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Event Notification Report for February 24, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/23/2006 - 02/24/2006

** EVENT NUMBERS **


42349 42350 42354 42365 42366 42367 42369 42370 42372

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General Information or Other Event Number: 42349
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: MCAFEE, HENDERSON AND STRICK INC
Region: 4
City: WINCHESTER State: KS
County:
License #: 22-B834
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: BILL GOTT
Notification Date: 02/20/2006
Notification Time: 10:03 [ET]
Event Date: 02/19/2006
Event Time: [CST]
Last Update Date: 02/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
E. WILLIAM BRACH (NMSS)
TAS (email) ()

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

Between Saturday February 18, 2006 and Sunday morning February 19, 2006, a Troxler (Model 3440, S/N 31113, containing two sources; i.e., 0.3GBq [8 mCi] Cs-137 and 1.48 GBq [40 mCi] Am-241:Be) moisture density gauge was stolen from the operator's residence. The residence was the normal storage location for this gauge. The gauge was stolen along with other equipment from the operator's residence. The event was reported to local law enforcement.

Case Number: KS060001

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: 42350
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NONDESTRUCTIVE & VISUAL INSPECTION
Region: 4
City: HARVEY State: LA
County:
License #: LA-5601-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/20/2006
Notification Time: 15:35 [ET]
Event Date: 12/31/2005
Event Time: [CST]
Last Update Date: 02/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
E. WILLIAM BRACH (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL OVEREXPOSURE OF THREE EMPLOYEES

The State of Louisiana submitted the following report via fax:

"Event Date and Time: December 2005

"Nondestructive & Visual Inspection had three overexposures at the end of 2005. [The first employee] had a dose of 8445 mRem for the year 2005. He was questioned by the RSO and Vice President of the company but could not explain the readings. He was ordered to retake the 40 hour radiation safety course and finished it on February 9, 2006. [The second employee] received a dose of 5221 mRem, for the year 2005. 2092 mRem of this exposure came in September, but the September badge report did not reach Nondestructive Inspection until the end of December because of mail problems after Hurricane Katrina. The mail problem has been addressed by sending the badges to a different location. [The third employee] received a dose of 5221 mRem for the year 2005. [The third employee's] overexposure is still under investigation. The facility is still in the process of reviewing the circumstances that caused the overexposures and are implementing procedures to stop them from re-occurring."

LA Event Report ID No.: LA060002

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General Information or Other Event Number: 42354
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/21/2006
Notification Time: 17:21 [ET]
Event Date: 02/21/2006
Event Time: [CST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE - LOSS OF IRIDIUM SEED STRAND FOLLOWING MEDICAL TREATMENT

The following is a summary of information provided by the State via email:

The licensee's Radiation Safety Officer indicated that a gynecological implant of seeds contained in a nylon ribbon were missing at the completion of a patient treatment. The "strand" contained 10 seeds of 0.675 milliCi, each, which was part of a treatment that included 9 total strands of both Cs-137 and Ir-192 sources. The lost strand contained 10 Ir-192 seeds.

A resident physician removed the strands at the end of the treatment on the evening of 2/18/06. The treatment had begun on 2/15/06. After returning the strands to the radiation oncology lab it was noted that only 8 strands were present, rather than the 9 which were initially implanted. The patient was thoroughly surveyed and eventually x-ray'd to confirm the missing strand did not remain in the patient. The operating room, the patient's room, the remaining linen and trash from the patient's room, the hallway between the patient's room and the radiation oncology source storage location, the entire nursing floor, the radiation oncology department, the hospital's linen holding facility, the biohazardous waste holding facility and loading docks were all monitored without any success of locating the strand. The patient had been essentially immobilized for the treatment and had received a Foley catheter for relieving her bladder. As such, use of the toilet facilities were not likely (although they too were monitored). Surveys were conducted with instruments that were likely to detect the radiation field associated with almost 7 mCi of Ir-192 (i.e., 4 to 5 milliRem/hr at 1 meter) by the staff.

Interviews were conducted with the nursing staff to determine additional details regarding handling of trash and linen from the patient's room. Although the licensee's surveys showed no elevated levels present at the time, the licensee indicated that waste and linen from the room would be held pending potential surveys by the Division.

The licensee has also monitored their contracted biohazardous waste treatment facility in Cicero, IL on 2/20/06 with negative results. They also planned to visit the linen laundering facility in Palwaukee, IL on the slim chance that the strand was carried off in soiled linens that might have been changed during the patient's stay.

The resident involved, the residency staff and the residency director received additional instruction regarding established procedures, in conjunction with this event, with regards to explanation of sources and accounting procedures. Similarly, the nursing staff was interviewed and refreshed on established procedures with regards to linen and waste processing from patients' rooms. The patient was scheduled to return for a follow up visit on 2/22/06 at which time she was going to be interviewed again to determine if there was any additional information she could provide to help locate the missing strand.

