United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2006 > April 6

Event Notification Report for April 6, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/05/2006 - 04/06/2006

** EVENT NUMBERS **


42448 42460 42464 42471 42472 42473 42474 42475 42476 42477 42478 42479

To top of page
Other Nuclear Material Event Number: 42448
Rep Org: NATIONAL INST OF STANDARDS & TECH
Licensee: NATIONAL INST OF STANDARDS & TECH
Region: 1
City: GAITHERSBURG State: MD
County:
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: TIM MENGERS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/28/2006
Notification Time: 09:36 [ET]
Event Date: 03/27/2006
Event Time: 09:30 [EST]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
36.83(a)(5) - INOP ACCESS CTRL SYS
36.83(a)(1) - UNSHIELD STUCK SOURCE
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (NMSS)

Event Text

IRRADIATOR SHUTTER FAILS TO CLOSE

The air-actuated shutter mechanism on one of the facility's irradiators (Neutron Products S/N T1497 with 13,500 Curies Co-60) failed to re-close. The irradiator source remained in its shield. A staff scientist entered the irradiator room and isolated the air supply to the shutter allowing the shutter to close. The scientist received less than 2 mrem during the incident. The cause of the shutter failure is being investigated.

* * * UPDATED AT 1103 EDT ON 4/5/06 FROM TIMOTHY MENGERS TO S. SANDIN (via email) * * *

The licensee identified two (2) additional reporting requirements, i.e., 10CFR36.83(a)(1) and 10CFR30.50(c)(1) [Preparation and Submission of Reports], and provided a chronology of the incident. Contact the Headquarters Operations Officer for additional details. Notified R1DO (Finney) and NMSS (Essig).

To top of page
General Information or Other Event Number: 42460
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: ALPHA TESTING LABS, LC
Region: 4
City: SANDY State: UT
County:
License #: UT 1800485
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/31/2006
Notification Time: 16:27 [ET]
Event Date: 02/23/2006
Event Time: 09:15 [MST]
Last Update Date: 03/31/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MALFUNCTIONING RADIOGRAPHY CAMERA

The State provided the following information via facsimile:

"This event involved a crank cable for a Source Production & Equipment Company radiographic exposure device (model SPEC 150, serial number 876; with sealed source model SPEC G-60, serial number ML0608). The activity contained in the radiographic exposure device at the time of the incident was 2.66 terabecquerels (72 Ci). A crimped fitting on the crank cable housing came loose when a radiographer was moving the radiographic exposure device. The source was in the shielded position at all times when it was being moved. No source disconnect occurred. The cause of this incident is not known since the equipment had been functioning until this incident. The licensee believes it to be a manufacturing problem. When the incident occurred, radiographic operations were immediately stopped. And the radiography crew (radiographer, radiographer's assistant, and Radiation Safety Officer) returned to the licensee's Utah facilities. The control cable was tagged out of operation until a new housing could be obtained from the manufacturer.

"The Utah Division of Radiation Control was notified by the licensee in a letter dated March 23, 2006 (received on March 29, 2006).

"The licensee notified the manufacturer and the malfunctioning equipment was returned. It was immediately replaced with a new cable housing.

"Event Location: Structural Steel & Plate Fabrication, 555 N. Main, North Salt Lake, Utah 84054"

Utah Event Report ID No. : UT-06-0001

To top of page
General Information or Other Event Number: 42464
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GEOTECH LAB INC
Region: 1
City: COLUMBIA State: MD
County:
License #: MD-27-075-01
Agreement: Y
Docket:
NRC Notified By: BOB NELSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/01/2006
Notification Time: 00:12 [ET]
Event Date: 03/31/2006
Event Time: 16:00 [EST]
Last Update Date: 04/01/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE KOKAJKO (NMSS)
WILLIAM COOK (R1)

Event Text

AGREEMENT STATE REPORT: DAMAGED TROXLER

A Troxler moisture density gauge was left unattended at a site in Clinton, Maryland and was run over by a bulldozer. The Troxler was broken in two parts. No external contamination was detected and the source was in the shielded position. Troxler Model 3430, serial #23881.

