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Event Notification Report for April 3, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/02/2007 - 04/03/2007

** EVENT NUMBERS **


42165 43188 43258 43261 43271 43272

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Fuel Cycle Facility Event Number: 42165
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2005
Notification Time: 15:54 [ET]
Event Date: 11/22/2005
Event Time: 12:05 [CST]
Last Update Date: 04/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
KERRY LANDIS (R2)
SCOTT FLANDERS (NMSS)

Event Text

IMPROPER CRITICALITY SPACING FOR WASTE DRUM

"At 1205 CST, on 11-22-05 the Plant Shift Superintendent was notified that during waste drum remediation activities, a drum was discovered that was in violation of one leg of double contingency. Drum #39666W has been determined to contain up to (deleted) g (grams) U235 exceeding the allowed (deleted) gram limit for NCS Spacing Exempt drums. This drum was previously located in an NCS (Nuclear Criticality Safety) Spacing Exempt storage area in violation of NCSA WMO-001 requirements. The drum was moved to the C-335 storage area under an approved Remediation Guide which established a safety basis for the movement of drums that had been roped off and posted per earlier direction. This drum is currently stored in a Temporary Fissile Storage Area maintaining a minimum 2 foot edge-to-edge spacing under NCSA WMO-001, which maintains double contingency."

SAFETY SIGNIFICANCE OF EVENTS

"While the (deleted) gram U235 limit was exceeded for this drum; DAC-832-2A1280-0001 demonstrates that drums containing less than (deleted) grams U235 in an NCS Spacing Exempt array are subcritical. The storage area is roped off and posted to prevent the addition of fissile material to the area; therefore another upset would be required before a criticality is possible."

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR)

"This drum is currently stored in the Temporary Fissile Storage Area under NCSA WMO-001, meeting double contingency. In order for a criticality to occur, two independent, unlikely, and concurrent events would have to occur."

CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.)

"Double contingency is maintained by implementing two controls on mass."

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS)

"The drum has been determined to contain (deleted) grams U235. Calculations performed demonstrate that drums containing less than (deleted) grams U235 each, in an NCS Spacing Exempt array are subcritical."

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES

"Although the drum contains greater than the WMO-001 limit of (deleted) grams U235 for NCS Spacing Exempt drums, it has been shown to be less than (deleted) grams U235 based on independent sample results. Calculations performed demonstrate that drums containing less than (deleted) grams U235 each, in an NCS Spacing Exempt array, are subcritical. Therefore, an additional process upset (i.e., spacing upset) would be necessary in order to have a criticality. Therefore, while the drum contained greater than (deleted) grams U235 in the spacing exempt array, the array has been shown to be subcritical for drums containing less than (deleted) grams U235 thus maintaining one leg of double contingency."

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED

"At the time of discovery, the drum was being stored according to NCS approved spacing controls. The drum will continue to be handled according to approved controls until the U235 mass can be reduced to meet the NCS Spacing Exempt criteria per NCSA WMO-001.

The NRC Senior Resident Inspector has been notified of this event."
See Related Event Report #40700.

* * * UPDATE 1802 EST ON 2/13/06 FROM K. BEASLEY TO S. SANDIN * * *

"At 1100 [CST], on 02-13-06 the Plant Shift Superintendent was notified that two additional waste drums were discovered that exceed the allowed [deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drums are currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

"The NRC Senior Resident Inspector has been notified of this event."

Notified R2DO(Ayres) and NMSS (Camper).

* * * UPDATE ON 3/20/06 AT 1859 EST FROM B. WALLACE TO HUFFMAN * * *

"At 1430, on 03-20-06, the Plant Shift Superintendent was notified that an additional waste drum has been discovered that exceeds the allowed (deleted) gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drums are currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

"The additional drum was determined to contain (deleted) grams U235. Calculations performed demonstrate that drums containing less than (deleted) grams U235 each, in an NCS Spacing Exempt array are subcritical."

