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Event Notification Report for August 1, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/31/2006 - 08/01/2006

** EVENT NUMBERS **


42729 42731 42735 42736 42738 42740 42743 42744 42745

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General Information or Other Event Number: 42729
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120780000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/26/2006
Notification Time: 10:48 [ET]
Event Date: 07/10/2006
Event Time: [EDT]
Last Update Date: 07/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following information was provided by the state related to prostate brachytherapy which was performed on 7/10/2006 using I-125 seeds.

"Prostate seed implant plans are specified in kerma units (U) by default in our computer planning system. However, the ordering of seeds is specified in mCi [milliCuries]. In this instance the default seed strength was not changed to mCi and a plan was developed for [the patient] to receive 111 seeds of an activity of 0.394 U per seed when 0.394 mCi was desired. The order form was completed for 111 seeds of the expected (not planned) activity of 0.394 mCi per seed. The result was an implant with seeds of activity 27% higher than planned."

The overdose was noticed by the hospital on 7/12/2006. The physician, the patient, and the State of Ohio were notified on 7/13/2006. The State inspected the facility on 7/18/2006.

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General Information or Other Event Number: 42731
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LEIGHTON AND ASSOCIATES
Region: 4
City: SANTA PAULA State: CA
County:
License #: 3109-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/26/2006
Notification Time: 23:50 [ET]
Event Date: 07/26/2006
Event Time: 14:05 [PDT]
Last Update Date: 07/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
EDWIN HACKETT (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"At approximately 2 P.M., the licensee called the Department to report that one of their moisture density gauges (CPN model MC3, serial # M39099115) had been run over by a large truck at approximately 12:20 P.M. earlier in the day. This happened when the gauge user had his back turned from the gauge and he was standing approximately 15-20 feet from the gauge. The gauge source rod (Cs-137) was in the shielded position at the time. The housing was severely damaged and the source rod handle was broken off near the weld joint where the source rod attaches to the source capsule. Both the 8 mCi Cs-137 and the 50 mCi Am-241:Be sources remained in their shielded positions as determined by subsequent surveys.

"The incident happened at a Cal Trans job in Santa Paula, CA on Highway 150 at the 28.12 mile marker. The Cal Trans supervisor immediately shut the job down and sent all of the workers home. The area where the gauge was located was secured and roped off until the sources were verified to still be in the gauge.

"The gauge and the broken gauge handle was transported back to the Santa Clarita storage location where a representative from RHB performed the survey to verify that the sources were in the gauge and in their shielded positions. The gauge will be transported to local CPN service representative , Maurer Technical Services in Laguna Hills, where they will do leak tests on the gauge."

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General Information or Other Event Number: 42735
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NONDESTRUCTIVE & VISUAL INSPECTION
Region: 4
City: HOUMA State: LA
County:
License #: LA-5601-01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/27/2006
Notification Time: 16:50 [ET]
Event Date: 07/27/2006
Event Time: [CDT]
Last Update Date: 07/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
EDWIN HACKETT (NMSS)
GREG MORELL (EMAIL) (NMSS)

Event Text

LOUISIANA AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The State provided the following information via facsimile:

"Non-Destructive & Visual Inspection (NVI) reported an excessive exposure to an industrial radiographer on July 27, 2006. [NAME DELETED], RSO, was called by Landauer [dosimetry service] with an exposure of 11,792 mrem for the month of June 2006 for [NAME DELETED]. [The RSO] is conducting an investigation into the excessive exposure and will supply further information once it is available. [The radiographer] told [the RSO] that he could not remember when he would have received such a high dose. Additional information will be provided to the NRC from the State of Louisiana as it becomes available."

