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Event Notification Report for April 20, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/19/2006 - 04/20/2006

** EVENT NUMBERS **


42499 42500 42503 42510 42511 42512 42514 42515

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General Information or Other Event Number: 42499
Rep Org: ALABAMA RADIATION CONTROL
Licensee: GALLET AND ASSOCIATES
Region: 1
City: EUTAW State: AL
County:
License #: AL-991
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2006
Notification Time: 08:57 [ET]
Event Date: 04/13/2006
Event Time: 09:30 [CDT]
Last Update Date: 04/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE - DAMAGED TROXLER GAUGE

The State provided the following information via facsimile:

"On the morning of April 13, 2006 at approximately 9:30 am CDT, a Troxler model 3430 moisture density gauge, serial number 22787 containing 8 millicuries of Cs-137 and 40 millicuries of Am-241:Be was damaged while in use at a temporary job site in Eutaw, Alabama when it was run over by a dump truck. The licensee, Gallet & Associates notified the Alabama Office of Radiation Control at 11:55 am. Gallet & Associates is authorized to possess and use radioactive material under their Alabama Radioactive Material License No. 991. The licensee representative stated that they were able to place the sealed source rod in the shielded position and lock the device in the safe position. Radiation levels around the gauge were found to be within the normal range. The gauge was placed back in the transport container and returned to the licensee's facility. The licensee was advised to perform a leak test of the gauge.

"This is all the information that this Agency has at this time and is current as of 8:00 am CDT, April 14, 2006."

Alabama Incident No 06-21

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General Information or Other Event Number: 42500
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS INSTRUMENTS, INC
Region: 4
City: DALLAS State: TX
County:
License #: 585-D-103-G
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2006
Notification Time: 10:10 [ET]
Event Date: 04/14/2006
Event Time: [CDT]
Last Update Date: 04/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE - TWO TRITIUM EXIT SIGNS LOST

The State provided the following information via email:

"Event type: Lost, two self-luminous, 20 Ci/ea., H-3, exit signs were discovered missing, presumed discarded.

"Event description:
The manufacturer is SRB Technologies (Canada), Inc.

1) Model: BetaLux-E/Luminexit, SN 272697, Activity: 20 Ci;

2) Model: BetaLux-E/Luminexit, SN 270605, Activity: 20 Ci.

"One sign was noted as being discarded by the housekeeping staff and a subsequent inventory investigation showed that another sign was missing from an area that was renovated in August of last year."

Texas Incident No.: I- 8325

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: 42503
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: ROSEL COMPANY
Region: 4
City:  State: KS
County: CLARK COUNTY
License #: 27-C057-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/14/2006
Notification Time: 15:35 [ET]
Event Date: 06/02/2005
Event Time: [CDT]
Last Update Date: 04/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE

The licensee provided the following information via facsimile:

"06/03/05: High Bluff Operating, LLC reported The Rosel Company of Liberal, Kansas lost a logging tool downhole in Clark County, Kansas. The logging cable broke, and the tool dropped to a depth of 5866 feet. The tool was 'fished' from the hole, but the density pad broke off the tool and stayed in the hole. An experienced 'fishing tool expert' recommended that cement the possible source in place.

"[High Bluff] proposes: 75' of red dyed cement on top of the pad with a 'whipstock' device preventing reentry of the hole. Set 5740 feet of production casing to prevent deepening. Post at the wellhead a plaque noting the required Information.

"06/04/05: [Kansas] replied to [High Bluff] and concurred with his plan.

"11/01/05: [High Bluff] sent in his final report. Correct the final depth to 5856'. Modified the plan of action to be 5710 feet of casing and 146 feet of red dyed cement by Allied Cement. The plaque was still awaiting production and placement.

"11/11/05: [High Bluff] reported the plaque was unacceptable, and a new plaque was being made.

"03/22/06: Received cd-rom of digital pictures taken of well site, time stamped 03/13/2006. Plaque meets general requirements. Event considered closed."

Source: 2 Curie Cs-137, Serial Number CSV-K98 manufactured by Gulf Nuclear

Kansas Report Number: KS050022

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Power Reactor Event Number: 42510
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JAMES M. KURAS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/19/2006
Notification Time: 11:13 [ET]
Event Date: 04/19/2006
Event Time: 09:00 [CDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KRISS KENNEDY (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

NON-CONSERVATIVE COLD OVERPRESSURE LIMIT CURVES DISCOVERED DURING ENGINEERING REVIEW

"Cold overpressure limit curve utilized in the EMG (Emergency Guidelines) network including EMG F-0, Critical Safety Function Status Trees is incorrect and non-conservative. This could have resulted in some instances where the operator may have diagnosed a green path (no challenge) when a yellow (potential challenge) or orange path (severe challenge) actually existed. The consequence would have been failure to implement the correct functional restoration procedure."

This problem was found during an Engineering review. The problem had existed since 1999.

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

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Hospital Event Number: 42511
Rep Org: UNITED HOSPITAL CENTER
Licensee: UNITED HOSPITAL CENTER
Region: 1
City: CLARKSBURG State: WV
County:
License #: 4701458-01
Agreement: N
Docket:
NRC Notified By: JAMES ISRAEL - RSO
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/19/2006
Notification Time: 14:13 [ET]
Event Date: 04/11/2006
Event Time: 11:40 [EDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT - ADMINISTRATION OF GREATER THAN 50 PERCENT OF PRESCRIBED DOSE TO PATIENTS

The RSO of the United Hospital Center called about a misadministration to 2 female patients being treated for cervical cancer. Each patient was to receive a total of 3000 centigrays, distributed via 6 treatments of 500 centigrays each. The treatment was a high dose rate Brachytherapy insertion of a 4.4 Curie Ir-192 sealed source into the cervical area. On their first treatment, patient #1 received 1040 centigrays at 11:40 EDT on 04/11/06, and patient #2 received 1058 centigrays at 11:45 EDT on 4/18/06. The attending physician is now going to alter the remaining treatments to 350 centigrays/treatment for each patient, thereby keeping the original total dose to the required 3000 centigrays/patient.

