Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 41973 | 7 September 2005 16:34:00 | The five events occurred between 3 patients and are explained in the following write-up. Events 'A', 'B', and 'C' involve the same patient who received three high dose rate (HDR) brachytherapy administrations on three different occasions with a GYN cylinder application. The dates of treatment occurred on December 19, and 26, 2002 and January 2, 2003. In this case, a 70 year old female, was treated with a Nucletron High Dose Rate (HDR) brachytherapy remote aflerloader unit for endometrial cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 3.0 cm diameter vaginal cylinder for an active length of 6.0 cm using a 8.01, 7.506 and 7.030 Ci iridium-192 source on the three dates of treatment. The treatment plan called for 25 indexer step positions at 2.5 mm spacing. The medical physicist entered 25 indexer step positions at 5.0mm spacing rather than 2.5mm spacing and treatment was delivered. A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation reveals that the patient may have received as much as 360 cGy to an unintended delivery site with each of the three fractions, for a total of 1,080 cGy for the entire course of treatment. The simulation further indicates that the intended treatment site may have received as much as 28% under dosage during the same treatment period. A thorough review of the patients chart indicates that the patient reported having had some "excoriation" of the unintended site initially following treatment but this area had healed prior to a follow up exam on February 6, 2003. This patient was last seen by her radiation oncologist January 3, 2004, with no evidence of clinical complications or abnormalities. As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical complications are anticipated or expected. Event 'D' occurred on December 18, 2002, involved an HDR brachytherapy which also involved a GYN cylinder application. In this case, a 56 year old female, was treated with Nucletron High Dose Rate (HDR) brachytherapy remote after loader for cervical. Cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 2.50 cm diameter vaginal cylinder for an active length of4.0 cm. using a 8.089 Ci iridium-1.92 source. The treatment plan called for 17 indexer step positions at 2.5mm spacing. Although the first two fractions were delivered in accordance with the written directive without incident (November 19 and November 26, 2002), for the third and final fraction (December 18, 2002) the medical physicist entered 17 indexer stop positions with 10.0 mm spacing rather than 2.5 mm spacing and treatment was delivered. A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation suggests the patient may have received as much as 200cGy to an unintended site and as much as 60% under dosage to the intended site during delivery of the final fraction. For the entire course of treatment, the calculated dosage through simulation indicates that 1200 cGy rather than 1500 cGy was delivered to the intended site. This represents a twenty percent (20%) under dosage for the overall treatment. A thorough review of the patient chart indicates no abnormal findings during follow up clinical exams and our Radiation Oncology Physicians verify these treatment parameters are within acceptable therapeutic and clinical dosages. This patient is currently in active follow-up with her radiation oncologist. This patient was last seen May 5th, 2005 with no evidence of complications or clinical abnormalities. As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical, complications are anticipated or expected. Event 'E' occurred on August 7, 2003, involved an HDR brachytherapy which also involved a GYN cylinder application. In this case, an 85 year old female, was treated with Nucletron High Dose Rate (HDR) brachytherapy remote after loader for cervical cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 2.00 cm diameter vaginal cylinder. For an active length of 6.0 cm using a 4.74 Ci iridium-1.92 source. The treatment plan called for 13 indexer step positions at 5.Omm spacing. In the delivery of the first fraction, on August 7, 2003, the medical physicist entered 13 indexer step positions with 2.5mm spacing rather than 5.0mm spacing and treatment was delivered. The delivery of the second and third fractions, August 21 and September 4, 2003, the written directive was followed accurately and treatment occurred without incident. A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation suggests that for the initial treatment fraction, the patient may have received as much as 60% over dosage to the proximal portion of the intended site and as much as 44% under dosage to the distal portion of the intended site. The calculated dosage through simulation indicates that 800 cGy was delivered to the proximal portion of the intended treatment site and approximately 280 cGy was delivered to