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Event Notification Report for June 20, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/19/2006 - 06/20/2006

** EVENT NUMBERS **


42627 42645 42646 42651 42652

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General Information or Other Event Number: 42627
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: AUBURN REGIONAL MEDICAL CENTER
Region: 4
City: AUBURN State: WA
County:
License #: WN-M0149-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOE O'HARA
Notification Date: 06/08/2006
Notification Time: 15:58 [ET]
Event Date: 05/30/2006
Event Time: [PDT]
Last Update Date: 06/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED SOURCES

The State provided the information via e-mail:

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): A patient received a total of 89 sealed Iodine-125 (half-life of 60 days) seeds implanted on a permanent basis in the prostate, for a total activity of 33.84 millicuries. This was done at Auburn Regional Medical Center (ARMC), Auburn, Washington, on 25 May 2006.

"The patient was seen / rechecked by ARMC personnel on 26 May 2006. Sometime after that visit, on the same day, he was taken by family members to Good Samaritan Hospital (GSH) in Puyallup, Washington, where he subsequently died of a myocardial infarction.

"The body was released to a funeral home in Buckley, Washington where it was cremated on 30 May 2006 (about 31 millicuries). The cremains were then boxed up on 31 May 2006 and buried that same day.

"Although it was reported the patient and the patient's family were given appropriate verbal and written instructions by ARMC; when the patient was treated at GSH it was for the MI only, and had nothing to do with the prior surgical prostate procedure. The family did not, for whatever reason, inform the staff at GSH. The urologists who had treated the patient for the prostate cancer did not work at GSH and had no connection there.

"Therefore, once the patient died, personnel at GSH had no idea they were also dealing with a radioactive source problem. Personnel at ARMC had no way of knowing of the treatment or death of the patient since it did not occur at their facility or in their city.

"The RSO for Tacoma Radiation Oncology Center (who provides medical physics support and treatment planning for sealed source therapy to clients such as ARMC and GSH) visited the funeral home on 7 June 2006 and surveyed the crematorium using a meter with a NaI probe. Background was noted at approximately 0.4 mR/hr. Readings of approximately 3.0 mR/hr were noted at the entrance to the retort. A filter in the air exhaust system was noted to be reading approximately 1.0 mR/hr so it was removed for decay and ultimate disposal by GSH.

"It appears that most retorts operate at 1600 degrees Fahrenheit, or more, and the titanium capsule would melt a few hundred degrees lower than that. The manufacturer confirmed that all seeds had most likely been melted and would not be recovered whole. The crematorium is at this time on standby until the crematorium is declared clean for further use. It appears the most reasonable way to safely handle this cleaning chore is to have a commercial cleaning company, properly informed and equipped, clean and vacuum the retort with ARMC physics personnel in constant attendance to protect workers from any potential radiation hazards and to remove any contaminated material for decay and disposal. This is scheduled to happen 8 June 2006.

"Notification Reporting Criteria: WAC 246-221-240

"Isotope and Activity involved: Iodine 125 / 31 millicuries (at time of cremation)

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): to be determined, likely none.

"Lost, Stolen or Damaged? (mfg., model, serial number): melted I-125 seeds.

"Disposition/recovery: clean and hold material for decay

"Leak test? NA

"Vehicle: NA

"Release of activity? Yes

"Activity and pharmaceutical compound intended: NA

"Misadministered activity and/or compound received: NA

"Device (HDR, etc.) Mfg., Model; computer program: I-125 seeds

"Exposure (intended/actual); consequences: minimal, likely no consequences

"Was patient or responsible relative notified? Yes

"Was written report provided to patient? Yes

"Was referring physician notified? Yes

"Consultant used? Yes"

Event Report No.: WA-06-042

* * * UPDATE ON 06/19/06 AT 1900 FROM ARDEN SCROGGS TO A. COSTA * * *

This incident was investigated by the WA Department of Health, Office of Radiation Protection and the Crematorium facility was released for use.

Notified R4DO (Graves) and NMSS EO (Collins).

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General Information or Other Event Number: 42645
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH SYSTEMS PACIFIC
Region: 4
City: SAN LUIS OBISPO State: CA
County:
License #: 6723-40
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/15/2006
Notification Time: 16:29 [ET]
Event Date: 06/14/2006
Event Time: [PDT]
Last Update Date: 06/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
GREG MORELL (NMSS)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LOST AND SUBSEQUENTLY FOUND NUCLEAR GAUGE

The State provided the following information via email:

"On 6/15/06, the RSO at Earth Systems Pacific contacted the RHB-Richmond office to report a nuclear gauge incident that occurred in the evening of 6/14/06. On 6/14/06 one of their moisture density nuclear gauges (CPN, Model MC1DR, S/N M10906353 containing 10 mCi of Cs-137 and 50 mCi of Am-241) fell off from a back of a truck onto the highway during transportation. A member of the public picked up the Type A container (with the gauge inside) and transported it into the jobsite. The jobsite personnel immediately contacted the Fire Department. The gauge was then handed over to the Fire Department. The Fire Department inspected the gauge and contacted the licensee. On the same day, the Alternate RSO picked up the gauge from the Fire Department and brought it back to the licensed facility. According to the RSO, the gauge was inside the Type A container during the whole incident and there was no visible damage to the gauge. They have performed a leak test and sent it for analysis. The RSO is expecting a report from the Fire Department. The RHB South RM office is awaiting additional information on the incident, including additional information concerning the Fire Department involved, and will investigate the reason the gauge was apparently unsecured in the licensee's vehicle."

