| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
05/04/2007 - 05/07/2007 ** EVENT NUMBERS ** |
 | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Power Reactor | Event Number: 43240 | Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK COVEY
HQ OPS Officer: JASON KOZAL | Notification Date: 03/14/2007
Notification Time: 22:22 [ET]
Event Date: 03/14/2007
Event Time: 14:35 [CDT]
Last Update Date: 05/04/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
MICHAEL SHANNON (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 TWO OUT OF THREE AUXILIARY FEEDWATER PUMPS OUT OF SERVICE
"A pinhole leak was discovered on B train Essential Service Water (ESW) system piping while preparing the pipe surface for non-destructive examination. Control room personnel were notified of the leak at 1435. B ESW was immediately declared inoperable. At the time of control room notification, surveillance testing on the Turbine Driven Auxiliary Feedwater Pump (TDAFP) was in progress. This surveillance testing made the TDAFP inoperable and non-functional. The surveillance activities were terminated and the TDAFP was returned to operable status at 1438.
"B ESW is the safety related water source for B train of auxiliary feedwater (AFW). For the three minute period between notification of the pinhole leak until the TDAFP was restored to operable status, there were two auxiliary feed pumps inoperable. This met the conditions for entry into T/S LCO Action 3.7.5.D which requires a plant shut down to Hot Standby within 6 hours. This action was exited when the TDAFP surveillance testing was terminated. Additionally, with 2 of 3 auxiliary feedwater pumps non-functional for 3 minutes, there was a condition which could have prevented fulfillment of a safety function for those 3 minutes."
The licensee notified the NRC Resident Inspector.
* * * UPDATE AT 1555 EDT ON 5/4/07 FROM KEITH DUNCAN TO S. SANDIN * * *
The licensee provided the following information as the basis for retracting this report:
"On March 14, 2007, (Event Number 43240) Callaway Plant reported a condition that, at the time, was believed to be a condition which could have prevented fulfillment of a safety function. At that time the 'A' motor driven auxiliary feedwater pump (MDAPP) was operable, the turbine driven auxiliary feedwater pump was not functional because of a surveillance test in progress. The 'B' MDAFP was presumed to be non-functional because of a pinhole leak in the 'B' train essential service water (ESW) system piping. 'B' ESW is the safety related water source for the 'B' MDAFP.
"Subsequent inspection, non-destructive examination, analysis and evaluation of the 'B' train ESW piping determined that the structural integrity of the pipe was retained. 'B' ESW pump was able to provide the required flow to the train. 'B' train ESW was functional with the pinhole leak. With the 'B' ESW train functional, the 'B' train of auxiliary feedwater had its emergency water source. The auxiliary feedwater system would have been able to fulfill its safety function. This event is not reportable per 10CFR50.72(b)(3)(v)."
The licensee will inform the NRC Resident Inspector. Notified R4DO (O'Keefe). |
| General Information or Other | Event Number: 43334 | Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKIN ELMER LIFE & ANALYTICAL SCIENCES
Region: 1
City: BILLERICA State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL HUFFMAN | Notification Date: 05/01/2007
Notification Time: 13:37 [ET]
Event Date: 05/01/2007
Event Time: 10:00 [EDT]
Last Update Date: 05/01/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (FSME)
| Event Text AGREEMENT STATE- MASSACHUSETTS - EXCESSIVE CONTACT RADIATION LEVEL ON SHIPPING PACKAGE
The State provided the following information via facsimile:
"Licensee received Type A package containing 100 millicuries of Na-22 from Los Alamos National Lab. External Radiation measurement of the package on contact was 360 mrem/hr. The TI on the package was listed as 7 (the licensee measured a TI of 8.5).
"Package was shipped on April 30, 2007 and flown to Boston Logan Airport by Fed Ex, after which it was trucked by Fed Ex to the licensee site at 331 Treble Cove road in Billerica, MA.
"The licensee has informed Fed Ex of the external radiation measurements." |
| General Information or Other | Event Number: 43336 | Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINAS MEDICAL CENTER
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: J. MARION EADDY III
HQ OPS Officer: JASON KOZAL | Notification Date: 05/02/2007
Notification Time: 09:39 [ET]
Event Date: 02/02/2007
Event Time: 13:39 [EDT]
Last Update Date: 05/02/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (FSME)
| Event Text AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The State provided the following information via facsimile:
"Patient was scheduled for administration of 30 millicuries of 90Y [Yttrium-90] microspheres. The delivery catheter developed a leak during the administration. Leakage was mostly contained within the Plexiglas box containing the vial of microspheres. There was very minimal contamination outside of the box.
"Licensee performed bremsstrahlung measurements of the patient and the Plexiglas box. Based on differences, the administered dose was determined to be only 66% of the prescribed dose.