Louisiana Event Report ID No.: LA-060016

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General Information or Other Event Number: 42736
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHILDREN'S MEMORIAL MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01165-01
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/27/2006
Notification Time: 18:45 [ET]
Event Date: 07/24/2006
Event Time: [CDT]
Last Update Date: 07/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
EDWIN HACKETT (NMSS)
GREG MORELL (EMAIL) (NMSS)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via email:

"On July 26, the RSO at a broad-scope medical facility contacted the agency to report a possible medical event involving I-131. He stated that on July 24, a 5 microCurie Na-I thyroid uptake diagnostic study was ordered by an endocrinologist at the facility; however, instead of 5 microCuries, the doctor ordered a 2 millicurie dose. The nuclear technologist did not question the request and the dose was drawn and administered to the 16-year old male patient. When the authorized user listed on the license came in to do the imaging on July 25, he noted the error. It appears the authorized user was not directly involved in ordering the study. The licensee estimated the whole body dose as 1.89 Rem and the dose to the thyroid of 4,140 Rem based on 59.2% uptake. Using the same assumptions, the intended dose for 5 microCurie I-131 would be 10.4 Rem. The licensee anticipates some depletion of thyroid function as a result of this administration of 2 millicuries. The RSO continues to investigate the matter and more information will be provided."

Illinois Item Number: IL-060036

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Power Reactor Event Number: 42738
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JIM KONRAD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/29/2006
Notification Time: 19:19 [ET]
Event Date: 07/29/2006
Event Time: 15:50 [EDT]
Last Update Date: 07/31/2006
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):
ANNE MARIE STONE (R3)

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 AND ECCS INJECTION DUE TO LOSS OF FEEDWATER

"At 15:50 EDT on 7/29/06, a Level 3 reactor scram occurred due to a loss of feedwater. The loss of feedwater was caused by a loss of Division 1 electrical power. All control rods fully inserted into the core. The lowest reactor vessel water level reached was 110 inches. HPCI and RCIC auto initiated on Level 2 and injected into the reactor pressure vessel. The Division 1 Emergency Diesel Generators auto initiated and supplied the Division 1 ESF buses. Level 3 and Level 2 isolations occurred as expected. Reactor water level is now being controlled in the normal water level band using Standby Feedwater. No SRVs lifted and RPV pressure is being controlled by the Turbine Pressure Regulator with the main condenser available as the heat sink.

"At the time of the scram, work was being performed on the 120kV mat which resulted in a loss of Bus 101.

"Group 13 (Drywell Sumps) isolated on Reactor Water Level 3. Group 10 (Reactor Water Cleanup Inboard), Group 11 (Reactor Water Cleanup Outboard), Group 12 (Torus Water Management System), Group 17 ( Reactor Recirc Pump Seals and Primary Containment Radiation Monitoring), and Group 18 (Primary Containment Pneumatic Supply) isolated on Reactor Water Level 2."

The licensee notified the NRC Resident Inspector. The licensee stated that HPCI injected for 2 minutes and was then secured as Standby Feedwater was started. At the time of the notification, Bus 101 had been re-energized, and preparations were being made to restore normal power to the Division 1 buses and return the Emergency Diesel Generators to standby. The licensee is investigating the exact cause of the loss of power.

* * * UPDATE FROM R. JOHNSON TO M. RIPLEY 1821 EDT 07/31/06 * * *

"The purpose of this report is to update the information provided at 19:19 ET on 7/29/2006.

"This event was originally reported under reporting criteria 50.72(b)(2)(iv)(A) as an ECCS injection. It has subsequently been determined that both the HPCI and RCIC systems auto-started in response to a reactor low water level 2 (Level 2) injection signal, however, only the RCIC system injected into the vessel. The Level 2 signal was only present for about 2.7 seconds until reactor water level recovered above Level 2. The HPCI injection logic is such that the Level 2 signal must be present until HPCI startup has completed. This includes time for the hydraulic pressure from the HPCI Auxiliary Oil Pump to develop enough pressure to open the HPCI turbine steam isolation valve (E4100F067) and time to stroke open the motor operated HPCI turbine steam isolation valve (E4100F001). It took about 12 seconds before steam was admitted to the HPCI turbine. Thus, the HPCI main pump outlet valve (E4150F006) did not open due to the short duration of the Level 2 signal. This is consistent with the HPCI system design. Therefore the event was not reportable as an event that resulted in or should have resulted in an ECCS injection into the reactor vessel. The event remains reportable under criteria 50.72(b)(2)(iv)(B) and 50.72(b)(3)(iv)(A).