The reason given for the misadministration was human error. The operator did not check the magnification reading on the computer before administrating the dose to each patient. The referring physician will be discussing this error with each patient when they come in for their next treatment on 4/21/06.

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Power Reactor Event Number: 42512
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/19/2006
Notification Time: 15:58 [ET]
Event Date: 04/19/2006
Event Time: 09:45 [CDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KRISS KENNEDY (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

POSTULATED SCENARIO WHERE CONTAINMENT SPRAY SYSTEM MAY BE UNABLE TO FULFILL DESIGN SAFETY FUNCTION

"During a review of the operation of the plants emergency cooling system for the containment an unanalyzed single failure was discovered. The identified single failure scenario could result in the containment spray system being unable to fulfill its design safety functions.

"In the event of loss of offsite power occurring after the initiation of an accident signal, the 480V undervoltage relays serve to trip open containment spray pump breakers (as well as other ESF breakers) in order to prepare the breakers for resequencing after the diesel generator output breakers have closed onto their associated buses. The undervoltage trip bypass function performed by the sequencer timer relay contacts serves to prevent tripping ESF breakers due to inadvertent actuation of the undervoltage trip circuits and allows ESF breakers to trip only when sequencers have been reset by a loss of voltage at the 4160V bus level.

"In situations where a loss of power occurs at the 480 volt level without a coincident loss of power at the associated 4160 volt level, ESF loads supplied from the lost 480 volt bus, such as containment spray pumps, do not receive a trip signal due to the undervoltage blocking feature of the sequencing relays. For most ESF loads, this is not a problem and can be considered part of a single failure scenario affecting only one train of ESF equipment. In the case of containment spray pumps SI-3B and SI-3C, however, the failure of the associated breakers to trip during a single failure of bus 1B4B, results in the operation of a single spray pump, SI-3A with two containment spray valves open. This results in one pump operation to two containment spray headers.

"Operating the containment spray system in a one pump, two header configuration creates the possibility of inadequate system performance. This configuration may result in overloading the running pump (due to runout) and inadequate NPSH to the running pump. This condition was intended to be prevented by a modification which installed an interlock between spray pumps SI-3B and SI-3C and spray valve HCV-344. The modification apparently failed to consider the single failure of specific 480 Volt buses.

"Spray valve HCV-344 has been disabled in the closed position so that no external signals will allow the valve to be opened. Disabling this valve places the plant in a 24 hour LCO (Technical Specification 2.4.2.d) starting at 0950 CDT."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42514
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: DANIEL MALONE
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/19/2006
Notification Time: 18:49 [ET]
Event Date: 04/19/2006
Event Time: 17:50 [EDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
STEVE ORTH (R3)
TIM MCGINTY (IRD)
WILLIAM BECKNER (NRR)

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

Event Text

RADIATION READING IN CONTAINMENT READ 100 TIMES ABOVE NORMAL LEVELS

"At 0225 hrs on April 19, 2006, a container storing in-core instrument pieces rose to the surface of the flooded reactor cavity under its own bouyancy, causing unexpected high radiation readings in the general vicinity of the reactor cavity for a few seconds before the container returned to the bottom of the reactor cavity. Emergency Action Level RU2.2 was promptly reviewed, and it was determined that the threshold for an unusual event was not exceeded, because the area radiation monitors rose by a factor of approximately 100 versus the EAL setpoint of 1000 over normal levels.

"Subsequently, at 1750 hrs, during post event investigation, it was discovered that dose rates indicated by an electronic dosimeter worn by an individual in the area at the time of the event may have exceeded the EAL setpoint of 1000 times the normal radiation levels for that area of containment for a few seconds. The total exposure received by the individual was less than 50 millirem. Therefore, this event is being reported in accordance with NUREG 1022, Revision 2, Section 3, "Discussion." as a potential event discovered after-the fact."


The licensee notified the NRC Resident Inspector, and Al Svilpe, Emergency Management Office in Van Buren County, MI. There is also expected to be some media attention from this incident.

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Other Nuclear Material Event Number: 42515
Rep Org: MALLINCKRODT- MARYLAND HEIGHTS
Licensee: MALLINCKRODT- MARYLAND HEIGHTS
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: JIM SCHUH -RSO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/19/2006
Notification Time: 18:49 [ET]
Event Date: 04/19/2006
Event Time: 17:10 [CDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
STEVE ORTH (R3)
GARY JANOSKO (NMSS)

Event Text

POTENTIALLY LOST DEPLETED URANIUM SHIPPING SAFES

The licensee recently performed a physical inventory of the depleted uranium "safes" used for shipment of Technetium-99m generators. These safes weigh about 45 lbs each and are used to provided shielding during the Tc99m shipments. Of approximately 3200 safes possessed by the licensee, 145 could not be located. The licensee is continuing its investigation and has expanded the search area within other buildings in the 20 acre facility. The licensee is also investigating possible inventory record keeping errors associated with the inventory tracking program.

The licensee has informed the NRC R3 (Gattone) of the missing safes.

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.

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