"Licensee noted that this was the first of a two part administration of the microspheres and the dose at the next treatment will be adjusted to compensate for the 'missing' activity.
"The device manufacturer (Sirtex) traced the leaky units to one operator who had deviated from the normal assembly procedure. Sirtex destroyed the remainder of that lot number and replaced them with a new, tested lot."
NC Event Report ID number: NC-07-02
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.
* * * UPDATE FROM C. FLANNERY TO P. SNYDER AT 1436 ON 5/02/07 * * *
The NRC's medical events review committee has determined that this report is a medical event. Notified R1DO (Holody) and FSME (Morell) via e-mail. |
| General Information or Other | Event Number: 43337 | Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: AROOSTOOK MEDICAL CENTER
Region: 1
City: PRESQUE ISLE State: ME
County:
License #: 03803-02
Agreement: Y
Docket:
NRC Notified By: SHAWN SEELEY
HQ OPS Officer: PETE SNYDER | Notification Date: 05/02/2007
Notification Time: 14:00 [ET]
Event Date: 01/16/2007
Event Time: [EDT]
Last Update Date: 05/03/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (FSME)
| Event Text AGREEMENT STATE REPORT - DOSE TO PATIENT
On March 9, 2007, a consultant for the Aroostook Medical Center (TAMC) notified the TAMC Nuclear Medicine Department a medical event may have taken place on January 16, 2007.
The licensee investigated the report and found that a 4millicurie dose of I-131 was given to a patient on the date in question as a whole body scan. However, the licensee determined that the ordering physician actually wanted an I-131uptake and scan of 150 microCuries of I-131. Upon further investigation, the licensee determined that the scheduling person (who does not have a background in Nuclear Medicine) ordered the I-131 whole body scan. The licensee initiated a report of medical event and contacted the patient's physician.
The licensee calculated the whole body effective dose equivalent and the dose to the thyroid from the excess dose of I-131. The dose to the patients thyroid gland was calculated to be approximately 14000 rem and the whole body effective dose equivalent was calculated to be approximately 6.4 rem. The licensee determined that if the proper amount of I-131 had been administered, the doses would have been 525 rem and 0.24 rem respectively. A doctor at the licensee's facility determined that the dose given to the patient on March 16, 2007 will not have any effects on the patient.
"To prevent further events as this one, the Hospital and Radiation Safety Officer has decided that any further requests for I-131 procedures will be verified directly with the referring physician." There are now policies in effect to prevent this situation from happening again.
The state of Maine entered this report into NMED as number ME070016.
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.
* * * UPDATE AT 07:07 ON 5/3/2007 FROM CINDY FLANNERY TO MARK ABRAMOVITZ * * *
"This event (EN43337) has been reviewed and determined to be a reportable medical event." |
| Power Reactor | Event Number: 43343 | Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: ALAN J. McLAUGHLIN
HQ OPS Officer: JOHN MacKINNON | Notification Date: 05/04/2007
Notification Time: 12:40 [ET]
Event Date: 05/04/2007
Event Time: 08:53 [CDT]
Last Update Date: 05/04/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
| Person (Organization):
CHRISTINE LIPA (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 | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text FITNESS-FOR-DUTY REPORT INVOLVING A NON-LICENSED SUPERVISOR
A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access has been suspended. Contact the Headquarters Operations Officer for additional details.
The licensee informed the NRC Resident Inspector. |
| Power Reactor | Event Number: 43344 | Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MATT HUMMER
HQ OPS Officer: JOHN MacKINNON | Notification Date: 05/04/2007
Notification Time: 14:21 [ET]
Event Date: 04/04/2007
Event Time: 16:47 [PDT]
Last Update Date: 05/04/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
| Person (Organization):
NEIL O'KEEFE (R4)
MJ ROSS-LEE (NRR)
| | This material event contains a "Less than Cat 3" level of radioactive material. |
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 97 | Power Operation | 97 | Power Operation |
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text 30-DAY REPORT INVOLVING A LOSS OF ACCOUNTABILITY OF LESS THAN 1 GRAM SNM
"This is a non-emergency Event Notification made in accordance with 10 CFR 20.2201(a)(1)(ii) to inform the NRC of a loss of accountability of a very small amount (e.g., particle size) of special nuclear material (SNM). As part of preparations for an NRC inspection of Columbia's SNM Control and Accounting Program (April 16-19, 2007), documentation concerning the recovery of two pieces of a broken fuel rod was obtained. The documentation revealed existence of potential fuel particles estimated to be less than 1 gram in aggregate located in the spent fuel pool. The location of these particles cannot be positively identified at this time and is therefore being reported as missing SNM under 10 CFR 20.2201(a)(1)(ii).