the distal portion of the intended treatment site. In accordance with the written directive, the intended site was to receive a dosage of 500 cGy for three fractions for a total of 1500 cGy throughout the course of treatment. The calculated simulation reveals the proximal site received 1800 cGy (20% over dosage) and the distal site received 1280 cGy (15% under dosage) over the course of the three treatments. A. thorough review of the patient chart indicates no abnormal findings during follow up clinical exams and our Radiation. Oncology Physicians verify these treatment parameters are within acceptable therapeutic and clinical dosages. This patient is currently in active follow-up with her radiation oncologist. This patient was last seen August 15, 2005 with no evidence of complications or clinical abnormalities. As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical complications are anticipated or expected, It is believed that the conditions and practices which contributed to the five medical events listed above were identified during the course of investigating the previous medical event of April, 2004. It is further believed that St. Vincent Hospital has implemented corrective action since the event of April, 2004 that has eliminated (or significantly reduced the risk of) recurrence of these conditions/practices. |
| ENS 41962 | 30 August 2005 13:27:00 | The licensee reported that a 0.958 microCurie (as of 02/05/83) source of Californium 249 was unaccounted for when the device was inspected prior to usage. The source is a solid electrode deposit on a platinum foil which is used to calibrate nuclear physics instrumentation. The last inventory was conducted on 07/25/05, but it was only a visual check of the container. The last activity identification of the device was on 05/11/04. They have searched and are continuing the search to find the material. No evidence of contamination has been detected in the area at this time. This is a IAEA Category 5 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. For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
The licensee made a correction to the 3rd sentence in the first paragraph to read as follows: "The last inventory was conducted on 07/25/05, which was a physical inventory of the source. Notified R3DO (Cameron) and NMSS (Hickey), and emailed TAS (Danis).
The licensee located the lost material on November 10, 2005. The source was in the restricted area of the facility but was not in the normal storage location. The source in now in the appropriate locked storage location. The licensee notified Regions 3 (S. Bakhsh). Notified R3DO (Stone), NMSS (G. Morell), email Canadian Nuclear Safety Commission, and TAS (Whitney). |
| ENS 41963 | 30 August 2005 14:25:00 | A Troxler moisture density gauge was stolen from the company truck while parked at the private residence of a Wingerter Laboratory employee. The gauge was checked out from the company at 0630 and taken to his residence to pick up job related paperwork. While at the job site the RSO was notified at 0830 that the gauge was missing. The driver said he made no stops while driving from his residence to job site. The Troxler gauge (model 3440, serial #19973) contained 8 mCi (milliCuries) of Cs-137; 40 mCi of AM-241/Be. Wingerter is offering a $1000 reward for the return of the gauge in local newspaper. Florida incident #FL05-120 This is less than the quantity of a IAEA Category 3 source. 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. For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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. |
| ENS 41961 | 29 August 2005 19:22:00 | The licensee's ERDS was unavailable for 20 minutes. After another attempt was made to activate ERDS, it was successful when the phone modem was cycled and the connection was established. The NRC resident Inspector was notified.. |
| ENS 41960 | 29 August 2005 15:14:00 | On August 29, 2005 at approximately 10:30 Mountain Standard Time (MST), the Palo Verde Emergency Preparedness Department identified an inoperable single siren (#18). The siren was vandalized by stealing the internal battery. The affected siren is estimated to impact approximately 131 members of population in the emergency planning zone (EPZ) within 5 miles. This call is being placed due to the relatively large segment of the population affected and the uncertainty of the length of time that will be needed to restore the siren to operable condition. The Palo Verde Emergency Plan (section 6.6.2.1) has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area's) when sirens are inoperable. Maricopa County and State agencies have been informed to implement the MCSO notification if a need arises. There are no events in progress that require siren operation. The NRC Resident Inspector has been notified |
