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Event Notification Report for August 18, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/17/2006 - 08/18/2006

** EVENT NUMBERS **


42768 42769 42770 42771 42772 42773 42774 42775 42781 42782 42783

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General Information or Other Event Number: 42768
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NORTH OAKS RADIATION CENTER
Region: 4
City: THOUSAND OAKS State: CA
County:
License #: 3693-56
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/14/2006
Notification Time: 19:19 [ET]
Event Date: 08/09/2006
Event Time: [PDT]
Last Update Date: 08/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE - MEDICAL EVENT

The State provided the following information via email:

"On August 11, 2006, RHB received notification from North Oaks Radiation Center of a potential medical event. On August 9, 2006, a patient was undergoing the third of three fractional doses from a Nucletron Model MicroSelectron-HDR Classic Afterloader, using Ir-192. The first two fractions had been delivered properly. When this fraction was delivered, the medical physicist inadvertently selected the wrong delivery tube. There are two delivery tubes available depending upon the treatment plan. In this case, the longer tube was incorrectly selected for this fraction, and the source remained outside the patient for the entire fraction. The preliminary estimate of the highest dose in this configuration was approximately 100 - 125 rads to the perineum, which was not the intended treatment site, and which would have received less than 50 rads with the intended configuration. The patient has been notified. The California Radiologic Health Branch will investigate this incident."

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General Information or Other Event Number: 42769
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: SVERDRUP CIVIL, INC
Region: 1
City: BOSTON State: MA
County:
License #: 48-0223
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 10:01 [ET]
Event Date: 08/07/2002
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE DAMAGED BY FIRE

The State provided the following information regarding a previously unreported event via facsimile:

"A fire, which started in garage/storage facility, at a golf course construction site near the summit of a former city landfill was allowed to burn for two days by the local fire department. However, during the fire and immediately after the proximity of the device storage shed was disclosed by the licensee to the local authorities, the City of Quincy Fire Department summoned the Agency [MA Radiation Control Program] to the scene. At the scene the Agency representative was able to overview the situation, to take measurements and to advise the fire officials that the radiological device in the nearby stage shed was neither an immediate or imminent health or safety hazard. On the third day, the Agency representative [and] the licensee Radiation Safety Officer (RSO) were allowed by the Fire Chief to enter the separate device shed with instrumentation and to retrieve the device. The device was located with appropriate instrumentation, separated from the rubble and stored securely elsewhere on-site. Surveys were subsequently conducted to release the remains of the storage shed. The manufacturer of the device was engaged by the licensee to come to the job site to confirm recovery of both Cesium-137 and Am-241:Be sealed sources; to conduct appropriate leak testing and leak test analyses; and to package, mark and label the 55 gallon drum for shipment to the manufacturer's headquarters. Leak test results disclosed no apparent leakage of material from either sealed source. These sources were packaged on August 22, 2002, and the shipment was secured on-site in a vault pending completion of attendant paperwork, obtaining the certificate of compliance for the shipping container, and arranging for the transportation pickup of the hauler. Event closed by state."

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General Information or Other Event Number: 42770
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: NEN LIFE SCIENCE PRODUCTS
Region: 1
City: BOSTON State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 10:01 [ET]
Event Date: 06/04/2002
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)

Event Text

AGREEMENT STATE REPORT - DEFECTIVE PACKAGING OF RADIOACTIVE MATERIAL SHIPMENT

The State provided the following information regarding a previously unreported event via facsimile:

"On June 4, 2002, the surface and 1 meter radiation dose rates from a package containing 8 curies of phosphorus-32 (P-32) was found to be 1 R/hr at the surface and 4 milliR/hr at 1 meter. The package had a Yellow II label affixed which has a surface dose rate limit of 50 milliR/hr and a dose rate at 1 meter of 1 milliR/hr per Massachusetts regulation 120.775(A)(1). There was no removable contamination on the package hence the inner container appeared to be intact. However, the inner container appeared to be loose in the packaging rather than in the fixed geometry as evidenced in other similar packages in the same shipment.

"The package dose rate at the surface is greater than 0.2 R/hr but less than 0.01 R/hr at 1 meter hence the package exceeded the requirements of a Yellow III.

"In summary the defective packaging resulted in a radiation field at the surface of the package in excess of the limit for a common carrier and the Yellow II label on the package.

"The licensee has suspended all shipments from this supplier until the investigation of the package failure is complete.

"The root cause investigation of this event by the licensee has been postponed until September with the approval of the Massachusetts Radiation Control program pending decay of the radioactive material and adherence to the Perkin Elmer Life Sciences ALARA policy. A preliminary investigation concluded that persons handling the package during shipment would not have received a significant radiation dose because of the limited area of the package in excess of Yellow Il limits and the limited time of handling package by transportation personnel.

"UPDATE

"Excessive radiation field is due to seepage of radioactive material from cracked glass vial. There is a metal cap used to seal the vial. The metal cap is fastened using a hand operated crank. This tool can be mishandled resulting in over-tightening of the cap and causing the glass to crack. This vial, cap and tool are provided by Perkin Elmer and the firm is familiar with this potential failure mode. Root cause: improper training or supervision of operator of capping tool.

