

To top of page
Power Reactor Event Number: 42104
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID FUNK
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/31/2005
Notification Time: 23:02 [ET]
Event Date: 10/31/2005
Event Time: 22:27 [EST]
Last Update Date: 11/02/2005
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEPHEN CAHILL (R2)
TOM BLOUNT (IRD)
JOHN HANNON (NRR)
J. FROST (DHS)
L. BISCOE (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N N 0 Hot Standby 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARATION: LOSS OF OFFSITE POWER DUE TO LOSS OF STARTUP TRANSFORMER

"Unusual event category 10A on Unit 4. Loss of offsite power to Unit 4 due to loss of Unit 4 Startup Transformer. Auto AFW actuation. Auto starting and loading of both Unit 4 Emergency Diesel Generators."

The licensee stated that the plant is stable in Mode 3 at approximately 700 psi and 380 deg F. The plant was experiencing electrical grid instabilities at the time of the trip of the Startup Transformer. The exact cause of the transformer trip is being investigated. The grid instabilities were associated with the plant's Northwest Bus, therefore, Unit 3 is not affected and continues to operate at approximately 60% power.

The licensee notified the State of Florida and will notify the NRC Resident Inspector


*** UPDATE FROM D. FUNK TO J. KNOKE AT 02:15 ON 11/02/05 ***

"The licensee terminated from their Unusual Event (EAL 10A) at 0200 EST on 11/02/05. Unit 4 A & B 4 KV busses are now powered from off-site power using Unit 4 startup transformer."

The power / mode for Unit 4 is now 0% power / Mode 5.

The licensee will notify the NRC Resident Inspector and has notified State, local and other government agencies. Notified R2DO (Ayres), NRR EO (Case), IRD-MOC (Wilson), DHS (J. Frost) and FEMA (S. Kimbrell).

To top of page
Power Reactor Event Number: 42105
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: POUL CHRISTIANSEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/01/2005
Notification Time: 02:14 [ET]
Event Date: 10/31/2005
Event Time: 22:23 [EST]
Last Update Date: 11/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEPHEN CAHILL (R2)

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

Event Text

CONTAINMENT EVACUATION AND SMOKE INHALATION TREATMENT DUE TO SMALL FIRE

"On October 31, 2005, at 22:23 fire and smoke was reported in the Unit 1 Reactor Containment Building. Unit 1 is currently shut down for a refueling outage. Investigation into the cause of the fire continues. The fire appears to have been caused by slag from cutting/grinding work contacting a temporary ventilation hose. The containment evacuation alarm and fire alarm was sounded. The fire was reported extinguished at 22:25. The fire team and first aid team responded. First aid team reported several people were overcome by smoke inhalation. The Unit 1 control room called '911' to request ambulance and EMT assistance. Eight people have been transported to local hospitals for treatment of smoke inhalation. None of the people transported offsite were contaminated. 29 CFR 1904.8 requires notification of the Occupational Safety and Health Administration (OSHA) within eight hours of this event because it resulted in the hospitalization of three or more employees as a result of a work related incident. This NRC notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to the notification of offsite governmental agencies via '911' as well as the OSHA notification."

Unit 2 is at 100% power and was not impacted by this event. The licensee notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 42109
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: CHARLES STALZER
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/02/2005
Notification Time: 01:13 [ET]
Event Date: 11/01/2005
Event Time: 23:00 [CST]
Last Update Date: 11/02/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 99 Power Operation

Event Text

TECH SPEC REQUIRED SHUTDOWN DUE TO DEGRADATION OF CONTAINMENT COATINGS

"On November 2, 2005 at approximately 00:00 Central Standard Time (CST), Point Beach Nuclear Plant (PBNP) Unit 2 commenced a reactor shutdown required by Technical Specification 3.0.3.

"During a review of the containment coatings in both Unit 1 & 2 containments, it was discovered that the containments have not been maintained with the analysis of record performed by Sergeant and Lundy (S&L). The S&L analysis performed for Unit 2 was based on the known condition of coatings when the analysis was performed. There was no explicit margin for further degradation. Subsequent discoveries of degraded or unqualified coatings cannot be accommodated by the existing analysis as written.

"An Operability Recommendation (OPR) was performed for Unit 2 and approved on 10/30/05 at 2000. Following this OPR, a further review of containment coatings in the Unit 2 containment was performed and showed a potential for approximately 11 square feet of unqualified coatings [in] the Zone of Influence (ZOI) for the containment sump. The OPR allowed for a maximum of 5.68 square feet of loose material in the ZOI.
A Unit 2 containment walk-down was performed on the evening of November 1, 2005. This revealed that the unqualified coatings in the ZOI were approximately 11 square feet. This information placed Unit 2 in an unanalyzed condition, which lead the operators to enter Technical Specification 3.0.3 at 2300 on November 1 due to both trains of Emergency Core Cooling System (ECCS) being declared inoperable for sump recirculation capability.

"Actions are currently underway to remove enough unqualified coatings to be within the assumptions made in the OPR and restore Containment Sump recirculation capability. When this is completed, the technical specification shutdown will be terminated, and Unit 2 will make preparations to return to full power.

"Unit 1 is currently in Mode 5 and ECCS is not required. However, the condition is also applicable to Unit 1 containment. Actions have been underway since the identification of the original issue to remove unqualified containment coatings. The Plant Manager has placed a hold on entering Mode 4 on Unit 1 pending completion of corrective actions."

Presently there are 2 workers and a Radiation Protection technician inside containment. The licensee said that workers will go inside containment and remove the degraded coating. This will take approximately 45 minutes and have a total exposure to personnel of 85 millirem.

The licensee notified the NRC Resident Inspector.


*** UPDATE FROM C. STALZER TO J. KNOKE AT 03:15 ON 11/02/05 ***

At 01:06 CST the licensee exited from Technical Specification 3.0.3. requirements and plans to hold power on Unit 2 at 97% power pending further assessment and evaluation.

The licensee will notify the NRC Resident Inspector. Notified the R3DO (Kozak).

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