Event Notification Report for December 16, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/15/2005 - 12/16/2005

** EVENT NUMBERS **


41189 42188 42198 42200 42206 42208

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 41189
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HARRIS METHODIST FORT WORTH
Region: 4
City: FORT WORTH State: TX
County:
License #: L01837-000
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/10/2004
Notification Time: 14:21 [ET]
Event Date: 05/16/2004
Event Time: 12:00 [CST]
Last Update Date: 12/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT FROM TEXAS: EQUIPMENT FAILURE THERAPY DEVICE AT HOSPITAL

"On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device."

Texas Incident No.: I-8179

* * * UPDATE FROM HANSON TO KNOKE AT 17:27 ON 12/13/05 * * *

The State provided the following information via email:

"A letter was sent to the licensee on 9/14/05 from Robert Free [State] informing the licensee that Condition 21 on their Texas License L01837, required them to report as follows:

"The licensee shall cease treatment of patients when any safety related system of a LDR device is found inoperative, to include the source drive mechanisms treatment timing system, safety interlocks and radiation field alarms. The licensee shall report to the Deputy Director, Emergency Response and Incident Investigation, any malfunction that requires the termination of patient treatments for more than 24 hours and submit a written report of the incident and corrective actions within seven calendar days.

"The response letter from the licensee dated 10/04/05, stated that there were actually 5 events affecting a total of patients; on 3 of these events there were 2 patients being treated simultaneously with the same LDR machine. In each case the attending physician was either on the premises or notified immediately. The physician either deemed the treatment received was sufficient or the treatments were rescheduled, some within 3 hours.
It was discovered by the licensee that during the investigation of these events that severe thunderstorms preceded all LDR malfunctions. It was the conclusion that the LDR had functioned as designed by detecting the significant change in power & shut itself down. No misadministrations occurred.

"The manufacturer replaced the column, interface board, printer mechanism and power supply. The LDR has not been used in the past 12 months. In August 2005 the decision was made to take the LDR machine out of service."

Notified R4DO (Johnson) and NMSS (Essig).

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Power Reactor Event Number: 42188
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WILLIAM MATHER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/05/2005
Notification Time: 10:45 [ET]
Event Date: 12/05/2005
Event Time: 09:00 [CST]
Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
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

Event Text

PLANT PROCESS COMPUTER SYSTEM (PPCS) WILL BE TAKEN OUT OF SERVICE FOR APPROXIMATLEY 2 WEEKS.

"The Plant Process Computer (PPCS) will be taken out of service for an approximately 2 week period to implement a planned modification. The current PPCS is being replaced and the computer outage is required to allow cutover to the new PPCS. During this time period ERDS and SPDS will not be available. ERDS and SPDS parameters will be monitored by control board indications. Compensatory actions have been developed.

"This is an 8-hour reportable event per 10 CFR50.72(B)(3)(XIII) Major Loss of Assessment Capability. The operation of plant systems will not be affected due to this planned action.

"The PPCS outage is expected to commence around 0600 CST on 12/5/05. The licensee has informed the NRC Resident Inspectors of the modification and schedule. The NRC was previously notified of this planned outage via letter dated November 7, 2005."

The NRC Resident Inspector was notified of this event by the licensee.

* * * UPDATE PROVIDED BY JOHNSON TO ROTTON AT 0324 EST ON 12/16/05 * * *

"The Plant Process Computer System was restored at 2330 CST on 12/15/05. The Safety Parameter Display System (SPDS) has been returned to service. The Emergency Response Data System (ERDS) portion of the system will be turned over once the testing has been completed."

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

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General Information or Other Event Number: 42198
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: SIEMENS MEDICAL SOLUTIONS, USA
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0895-1
Agreement: Y
Docket:
NRC Notified By: MARION EADDY
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/12/2005
Notification Time: 17:30 [ET]
Event Date: 12/09/2005
Event Time: 21:30 [EST]
Last Update Date: 12/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
M. WAYNE HODGES (NMSS)
TAS - email ()

Event Text

STOLEN SEALED CALIBRATION SOURCE - 2 MILLICURIES OF AM-241

"The North Carolina Radioactive Materials Branch was notified at 16:00 [EST] today [12/12/05] of the theft of an Am-241 sealed calibration and reference source from a Siemens Medical Solutions USA, Inc. (N.C. Radioactive Materials License No. 068-0895-1) service vehicle. The theft occurred on 09 December 2005 between 21:30 and 23:00 in Statesville, NC.

