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Event Notification Report for August 28, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/27/2007 - 08/28/2007

** EVENT NUMBERS **


43539 43599 43600 43601 43602 43603

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43539
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/31/2007
Notification Time: 15:40 [ET]
Event Date: 07/16/2007
Event Time: 12:00 [CDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM WISCONSIN - LOSS OF TWO PALLADIUM-103 SEEDS

RSO telephoned DHFS July 31, 2007.

"The RSO notified DHFS by telephone of the possible loss of two Pd-103 implant seeds. The two seeds were unaccounted for following a July 16, 2007 prostate seed implant procedure.

"During the procedure, the Physicist was making the strands using the BARD QuickLink system. About half way through the case he made a relatively long link. When the authorized User tried to load this link it was easily traveling through the implant needle so he retracted it and emptied the entire strand on the OR table backwards through the needle. A new link was made and properly implanted into the patient. Because they needed to use nearly all the ordered seeds for the procedure, the Physicist attempted to take apart the problem link using a pair of tweezers. This required some force to separate the links and seeds. While doing this at least two of the links separated and 'flew' off the table. The past experience with seeds falling in the operating room was that they were relatively easy to find immediately post procedure with the survey meter, so they completed the implant. The on-going inventory indicated there would be 5 leftover seeds. Multiple surveys of the operating room resulted in the recovery of 3 seeds. Surveys of all bed linens were conducted, no additional seeds were located."

The patient will be returning to the facility for routine post implant CT imaging. The implant seed count will be repeated at that time.

Event Report ID No.: WI070015


* * * RETRACTION ON 08/27/07 AT 1005 EDT FROM LEOLA DEKOCK VIA EMAIL TO MACKINNON * * *

"DHFA has received additional information from the licensee. The patient returned to the facility for routine post implant imaging. The implant seed count was repeated at that time. The seed count performed at the time of the implant indicated 115 seeds had been implanted. The additional imaging has identified the presence of 117 seeds."

R3DO (J. Lara) & FSME (C. Flannery) notified.


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: 43599
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: CHRIS SERATA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/27/2007
Notification Time: 06:48 [ET]
Event Date: 08/27/2007
Event Time: 06:00 [EDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
Person (Organization):
JAMES DWYER (R1)
EDWIN HACKETT (FSME)
THOMAS BLOUNT (IRD)
L ENGLISH (ILTAB) (NSIR)

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

SHIPMENT FAILED TO ARRIVE ON TIME


A shipment failed to arrive on time.

The NRC Resident Inspector will be notified.

Contact HOO for further details.



* * * UPDATE FROM J.R. TRAUTVETTER TO J. MACKINNON AT 0730 ON 08/27/07 * * *

Shipment arrived on site at 0720 EDT.

R1DO (J. Dwyer), FSME (C. Flannery), IRD (T. Blount ) and ILTAB (L. English) notified.

NRC Resident Inspector was notified by the licensee.

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Other Nuclear Material Event Number: 43600
Rep Org: LOGAN GENERATING PLANT
Licensee:
Region: 1
City: SWEEDESBORO State: NJ
County: GLOUCESTER
License #:
Agreement: N
Docket:
NRC Notified By: TERRY SHANNON
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2007
Notification Time: 15:19 [ET]
Event Date: 08/27/2007
Event Time: [EDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ART BURRITT (R1)
EDWIN HACKETT (FSME)
LANCE ENGLISH (ILTB)

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

Event Text

LOST TRITIUM EXIT SIGN

On August 15, 2007 Logan Generating Station personnel noted that a tritium exit sign was missing from its installed location. They did an extensive search of the premises from that time until August 27, 2007 when they concluded that the sign was lost. The search involved looking in the coal crushing area as well as the feeder and conveyor sites. An email was sent to plant employees asking if they knew the whereabouts of the sign. They completed walking searches of the remainder of the Coal Storage Building as well as a search through their trash cans and dumpsters without finding the sign. The sign was last seen present in its expected location during an inventory of tritium exit signs conducted on July 10, 2007.

The activity of the sign was originally 15 to 20 curies in the 1993 to 1994 time frame in which it was purchased.

The plant will conduct additional training on exit signs during its regular annual training period as well as continuing their monthly and quarterly inspections of installed nuclear devices.

The lost sign was additionally reported to the New Jersey Environmental Radiological Group.