The licensee notified the NRC Resident Inspector. R2DO (Ernstes) and NMSS EO (Pierson) notified.

* * * UPDATE ON 4/20/06 AT 1750 EDT FROM B. WALLACE TO HUFFMAN * * *

" At 1130, on 04-20-06 the Plant Shift Superintendent was notified that an additional waste drum has been discovered that exceeds the allowed (deleted) gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drums are currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

"The additional drum (#41663) was determined to contain (deleted) grams of U235."

The licensee notified the NRC Resident Inspector. R2DO (Lesser) and NMSS EO (Janosko) notified.

* * * UPDATE ON 4/21/06 AT 2040 EDT FROM WALKER TO HUFFMAN * * *

"At 1333, on 4-21-06 the Plant Shift Superintendent was notified that seven additional waste drums had been discovered that exceed the allowed (deleted) gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drums are currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

"Seven additional drums (41160W,41161W,41162W,41158W,41159W,40605W.41681W) were determined to contain in excess of the (deleted) gram limit of U235 but less than the (deleted) gram safety limit."

The licensee notified the NRC Resident Inspector. R2DO (Lesser) and NMSS EO (Janosko) notified.

* * * UPDATE ON 4/28/06 AT 1802 EDT FROM WALKER TO A. COSTA * * *

"At 1430, on 04-28-06 the Plant Shift Superintendent was notified that an additional waste drum has been discovered that exceeds the allowed [DELETED] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

"[This] one additional drum, # 43170W was determined to contain in excess of the [DELETED] gram limit of U235 but less than the [DELETED] gram safety limit."

The licensee notified the NRC Resident Inspector. Notified R2DO (Landis) and NMSS EO (Giitter).

* * * UPDATE ON 10/11/06 AT 1551 EDT FROM WALLACE TO HUFFMAN * * *

At 0900, on 10-11-06 the Plant Shift Superintendent was notified that an additional waste drum (#41470W) has been discovered that exceeds the allowed limit (but less than the safety limit) for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

The licensee notified the NRC Resident Inspector. Notified R2DO (Decker) and NMSS EO (Essig).

* * * UPDATE ON 10/24/06 AT 1130 EDT FROM K. A. BEASLEY TO MACKINNON * * *


At 1000, on 10/24/06 the Plant Shift Superintendent was notified that an additional waste drum has been discovered that exceeds the allowed [Deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

The NRC Senior Resident Inspector has been notified of this event. Notified R2DO (Brain Bonser) and NMSS (Sandra Wastler).


* * * UPDATE ON 12/08/06 AT 1604 EST FROM K. A. BEASLEY TO KOZAL * * *

At 1140 on 12/08/06 the Plant Shift Superintendent was notified that an additional waste drum (42171W) has been discovered that exceeds the allowed [Deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NSCA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

The licensee notified the NRC Resident Inspector. Notified R2RDO (Lesser) and NMSS EO (Janosko).

* * * UPDATE ON 12/18/06 AT 1250 EST FROM B. W. WALLACE TO KOZAL * * *

At 1250 on 12/18/06 the Plant Shift Superintendent was notified that 4 additional waste drums (39639W, 42118W, 42488W, & 43521W) had been discovered that exceeds the allowed [Deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NSCA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

The licensee notified the NRC Resident Inspector. Notified R2RDO (Moorman) and NMSS EO (Ruland).

* * * UPDATE ON 3/23/07 AT 1602 EDT FROM C. PITTMAN TO JOE O'HARA * * *

"At 1345 on 3/23/07 the Plant Shift Superintendent was notified that an additional waste drum (43561W) had been discovered that exceeds the allowed [Deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NSCA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency."

The licensee notified the NRC Resident Inspector. Notified R2RDO (Lesser) and FSME EO (Brach).

