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Event Notification Report for March 9, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/08/2006 - 03/09/2006

** EVENT NUMBERS **


42383 42384 42388 42391 42395 42396 42397 42398 42399

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General Information or Other Event Number: 42383
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: GE ION TRACK
Region: 1
City: WILMINGTON State: MA
County:
License #: 15-5254
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/03/2006
Notification Time: 14:30 [ET]
Event Date: 09/19/2005
Event Time: [EST]
Last Update Date: 03/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
SCOTT FLANDERS (NMSS)
TAS (E-MAIL) ()

Event Text

AGREEMENT STATE REPORT - LOST NICKEL-63 SOURCES

The Commonwealth of Massachusetts submitted the following report via e-mail:

"A shipment of 23 devices was scheduled for delivery to a customer in Georgia. AIT Worldwide Logistics, the contract freight forwarder, acknowledged receipt of the 23 devices on September 14, 2005 from GE Ion Track. On Sept. 19th, 2005, when the truck checked into the forwarder's final distribution hub, the shipment was noted to be 2 devices short. The freighter forwarder conducted searches of its distribution centers, and was unable to locate the devices.

"GE Ion Track performed a thorough search of their Wilmington, MA facility and the devices were not located. GE Ion Track's and its subcontractor's database showed that the devices had not been transferred to another customer or recipient.

"GE Ion Track discovered that these sources were missing on January 24, 2005 and made notification to the Massachusetts Radiation Control Program on January 30, 2006.

"The customer in Kuwait and Georgia compared the shipping list to what they received and it was determined that the two missing devices are:
"1) Vapor Tracer 2, serial number 120014, source number 09-13171
"2) Itemizer 3, serial number 20566, source number 09-13480

"Each device contained an 8 mCi source of Ni 63 in a foil form, model NER 004 manufactured by Isotope Products Laboratories.

"GE Ion Track has concluded that the devices were lost in shipment. As a preventative measure, freight forwarders and transport companies will be asked to verify quantity before accepting shipment from GE Ion Track.

"MRCP will be visiting the licensee on Monday March 6, 2006 for investigation."

The missing sources were originally reported in a lost voice mail message to the Massachusetts Radiation Control Program on 1/30/2006. The state verified the loss on 3/3/2006.

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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General Information or Other Event Number: 42384
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: ANVIL INTERNATIONAL
Region: 1
City: NORTH KINGSTON State: RI
County:
License #: 3D064-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/03/2006
Notification Time: 16:52 [ET]
Event Date: 03/03/2006
Event Time: 14:15 [EST]
Last Update Date: 03/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
SCOTT FLANDERS (NMSS)
BETH HAYDEN (OPA)
SANDRA LAI (OSTP)

Event Text

AGREEMENT STATE REPORT - PERSONNEL OVEREXPOSURE

A radiography trainee was traversing from one cell to another with the trainer at a fixed radiography facility. Neither individual had a radiation meter. The trainee picked up a guide tube containing a 93 Curie Ir-192 source. The guide tube was held for approximately one minute and the individual was in the vicinity for approximately three minutes.

The licensee estimates the individual received a dose of 2-3 rems whole body and 1000 rems to the hand. Rhode Island Department of Health Radiation Control estimates the dose at 8 rems whole body and 18000 rems to the hand. The individual is being transferred to the Emergency Room.

The job has been shut down. The state Department of Radiation Control will visit the site on Monday.

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General Information or Other Event Number: 42388
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: VIA CHRISTI CANCER CENTER
Region: 4
City: PONCA CITY State: OK
County:
License #: OK-14046-02
Agreement: Y
Docket:
NRC Notified By: M. BRODERICK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/06/2006
Notification Time: 10:30 [ET]
Event Date: 03/01/2006
Event Time: 12:00 [CST]
Last Update Date: 03/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
MICHELE BURGESS (NMSS)

Event Text

INCORRECT DOSE GIVEN TO PROSTATE PATIENT

The State provided the following information via facsimile:

"The medical physicist for the Via Christi Cancer Center reported that a medical event had occurred the day before. A patient was treated for prostate cancer with I-125 seeds. An activity of 0.4 air kerma units per seed was ordered. The seeds were received with an activity of 0.4 millicuries per seed. The difference in activity units was not detected until after the surgery was completed. The patient received a total dose of 12,850 centigray rather than the prescribed 10,000 centigray; a 28% difference. The radiation oncologist has determined that this larger dose should not cause any untoward harm to the patient. The referring urologist and the patient have been notified of the dose discrepancy. As corrective action, the licensee plans to introduce a new form to be used as part of the procedure followed during permanent implant preparation. This form will be used to record seed activity, including the units, used in treatment planning, listed on the shipping form as well as the seed activity observed at the time of implant."