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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Other Nuclear Material Event Number: 43601
Rep Org: MICRON TECHNOLOGY INC.
Licensee:
Region: 4
City: BOISE State: ID
County: ADA
License #:
Agreement: N
Docket:
NRC Notified By: KEVIN LUNDHAGEN
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2007
Notification Time: 16:12 [ET]
Event Date: 08/27/2007
Event Time: [MDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
REBECCA NEASE (R4)
EDWIN HACKETT (FSME)
ILTAB (email) ()

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

Event Text

LOST STATIC ELIMINATORS

On 7/27/07 when completing an inventory, Micron Technology, discovered that nine (9) static eliminators were missing. The company did a thorough search of areas in and around where these instruments were expected to be installed and looked in their warehouse where removed equipment is typically taken when removed from use but the eliminators were not found. The company is continuing its search.

All of the eliminators had Po-210 sources with an activity of about 10 millicuries when purchased. One source was purchased in August of 2003. Four sources were purchased in June of 2005 and four sources were purchased in August of 2005.

The company plans on implementing a number of measures to ensure that eliminators are not lost in the future: 1. A cradle to grave tracking system will be implemented along with; 2. implementation of additional training and; 3. procedures for a more structured process from start to finish.

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: 43602
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ELLIS VANN
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2007
Notification Time: 20:26 [ET]
Event Date: 08/27/2007
Event Time: [CDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

Event Text

ONE CHANNEL OF LOW MAIN STEAM LINE PRESSURE SIGNAL MISTAKENLY REMOVED FROM SERVICE FOR 33 MINUTES

"On 8/27/07 at approximately 12:05, during performance of STP 3.3.6.1-02 step 7.7.2 the jumper was installed on contacts 1 and 2 of relay A71B-K4A PCIS TRIP CHANNEL A1 A MAIN STEAM LINE LO PRESSURE. The jumper should have been installed on contacts 1 and 2 of relay A71B-K4C PCIS TRIP CHANNEL A2 C MAIN STEAM LINE LO PRESSURE.

"The incorrectly installed jumper on contacts 1-2 of relay A71B-K4A resulted in the channel A1 not being able to trip on a low main steam line pressure signal of 850 psig (PS1014) thus making the function of PS1014 inoperable. At the same time PS1016 was being tested for channel A2 thus making the function for pressure switch PS1016 inoperable. Per Technical specification 3.3.6.1 'Primary Containment Isolation Instrumentation' function 1b 'Main Steam Line pressure - Low' with both PS1014 and PS1016 inoperable, the tripping capability for channel A for Main steam Line Pressure - Low would be lost. This would be a automatic function with isolation capability not maintained per TS 3.3.6.1 condition B. Required action B.1 requires isolation capability to be restored in 1 hour. The I&C techs entered the AOT time for PS1016 at 11:32 AM and exited the AOT at 12:05 PM. Therefore, the isolation capability was lost for 33 minutes of the 1 hour.

"There was no violation of Technical Specification 3.3.6.1 function 1b.

"This event is reportable under 10 CFR 50.72(b)(3)(v), 'Any event or condition that alone 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 licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43603
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: AL RABENOLD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/27/2007
Notification Time: 20:45 [ET]
Event Date: 08/27/2007
Event Time: 16:45 [EDT]
Last Update Date: 08/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
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

Event Text

GRATING INSIDE CONTAINMENT FOUND UNSECURED

"At 1645 hours on 8/27/07 it was determined that a section of grating in the containment pool swell region was not properly restrained. During a postulated large break Loss of Coolant Accident, the grating could become dislodged and subsequently impact the ECCS suction strainer located in the suppression pool below the grating. An engineering review determined that the force of the impact could be larger than the impingement forces that had been previously evaluated. The forces were postulated to impact one of two concentric suction strainers. The resulting damage could cause either Residual Heat Removal B and C loops or High Pressure Core Spray (not both) to be inoperable. This condition was determined to meet the reporting requirements for 10 CFR 50.72(b)(3)(ii)(B), 'Any event or condition that results in: (B) The nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.' Since one of the strainers was for High Pressure Core Spray, a single train safety system, this event was also determined to meet the reporting criteria for 10 CFR 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 systems needed to (D) mitigate the consequences of an accident.'

"Technical Specification 3.5.1, ECCS - Operating, was entered and Required Actions taken within the specified completion time. The grating was subsequently restored to design configuration and the Technical Specification LCO was exited."

"Time of restoring grating to design was 1838 8/27/07, exited Tech Spec 3.5.1. Location of grating is in the Containment Building on the 599' elevation near the lower air lock. The section is a 3 X 7 foot piece of grating that is located on the level just above the suppression pool. We still are investigating when the grating hold down plates were removed, potentially removed during our recent recirc motor replacement in July 07. The grating hold down plates were discovered by an Operations Roving Operator during his tour on rounds."

The licensee notified the NRC Resident Inspector.

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