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Event Notification Report for May 29, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/25/2007 - 05/29/2007

** EVENT NUMBERS **


43377 43380 43382 43383 43386 43388 43391 43392 43393

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General Information or Other Event Number: 43377
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: LARGO MEDICAL CENTER
Region: 1
City: LARGO State: FL
County:
License #: 1284-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/21/2007
Notification Time: 14:40 [ET]
Event Date: 05/17/2007
Event Time: [EDT]
Last Update Date: 05/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"RSO contacted this office [Florida Bureau of Radiation Control] at 1335 hours 21-May-2007 to report a medical event. Patient has metastatic cancer and no thyroid. Doctor prescribed a whole body scan. Technologist gave patient a therapy dosage for the cancer, instead of the scan. Doctor and patient notified of misadministration. This incident referred to the radioactive materials office for investigation. No further action will be taken on this incident."

The therapy dosage administered was 26.8 mCuries of I-131 in liquid form.

Florida Incident number: FL07-081

* * * UPDATE BY E-MAIL AT 1547 EDT ON 5/22/2007 FROM C. FLANNERY TO JEFF ROTTON * * *

"This event has been reviewed and determined to be a reportable 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: 43380
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONVERSE CONSULTANTS
Region: 4
City: MONROVIA State: CA
County:
License #: 4507-19
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/22/2007
Notification Time: 12:07 [ET]
Event Date: 05/22/2007
Event Time: 05:15 [PDT]
Last Update Date: 05/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
GREG MORELL (FSME)
ILTAB via email ()
CNSNS (Mexico - fax) ()

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

Event Text

CALIFORNIA AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

"At 0830 on 5-22-07, the radiation safety officer notified [California Radiological Health Branch] that a vehicle (Chevy Silverado with an attached camper shell) was stolen with a nuclear gauge locked in the camper shell (Troxler, model 3440, #18250 with 8 mCi Cs-137 & 40 mCi Am-241:Be). The gauge was locked inside a transport case, the transport case was chained, blocked, & braced in the camper shell. The gauge user does not remember if the door to the camper shell was locked. The gauge user had not secured and locked the club to the steering wheel and he does not think the handle of the gauge was locked. The driver discovered the theft around 0515 this morning when he returned to his vehicle after being in a donut shop for approximately 10 minutes. The donut shop is located in Bellflower on the corner of Alondra and Eucalyptus. The Lakewood Police Department were notified and they took the report of the theft. The RSO was asked to notify [California Radiological Health Branch] immediately if the gauge was recovered. The licensee will be cited for failing to properly secure the gauge. Corrective actions: The licensee will counsel the gauge user, will provide refresher training to all gauge users on the required security of the gauge while in transit, and will perform unannounced inspections of each gauge user's vehicle to ensure they are following the company's established policies and procedures regarding the security of gauges while in transit."

Lakewood Police Report #: 607-14202-1337-093

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.

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Power Reactor Event Number: 43382
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEN McKUNE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/24/2007
Notification Time: 05:11 [ET]
Event Date: 05/24/2007
Event Time: 02:32 [EDT]
Last Update Date: 05/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
EUGENE COBEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON LOW STEAM GENERATOR WATER LEVEL

"This 4-hour notification is being made to report that Salem Unit 2 automatically tripped on low steam generator water level. The automatic trip was preceded by lowering steam generator feed pump suction pressure, followed by the trip of both steam generator feed pumps on low suction pressure. The cause of the low suction pressure was due to a condensate system breach that occurred in the Condensate Polisher building. The condensate polishing system has been isolated and condensate pressure has stabilized.

"Salem Unit 2 is currently in mode 3 with reactor coolant system temperature at 547 degrees with pressure at 2235 psig. Auxiliary feedwater pumps 21, 22, and 23 started automatically, as expected, due to the low steam generator level. Decay heat removal is via the steam dumps to the main condenser. All equipment functioned as designed. There were no personnel injuries.

"A 15 minute notification was made to the State of New Jersey due to hydrazine laden water exiting the Condensate Polisher building and entering the storm drainage system."

All control rods fully inserted following the reactor trip. Emergency Diesel Generator are available, if needed. The licensee informed the NRC Resident Inspector.

* * * UPDATE AT 17:18 ON 5/25/2007 FROM ERIC POWELL TO MARK ABRAMOVITZ * * *

"In addition to hydrazine that was contained in the condenser water that exited the Condensate Polisher Building, supplemental samples determined that the water also contained tritium at approximately 50,000 picoCuries per liter. The state of New Jersey was updated with this information."

Notified the R1DO (Trapp).

The licensee will notify the NRC Resident Inspector.