* * * UPDATE 1155 EDT ON 4/2/07 FROM CALVIN PITTMAN TO MARK ABRAMOVITZ * * *

The following information was received as an update:

"UPDATE 4/02/07 at 0845, on 4/02/07 the Plant Shift Superintendent was notified that an additional waste drum (43557W) has been discovered that exceed the allowed [Deleted] gram limit for NCS Spacing Exempt drums and had previously been located in an NCS Spacing Exempt storage area in violation of NCSA WMO-001. The drum is currently stored in a Temporary Fissile Storage Area under NCSA WMO-001, which maintains double contingency.

The licensee informed the NRC Resident Inspector. Notified R2DO(Henson) and FSME(Wastler).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43188
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SOUTHWEST RESEARCH INSTITUTE
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L00775
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/26/2007
Notification Time: 15:31 [ET]
Event Date: 02/26/2007
Event Time: [CST]
Last Update Date: 04/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SANDRA WASTLER (NMSS)
DALE POWERS (EMAIL) (R4)

Event Text

AGREEMENT STATE REPORT

"On 2/26/07 at about 13:30 the licensee notified the Agency that they had received 8 sources from White Sands Missile Base containing cobalt sixty (Co-60) sources. Four were estimated to have activities of 3,000 curies and four had estimated activities of 1,000 curies. Southwest opened one of the containers used to ship the sources to leak test the source. Upon opening the container, it appeared that the source was no longer contained in a source capsule. The leak test results indicated 5 million DPM. The container was resealed and no other containers were opened."

Containers were opened with automation equipment, therefore no exposure to personnel occurred.

TX Report TX-07-43188


* * * UDPATE ON 02/27/07 AT 0950 EST FROM ARTHUR TUCKER VIA E-MAIL TO MACKINNON * * *

"On 2/26/07 at about 11:00 the licensee notified the Agency that they had received eight (8) cobalt sixty sources from White Sands Missile Range. Each of the eight sources was contained in a separate container. Four sources had estimated activities of 3,000 curies and four had estimated activities of 1,000 curies. The outside of each container was surveyed after receipt and contamination levels were found to be below their limits. SWR opened one of the containers used to ship the sources to leak test the source. The source was a Neutron Products Inc. model no. NPU-25-13000 capsule serial # T-96-5. The container was opened in SWR hot cell using manipulator arms. Upon opening the source container, it appeared that the source capsule had been breached. The leak test results indicated 5 E6 dpm of contamination. The container was sealed and no other sources were opened. The sources were removed from the hot cell. The hot cell was surveyed and found to be contaminated. The hot cell was decontaminated and returned to service.

R4DO (Dale Powers) & NMSS EO (Greg Morell) notified.

* * * UPDATE PROVIDED BY ART TUCKER (STATE OF TEXAS) TO JEFF ROTTON AT 1652 EDT ON 04/02/07 * * *

"The State of Texas, Department of State Health Services, Radiation Control Program, is retracting event number TX-07-43188 [NRC EN #43188]. The eight sources sent to Southwest Research of San Antonio, Texas, were included in a group of sources identified at White Sands Missile Range in 1996 by the Nuclear Regulatory Commission (NRC) as failing during use. NMED item Number 960300, [and] NRC EN# 30353 documents this as well as an Executive Summary Report done by the United States Army. These sources were removed from service, and the source carrier and source itself were redesigned to operate as required. The State was not aware that the NRC had already addressed the source failures prior to sending our Event Notification [#43188] to the NRC."

R4DO (Chuck Cain) & FSME EO (Larry Camper) notified.

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General Information or Other Event Number: 43258
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALIFORNIA SURGERY CENTER
Region: 4
City: Bakersfield State: CA
County:
License #: 6833-15
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/27/2007
Notification Time: 17:52 [ET]
Event Date: 03/19/2007
Event Time: [PDT]
Last Update Date: 04/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - CALIFORNIA - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days."

CA Report #032707

* * * UPDATED 1346 EDT ON 4/2/07 FROM CYNTHIA FLANNERY (FSME) * * *

"This event has been reviewed by FSME and found to be a medical event."