Illinois Report #IL060013

* * * UPDATE PROVIDED BY PERRERO TO JEFF ROTTON AT 1034 EST ON 02/23/06 * * *

The missing radioactive sources reported by the Illinois Emergency Management Agency (IEMA) on February 21, 2006 at 17:21 from Northwestern Memorial Hospital have been recovered by the facility's radiation safety officer. A radiation monitor alarm was reported to IEMA by the Prairie Hills Landfill staff in Morrison, IL on 2/21/2006. IEMA personnel investigated that alarm yesterday [02/22/06] and confirmed the presence of Ir-192 by gamma spectroscopy as part of a load of trash that was traced back to the hospital's laundry service provider. Arrangements were made to have the ribbon of 10 sources picked up by hospital staff this morning and returned to the hospital for proper disposal.

Notified R3DO (Hills) and NMSS EO (Morell)


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42365
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: KEITH DROWN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/23/2006
Notification Time: 04:29 [ET]
Event Date: 02/23/2006
Event Time: 03:31 [EST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
PAMELA HENDERSON (R1)

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

Event Text

ACCIDENT INVOLVING TRANSPORTATION OF RADIOACTIVE MATERIAL

At 0331 EST on 2/23/06, a tractor trailer truck delivering new fuel assemblies backed into the Fuel Handling Building roll up door. The door was 4 feet from the full up position. The upper fuel transport container was pushed into the door but had no visible damage. The truck sustained no damage also. The Fuel Handling Building roll up door had slight damage. This door is only required as a barrier during spent fuel handling which is not in progress. No release of radioactivity occurred.

The licensee notified the NRC Resident Inspector.

*** UPDATE FROM PRUSSMAN TO KNOKE AT 12:44 EST ON 2/23/06 ***

Licensee is retracting this event based on the following information:

"At 0429 hours EST, Indian Point 2 reported a tractor trailer truck delivering new fuel assemblies backed into the Fuel Handling Building roll up door. This was event 42365. This event was reported based upon procedural guidance that referenced 49CFR171.15. Indian Point 2 is retracting this notification based on a review of the detailed reporting requirements of 49CFR171.15(b) and a conclusion that none of those reporting requirements was met."

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

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Power Reactor Event Number: 42366
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: JOE O'HARA
Notification Date: 02/23/2006
Notification Time: 10:54 [ET]
Event Date: 02/23/2006
Event Time: 08:16 [CST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
GREG PICK (R4)

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

FITNESS FOR DUTY EVENT

"At approximately 0816 CST a senior licensed operator failed a random fitness-for-duty test administered by the station. The individuals access to the site has been blocked."

The licensed employee supervisor had a confirmed positive test for alcohol during a random fitness -for-duty test. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42367
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MARK STROLLO
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/23/2006
Notification Time: 11:16 [ET]
Event Date: 02/23/2006
Event Time: 10:22 [EST]
Last Update Date: 02/23/2006
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):
PAMELA HENDERSON (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF MAIN FEEDWATER

Loss of main feedwater occurred due to an instrument air line failure during a maintenance activity. The reactor was manually tripped and all control rods inserted fully. Auxiliary feedwater received an auto start signal and is providing feedwater to the steam generators. No safety relief valves or PORVs lifted. Decay heat removal is via the turbine bypass valves to the condenser. The plant is in a normal shutdown plant electrical lineup and there was no effect to Unit 3. The licensee notified the State of Connecticut and the city of Waterford. A media press release will be made at a later time.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 42369
Rep Org: FEDERAL AVIATION ADMINISTRATION
Licensee: GENERAL LICENSE
Region: 1
City: WASHINGTON State: DC
County:
License #: GENERAL
Agreement: N
Docket:
NRC Notified By: TERRY LAYDON
HQ OPS Officer: ARLON COSTA
Notification Date: 02/23/2006
Notification Time: 13:50 [ET]
Event Date: 01/01/1994
Event Time: [EST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

LOST STATIC ELIMINATORS

Federal Aviation Administration (National Aeronautics Charting Office) was in the process of changing photo processors equipment from a PAKO processor system that used static eliminators (manufactured by NRD LLC, Grand Island, New York) to a coax processor which do not use anti-static bars, in the mid 1990s (1994-1995). Around that time it was possible that six static eliminators left unaccounted with the excessed equipment sent to a NOAA warehouse surplus office. The specific information for these static eliminators are: serial numbers SA2201 and SA2203 (Each: 20.25 mCi, Am-241, bar is 54" long by 1.5" x 1.25"); SA2204 and SA2205 (Each: 18 mCi, Am-241, bar is 48" long by 1.5" x 1.25"); SA2206 and SA2207 (Each: 6.75 mCi, Am-241, bar is 18" long by 1.5" x 1.25"). The Environmental Officer at the Department of Commerce will contact NOAA in an effort to track down the material.