Sources:
8 milliCurie Cs-137
40 milliCurie Am-241:Be

To top of page
Power Reactor Event Number: 42471
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/05/2006
Notification Time: 02:22 [ET]
Event Date: 04/05/2006
Event Time: 00:16 [EDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(iv)(A) - ECCS INJECTION
Person (Organization):
BRIAN BONSER (R2)

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

Event Text

REACTOR SCRAM FOLLOWING MAIN TURBINE CONTROL VALVE FAST CLOSURE

"Two I & C technicians were performing a 24 month calibration on 2S32R017, Megavar & Voltmeter Recorder in accordance with 57CP-CAL-010-2, Esterline Angus Megavar & KV Recorder. This activity was being performed on Work Order 2042825001. At the approximate time the recorder was being removed from service the shift received a RPS trip from a MTCV [Main Turbine Control Valve] Fast Closure. The control valve fast closure scram was caused by a power load imbalance. Both RFP's [Reactor Feed Pumps] tripped on high reactor water level and RCIC and HPCI were used (for 7 and 2 minutes respectively) to control RWL [Reactor Water Level]. Eight SRV's [Safety Relief Valves] opened momentarily on high reactor pressure. The highest reactor pressure indicated was 1120 psig and the lowest RWL indicated was +7 inches. A main condenser vacuum transient due to loss of seals required use of HPCI and RCIC."

The licensee characterized the scram as uncomplicated. All systems functioned as required and nothing unusual or not understood besides what caused the initial power load unbalance signal and resulting MTCV fast closure. All rods fully inserted. The unit is currently at normal pressure and water level for Mode 3. MSIVs remained opened and decay heat is being discharged to the main condenser. The scram had no impact on Unit 1. Offsite on onsite electrical conditions remained normal. The licensee was not in any significant LCO at the time of the event.

The licensee notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 42472
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GREG BAKER
HQ OPS Officer: JOE O'HARA
Notification Date: 04/05/2006
Notification Time: 11:45 [ET]
Event Date: 04/05/2006
Event Time: 06:35 [CDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
ANNE MARIE STONE (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

FITNESS FOR DUTY - CONFIRMED POSITIVE FOR NON-LICENSED CONTRACTOR SUPERVISOR

A non-licensed contract supervisor had a confirmed positive for alcohol while attempting to gain access the plant this morning. The contractor's access to the plant has been suspended. A review of previous work is being performed. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector has been notified.

To top of page
Other Nuclear Material Event Number: 42473
Rep Org: MICHIGAN TECHNOLOGICAL UNIVERSITY
Licensee: MICHIGAN TECHNOLOGICAL UNIVERSITY
Region: 3
City: HOUGHTON State: MI
County:
License #: SNM-256
Agreement: N
Docket:
NRC Notified By: ALLEN NIEMI
HQ OPS Officer: BILL GOTT
Notification Date: 04/05/2006
Notification Time: 11:30 [ET]
Event Date: 03/16/2006
Event Time: [EDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANNE MARIE STONE (R3)
TOM ESSIG (NMSS)
ILTAB (EMAIL) ()
CNSC (fax) ()

Event Text

LOST LICENSED MATERIAL

In 1967 the Michigan Technological University Physics Department obtained 10 Uranium fuel plates. The plates had a triangular shaped tip on the end that measured about 1 inch at the base, 1 inch high and was 0.1 inch thick. On one of the fuel plates, the tip broke off and the Department's RSO maintained the piece in an envelope in the same locked container where he kept the fuel plates. In 1977 during the course of routine laboratory nuclear training work with the fuel plates, one of the students wanted to look at the structure of the piece microscopically for a course in Metallurgy. The RSO gave the student the tip in an envelope sandwiched between 2 copper sheets. The student returned the piece in the envelope, and the envelope was returned to the safe unopened.

On March 16, 2006, the envelope was opened to obtain data on the piece for return to Federal control, and the piece was not in the envelope.

Further investigation determined that the tip was too large to be used in the Scanning Electron Microscope (SEM), and a small piece of the tip was removed. It appears that only this small piece was returned to the RSO. Personnel from the Metallurgy laboratory were questioned and it appears that the tip remained in the Metallurgy facility until after 1991 when it is thought that it was disposed of in the regular trash.

