United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2006 > March 20

Event Notification Report for March 20, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/17/2006 - 03/20/2006

** EVENT NUMBERS **


42418 42419 42423 42425 42426 42428 42429

To top of page
General Information or Other Event Number: 42418
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: MONROE State: LA
County:
License #: LA-5119-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: JOE O'HARA
Notification Date: 03/14/2006
Notification Time: 14:45 [ET]
Event Date: 03/05/2006
Event Time: [CST]
Last Update Date: 03/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
ROBERT PIERSON (NMSS)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED IMPROPER MEDICAL DOSE

The State provided the following information via facsimile:

"On March 5, 2006, a technician at St. Francis North Hospital contacted the Cardinal Health pharmacy to inform them that a scan on a patient had shown lung imaging instead of the expected cardiac imaging after administering a dose labeled Myoview. An investigation revealed that the customer's Tc-99m Myoview dose for cardiac imaging had mistakenly been dispensed as a Tc-99m MAA dose which is for lung imaging.

"The cause of this event was a failure by the dispensing pharmacist to follow proper Cardinal Health compounding procedures. The pharmacist pulled the wrong kit from the refrigerator. The pharmacist performed a QC test on the dose, but failed to label the starting point on the QC chromatography strip, which led to a misinterpretation of the failing test as a passing test.

"In order to prevent a recurrence of this event, the pharmacy is going to begin requiring all employees performing QC tests to label the starting point of all QC strips. Also, the pharmacy is planning to switch brands of MAA since the Drax MAA vial and the Myoview vials are identical in appearance."

To top of page
General Information or Other Event Number: 42419
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAKER HUGHS INTEC
Region: 4
City: HOUMA State: LA
County:
License #: LA-6025-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/14/2006
Notification Time: 11:39 [ET]
Event Date: 03/13/2006
Event Time: [CST]
Last Update Date: 03/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - WELL LOGGING SOURCE ABANDONED

The State provided the following information via facsimile:

"Baker Hughs Intec abandoned a 2.5 Ci source of Cs-137 and a 5 Ci source of Am-241 down hole on March 13, 2006. The depth of the sources is between 14,423 feet and 14,430 feet. The hole has [been] back filled with cement to a depth of 12,095 feet to prevent reentry into the hole."

Louisiana license number: LA060004

To top of page
Power Reactor Event Number: 42423
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GORDY ROBINSON
HQ OPS Officer: BILL GOTT
Notification Date: 03/15/2006
Notification Time: 09:41 [ET]
Event Date: 03/15/2006
Event Time: 05:57 [EST]
Last Update Date: 03/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1)

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

Event Text

LOSS OF ASSESSMENT CAPABILITY - SAFETY PARAMETER DISPLAY SYSTEM

"Unit 1 is currently in Mode 5 for the planned 14th Refuel and Inspection Outage.

"At 05:57 on March 15, 2006 the Unit 1 Safety Parameter Display System (SPDS) was deenergized during planned refuel outage activities. It has been determined that it will not be restored within the required eight hours. Currently, restoration is scheduled for March 17, 2006 at 00:01. All required instrumentation is available in the control room.

"ERDS will remain operable during the work window but several points will not be available. For example 23 of 58 ERDS points will be unavailable while SPDS is out of service. However, the ERDS system will still be operable and transmit the remaining points.

"Loss of Emergency Assessment Capability - A review of the ability of the Emergency organization to function without SPDS was performed. Alternate sources for many of the points in SPDS were identified and are contained on an Emergency Plan format in PICSY (plant integrated computer system). Those points not available from PICSY can be obtained from the control room. With these compensatory actions and the communications in place between the facilities, there will not be a major loss of emergency assessment capability.

"Since the Unit 1 SPDS computer system will be unavailable for greater than 8 hours, this is considered reportable under 10CFR50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM J. HUFFORD TO J. KNOKE AT 10:41 EST ON 03/18/06 * * *

Licensee has restored the Unit 1 Safety Parameter Display System (SPDS), which was deenergized during planned refuel outage activities for scheduled maintenance.

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

To top of page
Power Reactor Event Number: 42425
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOHN BRADY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/17/2006
Notification Time: 01:30 [ET]
Event Date: 03/16/2006
Event Time: 22:50 [EST]
Last Update Date: 03/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MIKE ERNSTES (R2)

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

LOSS OF COMMUNICATION - ERDADS COMPUTER FAILED

"On 3/16/2006 at approximately 2010 [EST], the U2 ERDADS computer failed and stopped providing updated plant data to the Unit 2 and Technical Support Center operator consoles, leaving the displays essentially static. Investigation of the failure mode is ongoing and attempts to restore the ERDADS to normal are in progress.

"Loss of the ERDADS output for greater than one hour is reportable as a major loss of assessment and communication capability under 10 CFR 50.72(b)(3)(xiii)."