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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General Information or Other Event Number: 43261
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: NOVA ENGINEERING
Region: 1
City:  State: GA
County: Fayette
License #: GA-1323-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/28/2007
Notification Time: 16:44 [ET]
Event Date: 03/27/2007
Event Time: [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - GEORGIA - DAMAGED DENSITY GAUGE

The State provided the following information via email:

"Nova personnel had placed the portable density gauge on the tailgate of the truck and drove off prior to secure the gauge to the truck bed. The Radiation Safety Officer (RSO) of Nova was notified of the incident and responded to the scene. The RSO stated the gauge case had broken apart and the circuit board on the gauge had been damaged. He had surveyed the source rod and source and based on the measurements determined the source rod to be intact and the source not leaking. The fire department and the County had the area secured until it was determined the gauge could be packed up and removed from the road. The RSO stated he would send the gauge to Regis [a gauge repair firm] for either disposal or repair. "

Georgia Report GA-2007-07

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Power Reactor Event Number: 43271
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MIKE DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/02/2007
Notification Time: 12:48 [ET]
Event Date: 04/02/2007
Event Time: 11:25 [CDT]
Last Update Date: 04/02/2007
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):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 98 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO LOWERING REACTOR VESSEL WATER LEVEL

"This report is being made under 50.72(b)(2)(iv)(B) for inserting a manual scram due to lowering reactor pressure vessel level. The lowering level resulted from a loss of non-essential 4160 VAC bus 1A2 and subsequent loss of 'B' Reactor Feed Pump.

"In addition this report is being made under 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any systems listed in paragraph (b)(3)(iv)(B) of this section due to PCIS groups 2, 3, and 4 being received when reactor water level dropped below 170". All isolations went to completion. The reactor water level drop is normal following a scram from full power due to void collapse in the reactor vessel.

"After the initial scram, vessel level rose to 211" causing the 'A' Reactor Feed Pump to trip. Before a Reactor Feed Pump could be restarted and adequate feed flow established, another scram signal and isolation occurred when vessel level dropped below 170". Control rods were already fully inserted and isolation valves in the isolated condition when this occurred. Reactor water level was restored to normal and the PCIS group isolations were reset.

"The current plan is to remain in Hot Standby (Mode 3) and determine the cause of the loss of 1A2 non-essential 4160 VAC bus."

The licensee informed the NRC Resident Inspector.

* * * UPDATE PROVIDED BY MIKE DAVIS TO JEFF ROTTON AT 1621 EDT ON 04/02/07 * * *

"This update is being added to clarify that the second scram on 170 " vessel level described in the original report also constituted a 50.72 (b)(3)(iv)(A) reportable event."

The licensee notified the NRC Resident Inspector. Notified R3DO (Kozak)

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Power Reactor Event Number: 43272
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: PHIL SANTINI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/03/2007
Notification Time: 05:07 [ET]
Event Date: 04/03/2007
Event Time: 04:16 [EDT]
Last Update Date: 04/03/2007
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):
HAROLD GRAY (R1)
BILL BATEMAN (NRR)
CATHY HANEY (NRR)
JEFFREY CRUZ (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 60 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP WHILE PERFORMING BOILER FEED PUMP MAINTENANCE

"The Indian Point Unit 3 reactor was manually tripped at 04:16 on 4/3/2007 due to low steam generator levels that occurred while the 31 MBFP [main boiler feed pump] speed control was being isolated for maintenance. Indian Point Unit 3 is currently in mode 3 with all automatic actions for a manual reactor trip occurring as required. Unit 2 was unaffected and remains in mode 1 at 100% power."

The reactor was manually tripped when steam generator levels reduced to 18% in all four steam generators. All rods inserted on the trip. No safety or relief valves lifted due to the trip. The motor driven aux feedwater pumps automatically started on low steam generator level and are being used to maintain steam generator level. Atmospheric steam dumps are maintaining reactor temperature. The Unit 3 electrical lineup is the normal shutdown electrical lineup. The licensee has notified the state Public Service Commission.

The licensee will notify the NRC Resident Inspector.

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Thursday, March 29, 2012