Recently the National Aeronautics Charting Office was in the process of moving equipment from the basement of the Department of Commerce building in Washington, DC to a new facility and during the cleanup, two unused static eliminators ended up in a trash compactor and subsequently at the Mosteller Landfill facility in Pennsylvania. The specific information for these static eliminators are: serial numbers SA2200 and SA2202 (Each: 20.25 mCi, Am-241, bar is 54" long by 1.5" x 1.25"). It was reported that one of these static eliminators could be leaking. Arrangements are being made to send these devices from the landfill to the manufacturer for proper disposal.

There is one more static eliminator (serial number SA2199 (25.875 mCi, Am-241, bar is 71" long by 1.5" x 1.25") in the basement of the Department of Commerce building in Washington, DC and a survey for low-level contamination is being conducted in response to the static eliminators found at the Mosteller landfill which could possibly be leaking.


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: 42370
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEE KELLY
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/23/2006
Notification Time: 15:07 [ET]
Event Date: 02/23/2006
Event Time: 04:00 [PST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG PICK (R4)

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

Event Text

MINOR LEAKAGE OF WASTEWATER FROM TRANSPORT TRUCK

"On February 22, 2006, at 1000 PST, two tankers containing wastewater with trace levels of radioactivity departed San Onofre Nuclear Generating Station (SONGS) Unit 1 Industrial Site for Clive, Utah. Each truck contained about 4500 gallons of water. At about 0400 PST February 23, 2006, SCE was notified by the trucking company [Triad Transport Company] that minor leakage from a valve on top of one of the trucks had been observed. The leakage was observed while the truck was stopped in Parawan, Utah approximately 4 hours from its destination.

"The driver of the truck immediately notified his management who traveled to the site, identified the origin of the leak as spray from a valve on top of the truck, relieved the tank pressure from a vent valve, and stopped the leak. Dampness was observed on the ground beside the tanker. Unconfirmed measurements indicate radiation levels are near background.

"SCE has dispatched a team to the site to coordinate remediation efforts as necessary. The second tanker has arrived at the site in Clive, Utah and no leakage was observed during receipt inspection. The Director of the Utah's Division of Radiation Control and the NRC Resident Inspectors have been notified of this occurrence. At the time of this report, Unit 1 was undergoing decommissioning."

The activity from the radionuclides totaled 70.9 mCi, and primarily consisted of Cs-137 (41 mCi), Ni-63 (15 mCi), and Co-60 (5 mCi). The transport company notified the National Response Center. The truck traveled thru 4 States: CA, NV, AZ UT.

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Power Reactor Event Number: 42372
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK GORLEY
HQ OPS Officer: JOE O'HARA
Notification Date: 02/23/2006
Notification Time: 23:37 [ET]
Event Date: 02/23/2006
Event Time: 18:50 [EST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BRIAN BONSER (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

DEGRADED CONDITION OF SHROUD TIE RODS

"While performing Unit One [In-Vessel Visual Inspection] IVVI examination of the four Shroud Tie Rods (Upper Support Horizontal Support Surface) the following results were reported:

"Tie Rod at 135 degree location: Crack-like indications beginning at the inner corner on both sides of the left support and extend to two thirds of the way to the outer corner with full penetration.

"Tie Rod at 225 degree location: Crack-like indication beginning at the inner corner on one side of the left support and extending a small portion of the way toward the outer corner. The indication is similar to that described for the shroud tie rod in the 135 degree location except that it is much less pronounced and is only on one side.

"Tie Rod at 45 degree location: No apparent indications present.

"Tie Rod at 315 degree location: No apparent indications present.

"One of the design criteria of the Shroud Tie Rods is to maintain zero separation between the shroud horizontal welds at 100% uprated power, assuming all of the horizontal welds (H1 thru H8) are fully cracked. The Shroud Tie Rods are also designed to maintain structural integrity of the shroud during all design basis accidents and transients.

"These findings bring into question the ability of these shroud tie rods to have performed their design function with the reactor in operation. This condition constitutes a serious degradation of a principal safety barrier had the unit been operating. The reactor is presently shutdown and the condition discovered does not represent an immediate safety concern for Unit 1. The extent of this condition is believed to be limited to Unit 1, since Unit 2 core shroud tie rods are made of different materials and installed in a different configuration."

The licensee notified the NRC Resident Inspector.

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