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Event Notification Report for February 22, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/21/2006 - 02/22/2006

** EVENT NUMBERS **


41750 42334 42347 42353 42356

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 41750
Rep Org: PENN STATE UNIVERSITY
Licensee: PENN STATE UNIVERSITY
Region: 1
City: UNIVERSITY PARK State: PA
County:
License #: 37-185-4
Agreement: N
Docket:
NRC Notified By: ERIC BOELDT
HQ OPS Officer: BILL GOTT
Notification Date: 06/07/2005
Notification Time: 10:44 [ET]
Event Date: 06/06/2005
Event Time: 11:00 [EDT]
Last Update Date: 02/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
TODD JACKSON (R1)
JOHN HICKEY (NMSS)
CHUCK CAIN (R4)

Event Text

LOST OR STOLEN VIAL OF PHOSPHORUS 32

"In accordance with 10 CFR 20.2201 Reports of theft or loss of licensed material [the Penn State University Radiation Safety Officer called] to report missing radioactive material in excess of 10 times the quantity specified in appendix C to part 20. The missing material is one vial of phosphorus-32. The vial contained a nominal 74 MBq (2 milliCuries) of P-32. The material in question was never in the possession of Penn State University.

"On June 4, 2005, a Type-A package containing three vials of radioactive P-32 was shipped from California to Penn State University via FedEx (tracking number 689818990843). When the package arrived at Penn State University on June 6, 2005, it only contained two of the three vials of P-32. When the vendor was contacted by Penn State University personnel, the vendor insisted that the material had been placed inside the package as was indicated on the shipping papers. The Penn State Health Physics Office staff member who opened the package reported that the security seal tape was properly attached and that the package displayed no evidence of tampering.

"The frozen liquid radioactive material that was not received was in the chemical form of Adenosine 5-Triphosphate (gamma P-32) End Labeling (P-32). Lot number J5E32. The package also contained dry ice.

"All other packages in the shipment were double checked to verify that the vial was not present in a separate package. The activity reported on the package's shipping label indicated the that the vial was within the package, the shipping papers indicated that the vial was within the package. The package was shipped by the vendor via FedEx in accordance with their normal procedures."

The licensee does not believe the box was opened or the material misdirected.

Vendor:
MP Biomedicals, Inc
15 Morgan
Irvine, CA

* * * UPDATED AT 0730 EDT ON 6/8/05 BY HUFFMAN TO MAKE A CORRECTION IN THE EVENT HEADER * * *

* * * UPDATED AT 1430 EST ON 2/21/06 FROM CA RAD PGM OFFICE (DONELLE KRAJEWSKI) TO S. SANDIN * * *

Received a call from the State of California Rad Program representative. During a followup investigation by CA, it was determined that only two of the three vials ordered had been shipped. CA would update the original licensee NMED report to show that there was no missing rad material. Notified R4DO(Pick) and NMSS(Morell).

* * * UPDATED AT 1445 EST ON 2/21/06 FROM ERIC BOELDT TO S. SANDIN * * *

Contacted the licensee to provide information received from the State of CA. The licensee is retracting this report based on this information. Notified R1DO(Henderson) and NMSS(Morell).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42334
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/13/2006
Notification Time: 17:18 [ET]
Event Date: 02/13/2006
Event Time: 09:33 [EST]
Last Update Date: 02/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PAUL KROHN (R1)

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 SINGLE POWER SUPPLY COULD RESULT IN LOSS OF VENTILATION FOR DC SUBSYSTEMS IN BOTH UNITS

"At 09:33 on February 13, 2006, a Susquehanna field operator inadvertently tripped an essential instrument AC panel breaker, while applying an energy control tag. He immediately communicated this condition to the control room, and then closed the breaker to restore power. During the subsequent investigation to determine applicable technical specifications, control room operators discovered that the tripped breaker resulted in a momentary loss of both battery room exhaust subsystems. To comply with the required actions for a loss of both battery room exhaust subsystems, Susquehanna declared all Unit 1 and Unit 2 DC subsystems inoperable, which resulted in LCO 3.0.3.

"Although the entry into LCO 3.0.3 is not reportable, Susquehanna did discover an unanalyzed condition on both units that significantly degrades plant safety, which is reportable in accordance with 10CFR50.72(b)(3)(ii). The loss of a single power supply could result in the loss of ventilation and cooling for all DC subsystems on both units, leading to degradation of essential DC power sources. This condition does not meet single failure criteria for safety-related equipment."

The licensee notified the NRC Resident Inspector.

* * * UPDATE 1342 EST ON 2/21/06 FROM GORDY ROBINSON TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"At 0933 hours on February 13, 2006, a Susquehanna field operator inadvertently tripped an essential instrument AC panel breaker while applying an energy control tag. The field operator immediately communicated this condition to the control room and was directed to close the breaker to restore power. The breaker trip resulted in a momentary loss of exhaust flow from the Class 1E 125 VDC and 250 VDC battery rooms. In response, operators declared all Unit 1 and Unit 2 batteries inoperable. An ENS notification (# 42334) was initiated in accordance with 10CFR50.72(b)(3)(ii)(B), Unanalyzed Condition that Significantly Affects Plant Safety, because the loss of a single power supply rendered the status of all station essential DC power sources (Batteries) indeterminate and, thus, inoperable. It was believed that this condition did not meet single failure criteria for safety-related equipment.

"Subsequent analysis of this event has revealed that the battery room exhaust system acted per design. The system's design is consistent with intended logic that ensures single failure proof isolation of the system, in compliance with the single failure criterion, in response to a toxic gas release. The single failure proof design of the battery exhaust system ensures isolation, not continued operation, in the presence of a single failure. The analysis further concluded that a short term loss of battery room exhaust does not compromise a battery's ability to function. The insights obtained through this analysis provide the basis for retraction of the ENS report of February 13, 2006."