| ENS 41913 | 12 August 2005 03:26:00 | On August 12, 2005, at approximately 00:19 hours Mountain Standard Time (MST), Palo Verde Nuclear Generating Station (PVNGS) Unit 1 commenced a reactor shutdown required by Technical Specification 3.8.1. Limiting Condition for Operability (LCO) 3.8.1 requires two diesel generators (DGs) each capable of supplying one train of the onsite Class 1E AC Electrical Power Distribution System be available. On August 9, 2005, at approximately 04:20 MST, Unit 1 Diesel Generator 'B' failed to maintain the proper steady state output voltage (4080-4300 VAC) during monthly operability surveillance testing per '40ST-9DG02'. Diesel Generator 'B' was declared inoperable and the Unit entered LCO 3.8.1 action 'B'. An engineering action plan was initiated in an attempt to identify the cause of the generator output voltage fluctuation and correct the problem. To date, troubleshooting efforts have unable to isolate the problem. On August 12 at 0420 MST the 72 hour Completion Time associated with LCO 3.8.1 Action 'B' will expire and at 00:19 MST Unit 1 commenced a reactor shutdown in compliance with LCO 3.8.1 Action 'H'. The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public. The required offsite power sources are operable and the electrical grid is stable. The NRC Resident Inspector will be notified. |
| ENS 41972 | 7 September 2005 12:42:00 | On July 28, 2005, a 100 milliCurie Cs-137 sealed source (New England Nuclear, Model 572, serial number 1623) became lodged near the bottom of a 240 foot shaft The logging probe and source had descended to that depth after breaking loose from the logging cable at the surface of the well. Repeated efforts to retrieve the source failed, Retrieval efforts were discontinued when a 4 foot section of an overshot device twisted off at approximately 210 feet down-hole. The licensee submitted a written description of the event on August 23, 2005 and provided supplemental information on September 1, 2005 and September 2, 2005. Authorization to abandon the well formally approved on September 6, 2005. |
| ENS 41869 | 25 July 2005 18:38:00 | As a result of NRC Bulletin 2005-01 "Material Control and Accounting at Reactors and Wet Spent Fuel Storage Facilities", Oconee has been conducting an inventory of Special Nuclear Materials (SNM), other than complete fuel assemblies, stored in the spent fuel pools at Oconee. One canister, documented as containing 383 fuel pins, was found to actually contain 382 fuel pins. At this time it is uncertain if this is a record keeping error or an actual "lost" pin. Initial Safety Significance: The inventory process for other canisters is not complete, and it is possible that the pin may be in another container. These containers being inventoried have been stored underwater in the spent fuel pool for years. The affected canister was filled in 1982. Oconee has no reason to believe that this pin or any other SNM has been stolen or unlawfully diverted. For reference, one fuel assembly contains 208 fuel pins. Corrective Action(s): The inventory process is continuing. This notification is being trade per 10 CFR 74.11. The NRC Resident Inspector will be notified.
On July 17, 2005 at 1838 (ET) Oconee reported that during an inventory of Special Nuclear Material (SNM), other than complete fuel assemblies stored in the spend fuel pools at Oconee, one canister, documented as containing 383 fuel pins, was found to actually contain 382 fuel pins. At that time it was uncertain if this is a record keeping error or an actual "lost" pin. Further investigation has located the suspect fuel pin in a different canister; consequently, this issue no longer meets the reporting requirements as previously stated and this report is being retracted. Initial Safety Significance: There is no initial safety significance. Corrective Action(s): No additional corrective actions planned at this time. R2DO (C. Julian), NMSS EO (M. Burgess) and IRD Manger (M. Leach) notified. NRC resident Inspector was notified of this retraction by the licensee. |
| ENS 41800 | 27 June 2005 04:19:00 | UNUSUAL EVENT (EAL #16 - Fire) declared at 0327 on 6/27/05 due to uncontrolled fire in the Unit 4 Main Transformer lasting longer than 10 minutes. Unit 4 experienced an automatic reactor trip from 100% on a turbine trip due to a fire in the Main Transformer. The fire was extinguished after approximately 25 minutes. On-site fire brigade and Miami-Dade fire department responded. The cause of the fire is under investigation. The reactor is stable in Mode 3. No safety systems were affected. All rods fully inserted, no ECCS actuations, no relief valves lifted and no personnel injuries occurred. Offsite power is still available and no emergency diesels auto started, however, there was an auxiliary feedwater actuation. Hazardous Material response is being implemented due to discharge of transformer oil. There may be a possible press release on this event. The NRC Resident Inspector was notified along with State and local agencies.
