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Event Notification Report for January 17, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/16/2006 - 01/17/2006

** EVENT NUMBERS **


42255 42261 42262

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General Information or Other Event Number: 42255
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHICAGO PROSTATE CANCER CENTER
Region: 3
City: WESTMONT State: IL
County:
License #: IL-02015-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: ARLON COSTA
Notification Date: 01/12/2006
Notification Time: 17:32 [ET]
Event Date: 01/05/2006
Event Time: [CST]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
C.W. (BILL) REAMER (NMSS)

Event Text

LEAKING SEALED SOURCE DUE TO IMPROPERLY PACKAGED MATERIAL

The State provided the following information via email:

"On January 11, 2005 the Division learned of an event involving a leaking sealed source that was intended for the therapeutic treatment of prostate cancer. On January 5, 2006, the Chicago Prostate Cancer Center (CPCC) in Westmont, IL (IL-02015-01) received four packages [which] contained sources that had been loaded into [an] applicator as well as 'loose seeds' for reference and potential application. One of the four packages contained 10 sealed sources of Cs-131 and 42 additional sources (actual activity of 3.8 milliCi, each) [were] pre-loaded into treatment applicators by Anazao Health of Tampa Florida via IsoRay, Inc of Richland Washington who manufactured the sources.

"Although the outer packaging was shown to be free from contamination, once the cardboard outer container was opened, and the secondary lead container was opened, a seed was visually detected on the outer lead container. The seed was also notably damaged. Associated contamination was subsequently found on the secondary container, and the primary lead container as well as a second 'seed' of Cs-131 that had been trapped and bent within the primary lead container. Although all the sources were accounted for, none of the 10 seeds were contained within the innermost glass vial as its lid was not engaged with the vial. Cs-131 is a very low energy gamma emitter (33 KeV) with a half life of 9.7 days. The form of Cs involved is bound to a non-volatile, insoluble material.

"The Division discovered that the CPCC had experienced widespread contamination within the source preparation area as a result of the damaged sources and the failure to don proper protective gloves. The affected surfaces and items had been subsequently decontaminated and set aside as waste by the staff that was present on January 5, 2005. Contamination levels ranged from 1,000 cpm to 5,000 cpm as measured by their Geiger counter and rate meter. Items which had been touched by the medical physicist who had not been wearing disposable gloves were found to be contaminated. One of the assisting staff members experienced contamination on their hand that was later completely decontaminated.

"A Division representative was dispatched from the West Chicago offices to the facility shortly after we were notified, to determine the effectiveness of the decontamination effort, the extent of contamination that may have remained and to interview the Radiation Safety Officer [redacted]. The inspector's initial investigation today showed that contamination was limited to the source handling room which is a restricted area and that indeed all the sources were accounted for and secured. She also obtained the verbal report from [the RSO]. The only remaining contamination she was able to find were two spots on a counter of approximately 1,000 cpm - 2,000 cpm and the containers which were involved. The inspector returned to the facility on the following day to interview the responsible physicist, and the assisting technician. Gamma spectroscopy performed on samples of the contaminated items indicate the presence of Cs-131 rather than any of the other nuclides used by the facility.

"The Division is continuing its investigation and is acquiring additional information from the licensee. The Division has been in contact with the State of Washington regarding this matter. A formal report is due from the licensee within the next 30 days. This event was reported to the U.S. NRC Operations Center on January 12 and assigned event number 42255."

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Power Reactor Event Number: 42261
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BRUCE PARRISH
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/16/2006
Notification Time: 19:36 [ET]
Event Date: 01/16/2006
Event Time: 17:03 [EST]
Last Update Date: 01/16/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD CONTE (R1)

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

Event Text

SMALL FIRE OCCURRED IN SECURITY DEPARTMENT STORAGE AREA.

A small fire occurred in the Security Department storage area, located in a administration building. The licensee requested off-site assistance and the fire was extinguished in approximately 15 minutes. As a result of the fire, there was no damage to plant related equipment and station security was not compromised. An Event Review Team is being assembled to investigate the cause of the fire, which at this time is unknown.

The following fire departments responded to the site:
Jordan Fire Department
Goshen Fire Department
Oswegatchie Fire Department
Cohanzie Fire Department
Niantic Fire Department"

The licensee stated there will not be a press release concerning this fire, nor is there expected to be a press inquiry.

The licensee notified the NRC Resident Inspector, as well as State and local governments.

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Power Reactor Event Number: 42262
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/16/2006
Notification Time: 23:16 [ET]
Event Date: 01/16/2006
Event Time: 18:31 [EST]
Last Update Date: 01/16/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 72 Power Operation 72 Power Operation

Event Text

HPCI SYSTEM ISOLATED DUE TO ATTS CARD FAILURE

"HPCI (High Pressure Coolant Injection) isolation rendered the HPCI system inoperable. An ATTS card 2E41-N658B, for HPCI steam line low pressure, failed. Concurrent with this card failure was several annunciators, one of which was 'HPCI Steam Line Diff. Press High'. One HPCI steam line low pressure card failing or tripping will not cause a HPCI isolation, but one HPCI steam line differential press high trip condition (indication of high flow) will cause an isolation. Both of these cards are fed from the same power supply. Investigation to confirm the isolation cause is in progress."

Licensee indicated 2E41-F003, outboard isolation valve, auto closed and 2E41-F002, inboard isolation valve was manually closed.

The licensee notified the NRC Resident Inspector.

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