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General Information or Other Event Number: 43383
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: GREENHORNE & O'MARA, INC.
Region: 1
City: NOKOMIS State: FL
County: SARASOTA
License #: FL2143-1
Agreement: Y
Docket:
NRC Notified By: HECTOR TABARES
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/24/2007
Notification Time: 10:08 [ET]
Event Date: 05/23/2007
Event Time: [EDT]
Last Update Date: 05/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
GREG MORELL (FSME)
ILTAB (via email) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING TWO STOLEN TROXLER MOISTURE DENSITY GAUGES

Greenhorne and O'Mara Consulting Engineers Report:
"Licensee called BRC at 8:20am on 5/24/07 to report (2) Troxler gauges stolen from their temporary work site in Nokomis, FL [corner of SR 681 and US 41]. Both gauges were last seen 5/23/07 around 6 pm and were discovered missing early morning 5/24/07. Gauges were locked and secured inside a steel container (conex box) at the temporary job site. Sarasota County Sheriffs department was notified and is investigating. A police report is expected shortly. One of the Troxler gauges belongs to another licensee at the work site: Hubbard Construction company (see incident # FL-07-084). Both licensees were made aware that the BRC recommends that they offer a reward for information leading to the recovery of the gauges and that they advertise in the newspaper, and/or inform the local TV News regarding the reward offer. NRC and HSER were notified. Investigation will continue."

Both gauges are Troxler Model 3411B (S/N's 20029 and 6127), each containing two (2) sources, i.e., 8 millicuries Cs-137 and 40 millicuries Am-241:Be.

At the time the State of FL was notified, the Sarasota Sheriff's Department was enroute to the scene.

Florida report: #FL-07-083 and FL-07-084.
Florida License Numbers:
Hubbard: 1100-1,
Greenhorne and O'Mara: 2143-1

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: 43386
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: ROGERS GROUP, INC.
Region: 1
City: HOPKINSVILLE State: KY
County: CHRISTIAN
License #: 202-312-51
Agreement: Y
Docket:
NRC Notified By: BRAIN PARSLEY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/24/2007
Notification Time: 12:45 [ET]
Event Date: 05/22/2007
Event Time: 17:00 [CDT]
Last Update Date: 05/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
GREG MORELL (FSME)
ILTAB (e-mail) ()

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

Event Text

LOST/STOLEN TROXLER MOISTURE DENSITY GAUGE

Rogers Group Company conducted a test at mile marker 63 on Edward T. Breathitt Parkway. After the test was completed they placed the Troxler 4640-B Moisture Density gauge [S/N 1772], 9 millicuries of Cs-137 [Sealed Source Model No. A-102112], in the back of the bed of truck, did not store it or tie it down, and they drove 3.5 miles South on Edward T. Breathitt Parkway at which time they turned around and drove back to mile marker 63. When they arrived back at mile marker 63 they discovered that the gauge was missing, believe that the gauge had fallen out of the truck while it was being driven. They retraced their route that they taken and asked several working crews if they had seen the missing gauge. The gauge was not found and the licensee believes that a motorist had stopped and picked up the gauge. The licensee notified the State Police of the missing gauge.

Reference Number: KY070002

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: 43388
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: IMMANUEL-ST. JOSEPH'S HOSPITAL
Region: 3
City: MANKATO State: MN
County:
License #: 1025-200-07
Agreement: Y
Docket:
NRC Notified By: GEORGE F. JOHNS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/24/2007
Notification Time: 17:14 [ET]
Event Date: 05/23/2007
Event Time: 12:00 [CDT]
Last Update Date: 05/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3)
LAWRENCE KOKAJKO (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM MINNESOTA - MISSING IODINE-125 SEED

The following event was received via e-mail

"On April 23, 2007, 101 I-125 seeds (10 strands, each strand containing 10 seeds, and one calibrated seed) were received the Nuclear Medicine Hot Lab and transported from the Nuclear Medicine Hot Lab to Rad Oncology for assay on April 24, 2007. All seeds were accounted for. One strand was dismantled and all 10 seeds were assayed and stored in a lead pig. The area was surveyed at the end of the assay process, and the seeds were maintained under lock until the next morning when they were retrieved for the procedure.

"The following morning the strands were taken to the Operating Room for the procedure. The 10 loose seeds used in the assay were loaded in a Mick Cartridge (a device used for surgery) and transported to the OR.

"After the procedure all seeds implanted, seeds in strands and the cartridge (as a whole and not counting the seeds loaded in it) were accounted for. All strands were stored in a lead pig, and the cartridge was stored in a second pig. The package containing both pigs was transported to Rad Oncology and was kept under lock at all times.

"On May 23, 2007, a re-count of the seeds was completed before sending them to the manufacturer. The calibrated seed and the seeds from the strands were accounted for. The cartridge contained 9 out of the 10 seeds it was supposed to be holding. The seed activity at the time it was missed (5/23/07) was 0.361 mCi.

"The area where the cartridge was loaded and unloaded was surveyed as well as the two units that were used to sterilize the seeds. Surveys of some of the areas where the package was transported are still in progress."