The NOUE was terminated at 05:00 due to the fire being extinguished and the emergency no longer existing. The NRC Resident Inspector was notified. Notified RDO 3 (Evans), EDO (Case), IRO (Frant), FEMA (Bagwell), DHS (Reed)
Received a call from a member of the Turkey Point Communications Group. The licensee does not plan on issuing a press release at this time. Notified R2DO (Evans). |
| ENS 41792 | 24 June 2005 02:57:00 | An NOUE was declared at the site at 2327 PDT due to the discovery of flammable gas in the General Services Building (office space) which is attached to the turbine and reactor building. The source and type of gas has not been identified and investigation is ongoing by HAZMAT trained personnel. The highest level of flammability measured is 50% of LEL (Lower Explosive Limit). The building has been evacuated. The NRC Resident Inspector will be notified and State local and other Gov agencies have been notified.
EAL # 9.3.U.3 - Report or detection of toxic or flammable gases that could enter or have entered within the Protected Area Boundary in amounts that could affect the health of plant personnel or safe plant operation. The event has been terminated based on a thorough survey of the building by HAZMAT personnel. The building in question has been determined to be free of any flammable gases. Probable source of gas is from a sewage treatment plant. The gas was carried by a stable breeze to the building's air intake. Immediately prior to the event, initial reports of odorous gas from several building occupants was confirmed using portable instrumentation. The highest flammable gas levels were found at a building air intake. Dissipation of gas concentration was accomplished using normal building ventilation. The NRC Resident Inspector will be notified and State local and other Gov agencies have been notified. Notified R4 DO (R. Bywater), NRR EO (M. Case), IRD Manager (S. Frant), DHS (Ceasar), and FEMA (Sullivan). |
| ENS 41779 | 15 June 2005 18:38:00 | On June 15, 2005 at 1400 PDT Columbia Generating Station experienced a Reactor Protection System (RPS) actuation while operating at full power. Currently, reactor level is being controlled with the feedwater system and reactor pressure is being controlled via the turbine bypass valves to the condenser. All safety systems functioned as expected and there was no ECCS system injection. The initial attempt to trip the main turbine from the control room was unsuccessful and it was subsequently tripped locally. At this time the plant is stable and indications show that the RPS actuation originated from closure of turbine throttle valves. Determination of the cause of the RPS actuation is ongoing at this time. All rods fully inserted and no relief valves lifted. The NRC Resident Inspector was notified. |
| ENS 41773 | 14 June 2005 17:13:00 | On June 14, 2005, at 1124 hours (CDT), greater than 25% of the CPS (Clinton Power Station) notification sirens became unavailable due to a loss of power. The loss of power affected 13 of the 44 emergency sirens. The cause has not yet been determined. At 1307, three sirens were restored. As of 1436 hours, only one siren was inoperable. Restoration of the inoperable sirens is continuing. The NRC Senior Resident Inspector, Illinois Emergency Management Agency, and DeWitt County ESDA have been notified. |
| ENS 41771 | 14 June 2005 13:52:00 | The licensee reported they discovered one missing gaseous tritium light source from a total of 892 at the site (550 had previously been shipped to their Mexico plant). The missing light source, which measured 27 millicuries, was to be part of a shipment of 700 to be returned to the manufacturer, SRB Technologies, since they are being replaced by LED light sources. These lights, which are mounted in blocks of Lucite, are used in the production of photomultipliers which are used in equipment produced for the medical industry. |
| ENS 41772 | 14 June 2005 15:37:00 | The Interstate Concrete and Asphalt Company reported that a dump truck ran over a CPN nuclear gauge at a construction site in Coeur d' Alene, ID. The gauge was tested for source leakage and non was detected. The gauge which contained 10 millicuries Cs 137 and 50 millicuries Am/Be was still intact, however, it was not operational. It will be returned to the manufacturer in CA. |
| ENS 41778 | 15 June 2005 18:21:00 | Consultant for Lamco was conducting a source retrieval on June 8, 2005 and personnel monitor fell near the 70 Curie radiography source. She picked it up when she realized it and had it returned to the supplier for processing. After receiving the results on June 13, 2005, she called to report the results. The personnel monitor received 9.477 rem, deep dose equivalent. The consultant estimated she received 1.5 rem based on her direct reading dosimeter after the source recovery was completed. Texas Incident # I-8236 |
