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Event Notification Report for January 27, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2006 - 01/27/2006

** EVENT NUMBERS **


42171 42284 42288

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42171
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: NOEL CLARKSON
HQ OPS Officer: BILL GOTT
Notification Date: 11/27/2005
Notification Time: 11:11 [ET]
Event Date: 11/27/2005
Event Time: 05:30 [EST]
Last Update Date: 01/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
KERRY LANDIS (R2)

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

Event Text

LOSS AND RESTORATION OF BACK-UP INSTRUMENT AIR TO FEEDWATER CONTROL VALVES

"Event:

"At 0530 hours on 11/27/2005, while in Mode 3 following a Unit 2 refueling outage, it was discovered that the nitrogen backup supply to 2FDW-315 and 2FDW-316 was valved out. 2FDW-315 and 2FDW-316 are the emergency feedwater (EFW) control valves which function to regulate steam generator level on a loss of main feedwater event. Motive force to these valves is normally supplied by instrument air and nitrogen provides backup to instrument air in the event that instrument air becomes unavailable. At 0530 hours on 11/27/2005, both EFW flow paths were declared inoperable and Technical Specification 3.7.5, Conditions B and E were entered. Condition E of TS 3.7.5 specifically deals with the inoperability of two EFW flow paths. The Required Action is to initiate actions to restore one EFW flow path to operable status, immediately.

"Initial Safety Significance:

"2FDW-315 and 2FDW-316 are the control valves for the Unit 2 'A' and 'B' steam generators, respectively. These valves must be able to function in order to control steam generator level during an event where main feedwater is lost. The motive force for these valves is normally instrument air. However, in the unlikely event where main feedwater is lost, and instrument air is unavailable, these valves rely on a nitrogen backup to supply their motive force. The events where this nitrogen backup is credited are a station blackout (SBO) and a loss of instrument air. While nitrogen backup to 2FDW-315 and 2FDW-316 was unavailable between 0530 hours and 0710 hours on 11/27/2005, it is reasonable to assume that the ability to remove decay heat would have been available. In the case of a loss of instrument air, 2FDW-315 and 2FDW-316 fail open, with the motor driven EFW pumps providing EFW supply to both steam generators. In this case, the Emergency Operating Procedure (EOP) provides guidance to realign EFW through the electric powered startup control valves. Should this realignment attempt fail, the EOP provides further guidance to control EFW flow by manually throttling closed on 2FDW-315 and 2FDW-316. In the event of an SBO, power to the instrument air compressors would be lost, resulting in a loss of instrument air header pressure. The motor driven EFW pumps would be unavailable, however, the turbine driven EFW pump would automatically start and provide EFW flow. As with the loss of instrument air event, 2FDW-315 and 2FDW316 would fail open. The EOP provides guidance to dispatch operators to manually throttle closed on these valves to control flow to the steam generators. Additionally, while not credited for this event, Oconee has diesel driven air compressors which auto start on low instrument air pressure and supply the instrument air header. Also, in the event of a SBO, the Standby Shutdown Facility (SSF) is manned within 10 minutes of event initiation. The SSF is a SBO coping facility with a dedicated diesel generator and the pumps and valves necessary to supply and control steam generator feed in the event of an SBO.

"Corrective Action(s):

"At 0702 hours on 11/27/2005, nitrogen was realigned to 2FDW-316 and TS 3.7.5, Condition E was exited. At 0710 hours on 11/27/2005, nitrogen was realigned to 2FDW-315 and TS 3.7.5 Condition B was exited."

The licensee is investigating the cause of the valve line up problem. The licensee notified the NRC Resident Inspector.



* * * RETRACTION OF EVENT RECEIVED BY JOE O'HARA FROM TRACY ROLAND AT 1333 0N 1/26/06 * * *

"After detailed review of this event, it was concluded that Technical Specification 3.7.5 limiting conditions for operation were met at all times during this event. Control valves 2FDW-315 and 2FDW-316 fail open on loss of air/nitrogen by the spring return design of the actuators. Therefore, the required flow path would not have been lost due to the failure of normal air supply and the isolation of nitrogen supplies to the actuators. It has been further concluded that all throttling functions of these control valves could have been performed manually by use of a local handwheel on each valve actuator. Appropriate procedure guidance exists to operate the system with these valves failed open until the operators can access the local handwheel and take local control. Therefore, the valves and the associated flow paths were operable during this event. As a result of this determination, no reportability criteria under 50.72 and 50.73 apply to this event and the associated event report is hereby retracted."

The licensee notified the NRC Resident Inspector. R2DO(Payne) was notified.

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General Information or Other Event Number: 42284
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TULANE UNIVERSITY HOSPITAL
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0004-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/24/2006
Notification Time: 10:23 [ET]
Event Date: 10/18/2005
Event Time: [CST]
Last Update Date: 01/24/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
GREG MORELL (NMSS)
ENGLISH(e-mail) (TAS)

Event Text

AGREEMENT STATE - MISSING SOURCES FOLLOWING HURRICANE KATRINA

The State reported that a number of radioactive sources are missing following detailed inventories in the aftermath of Hurricane Katrina.