"Licensee informed vendor that supplies the glass vial and have discontinued using this vendor. This event is closed by the state"

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Power Reactor Event Number: 42771
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOHN BRADY
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/15/2006
Notification Time: 13:23 [ET]
Event Date: 08/15/2006
Event Time: 10:15 [EDT]
Last Update Date: 08/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK LESSER (R2)

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

LOSS OF ERDADS COMMUNICATION

"On 08/15/2006 during performance of the quarterly ERDADS functional communications test, the ERDADS communication link from the U1 Control Room to the NRC Operations Center was determined to be unavailable. Initial notification was made to the NRC Operations Center and the communications vendor was contacted to investigate the source of the problem. Subsequent notification was made by the vendor to the Site identifying that the communications failure was occurring within the portion of the system under control of the Site. Troubleshooting by the Site is in progress. Note: the U2 ERDADS communication link tested satisfactory. This non emergency notification is being made pursuant to 10 CFR 50.72(b)(3)(xiii) regarding loss of communications capability."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 14:50 ON 8/17/06 FROM JOHN BRADY TO ABRAMOVITZ * * *

"Subsequent troubleshooting of the failed ERDADS communication link identified a faulty wiring connection in onsite communications equipment. Repairs were performed and a successful ERDADS functional communications test was completed at 1137 on 08/17/06. The U1 ERDADS comm link is back in service and communications capability has been restored."

The licensee will notify the NRC Resident Inspector.

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General Information or Other Event Number: 42772
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LEVEL 1, INC
Region: 1
City: ROCKLAND State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 10:01 [ET]
Event Date: 12/15/2002
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)
ILTAB (Email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST GENERAL LICENSED DEVICE

The State provided the following information regarding a previously unreported event via facsimile:

"By letter dated 1/28/03, Level 1, Inc. notified the Agency [MA Radiation Control Program] of the loss of a GL device.

"The device was an NRD air deionizer model number P-2021-0101, serial number 109646 which was shipped to the licensee on March 3, 1999. The device was used to de-ionize air during their clean-room assembly process. The device was taken out of service in March of 2002. When units are taken out of service the licensee stated that the devices are stored in a cabinet. The licensee discovered that the device was lost when they sent back all devices (30) in the program that were beyond their usefulness. They had 31 and could not account for one device when they were going to send the devices back. The device was discovered to be lost in December 2002. They have tried unsuccessfully to locate the device. They believe that it may still be in their facility and will continue to locate it.

"In order to prevent future losses, the licensee has implemented a Preventive Maintenance (PM) Program and have included all air deionizers as part of the PM program. The PM program will consist of a computer program that tracks all devices that are to be accounted for in the company for maintenance. The GL devices will be added to the list.

"The devices had 10 millicuries of Po-210 loaded in March of 1999. With the 138.38 day half life of Po-210, the device contains about 6 microCuries at this time. The safety significance is low for this lost device.

"Corrective action

"In order to prevent future losses, the licensee has implemented a Preventive Maintenance Program and have included all air deionizers as part of the PM program. The PM program will consist of a computer program that tracks all devices that are to be accounted for in the company for maintenance. The GL devices will be added to the list. EVENT CLOSED BY STATE."

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.

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General Information or Other Event Number: 42773
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKINELMER LIFE SCIENCES
Region: 1
City: BOSTON State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 13:24 [ET]
Event Date: 01/30/2006
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)
ILTAB (email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST SULFUR - 35 SHIPMENT

The State provided the following information regarding a previously unreported event via facsimile:

"S-35 (7 mCi) package was shipped via FedEx, from PerkinElmer in Boston, MA on 1/30/06.

"FedEx tracking indicates 1) the package was picked up from PerkinElmer in Boston, MA; 2) the package left the FedEx South Boston station; 3) the package arrived at FedEx Hub in Memphis, TN; 4) the package had an In-transit scan to Montreal on 1/31/06. There were no package scans after that.

"PerkinElmer Canadian Customer Service reported the customer did not receive the package. PerkinElmer asked FedEx several times to locate the package. PerkinElmer receiving department did not receive the package as a return and verified with the customer, again, that the package was not received. FedEx was unable to locate the package.

"PerkinElmer declared the package as lost on February 12, 2006, and reported to the Agency [MA Radiation Control Program] by phone on March 10, 2006. A written report was received to the Agency on April 10, 2006.

"Corrective action: PerkinElmer advised FedEx that all radioactive shipments require a Proof of Delivery; this issue has been escalated to FedEx Dangerous Goods Administrator; and a letter was sent to FedEx explaining the requirements of delivering radioactive packages."


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.

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General Information or Other Event Number: 42774
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM & WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 13:24 [ET]
Event Date: 05/12/2003
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information regarding a previously unreported event via facsimile:

"The Agency [MA Radiation Control Program] received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again.

"Corrective action
1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery.
2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means.
3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device."