| ENS 41754 | 7 June 2005 22:33:00 | This report is a result of an ongoing evaluation of a previously identified deficiency with the Appendix R Safe Shutdown Strategy with respect to use of charging pumps for a fire in Fire Area A06, 1B-32 480V MCC area. This issue was originally identified on April 8, 2005 during work on the Fire Probabilistic Risk Assessment Project. This was entered into the Point Beach Corrective Action Program, and compensatory fire rounds were initiated. A postulated fire in the east side of the MCC 1 B-32 could damage both the power and the control cables for charging pumps 1 P-2A and 1 P-2B, and the control cables for redundant charging pump 1 P-2C. The resultant condition of the 1 P-2C charging pump control circuit could prevent operation of this pump as directed in the Safe Shutdown Analysis and FOP 1.2, Potential Fire Effected Safe Shutdown Components. The condition exists as the result of a lack of physical cable separation for power and control cables for the Unit 1 charging pumps. An Operability recommendation was performed for this issue and determined that the condition was Operable but Non-Conforming. Based on a continuing review of further information related to this condition, it has been determined that this condition is reportable based on the resultant effect on available charging pump capability. The condition could have resulted in losing the availability of all but a single charging pump operating at slow speed, which would not provide sufficient reactor coolant pump seal cooling, and thereby degrade the level of plant safety. The identified condition requires a revision to the Safe Shutdown Analysis. Plant fire mitigation procedure changes to ensure adequate charging pump capability, and reactor coolant pump seal cooling have been made. The Safe Shutdown Analysis will be revised. The Resident Inspector will be notified. |
| ENS 41665 | 4 May 2005 15:20:00 | At 1432 on May 4, 2005, V.C Summer declared a Notification of Unusual Event (NUE) due to a small fire in the reactor building that lasted for more than 15 minutes inside the protected area of the plant. The reactor was defueled at the time. There were no injuries, radiological conditions remained unchanged, and no safety related equipment was affected. Personal were not required to evacuate the building and the fire brigade was not activated. The resident NRC inspector and all appropriate state and local officials were notified. There was no radiological release. Details are as follows: At 1410, a health physics technician noticed smoke in the refueling cavity. Upon investigation, it was noted that a temporary lighting power cord had electrically shorted. The power source was isolated at 1420. The electrical short had ignited a small patch of strippable coating that was applied to the cavity floor for contamination control. The resulting flames were extinguished with demineralized water at 1430. A NUE was declared at 1432 in accordance with licensee procedure EPP-001, Activation and Implementation of Emergency Plan. The area was monitored to ensure that there were no further issues and the NUE was downgraded at 1517. |
| ENS 41663 | 3 May 2005 14:32:00 | TMI Issue Report # 329440 identifies an issue associated with a previously unidentified/unanalyzed Appendix R fire scenario involving multiple high impedance faults. An engineering evaluation has determined that certain safety related power circuits are not protected against multiple high impedance faults, which in combination with a fire in the 305' elevation of the Control Building, could cause a loss of safe shutdown functions from the control room and the remote shutdown panel. An hourly fire-watch has been established in the affected fire zone in the 305' elevation of the Control Building as an interim compensatory measure. The NRC Resident Inspector will be notified. |
| ENS 41660 | 2 May 2005 20:47:00 | An employee discovered a substance wrapped in paper lying on the floor of the Maintenance Building. The substance is being submitted to the state laboratory for further analysis. The licensee notified the NRC Resident Inspector. Contact Headquarters Operations Officer for additional details. |
| ENS 41659 | 2 May 2005 12:18:00 | On May 2, 2005, with Waterford 3 in Mode 6, it was determined that Steam Generator 1 In-Service Inspection had identified more than 1 % defective tubes. Per Technical Specification table 4.4.2-C. this percentage of defective tubes is characterized as "C-3" and should be reported to the NRC. Accordingly, this event is being reported pursuant to 10CFR50.72(b)(3)(ii) as an 8-Hr Non-Emergency Degraded Condition. In addition, per Technical Specification 4.4.4.5, the final results of the Steam Generator tube inspection, which fall into category C-3, shall be reported in a special report within 30 days and prior to resumption of plant operation. Defective tubes will be plugged. The NRC Resident Inspector was notified. |
| ENS 41641 | 26 April 2005 13:21:00 | The licensee reported that there was a small fire lasting for 15-20 minutes in the wiring of a manlift on the charging floor of the Containment Building. It was a smoldering fire with lots of smoke. Offsite fire department was called for assistance. There were two minor injuries to licensee personnel due to smoke inhalation requiring them to be taken to a clinic. Damage was restricted to the manlift. The NRC Resident Inspector along with State and Local Agencies were notified. |
| ENS 41642 | 26 April 2005 13:21:00 | There was an oil spill of between 10 - 25 gallons of 90 weight oil outside of the turbine building. Cleanup has begun and the State of Connecticut and Department of environmental protection were notified. The NRC Resident Inspector, State and local agencies were notified.
