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Event Notification Report for September 15, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/12/2008 - 09/15/2008

** EVENT NUMBERS **


44474 44476 44477 44479 44481 44484 44485 44486

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General Information or Other Event Number: 44474
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: QUAKER OATS
Region: 4
City: DALLAS State: TX
County: DALLAS
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2008
Notification Time: 09:04 [ET]
Event Date: 09/08/2008
Event Time: [CDT]
Last Update Date: 09/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4)
CINDY FLANNERY (FSME)
ILTAB (E-MAIL) ()

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

Event Text

AGREEMENT STATE - AMERICIUM 241 LEVELING DEVICE MISSING

"On September 9, 2008, the Agency was notified by the Radiation Safety Officer (RSO) that while conducting source leak surveys on installed generally licensed devices, a device containing 100 millicuries of Americium (Am) - 241 could not be located. The device was installed on a component that had been removed from the product line and placed in an area of the facility frequented by vagrants. The area where the device had been stored had been vandalized and much of the steel and copper from various components had been removed. The RSO stated that all other sources listed on their license were installed on components still in operation and were verified intact. The facility has increased its security and their security team is searching for the source. Additional information will follow as it is obtained."

Texas Incident #: I 8554

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: 44476
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: HI TECH TESTING
Region: 4
City: KEITHVILLE State: LA
County:
License #: LA-7985-L01A
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2008
Notification Time: 09:46 [ET]
Event Date: 08/17/2008
Event Time: [CDT]
Last Update Date: 09/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE - INDUSTRIAL RADIOGRAPHER OVEREXPOSURE

The following was provided by the state via facsimile:

"On August 19, 2008, Hi Tech Testing reported an overexposure to an industrial radiographer. On August 17, 2008, two industrial radiographers noticed that their pocket dosimeters were 'off scale'. Their film badges were sent to Landauer for emergency processing and it was determined that one of the radiographer's dose for August 2008 was 3.719 rem. Adding this to the year to date dose for this radiographer gave the radiographer a year to date dose of 5.776 rem for 2008. Hi Tech Testing investigated the incident and determined that the radiographers were not using a survey meter or performing a proper survey after each exposure. The following corrective action was taken for this incident: The radiographer that had the excessive exposure has had his employment with Hi Tech Testing terminated. Hi Tech Testing also had a mandatory company safety meeting concerning this incident."

Louisiana report number - LA0800017

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General Information or Other Event Number: 44477
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NORTH OKALOOSA MEDICAL CENTER
Region: 1
City: CRESTVIEW State: FL
County:
License #: 3297-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/09/2008
Notification Time: 11:22 [ET]
Event Date: 08/06/2008
Event Time: [EDT]
Last Update Date: 09/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (FSME)
ILTAB (E-MAIL) ()

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

Event Text

AGREEMENT STATE REPORT - MISSING PALLADIUM 103 SEEDS

The State of Florida provided the following information via facsimile:

"21st Oncology was performing a medical procedure under the license of North Okaloosa Medical Center on 9 July 2008. Pd-103 with 114 seeds (126.5 mCi as of July 9, 2008) were used. Source strength was thought to be too low for procedure. Seeds were put in a lock box at the surgery center. Seeds were visually checked as present on 11 July 2008.

"Seeds were sent back to Triad Radiopharmaceutical on 25 July 2008. Triad reported that shipping container was empty upon receipt at their facility on 6 Aug. 2008. Facility was thoroughly searched and also the dumpster. Surgery Center was under renovation between 11 July and 25 July. Some discrepancy between charge nurse and Med. Physicist if lock box was locked after 11 July.

"Radioactive Materials Office will investigate."

This report is also identified as Florida Incident Number FL08-127.