OK Item # - OK060004

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General Information or Other Event Number: 42391
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COTTER CORP URANIUM MILL
Region: 4
City: CANYON CITY State: CO
County:
License #: 369-01
Agreement: Y
Docket:
NRC Notified By: PHILIP EGIDI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/06/2006
Notification Time: 20:00 [ET]
Event Date: 03/01/2006
Event Time: 01:00 [MST]
Last Update Date: 03/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SCOTT FLANDERS (NMSS)
MELVYN LEACH (IRD)

Event Text

YELLOW CAKE DRUM EVACUATED INTO ENCLOSED ROOM

At approximately 14:00 on 2/28/2006, an employee noticed that a drum of soluble yellow cake had a bulging lid and bottom cap. At 01:00 on 3/1/06, an employee in full protective clothing entered the calciner to release the lid. When the lid was released, approximately half of the barrel's contents evacuated the barrel. Some of the yellow cake went under the employee's hood.

The employee will undergo testing 3/7/06.

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Power Reactor Event Number: 42395
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL ABBOTT
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/08/2006
Notification Time: 14:08 [ET]
Event Date: 03/08/2006
Event Time: 11:09 [EST]
Last Update Date: 03/08/2006
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):
JOHN WHITE (R1)
ERIC BENNER (NRR)
PETER WILSON (IRD)

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

Event Text

AUTOMATIC REACTOR TRIP AS A RESULT OF A TURBINE GENERATOR TRIP

"This 4-hour notification is being made in accordance with 10CFR50.72(b)(2)(iv)(b). Salem Unit-1 reactor automatically tripped at 1109 (RPS actuation). The trip was initiated due to turbine trip. The cause of the turbine trip is being investigated.

"All safety systems functioned as designed with the exception of control rod 1SC1, which did not fully insert. 1SC1 indicates 16 steps. It should indicate zero steps when fully inserted. Auxiliary Feedwater pumps started as expected. Off-site power is available. Emergency diesel generators are available but not required at this time.

"During the implementation of the EOP's, a steam leak was reported in the Turbine Building. The Main Steam Isolation Valves (MSIV's) were closed as a conservative measure. This is an 8-hour reportable occurrence in accordance with 10CFR50.72(b)(3)(iv)(a). The leak was subsequently identified as a feedwater leak on the 11CN32 (11 Steam Generator Feed Pump suction valve). The Condensate System was placed in a normal shutdown line-up and the leak is not an impact to personnel safety or plant stability. Decay heat removal is via the atmospheric steam dumps at this time. The MSIV's are being bypassed to restore the main condenser as a heat sink.

"Salem Unit-1 is currently in Mode 3 with reactor coolant system temperature at approximately 549 deg F with pressure at 2235 psig.

"There was no equipment out of service that contributed to this event and there were no personnel injuries or radiological occurrences associated with this event."

The licensee has notified the NRC Resident Inspector and will be making State and local notifications. A press release is expected.

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Power Reactor Event Number: 42396
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: STEVE PRUSSMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/08/2006
Notification Time: 17:15 [ET]
Event Date: 03/08/2006
Event Time: 10:30 [EST]
Last Update Date: 03/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN WHITE (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS - SIRENS IN EMERGENCY PLANNING ZONE

"On March 8, 2006, at approximately 1030 hours, a full alert siren test was initiated for the sirens in the Indian Point emergency planning zone. Of the 156 sirens, the system initially reported that the activation was underway at 138 sirens. Eighteen of the fifty one sirens in Rockland County (one of the four counties in the 10 mile emergency planning zone) indicated communications failures. One of these, siren R-17, was out of service prior to the test. A final activation report was not available from the system. However, the initial system report was accepted as a basis for the ENS notification since twenty five percent of the sirens had observers who confirmed the initial report results for the sirens they observed.

"During the test the siren system computer locked up. None of the 156 sirens could be activated with the computer in this condition. These conditions represent a degraded emergency siren notification system which is reportable under 10 CFR 50.72(b)(3)(xiii). Both Units 2 and 3 were at 100 percent power and remain at 100 percent power.