"Additional clarification of the cause of the scram is also provided. The loss of bus 101 resulted in the loss of power to the operating south reactor feed pump (SRFP) turbine lube oil pump resulting in a loss of feedwater flow from the SRFP. The north reactor feed pump continued to operate. The plant is designed with an automatic runback of the recirculation system to allow continued operation following the loss of a single feed pump. However, the loss of bus 101 also resulted in the locking of the reactor recirculation pump speeds (scoop tube lock), disabling the runback feature. This led to a reactor scram on reactor low water level 3 (Level 3) since a single feed pump is not able to maintain reactor water level at 100% power operation. When south reactor feed pump lubrication pressure recovered, feedwater flow from the SRFP recovered. Recovering feedwater injection from the SRFP following the scram caused a rapid increase in reactor water level and a high reactor water level 8 (Level 8) shutdown of the HPCI, RCIC and reactor feedwater pumps. The standby feedwater system was subsequently started and used to maintain reactor level.

"The plant is restarting, and is in Mode 2 with reactor temperature at approximately 508F and reactor pressure at approximately 817 psi at the time of this report."

Based on this update, ECCS injection was removed from CFR Section of the report. The licensee notified the NRC Resident Inspector. Notified R3 DO (K. O'Brien)

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Power Reactor Event Number: 42740
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: CHET DEMARAIS
HQ OPS Officer: JASON KOZAL
Notification Date: 07/31/2006
Notification Time: 00:11 [ET]
Event Date: 07/30/2006
Event Time: 17:30 [CDT]
Last Update Date: 07/31/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
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

SECONDARY CONTAINMENT ISOLATION DUE TO 'B' SPENT FUEL RAD MONITOR FAILURE

"At 1730 on 7/30/06 the 'B' Spent Fuel Pool Radiation Monitor spiked high, which resulted in the closure of the DW CAM (Continuous Air Monitor) and the Oxygen analyzer primary containment isolation valves. The spikes (2) of approximately 50 mR/hour occurred during this event. Only 1 automatic isolation occurred. The Spent Fuel Pool Radiation Monitor High Rad signal also resulted in a Reactor Bldg Isolation (Secondary Containment), start of 'A' Standby Gas Treatment, and transfer of the Control Room Ventilation to the High Rad Mode. The 'A' Spent Fuel Pool Monitor remained constant at its background radiation level. No activities were in progress on the Refuel Floor at the time of the trips. Rad Protection Tech surveyed the area with no abnormal readings noted. The 'B' Spent Fuel Pool Radiation Monitor was declared inoperable. All automatic isolation valves have been reset, Rx Bldg Ventilation, Control Room Ventilation have been reset and SBGT (Standby Gas Treatment) has been secured. Normal trip setpoint is 50 mR/ hour."

The licensee has taken the actions of LCO 3.2.E

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42743
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BILL WALLAND
HQ OPS Officer: ARLON COSTA
Notification Date: 07/31/2006
Notification Time: 14:04 [ET]
Event Date: 07/31/2006
Event Time: 13:26 [EDT]
Last Update Date: 07/31/2006
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
KENNETH O'BRIEN (R3)
IAN JUNG (NRR)
THOMAS BLOUNT (IRD)
HASELTON (DHS)
LIGGETT (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 6 Startup 6 Startup

Event Text

UNUSUAL EVENT DECLARED DUE TO CO2 DISCHARGE TO THE CABLE TRAY ROOM

"At 1326 on 7/31/06 there was a discharge of CO2 to the cable tray room. This is not a normally accessible room. Plant personnel verified no smoke, no fire. At 1340 the order was given to evacuate all personnel from the Reactor and Auxiliary Buildings as a precautionary measure. An Unusual Event was declared (HU3) at 1344 due to the affect on normal operation of the plant. The CO2 has been isolated, the buildings are being walked down and atmospheric testing is underway in the affected areas."