The licensee notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 42426
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ERIC SCHULTZ
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/17/2006
Notification Time: 10:16 [ET]
Event Date: 03/17/2006
Event Time: 07:58 [CST]
Last Update Date: 03/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVE PASSEHL (R3)

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

OFFSITE NOTIFICATION - LOCAL SHERIFF CONTACTED

"On March 17 at approximately 0758 Central Standard Time (CST), the remains of a human body were discovered to have washed ashore immediately North of the Unit 2 circulating water discharge canal. The Manitowoc County Sheriff's Department was contacted to investigate. The body is believed to have randomly washed ashore from Lake Michigan."

The county is presently on-site to pick up the human remains.

The licensee notified the NRC Resident Inspector and expects to issue a press release at a later date.

* * * UPDATE ON 03/17/06 AT 1458 EST FROM ERIC SCHULTZ TO MACKINNON * * *

"NMC previously reported that on March 17 at approximately 0758 Central Standard Time (CST), the remains of a human body were discovered to have washed ashore immediately North of the Unit 2 circulating water discharge canal. The Manitowoc County Sheriff's Department was contacted to investigate. The body is believed to have randomly washed ashore from Lake Michigan.

"The following article has subsequently appeared on the web site of the local newspaper (Herald Times Reporter).

"MANITOWOC - Manitowoc County Sheriff's Department investigators responded to the area of the Point Beach Nuclear Plant before 8 a.m. today after a body washed up onto the shore of Lake Michigan there, according to Inspector (Deleted). (Deleted) said the body is that of a 46-year-old man, but said further details are not immediately available.

"Sheriff (Deleted) said early indications point to suicide, adding that is still under investigation.

"Department personnel were still on the scene, near the Two Creeks boat launch, as of 10 a.m. today.

"The County Sheriff and Coroner removed the discovered body and left site at 1008 on 3/17/06."

The NRC Resident Inspector and local officials were notified of this event by the licensee. NRC R3DO (Dave Passehl) notified.

To top of page
Power Reactor Event Number: 42428
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: DAVE COSEO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/17/2006
Notification Time: 14:34 [ET]
Event Date: 02/10/2006
Event Time: 11:20 [EST]
Last Update Date: 03/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVE PASSEHL (R3)

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

INVALID SPECIFIED SYSTEM ACTUATIONS

"The following information is provided as a 60 day telephone notification to NRC under 10 CFR 50.73(a)(1) in lieu of submitting a written LER to report a condition that resulted in an invalid actuation of a 10 CFR 50.73(a)(2)(iv)(B) system. NUREG1022 Revision 2 identifies the information that needs to be reported as discussed below.

"(a) The specific train(s) and system(s) that were actuated:

"On February 10, 2006, at 1120 EST, a surveillance was in progress to calibrate the Division 2 Fuel Pool Ventilation Exhaust Radiation Monitor D11-K611D. During jumper removal an adjacent terminal was contacted by the jumper while still connected to a 24 VDC power source resulting in a blown power supply fuse. The loss of the power supply resulted in the following automatic actions: Primary Containment Isolation Valve Group 14; Drywell and Suppression Chamber Ventilation System; and Group 16, Nitrogen Inerting System received an isolation signal. All primary containment isolation valves in both groups were previously in their safety function position (closed).

"Secondary containment isolated resulting in a trip of the Reactor Building Heating and Ventilation System and Division 2 Standby Gas Treatment System automatically started. The Control Center Heating, Ventilating and Air Conditioning System automatically shifted into the Recirculation mode. The initiation signal was invalid because it did not result in response to an actual high radiation condition, nor did it trip as a result of any other requirement for initiation of the safety function, such as a downscale or inoperable trip, for example.

"(b) Whether each train actuation was complete or partial.

"The Division 2 Standby Gas Treatment System automatically started, secondary containment fully isolated, Reactor Building Heating and Ventilation System tripped, and the Control Center Heating, Ventilating and Air Conditioning System automatically shifted into the Recirculation mode. These were complete actuations. The primary containment isolation valves Group 14 and 16 remained in their safety function (closed) position. This was a complete actuation.

"(c) Whether or not the system started and functioned successfully.

"The above systems functioned successfully."

The licensee will notify the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 42429
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CALVIN WARD
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/19/2006
Notification Time: 17:44 [ET]
Event Date: 03/19/2006
Event Time: 12:40 [EST]
Last Update Date: 03/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MIKE ERNSTES (R2)

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

UNIT 2 ERDADS (EMERGENCY RESPONSE DATA ACQUISITION AND DISPLAY SYSTEM) COMPUTER DECLARED INOPERABLE.

"On 3/19/06 at approximately 1240, the U2 ERDADS computer failed and stopped providing updated plant data to the Unit 2 and Technical Support Center Operator Consoles, leaving the displays essentially static. Investigation of the failure mode is ongoing and attempts to restore the ERDADS to normal are in progress. A similar event occurred on 3/16/06, EN# 42425. Loss of the ERDADS output for greater than one hour is reportable as a major loss of assessment and communication capability under 10 CFR 50.72(b)(3)(xiii)."

The ERDADS computer has been restored but the licensee does not considered it fully operable. Vendor is coming in on 3/20/06 to try to correct the ERDADS computer problem.

The NRC Resident Inspector was notified of this by the licensee.

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