The licensee informed the NRC Resident Inspector. Notified R1DO(Henderson).

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General Information or Other Event Number: 42347
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SCHLUMBERGER TECHNOLOGY CORPORATION
Region: 4
City: SONORA State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LATISCHA M. HANSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/17/2006
Notification Time: 16:08 [ET]
Event Date: 02/17/2006
Event Time: [CST]
Last Update Date: 02/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
SANDRA WASTLER (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT - WELL LOGGING SOURCES STUCK DOWNHOLE

"Event date and time of occurrence:
- Stuck 1/12/06 @1:35
- Multiple recovery attempts from 1/12/06 to 1/26/06
- Request to Abandon Source made by telephonic contact 1/25/06 @ 12:30 CST to Texas DSHS.
- Written notification to DSHS dated 1/26/06.

"Date notified of event by licensee: Incident Investigation received the written notification dated 02/06/06.

"Radionuclide, activity:
(1) - Cs-137 @ 1.7 Ci
(1) - Am241Be @ 16 Ci

"Sealed source, device, etc, (make, model #, serial #): Well logging tool - sealed neutron generator tube

"Leak test information, when applicable:
(1) Cs -137 - 1/12/06 - 9.48E-06 microcuries
(2) Am241BE - 1/12/06 - 1.52E-01 microcuries

"Equipment (make, model #, serial #), and clear description of any equipment problems:
(1) Cs- 137 - Amersham Corp., M# CDC.CY3, S# A5006
(2) Am241BE - Gammatron, Inc., M# NSR-F (AN-HP) S# G5044

"Cause, and contributing factors
While logging down at a location 14 miles West South-West of Sonora, Texas (Sawyer Canyon Field), the logging unit had multiple failures, causing a free spool of tools & 18,000 feet of cable to enter into the hole. The hole was drilled on AIR & was never loaded with fluid. Fishing tool company attempted ~11 runs to recover tools. Hole cemented on 1/27/06 @ 18:00

"Licensee corrective actions:
(1) Cs- 137 Density Source abandoned @ 8,607 feet.
(2) Am241BE Neutron Source abandoned @ 8,590 feet.
Abandonment plaque constructed with the relevant abandonment depth location information. Well depth: 8, 625 feet. Special instructions to not enter the well before contacting Radiation Control - DSHS.

"Provide status through resolution (update record when found):
Well sealed with cement & abandoned 1/27/06. Dominion E&P, Inc., Sutton County, Texas"

Texas Incident No.: Texas, I-8306

Abandoned in accordance with 10CFR39.77[c].

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Hospital Event Number: 42353
Rep Org: MIDSTATE MEDICAL CENTER
Licensee: MIDSTATE MEDICAL CENTER
Region: 1
City: MERIDEN State: CT
County:
License #: 06-05686-02
Agreement: N
Docket:
NRC Notified By: EILEEN NOBLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/21/2006
Notification Time: 17:00 [ET]
Event Date: 01/09/2006
Event Time: [EST]
Last Update Date: 02/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
PAMELA HENDERSON (R1)
SCOTT MOORE (NMSS)

Event Text

LOSS OF GADOLINIUM-153 SOURCE

The licensee reported that a gadolinium-153 source (1 Curie Amersham Source #2837LN assayed 08/21/91) cannot be accounted for. The source was installed in a bone mineral density device (LUNAR DP-3) that was retired in 1994. The licensee became aware of this issue when NRC Region 1 inquired into the status of the source during a license renewal application review. Based on the investigation to date, the licensee determined that the bone mineral density device was likely disposed of as scrap metal. The disposition of the source is uncertain. There is no indication that the source was removed from the device and placed into storage. There are also no records that it was returned to Amersham (or its predecessor company). The licensee stated that Amersham did not have source reclamation records dating to the mid-1990s.

The licensee noted that the Midstate Medical Center has undergone significant management change since the 1994 including the RSO position. The licensee does not have the same name (previously Veterans Memorial Medical Center) and is not even located in the same building as it was when the source containing bone mineral density device was retired. The current strength of the source based on decay would be 0.2 microCuries.

The licensee's investigation is continuing. NRC Region 1 (W. Lee and R. McKinley) have been interacting with the licensee on this event.

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: 42356
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DARYL CLARK
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/22/2006
Notification Time: 04:51 [ET]
Event Date: 02/22/2006
Event Time: 01:22 [CST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 85 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO VALID MAIN TURBINE LOAD REJECT SIGNAL

"At 0122 hours (CST) on February 22, 2006, the Unit 1 reactor automatically scrammed from 85% power due to a valid turbine-generator load reject signal. The maximum reactor pressure was approximately 1050 PSIG during the event. All control rods inserted to their full-in position. Reactor water level decreased to approximately -10 inches, which resulted in automatic Group 2 and 3 isolations as expected. All systems responded properly to the event. Unit 1 is in Mode 3, maintaining reactor pressure, and reactor water level in the normal level band. An investigation into the Unit 1 scram and load reject is in progress.

"Unit 2 remains at 85% power.

"This report is being made in accordance with 10CFR 50.72(b)(2)(iv)(B) and 10 CFR50.72(b)(3)(iv)(A)."

No SRVs opened during the transient. Post shutdown electrical lineup is normal with the exception of the loss of one offsite power supply. Decay heat is being removed via the turbine bypass valves to the main condenser and feedwater being provided via main feedwater. Unit 2 is in a Tech Spec LCO for Loss of One Offsite power source.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 25, 2021