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: 44479
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: GEORGIA PACIFIC PALATKA OPERATIONS
Region: 1
City: PALATKA State: FL
County:
License #: 1391-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/10/2008
Notification Time: 15:05 [ET]
Event Date: 07/25/2008
Event Time: [EDT]
Last Update Date: 09/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - TWO WORKERS BRIEFLY EXPOSED TO CESIUM SOURCE

"Jacksonville inspection office was called to report that today 25 July 2008 at 1:30pm, two workers from Georgia Pacific were briefly and inadvertently exposed to an unlocked beam from a Cesium-137 source. Source is part of a 50,000 gal. storage vessel. It was reported that the maximum dose received by the workers was 0.0104 rem to hands only.

"Investigation found that Georgia-Pacific did not follow proper procedures. Corrective action consists of training, and revising walk down sheets to provide verification and documentation of the lockout. This office will take no further action on this incident."

The source strength was 1098 mCi.

This is Florida Incident Number FL08-110.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44481
Rep Org: WOMACK ARMY MEDICAL CENTER
Licensee: WOMACK ARMY MEDICAL CENTER
Region: 1
City: FORT BRAGG State: NC
County:
License #: 32-04054-04
Agreement: Y
Docket:
NRC Notified By: CAPT BALDOCK
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/11/2008
Notification Time: 16:10 [ET]
Event Date: 08/30/2008
Event Time: 15:24 [EDT]
Last Update Date: 09/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
RAYMOND LORSON (R1)
JIM LUEHMAN (FSME)

Event Text

SURFACE CONTAMINATION ON RECEIVED PACKAGE EXCEEDING LIMITS

At 1600 EDT on 09/11/08, the RSO was notified of a contamination event by the Chief of Nuclear Medicine who was also notified today by the technician involved. The event occurred on Saturday, 08/30/08 at 1524 EDT when a technician received a Technetium 99 package from Cardinal Health in Fayetteville, NC for patient treatment. Initial swipe survey of package external surfaces showed 13,000 dpm of gamma contamination. Package was decontaminated to 1620 dpm and stored in the Hot Lab to decay and picked up on Monday, 09/01/08, by Cardinal Health with no contamination. The hospital is not aware of any internal contamination from the package, but will get a full statement from the technician involved on 09/13/08. Cardinal Health will be notified of the contamination issue on 09/13/08.

* * * RETRACTION PROVIDED AT 1630 EDT ON 09/12/08 FROM CAPT BALDOCK TO JEFF ROTTON * * *

Further investigation and discussion with NRC Region 1 DNMS (Michelle Simmons) has determined that the event is not reportable since the contamination level was below the maximum permissible limit of 220 dpm/sq cm for beta and gamma emitters.

Notified R1DO (Lorson) and FSME (Luehman).

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Power Reactor Event Number: 44484
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: JASON KOZAL
Notification Date: 09/12/2008
Notification Time: 01:54 [ET]
Event Date: 09/11/2008
Event Time: 22:47 [CDT]
Last Update Date: 09/12/2008
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
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVE PASSEHL (R3)
ANTHONY McMURTRAY (IRD)
MICHELE EVANS (NRR)

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

Event Text

REACTOR SCRAM AND ISOLATION DUE TO TRANSFORMER LOCKOUT

While the 1R transformer was out of service for maintenance, the 2R transformer experienced a lockout resulting in a loss of normal offsite power, a reactor scram, and a Group 1, 2 and 3 isolation. All rods fully inserted as expected. The cause of the 2R transformer lockout is unknown at this time. After initiation, the high pressure coolant injection (HPCI) system would not trip at the high reactor water level set point +48", as required. The operators then manually isolated the HPCI steam lines.

Plant decay heat removal is with the reactor core isolation cooling (RCIC) system and the safety relief valves. Torus cooling is in service. The vital electrical busses are being supplied by the 1AR transformer. Efforts are underway to restore the 1R transformer to service, and subsequently the non-vital busses.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY KIM HOFFMAN TO JASON KOZAL AT 0655 ON 09/12/08 * * *

The HPCI system was declared inoperable and isolated due to failure to automatically trip at +48" Reactor Water Level. The HPCI steam supply valves were automatically closed to remove HPCI from service. In addition, the HPCI turbine trip failed to trip with the turbine trip push button. The cause of the trip failure is unknown at this time. The licensee is continuing to investigate. HPCI did automatically start as designed and injected to the reactor vessel as designed. However, HPCI failed to trip at High Reactor Water Level as required.