The licensee notified the NRC Resident Inspector, Canada, State and County officials.

* * * UPDATE ON 07/31/06 AT 15:17 FROM B. WALLAND TO A. COSTA * * *

"At 1344 an Unusual Event was declared due to a toxic release into the Auxiliary Building (HU3). Release was due to a CO2 initiation, and has been isolated. Reactor building and Auxiliary building have been evacuated. Air sampling of the affected areas is underway."

Notified R3 DO (O'Brien).

* * * UPDATE ON 07/31/06 AT21:44 FROM N. MAJOR TO M. RIPLEY * * *

"Walk downs for atmospheric conditions are complete and satisfactory for all areas of the Auxiliary Building. Normal access to Auxiliary building has been restored. This restores access to all affected areas.

"Unusual Event is terminated at 2133."

Notified IRD (T. Blount), R3 DO (K. O'Brien), NRR EO (M. Tschiltz), DHS (Biasco) and FEMA (Kimbrell).

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Power Reactor Event Number: 42744
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GEOFF BENNETT
HQ OPS Officer: ARLON COSTA
Notification Date: 07/31/2006
Notification Time: 14:13 [ET]
Event Date: 07/31/2006
Event Time: 12:13 [EDT]
Last Update Date: 07/31/2006
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):
JAY HENSON (R2)
MICHAEL TSCHILTZ (NRR)
IAN JANG (NRR)

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 DUE TO MAIN GENERATOR TRIP

"At approximately 1213 hours on July 31, 2006, with Watts Bar Nuclear Plant Unit 1 operating normally at 100% power, the main generator tripped resulting in a reactor trip per design.

"All control rods inserted [fully] and the auxiliary feedwater system [AFW] automatically actuated per design and the reactor was stabilized in mode 3. This event is reportable under 10 CFR 50.72(b)(2)(iv)(B) for the reactor trip (4-hour report) and under 10 CFR 50.72(b)(3)(iv)(A ) for the RPS [reactor protection system] and AFW actuations (8-hour report).

"The cause of the generator trip is currently under investigation."

Steam is being released via steam dump to the condenser and all systems functioned as required.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 42745
Rep Org: ACUREN INSPECTION, INC.
Licensee: ACUREN INSPECTION, INC
Region: 4
City: LAPORTE State: TX
County:
License #: 42-27593-01
Agreement: Y
Docket:
NRC Notified By: KRISTI KENNEDY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/31/2006
Notification Time: 16:13 [ET]
Event Date: 07/09/2006
Event Time: 20:50 [CDT]
Last Update Date: 07/31/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH O'BRIEN (R3)
JEFFREY CLARK (R4)
EDWIN HACKETT (NMSS)

Event Text

RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

Acuren Inspection, Inc, a Texas corporation doing inspection work in Michigan, provided the following information via email:

"Description of Equipment Problem: The RT crew was using a 'pill stand' (a vertical metal pipe inserted into a coupling on a magnetic tripod with the source guide tube attached to a horizontal cross pipe) used to set up for an exposure. The 'pill stand' fell over during the exposure, thus crimping the source guide tube.

"Cause of Incident: The 'pill stand' was not stabilized on a flat and clean surface prior to exposure.

"Equipment: INC Exposure Device, Model IR-100, SN #4339, loaded with an 83 curie Iridium-192 source (Model 87703, SN #27923B).

"Place, Date, and Time of Incident: Filer City, Michigan, 8:50 PM CST, July 09,2006."

The technicians tried to retract the source assembly into the exposure device, but could not get the drive cable to move either way. Lead blankets were placed over the collimator and part of the guide tube. The technician located the crimp in the source tube and cut approximately a 1 1/2 inch piece of source tube out and freed up the drive cable and slowly cranked the source back in slowly. At 3:10 am, the source was back in the camera. The three licensee technicians involved in the retrieval received 181 mR, 60 mR, and 95 mR respectively by pocket dosimeter. The RSO stated that results for July film badge readings for the technicians will be available in early August. The RSO also stated that there was no damage to the camera or source, and that the guide tube has been replaced.

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