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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Power Reactor Event Number: 43391
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT COWARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/27/2007
Notification Time: 18:08 [ET]
Event Date: 05/27/2007
Event Time: 11:17 [PDT]
Last Update Date: 05/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CLAUDE JOHNSON (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R N 0 Hot Standby 0 Hot Standby

Event Text

MANUAL REACTOR TRIP IN MODE 3 DURING CONTROL ROD TESTING

"On May 27, 2007, at 11:17 PDT, with Diablo Canyon Power Plant (DCPP) Unit 1 in Mode 3 (Hot Standby) during day 28 of refueling outage 14, operators manually actuated the reactor protection system. All rods fully inserted.

"Operators were performing Surveillance Test Procedure (STP) R-1 C 'Digital Rod Position Indictor Functional Test'. While control bank C was being re-inserted, at 42 steps withdrawn, rod N-13 indicated position changed to 24 steps withdrawn. In response to this 18 step deviation, and in accordance with STP R-1C, operators opened the reactor trip breakers.

"At the time of the event, the reactor coolant system remained at normal operating temperature and pressure, and all other shutdown and control rod banks remained fully inserted.

"This event is being reported as an 8-hour non-emergency event in accordance with 10 CFR 50.72(b)(3)(iv)(A) for a valid actuation of the reactor protection system."

Unit-1 is maintaining temperature with atmospheric steam dumps and aux feed water. Electrical power is from 500 KV backfeed (normal electrical shutdown lineup). Control rod N-13 was being tested along with seven other control rods.

The licensee notified the NRC Resident Inspector.


* * * UPDATE ON 05/27/07 AT 2301 EDT BY JOY SKAGGS TO MACKINNON * * *

"(STP) R-1C 'Digital Position Indicator Functional Test' was re-performed on control bank C to obtain additional information.

"At 1706 hours, while control bank C was being re-inserted, at 138 steps withdrawn, rod N-13 indication dropped to 126 steps withdrawn. Rod motion was stopped to gather data. All other shutdown and control banks remained fully inserted.

"At 1725 hours, operators manually actuated a reactor trip to fully insert all control bank C rods. All rods fully inserted.

"(STP) R-1C 'Digital Rod Position Indicator Functional Test' was re-performed on control bank C for further evaluation. At 1838 hours, while control bank C was being re-inserted, at 168 steps withdrawn, rod N-13 indication dropped to 150 steps withdrawn. Rod motion was stopped to gather data. All other shutdown and control banks remained fully inserted.

"At 1840 hours, operators manually actuated a reactor trip to fully insert all control bank C rods. All rods fully inserted.

"At the time of the event, the reactor coolant system remained at normal operating temperature and pressure, and all other shutdown and control rod banks remained fully inserted." R4DO (C. Johnson) notified.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 43392
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW RASMUSSEN
HQ OPS Officer: JOE O'HARA
Notification Date: 05/28/2007
Notification Time: 08:48 [ET]
Event Date: 05/28/2007
Event Time: 01:00 [CDT]
Last Update Date: 05/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRIAN BONSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 9 Power Operation 9 Power Operation

Event Text

HPCI PUMP INOPERABLE DUE TO DIFFERENTIAL PRESSURE SETTING NOT WITHIN SPECIFICATION

"On 5/28/07 at 0100 CDT, Browns Ferry Unit 1 was performing 1-SR-3.5.1.7 (Comp) HPCI Comprehensive pump test when it was determined that HPCI pump set differential pressure was not within specifications and therefore would not support a declaration of operability for HPCI.

"The event is reportable under 10CFR 50.72(b)(3)(v)(B ) - '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 remove residual heat' and 10CFR 50.72(b)(3)(v)(D) - '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 mitigate the consequences of an accident'.

"This event also requires a 60 day written report in accordance with 10CFR 50.72(b)(3)(v)(B) and 10CFR50.73(a)(2)(v)(D).

"Initial investigation reveals a potential problem with the test equipment."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43393
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GARY ANDERSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/29/2007
Notification Time: 05:01 [ET]
Event Date: 05/28/2007
Event Time: 22:50 [PDT]
Last Update Date: 05/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHUCK CAIN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 8 Power Operation 8 Power Operation

Event Text

EMERGENCY DIESEL GENERATOR ACTUATION DUE TO MOMENTARY UNDERVOLTAGE CONDITION

"Unit 1 was making preparations to parallel to the grid on 5/28/07. All busses had been transferred to the Startup power supply (230 KV System). Operations then started a large 12KV motor, Circulating Water pump 1-2. Starting this large motor caused a momentary dip in startup voltage. This voltage dip was sufficient to pick up the undervoltage relay on vital bus G, causing a start of that bus's Emergency Diesel Generator (EDG). The bus remained supplied by the startup power supply, the EDG did not load. This valid start of EDG 1-2 is being reported per 10CFR50.72(b)(3)(iv)(A).

"The EDG was subsequently shut down and returned to it's normal standby condition."

There is nothing unusual or not understood about this event and all systems functioned as required.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012