"The siren system was returned to service at approximately 1510 hours on March 8, 2006, with the exception of siren R-17 which remains out of service. All four counties conducted a silent test to confirm functionality. The program application that malfunctioned has been identified and is now functioning properly. The cause of the malfunction is still under investigation.

"The counties and State were notified of the loss of sirens. In the event of an emergency, route alerting and outbound calling would have been available to compensate for the siren system loss. Condition report IP2-CR2006-01138 was written for this event."

The licensee notified the NRC Resident Inspector and other Government agencies.

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Power Reactor Event Number: 42397
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/08/2006
Notification Time: 17:26 [ET]
Event Date: 03/08/2006
Event Time: 08:00 [EST]
Last Update Date: 03/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JOHN WHITE (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

Event Text

24-HOUR CONDITION OF LICENSE REPORT DUE TO FAILURE TO SUBMIT TS REQUIRED EXPOSURE REPORT

"At 0800 on March 8, 2006, FPL Energy Seabrook discovered a failure to comply with administrative Technical Specification (TS) 6.8.1.2.a. This TS requires submittal of a radiation occupational exposure report by March 1 of each year. On March 8, FPL Energy Seabrook discovered that the report for 2005 had not been submitted and, consequently, failed to meet the March 1st submittal date specified by TS 6.8.1.2.a. This condition is being reported in accordance with the Seabrook Station Facility Operating License, condition 2.G, which requires a 24-hour notification of any violations of section 2.C.(2) of the operating license (FPL Energy Seabrook, LLC shall operate the facility in accordance with the Technical Specifications and the Environmental Protection Plan)."

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 42398
Rep Org: SABIA, INC
Licensee: SABIA, INC
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES MILLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/08/2006
Notification Time: 17:40 [ET]
Event Date: 01/11/2006
Event Time: [PST]
Last Update Date: 03/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CHUCK CAIN (R4)
JULIO LARA (R3)
MICHAEL MARKLEY (NMSS)

Event Text

PART 21 NOTIFICATION - DEFECT IN A MATERIAL ANALYZER

The RSO provided a report for the failure of a source position indicator on a SABIA, Model XC-series-25 materials analyzer (device per NR-1195-D-103-S) located at Cyprus Creek Mine in Indiana. During a scheduled NRC inspection on 01/11/06 of the shutter for the radioactive source, with the shutter indicating being in the locked out (OFF) position, the source was actually in the open position and the shutter lever appeared to be 180 degrees out of position. During an internal inspection by SABIA on 01/14/06, everything appeared to be in good working order. It was determined that prior to the NRC inspection on 01/11/06, a contractor who was performing a wipe survey of the device retracted the source, but rather than moving the source lever as indicated by the arrows, moved the lever the shortest distance to OFF. This action forced set screws to slip and move the handle to OFF but the sources remained active (ON).

In this instance, because the NRC inspector arrived soon after the lever position had been changed, no maintenance was done on the conveyor inside the analyzer while the indication was wrong and no one received any radiation dose resulting from this problem. The unit was repaired by removing the handle and replacing it in the proper position.

SABIA will prepare mechanical stops to put on all analyzers that will prevent the source handle from being moved in the wrong direction and will install them as analyzers are routinely serviced.

This information represents an interim report, and a final report, together with corrective actions, will be forwarded within 30 days.

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Power Reactor Event Number: 42399
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MICHAEL COEN
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/08/2006
Notification Time: 22:38 [ET]
Event Date: 03/08/2006
Event Time: 15:53 [EST]
Last Update Date: 03/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
PAUL FREDRICKSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

VALID ACTUATION OF EMERGENCY DIESEL GENERATORS

"While restoring power to the 3C 480V Load Center following planned maintenance, the 3A safety related 4KV Bus was deenergized by the 3A Sequencer. This resulted in a valid actuation of the emergency diesel generator. The plant was in Mode 5, depressurized, with reactor coolant system level at approximately the vessel flange level. This resulted in a temporary loss of residual heat removal flow which was restored within approximately seven (7) minutes. Reactor coolant system temperature increased from 113 degrees F to 140 degrees F.

"Reactor coolant system level and temperature were stabilized at pre-event values."

At this time the licensee is preparing to restore off-site power to the 3A Bus and put the emergency diesel generator in standby. The licensee is also investigating the cause of the power loss to the 3A safety related 4KV Bus.

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012