"The information for the missing source is as follows:
Isotope: Am-241
Activity: 2 millicuries
Make: AEA Technology
Model: AMC.P3
Serial No.: 0182LX

"The theft occurred at a restaurant parking lot in Statesville, NC. The source was contained within a locked tool-box stored inside of the locked service vehicle. The passenger side window was broken and the toolbox was taken, along with other items, from the vehicle.

"The licensee notified the Statesville, NC police department [Report No. 05-4284] and the police have conducted a preliminary investigation into the break-in/theft. The licensee has drafted a press release and is offering a $1,000 reward for the return of the source.

"The Radioactive Materials Branch continues to monitor the situation and will update the NRC when new information becomes available."


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

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General Information or Other Event Number: 42200
Rep Org: ALABAMA RADIATION CONTROL
Licensee: GOODWIN, MILLS & CAWOOD, INC
Region: 1
City: BIRMINGHAM State: AL
County:
License #: 1404
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/13/2005
Notification Time: 14:00 [ET]
Event Date: 12/12/2005
Event Time: 18:30 [CST]
Last Update Date: 12/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
MICHELE BURGESS (NMSS)
TAS email (TAS)

Event Text

STOLEN MOISTURE DENSITY TROXLER GAUGE

The licensee provided the following information via facsimile:

"On the evening of December 12, 2005 at approximately 6:30 pm CST, a Troxler model 3440 moisture density gauge, serial number 503557, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be was stolen from the back of a pickup truck at a Home Depot parking lot in Birmingham, Alabama. The licensee, Goodwyn, Mills & Cawood, Inc., notified the Birmingham Police Department and the Alabama Office of Radiation Control. The Alabama Office of Radiation Control advised the Alabama Emergency Management Agency of the event. Goodwyn, Mills & Cawood, Inc. is authorized to possess and use radioactive material under their Alabama Radioactive Material License No. 1404. The licensee representative stated that the transport case was not locked and chained in the bed of the truck as required. The licensee representative did state that the gauge shutter was locked. A pressure meter was stolen in addition to the gauge. The Agency advised the licensee to consider issuing a press release and a reward. The licensee has been able to view surveillance tapes from Home Depot which appear to indicate that the gauge was stolen by individuals riding around the parking lot looking for unsecured items to steal in the back of trucks. The licensee has provided the Birmingham Police Department with a picture of the gauge and is checking with the local businesses and pawn shops. This is all the information that this Agency has at this time and is current as of 11:20 am CST."

Alabama Event 05-70.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

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Power Reactor Event Number: 42206
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: STEPHAN C. NEWMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 12/15/2005
Notification Time: 12:19 [ET]
Event Date: 12/15/2005
Event Time: 09:30 [EST]
Last Update Date: 12/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS DECKER (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF EMERGENCY SIREN POWER

"On December 15, 2005, at 0930 hours, it was determined that approximately 17 of 65 Oconee Nuclear Station emergency sirens, located in Pickens and Oconee Counties, failed to send a feedback signal when checked. It is postulated that these sirens are inoperable due to a loss of power attributed to severe icing conditions currently being experienced in both counties. At the time of discovery, current weather conditions were a steady light rain with a temperature of 33 degrees F.

"Duke is currently attempting to restore power to the affected sirens but does not expect to have all of the inoperable sirens back in service until later in the day. During the loss of siren period, a compensatory means of notifying the public has been put into place to include routing of local law enforcement personnel to the affected areas for public notification should an emergency occur at the station. Because more than 25% of the sirens were unavailable as a result of this event, this event constitutes a major loss of notification capability; consequently, this event is reported as an eight -hour notification in accordance with 10CFR50.72(b)(3)(xiii) reporting criteria.

"The licensee notified the NRC Resident Inspector and applicable station personnel.

"Initial Safety Significance: None. Compensatory measures have been put into place to ensure that the members of the public located in the affected areas are appropriately notified by local law enforcement personnel. All three Oconee units remain operable in Mode 1 (100 percent Power) and are unaffected by this condition.

"Corrective Action(s): Duke will attempt to have all of the inoperable sirens restored as soon as possible and will maintain the compensatory action in-place until full restoration has been completed."

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Power Reactor Event Number: 42208
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM HEAFNER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/15/2005
Notification Time: 17:15 [ET]
Event Date: 12/15/2005
Event Time: 13:04 [EST]
Last Update Date: 12/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS DECKER (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

LOSS OF 38 OUT OF 67 EMERGENCY SIRENS DUE TO WEATHER

"During performance of weekly testing on ANS Sirens 38 of 67 sirens failed. Suspect due to inclement weather. Retested at 15:43 (EST) and currently 4 of 67 are inoperable. " Licensee notified Mecklenburg county.


NRC Resident Inspector was notified of this event by the licensee.

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