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General Information or Other Event Number: 42775
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 14:33 [ET]
Event Date: 08/08/2006
Event Time: [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
BLAIR SPITZBERG (R4)
CINDY FLANNERY (NMSS)

Event Text

AGREEMENT STATE REPORT - SURFACE CONTAMINATION

The State provided the following information via email:

"Licensee received an 'empty' lead pod with exterior contamination of 1.3 E-5 microCi/cm2. Contamination identified as Cs-137. Shipment came from Thermo Electron, 1410 Gillingham Lane, Sugarland, Texas via Conway Trucking."

"Licensee informed Conway Trucking of the contamination."

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Power Reactor Event Number: 42781
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: RICH LOWERY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/17/2006
Notification Time: 11:22 [ET]
Event Date: 08/17/2006
Event Time: 09:00 [CDT]
Last Update Date: 08/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAIR SPITZBERG (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

PHONE LINES OUT OF SERVICE FOR MAINTENANCE

"Phone line maintenance is occurring today 8/17/06. Maintenance starting at 0900 and is planned until 1600 hours. Line maintenance may impact ENS, HPN, and ERDS capabilities. An 8 hour notification per 10CFR50.72(b)(3)(xiii) is being made due to expected failures during line interruptions. Affected communications will be verified subsequent to completion of line maintenance."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1725 ON 8/17/06 * * *

The ENS and HPN lines were tested and declared operable at 16:55 CDT. The ERDS line was verified operable at 17:25 by sending plant data to the NRC. The licensee notified the NRC Resident Inspector. R4DO (Blair Spitzberg) notified.

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Power Reactor Event Number: 42782
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JIM BUNNING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/17/2006
Notification Time: 17:33 [ET]
Event Date: 08/17/2006
Event Time: 10:44 [CDT]
Last Update Date: 08/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (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

MAIN TURBINE BYPASS VALVES INOPERABLE

"At 1044 on August 17, 2006, operators received main control room annunciator alarm 'CONDENSER
VACUUM LOW' and status lights 'COND VACUUM TRIP' and 'COND VACUUM LOW.' All other indications
for main condenser vacuum indicated normal ~ 26.6 [inches Hg]. In response to the alarm, initial troubleshooting
determined that the main turbine bypass system was inoperable. This was due to concluding that with the low
condenser signal present, the bypass valves were prohibited from opening upon demand. Therefore at 1110,
Technical Specifications 3.7.6, 'Main Turbine Bypass System,' Condition 'A' was entered.

"This is reportable as an 8 hour report in accordance with 10 CFR 50.72 (b)(3)(v)(D) as 'Any event or condition
that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems
that are needed to: (D) Mitigate the consequences of an accident.'

"The devices that cause the annunciator are 1PY-ES063 and 1PY-ES066. A visual inspection of the device
cards revealed that on the 1PY-ES066 card the 'DC CURRENT ALARM' upper and lower lights were lit.
These same lights were not lit on the 1PY-ES063.

"At 1212 on August 17,2006, a lead was lifted to remove the low vacuum inhibit input from 1PY-ES066 for the
bypass valves. The main control room alarm cleared and the low vacuum light went out as expected. At 1215
the low vacuum inhibit was reset restoring the bypass valves to operable."

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 42783
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF YEAGER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/18/2006
Notification Time: 01:00 [ET]
Event Date: 08/17/2006
Event Time: 19:00 [EDT]
Last Update Date: 08/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (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

EMERGENCY DIESEL GENERATORS INOPERABLE DUE TO UNDERSIZED BREAKER CONTROL TRANSFORMERS

"At 1900 hrs on 8/17/06, all four Emergency Diesel Generators (EDGs) were declared INOPERABLE. The inoperability is a result of undersized control transformers for each of the Emergency Diesel Generator Service Water (DGSW) Pumps. The concern is that the DGSW pump contactors will not receive adequate voltage at the starters to ensure the starters pickup under degraded voltage conditions. A 2 hour Limiting Condition for Operability (LCO) was entered per LCO 3.8.1 to restore both EDGs in one division to OPERABLE status. At 2100 hours on 8/17/06 the two hour time requirement expired and a 12 hour LCO to place the plant in Mode 3 (Hot Shutdown) was entered.

"At 0042 hrs on 8/18/06, compensatory measures have been put in place to restore operability to both division 2 EDGs. The compensatory measures include placing the local control switch for both division 2 DGSW Pumps in run. Placing the local control switches in run ensures sufficient voltage will be available at the starters to ensure the starters pickup following a loss of offsite power, load shed, and restoration of power to the applicable busses. With operability restored to division 2 EDGs, the new expiration time for the LCO has been revised to 72 hours based on discovery of one or both EDGs in one division inoperable concurrent with CTG 11-1 [station blackout Combustion Turbine Generator 11-1] not available. After 72 hours, if operability is not restored to either CTG 11-1 or both division 1 EDGs, the plant will be required to enter Mode 3 within the following 12 hours.

"This report is being made pursuant to 10CFR50.72.(b)(3)(v) as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (A) Shut down the reactor and maintain it in a safe shutdown condition; (B) Remove Residual Heat; (C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident. The NRC resident inspector has been notified."

The licensee stated that the current 72 hour LCO will expire at 1900 EDT 08/20/06.

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