"The particles were created during a 1990 refueling outage while inspecting a leaking fuel bundle. To identify the leaking rod, the bundle was disassembled and rod-by-rod electronic sorting performed. Ultrasonic examination identified the leaking rod; however, during the inspection the rod bent and snapped while being guided through a fuel inspection funnel. A procedure was approved and successfully executed to recover the broken rod sections. Following the recovery, an inspection was performed with an underwater camera to determine if any fuel pellets had been released as part of the evolution. No fuel pellets were identified; however, a small dark particle of material surrounded by smaller black particles was observed in a stainless steel bucket which had been positioned under the broken fuel rod pieces. It is believed that the bucket containing the particles was suspended off the west wall of the spent fuel pool, north of the work table. The location of the particles within the bucket cannot be positively identified at this time.
"The contents of the bucket have been described by the individuals involved in the broken rod recovery as a small particle of material roughly the size of a fingernail clipping surrounded by a few black particles the size of ground pepper. An underwater survey indicated a radiation level of greater than 400 R on contact for the material. The total amount is believed to be considerably less than 10 percent of a single pellet's worth of material, or less than 1 gram.
"Energy Northwest is continuing to investigate this event. Based on the information gathered to date, the nature of the particles, and the existence of radiation monitoring, a high degree of confidence exist that the particles are located in the bottom of the spent fuel pool or in an otherwise radiologically controlled location such that the health and safety of the public would not be adversely affected. In addition, there is no evidence of theft or diversion.
"This notification satisfies the 30-day notification requirement of 10 CFR 20.2201(a)(1)(ii). A subsequent written report will be made in accordance with 10 CFR 20.2201(b).
"The NRC Resident and SNM Control and Accounting Inspectors have been informed of this issue."
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.
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Power Reactor | Event Number: 43345 | Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JIM SCHROEDER
HQ OPS Officer: JOHN MacKINNON | Notification Date: 05/04/2007
Notification Time: 16:01 [ET]
Event Date: 05/04/2007
Event Time: 12:56 [CDT]
Last Update Date: 05/04/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
| Person (Organization):
NEIL O'KEEFE (R4)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | M/R | Y | 70 | Power Operation | 0 | Hot Shutdown | Event Text MANUAL REACTOR SCRAM DUE TO LOSS OF COOLING TO NUMBER 2 MAIN TRANSFORMER
"At approximately 1256 CDT on May 4, 2007, a manual reactor scram was initiated following the loss of cooling to the no. 2 main transformer. Reactor power at the time of the scram was approximately 70 percent (initially 100% power). Following the scram, reactor water level briefly decreased below Level 3, resulting in the automatic closure of containment isolation valves in the suppression pool cooling system. This isolation was confirmed to have occurred as designed. Reactor pressure and water level control were promptly established. All control rods inserted, and no emergency injection system operation was required.
"This event is being reported in accordance with 10CFR50.72(b)(2)(iv)(B) as a condition resulting in a manual actuation of the reactor protection system."
The NRC Resident Inspector was notified of this event by the licensee. |
| Power Reactor | Event Number: 43346 | Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: CHRIS KENT
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 05/05/2007
Notification Time: 02:13 [ET]
Event Date: 05/04/2007
Event Time: 23:05 [CDT]
Last Update Date: 05/05/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
| Person (Organization):
CHRISTINE LIPA (R3)
MICHAEL CASE (NRR)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | M/R | Y | 100 | Power Operation | 0 | Hot Shutdown | Event Text MANUAL REACTOR SCRAM ON LOSS OF FEEDWATER
The condensate prefilters isolated earlier in the day and the bypass valve automatically opened. The computer controlling these valves was in the process of being replaced when the bypass valve shut.
"Unit experienced a loss of feedwater due to condensate pre-filter valves going closed. The reactor was manually scrammed and HPCI was used to restore reactor water level. MSIVs closed and the U2 and U2/3 EDGs auto started on low level."
All rods fully inserted on the manual scram. Minimum level was approximately -54 inches. Decay heat is being removed using the isolation condenser and level is being maintained with Control Rod Drive leak by. No safety or relief valves lifted during this event. The plant is in the normal shutdown electrical lineup.
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 43347 | Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: SCOTT LINDQUIST
HQ OPS Officer: JOHN MacKINNON | Notification Date: 05/05/2007
Notification Time: 15:00 [ET]
Event Date: 05/05/2007
Event Time: 12:10 [CDT]
Last Update Date: 05/05/2007 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
NEIL O'KEEFE (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 OFFSITE NOTIFICATION MADE TO THE STATE OF NEBRASKA DUE TO A SMALL OIL SPILL
Nebraska Department of Environmental Quality notified of an oil spill while backwashing a screen in the intake structure. Approximately 2 gallons of oil was spilled . Most of the oil spill was contained and was wiped up using oil drip pads. There is no evidence that oil was released to the Missouri River.
The NRC Resident Inspector was notified of this offsite notification by the licensee. | |