The uranium fuel plates were 20 weight percent enriched Uranium. The tip contained approximately 1.1 grams enriched uranium or 0.21 gm U-235. It had an activity of 0.3 micro curies U-238 and 0.4 micro curies U-235. On contact measurements for the tip are expected to be less than 1 milli rem per hour on contact.

On March 30, 2006, the Director, Occupational Health and Safety conducted a thorough search and survey of the Metallurgy laboratory and could not find the tip.


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.

To top of page
Hospital Event Number: 42474
Rep Org: COMMUNITY HOSPITALS OF INDIANA
Licensee: COMMUNITY HOSPITALS OF INDIANA
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 130600901
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: JOE O'HARA
Notification Date: 04/05/2006
Notification Time: 13:31 [ET]
Event Date: 11/08/2005
Event Time: [CST]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ANNE MARIE STONE (R3)
GREG MORELL (NMSS)

Event Text

NOTIFICATION OF A MEDICAL EVENT - DOSE TO INCORRECT AREA OF BODY

Community Hospitals of Indiana reported that a high dose rate (HDR) remote afterloader treatment field was incorrectly performed. On November 8, 2005, Community Hospital East in Indianapolis, Indiana performed a HDR treatment on a terminally ill lung cancer patient. Community Hospital East applied the correct dose to the patient. However, a catheter used to carry the source into the patients body was inserted into the patients airway without a cap on the end. As a result of the cap not being in its proper place on the catheter, the source was placed approximately 7 mm higher than originally intended per the physicians written directive. As a result, the field which was irradiated was greater by approximately 7 mm. Immediately following the treatment, the error was noted and the physician was informed. The physician noted that the area which was irradiated was within her area of concern and that everything was "o.k." This treatment was conducted to relieve patient symptoms rather than cure the disease. The patient succumbed to the disease approximately two weeks later. The treatment and its results were documented by the licensee in its Radiation Safety Committee Meeting minutes.

During a routine inspection of its records on 4/4/06, a Region III NRC Inspector noted that this event appeared to be a medical event and should be reported. As a result of that guidance, the licensee is reporting the event.

To top of page
Power Reactor Event Number: 42475
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: KEVIN COUGHLIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2006
Notification Time: 14:08 [ET]
Event Date: 04/05/2006
Event Time: 08:04 [EDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAT FINNEY (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

BOTH TRAINS OF HIGH PRESSURE INJECTION (HPI) DECLARED INOPERABLE DUE TO POTENTIAL AIR BINDING OF PUMPS

"TMI declared both High Pressure Injection Trains not operable due to air void in the suction line from the Sodium Hydroxide tank. The postulated issued is that in the event of a small break LOCA where the plant would need to go on HPI piggy back Ops (the Low Pressure Injection supplying suction to the High Pressure Injection pumps) the air could cause the HPI pumps to become air bound.

"The Plant entered a shutdown Tech Spec 3.0.1 at 0804 [EDT] and exited the timeclock at 0850 [EDT] when the Sodium Hydroxide tank was isolated, thus isolating the air void from the ECCS (Emergency Core Cooling System) pumps."

The licensee is continuing their investigation into root cause and operability.

The licensee will inform the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 42476
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KENNETH MEADE
HQ OPS Officer: JOE O'HARA
Notification Date: 04/05/2006
Notification Time: 15:05 [ET]
Event Date: 04/05/2006
Event Time: 12:00 [EDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANNE MARIE STONE (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

Event Text

OFFSITE NOTIFICATION TO STATE AND LOCAL OFFICIALS CONCERNING TRITIUM DETECTION IN DRAIN SYSTEM

"This notification is being made in accordance with 10CFR50.72(b)(2)(xi), i.e., notification of a government agency. FENOC provided a courtesy notification to state and local officials based on the detection of very low levels of tritium in the plant underdrain system.

"During routine quarterly sampling of the Perry plant's underdrain system on March 28, 2006, very low levels of tritium were detected in an underdrain system manhole. The plant's underdrain system directs water under the plant to the Emergency Service Water Pumphouse, where it is monitored and discharged.

"Samples taken off-site show no indications of detectable tritium. No reportable limits have been exceeded."

The NRC Resident Inspector has been notified.