The following two sources appear to have disappeared until suspicious circumstances (possibly associated with looting of the hospital after the Hurricane:

Co-57 Button IP SSM-057-100U #1111-41-2, 100 uCi 4/1/05 now 56.4 uCi
Co-57 Button IP SSM-057-100U #1111-41-5, 100 uCi 4/1/05 now 56.4 uCi

Material is also missing after the refurbishment of the Radiation Laboratory Room. The detectable radioactive sources were removed from the room before it was gutted. Inventory after the material was sorted out showed that the following sources were missing:

1. Co-57 button source Syncor 644-10A 200 uCi 3/1/99 now 0.4 uCi
2. Ba-133 liquid scintillation counter quench source 19 uCi 12/31/87 now 6 uCi
3. Lead pig containing approximately 0.1 uCi R-226 fixed contamination now 0.1 uCi
4. I-125 radiation therapy eye plaque seeds (886 seeds dating from 12/95 to 12/03) in lead container marked "Haik AA" now 0.6 uCi
5. I-125 radiation therapy eye plaque seeds (116 seeds dating from 4/04 to 3/05) in lead container marked "Haik BB" now 2.8 uCi

All material debris from the room was placed into dumpsters for disposal in landfills.

No Louisiana Event # was provided with this report.

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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Other Nuclear Material Event Number: 42288
Rep Org: SANJEL USA, INC
Licensee: SANJEL USA, INC
Region: 4
City: MILES CITY State: MT
County:
License #: 54-27692-01
Agreement: N
Docket:
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: JOE O'HARA
Notification Date: 01/26/2006
Notification Time: 16:11 [ET]
Event Date: 12/07/2005
Event Time: 15:15 [MST]
Last Update Date: 01/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BLAIR SPITZBERG (R4)
JOSEPH HOLONICH (NMSS)

Event Text

FIRE INVOLVING NUCLEAR GAUGE

"This is a follow-up report of an incident involving a nuclear gauge.

"The gauge was a model 5192, built by Thermo Measuretech. It was a 100 mCi source of Cesium 137 Serial # B-6809.

"This gauge was a sealed source, permanently mounted to a 2" high pressure pipe. It was mounted to the plumbing at the rear of Unit 4451, a cement pump unit. The fire apparently started in the building that this truck was housed in for the purposes of thawing a frozen pump. Control of the gauge was never relinquished. A fire started in the facility located approximately 2 miles East of Cut Bank, Mt. and owned by General Well Servicing. The fire is still under investigation by Sanjel's insurance carrier.

"The fire started approximately 1515 on the 7th of December 2005. I was notified at approximately 1801. I notified the USNRC Emergency number @1904.

"First responders were notified by the Sanjel Authorized Users about the gauge. The first responders didn't have access to a survey meter; I arrived on site at 0445 on the 8th of December 2005. I conducted a survey from upwind to the building and found no trace of radiation, but I was restricted from going into the facility by Sheriffs deputy until cleared by the Fire Chief at approximately 0730.

"At 0730, I surveyed the area around the rear of the truck under the observation of the Sheriff s deputy, and surveyed the gauge. I observed readings from 1.5 mRad to what I thought I had read, 11.5 mRad. The survey was made in darkness. I questioned the local fire chief and sheriffs deputy about any personnel coming close to the gauge; I was told that the fire was primarily contained to the front of the vehicle, and the fire fighters were cautioned and restrained from getting within 30 feet of the gauge. I feel that I received the highest dose there removing the gauge/detector and pipe and conducting the survey, taking 10 minutes at 11.5 mRad x 1 (quantifier for beta/gamma sources)= 1.91 mRem/hr.

"The gauge was removed @ 1200 with the permission of the State Fire Marshall and transported by covered vehicle to the Sanjel Miles City office. The area around where the gauge was mounted was surveyed, rendering no recordable readings. The path from the location of the gauge to the recovery vehicle was also surveyed rendering no noticeable readings. A second survey of the gauge was made at the recovery vehicle in daylight, showing a reading on 3 mRad on the sides of the source, 1.5mRad on the front and 2 mRad on the top, 1mRad on the bottom. This would change the highest dose received to 0.5mRem/hr.

"The reason for the delay in this report is my interpretation of RIS 2005-06, 10 CFR 20.2202, and HPPOS-322 I felt this was not a reportable incident. I am reporting this after contacting Jack Witten, Tony Gaines and Bob Brown on January 26, 2006. These are my contacts at the Region IV in Arlington, TX. And being advised that this is a reportable incident under 10 CFR 30.50, (b)(ii).

"The corrective action plan for this incident, is to advise Authorized Users that locations and facilities used on a temporary use must be inspected by management prior to use. As of today, 26 January 2005, the gauge has been transferred to Thermo-Electron for decommissioning due to the repair."

The following information was provided to the NRC Operations Center during the initial notification at 2104 EST on 12/07/05 by the RSO for Sanjel, USA, Inc.:

RSO for Sanjel, USA, Inc called to inform the NRC that his company owns a truck with a Cs-137 source mounted on the back for measuring cement density. The truck is parked inside a well servicing building in Cutbank, Montana and that building is on fire. Fire company personnel have responded and the local sheriff has set up a barrier to keep unauthorized personnel 1 mile from the site due to the hazardous chemicals stored in the building. Sanjel Technicians have informed the sheriff of the Cs-137 source on their truck. The source manufacturer is Thermal Measure Tech, model 5192, Serial # B-6809, Activity - 100 millicuries. The source is mounted on a pipe to measure the cement density pumped through the pipe, and is enclosed in a lead shield with normal on contact radiation readings of 2 mr/hr. Sanjel NRC license # is 54-27692-01. RSO is enroute to the site of the fire (8 hours away). While in route, he will keep NRC HQ notified of any updates he receives and will make a final report once he can access the situation properly.

Notified R4DO (Kennedy) and NMSS EO (Pierson)

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