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Event Notification Report for November 28, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/27/2006 - 11/28/2006

** EVENT NUMBERS **


43006 43008 43012 43013

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General Information or Other Event Number: 43006
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TSA SYSTEMS, LTD
Region: 4
City: LONGMONT State: CO
County:
License #: CO - 285-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2006
Notification Time: 14:17 [ET]
Event Date: 11/22/2006
Event Time: [MST]
Last Update Date: 11/28/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
MICHELE BURGESS (NMSS)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE - COLORADO - LOST CHECK SOURCE

The State provided the following information via facsimile:

"A licensee, TSA Systems, Ltd., Colorado License #285-01, notified the Department on this date that a 2.1 microcurie Cf-252 source was missing. The source, manufactured by Isotope Products Laboratories, is a Model A3014 with Serial #B2-833. The licensee's representative stated that they continue to search their facility for the source which is used for instrument response checks and calibrations.

"No other details are available at this time. The Department has initiated an investigation."

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: 43008
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON HARBORVIEW GAMMA KNIFE
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M0219-066
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2006
Notification Time: 18:06 [ET]
Event Date: 11/16/2006
Event Time: [PST]
Last Update Date: 11/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE - WASHINGTON - GAMMA KNIFE OVEREXPOSURE

The Washington State Department of Health (DOH) received a preliminary telephone report, November 22, from University of Washington, Harborview Gamma Knife, that a dose of 28 Grays had been administered to a patient. The exposure exceeded the prescribed exposure of 18 Grays by 10 Grays. The cause, thus far, is unknown. DOH is to receive a written report within 15 days.

The dose was administered by a Leksell Gamma System Model 24001 Type C gamma knife with 7,236 Curies of Co-60.

The patient or responsible relative has been notified.

The licensee is required to notify DOH within 24 hours. The notification is apparently several days late.

Washington State report number: #WA-06-066

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 43012
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANNY WILLIAMSON
HQ OPS Officer: BILL GOTT
Notification Date: 11/27/2006
Notification Time: 10:35 [ET]
Event Date: 09/29/2006
Event Time: 13:33 [CDT]
Last Update Date: 11/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RUSSELL BYWATER (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

INVALID SPECIFIC SYSTEM ACTUATION

"On September 29, 2006, at 1:33 pm CDT, a safety-related 120VAC distribution panel was inadvertently de-energized during a planned shift of its power supply. The plant was operating at 100 percent power at the time. The loss of power resulted in the automatic closure of primary containment isolation valves in the reactor water cleanup and the suppression pool cooling/cleanup systems. This event is being reported in accordance with 10CFR50.73(a)(1) as an invalid actuation of the containment isolation valves affecting more than one system.

"This event occurred during a planned shift of the inverters that supply the distribution panel. This shift was being performed to support post-maintenance testing of one of the inverters. The operators performing the shift were utilizing the appropriate procedure. At a certain point in the procedure, the off-going inverter was deenergized, and the operators discussed the expected equipment response. Following that discussion, a step was erroneously performed out of sequence, resulting in the loss of power to the 120VAC distribution panel. The primary containment isolation signal was actuated as designed, and the appropriate valves responded correctly.

"Reactor power was not affected by the containment isolation signal. The pertinent response procedures were implemented, and actions were taken to restore the distribution panel to service. This was completed at 5:31 pm CDT that day."

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 43013
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: CHUCK MARASCO
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/27/2006
Notification Time: 16:47 [ET]
Event Date: 11/27/2006
Event Time: 13:30 [CST]
Last Update Date: 11/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
RUSSELL BYWATER (R4)

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

Event Text

MOMENTARY LOSS OF SHUTDOWN COOLING DUE TO RHR ISOLATION SIGNAL

"On November 27, 2006 Fort Calhoun Station was on shutdown cooling, while in the process of moving the plant from Mode 3 to Mode 4 to fix a leak on an In-Core Instrument (ICI) Grayloc fitting. At 1327 Reactor Coolant Pump RC-3B was secured. At 1330, the last Reactor Coolant Pump (RC-3A) was secured. Once the reactor coolant pumps were secured, spray to the pressurizer was lost. This loss of pressurizer spray caused pressure in the pressurizer to rise; the systems pressure interlock caused HCV-347, Shutdown Cooling Loop 2 Outboard Isolation Valve, and HCV-348, Loop 2 to Shutdown Cooling Isolation Valve to close due to pressurizer pressure being greater than 250 psia.

"At 1330 the Control Room entered AOP-19 for a Loss of Shutdown Cooling. The control room operators initiated auxiliary spray, lowered pressure, reopened HCV-347/348, and started Low Pressure Safety Injection Pump SI-1A. At 1342 shutdown cooling was reestablished. At 1352 all conditions to exit AOP-19 were met and the procedure was exited. During the 12 minutes that shutdown cooling was lost the highest pressure reached in the RCS was 254 psia up from 233 psi and the highest temperature was 135 degrees, up from 134 degrees as read on the core exit thermocouples."

The licensee informed the NRC Resident Inspector.

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