"Additionally, the Automatic Depressurization System (ADS) timer showed erratic indication following the event. The ADS timer was inhibited to prevent automatic action. ADS is inoperable, but manual steam relief valve operation remains available."

The licensee will notify the NRC Resident Inspector.

Notified R3DO (Passehl), NRR EO (Ross-Lee), and IRD (McMurtray).

* * * UPDATE PROVIDED BY SCHREIFELS TO CROUCH AT 1656 EDT ON 09/12/08 * * *

"A [second] Group 2 isolation signal was received when reactor water level lowered below +9 [inches] [while pumping drywell sumps]. All Group 2 valves except the drywell sump isolation valves were closed due to a previously reported Group 2 signal. The drywell sump valves had been opened to allow manual pumpdown of the sumps. The sump valves closed as expected."

Licensee notified the NRC Resident Inspector.

Notified R3DO (Passehl).

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Power Reactor Event Number: 44485
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: FRED POLLAK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/14/2008
Notification Time: 06:07 [ET]
Event Date: 09/14/2008
Event Time: 02:41 [EDT]
Last Update Date: 09/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
CHARLIE PAYNE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 70 Power Operation 68 Power Operation

Event Text

DROPPED CONTROL ELEMENT RESULTING IN ENTRY INTO TECHNICAL SPECIFICATION REQUIRED SHUTDOWN LCO

"At 23:45 on 9/13/08, one control element assembly (CEA) dropped to the bottom of the core from the upper electrical limit. Technical Specification LCO 3.1.3.1 Action e. was entered. The CEA was not able to be realigned with the other CEA's in its group within the time constraints of the COLR. Technical Specification LCO 3.1.3.1 Action f. was entered and a down power to 70% was initiated. Actions to repair and retrieve the CEA could not be completed within the time constraint of LCO 3.1.3.1 Action f. and a shutdown was commenced to comply with Technical Specifications at 0241 on 9/14/08. The CEA was recovered and restored to OPERABLE at 0258 on 9/14/08 and the shutdown was halted. The plant is currently being returned to full power operation. This four hour non-emergency report is being made pursuant to 10 CFR 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by Technical Specifications.'"

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 44486
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: STEVE WAGNER
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/14/2008
Notification Time: 11:58 [ET]
Event Date: 09/14/2008
Event Time: 10:24 [CDT]
Last Update Date: 09/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
CHARLIE PAYNE (R2)
E. WILLIAM BRACH (NMSS)
ANTHONY McMURTRAY (IRD)

Event Text

COURTESY NOTIFICATION DUE TO SEVERE WEATHER DAMAGE AND EMERGENCY OPERATION CENTER ACTIVATION

Site experienced high winds and sustained weather related damage to mobile offices and isolated site power outages. Plant wide assessment in progress. Plant systems are still operational and have not been impacted by the wind damage. No chemical hazards have been identified at this time. AC power was lost to the offsite Public Warning System sirens, but battery power available for 72 hours. Licensee has requested expedited action from the electric utility company to return AC power to the siren system. The site EOC was activated to assist the on shift personnel with weather damage assessment and the licensee was in an Unclassified Emergency.

The licensee notified the McCracken County Sheriff's Dispatch office, Kentucky Division of Emergency Management, and the DOE Oak Ridge Operations Center.

* * * UPDATE PROVIDED AT 1339 EDT ON 09/14/08 FROM STEVE WAGNER TO JEFF ROTTON * * *

Licensee provided a courtesy notification that they had terminated their unclassified emergency at 1232 CDT and deactivated their EOC. All damage to the site was minor and they have established recovery teams.

The licensee notified the NRC Resident Inspector. Notified IRDMOC (McMurtray), R2DO (Payne) and NMSS EO (Brach)

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