To top of page
Power Reactor Event Number: 42477
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: PAT RYAN
HQ OPS Officer: JOE O'HARA
Notification Date: 04/05/2006
Notification Time: 16:07 [ET]
Event Date: 02/07/2006
Event Time: 22:59 [CDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
ANNE MARIE STONE (R3)

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

Event Text

INVALID SYSTEM ACTUATIONS

"The following 60-day report is being made under 50.73 (a)(2)(iv)(A) for an invalid actuation of Division 1 containment isolation valves that occurred at 2259 hours on February 7, 2006. As allowed by 10CFR50.73(a)(1) this notification is being made via telephone. NUREG-1022, Revision 2 identifies the information that needs to be reported as follows:

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

"An unexpected actuation of Division 1 containment isolation relays occurred during performance of WO 416930-02, EM - Agastat Relay Luayvg514b Replacement in panel 1H13P861. Momentary, inadvertent contact occurred between the top row R1-M1 pins of the Agastat relay being inserted and the second row T1-B1 contacts of the installed relay base while the Electrical Technician was attempting to align the relay for seating, prior to applying full seating force to the relay. The relay actuations resulted in closure of Division 1 isolation valves in the Fuel Pool Cooling and Cleanup, Suppression Pool Cooling and Cleanup, Component Cooling Water, Service Air, Containment and Drywell Equipment and Floor Drains, and Makeup Condensate systems.

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

"The actuations were complete for the portions that were enabled while relay testing was in progress.

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

"There no system starts associated with this event

"The NRC Resident Inspector was notified of this notification."

To top of page
Power Reactor Event Number: 42478
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [ ] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: TODD STRAYER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/05/2006
Notification Time: 16:43 [ET]
Event Date: 04/05/2006
Event Time: 16:15 [EDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAT FINNEY (R1)

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

Event Text

HIGH PRESSURE COOLENT INJECTION DECLARED INOPERABLE (HPCI)

"During performance of a Unit 3 High Pressure Coolant Injection System (HPCI) Logic System Functional Test, the High Pressure Coolant Injection (HPCI) system was found to be inoperable. The inoperability is due to a logic failure that would prevent the automatic opening of MO-3-23-015, 'HIGH TURBINE STEAM LINE INBOARD ISOLATION VAVLE'. MO-3-23-015 is a normally open valve located inside Primary Containment. The HPCI system initiates upon receipt of a reactor low water level (level 3) signal or a high drywell pressure signal. Upon a HPCI system initiation MO-3-23-015 is required to automatically open, if closed, with no isolation signal present. The automatic opening of MO-3-23-015 is required to ensure the design function of HPCI is fulfilled. The design function of HPCI is to assure that the reactor is adequately cooled to limit fuel-clad temperature in the event of a small break in the nuclear system and loss of coolant, which does not result in rapid depressurization of the reactor vessel. HPCI permits the nuclear plant to be shut down while maintaining sufficient reactor vessel water inventory until the reactor vessel is depressurized.

"The HPCI system inoperability has no immediate impact on plant operations. The inoperability places Unit 3 in a 14-day shutdown Tech Spec Action Statement. The 14-day shutdown Tech Spec action statement commenced on 04/05/06 @ 0824 when the Logic System Function Test was started.

"A troubleshooting and repair team has been initiated to determine a cause and repair of the deficiency."


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

To top of page
Power Reactor Event Number: 42479
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: W. BENTLEY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/05/2006
Notification Time: 21:23 [ET]
Event Date: 04/05/2006
Event Time: 18:55 [CDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ANNE MARIE STONE (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

ABNORMAL OPERATING PROCEDURE (AOP) FOR STATION BLACKOUT COULD NOT BE PERFORMED IN SPECIFIED TIME PERIOD


"DAEC (Duane Arnold Energy Center) abnormal operating procedure AOP 301.1 for Station Blackout specifies that 30 minutes are allowed to establish alternate ventilation for RCIC (Reactor Core Isolation Cooling) /HPCI (High Pressure Coolant Injection) rooms, switchgear rooms, battery rooms, and the Main control room. During validation demonstration conducted on April 5, 2006 for the NRC Components team (from NRC Region 3 Office) the 30 minutes requirement was not met with the control room alternate ventilation taking about 60 minutes and with the other areas also exceeding their time requirements. This event is reportable as an unanalyzed condition that significantly degraded plant safety pursuant to 10 CFR 50.72(b)(3)(ii) reportability notification."

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

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