California Report # 061506

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General Information or Other Event Number: 42646
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SCHLUMBERGER TECHNOLOGY CORPORATION
Region: 1
City:  State: MS
County: LAMAR
License #: MS-463-01
Agreement: Y
Docket:
NRC Notified By: B. J. SMITH
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/15/2006
Notification Time: 16:39 [ET]
Event Date: 06/05/2006
Event Time: [CDT]
Last Update Date: 06/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID SILK (R1)
ELMO COLLINS (NMSS)

Event Text

MISSISSIPPI AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE

The State provided the following information via email:

"[The State] received notification on 6-5-06 from Schlumberger that they had logging tool stuck in the Patterson #2 exploration well located at Midway Dome, Lamar County, Mississippi. Logging tool containing a 1.7 curie Cesium -137 source and a 16 curie Americium- 241:Be source was stuck below 12,000 feet. Operating company was fishing for logging tool string. Schlumberger discussed initial procedure of abandoning sources with DRH. During fishing operations logging tool containing sources was pushed to a depth of 14,854 feet. The fishing operation was successful in retrieving the tool string containing the Americium-241:Be source but they did not get the density tool skid containing the Cesium-137 source back. Licensee stated that tool would be cemented in hole with 200 feet of cement and whip stock deflection device. Plan was later modified to drill into cement plug and set casing 160 feet above the abandoned source prior to re-drilling the well to the side of the abandoned source.

"Schlumberger took survey readings of the recovered source and tool string and did not observe any readings out of the normal readings. Leak tests were also taken of the Americium-241:Be source, with no evidence of leaking.

"30 [-day] written report required from licensee. Licensee must also place plaque on well bore signifying that abandoned source is in well bore."

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Power Reactor Event Number: 42651
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JIM BLASEK
HQ OPS Officer: JOE O'HARA
Notification Date: 06/19/2006
Notification Time: 00:29 [ET]
Event Date: 06/18/2006
Event Time: 14:55 [MST]
Last Update Date: 06/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
ANTHONY GODY (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF ONSITE EMERGENCY SAFETY FUNCTION - "B" EDG FAILED TO START DURING TEST RUN

"The following event description is based on information currently available. If through subsequent reviews of this
event, additional information is identified that is pertinent to this event or alters the information being provided at this
time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On June 18, 2006, at approximately 1455 Mountain Standard Time (MST), Palo Verde Nuclear Generating Station
Unit 1 was operating at 0% power in Mode 6 with the 'A' Emergency Diesel Generator (EDG) inoperable for troubleshooting of the train 'A' load sequencer, The 'B' EDG failed to start during a test run resulting in a loss of the onsite emergency power safety function required by General Design Criterion (GDC) 17. The offsite power source safety function remains available to the plant.

"The unit entered Technical Specification 3.8.2, AC Sources - Shutdown Condition B for one required DG inoperable.
There was no movement of irradiated fuel assemblies, therefore the unit remained in compliance with the Required
Actions. The offsite electrical grid is stable.

"At 1810 MST the 'A' EDG was declared operable, exiting Technical Specification 3.8.2. With the 'A' EDG operable,
the safety function for the onsite emergency power was also restored.

"There were no structures, systems or components that were inoperable at the start of event that contributed to the
event. This condition did not result in any challenges to the fission product barrier or result in any releases of
radioactive materials. There were no adverse safety consequences or implications as a result of this event. This
condition did not adversely affect the safe operation of the plant or health and safety of the public.

"The NRC Resident Inspector has been notified of this condition and this ENS notification."

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Power Reactor Event Number: 42652
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RYAN RICHARDS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/19/2006
Notification Time: 04:06 [ET]
Event Date: 06/18/2006
Event Time: 23:19 [CDT]
Last Update Date: 06/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
PATRICK LOUDEN (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

RADIATION MONITOR SPIKED THREE TIMES

"At 2319 on 06/18/2006, the 'A' Plenum Radiation Monitor spiked high which resulted in the closure of the Drywell CAM (Continuous Air Monitor) and the Oxygen Analyzer Primary Containment Isolation Valves. The spike's (3) of approx. 30 mR/HR occurred during this event. The valves isolated once, the Reactor Building Ventilation trip was reset once and re-isolation occurred several minutes later from another spike on the Rad Monitor. Trip setpoint is 26 mR/hr. The Plenum high Rad signal also resulted in Reactor Building isolation (twice), start of 'A' Standby Gas Treatment, and transfer of the Control Room Ventilation to the high Rad Mode. The 'R' Plenum Rad Monitor remained constant at 1.3 mR/hr. The Reactor Building Ventilation and Control Room Ventilation have been reset and Standby Gas Treatment has been secured. The 'A' Plenum Radiation Monitor has been declared inoperable."

Instrument & Control Technicians are currently troubleshooting the problem associated with the 'A' Plenum Radiation Monitor.

The NRC Resident Inspector's have been left messages by the licensee.

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