The source of the Hydraulic oil leak was a crane that had undergone maintenance the night before. The oil and soil have been removed. Reg 1 RDO(Barkley) informed. |
| ENS 41638 | 25 April 2005 20:41:00 | On 4/25/05 @1655, Engineering completed an evaluation and notified Operations that leakage at the packing leak off plug on the bonnet of MO-2-23-014, the Unit 2 HPCI Turbine Steam Supply Valve, is part of the ASME Class 2 piping boundary. Per station procedures, upon discovery of leakage from a Class 2 component pressure boundary, the component is declared inoperable. Therefore MO-2-23-014 and the Unit 2 HPCI system was inoperable. Reactor operation is unaffected and Unit 2 remains at 100% power. The inoperability of the HPCI system places the Unit in a 14-day shutdown Tech Spec action statement. Further investigation of the cause and the ASME Code requirements is in progress. The NRC Resident Inspector was notified
The purpose of this notification is to retract a previous report made on 4/25/05 at 2041 hours (EN# 41638). Notification of this issue to the NRC on 4/25/05 was initially made it's a result of declaring the Unit 2 High Pressure Coolant Injection (HPCI) system inoperable as a result of leakage at the packing leak off line plug on the valve bonnet of the HPCI Turbine Steam Supply valve (MO-2-23-014). It was determined that this condition constituted ASME Section XI Class 2 pressure boundary leakage. Therefore, the associated equipment was declared inoperable in accordance with station procedures. Since the initial report, Engineering has determined that the HPCI system was capable of performing its safety function. Although station procedures require ASME Section XI Class 2 components to be declared inoperable when pressure boundary leakage is determined to exist, the safety function of the MO-2-23-014 was maintained. Leakage through the seal weld on the packing leak off line plug did not affect the capability of the MO-2-23-014 valve to perform its safety function. Therefore, HPCI was capable of performing its safety function. Maintenance was planned and HPCI was removed from service on 4/26/05 to repair the HPCI MO-2-23-014 valve bonnet. The valve was repaired and the system was returned to service by 1730 hours on 4/26/05 (CR 328735). The NRC resident has been informed of the retraction. Notified R1DO (Krohn). |
| ENS 41636 | 25 April 2005 15:57:00 | A technician for the Craig Testing Laboratory placed a Troxler gauge model 3430 and its transportation box into the back of his pickup securing it with a chain, however he did not latch the top of the box or close his truck's tailgate. When he drove from the job site in Pocoson, PA., he heard a noise but he did not stop until he reached a stop light (approx 2 miles away). He got out of the truck and noticed the transport box was dangling from the back of the truck still attached to the chain, but without the Troxler gauge inside. He retraced his route, but there was no Troxler gauge. The Troxler gauge (SN # 25540) contained 8 millicuries of Cs-137 and 40 millicuries of Am/Be-241. The local police Department was notified. |
| ENS 41632 | 25 April 2005 12:30:00 | On 4/2512005 at 12:00 p.m., EDT the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned maintenance and equipment modifications. The maintenance activities require relocation of the control panel (1X75-C001) which contains the HVAC controls and annunciators as well as the radiation monitoring meter and annunciator. The loss of this equipment requires taking the TSC out of service. The maintenance activities are scheduled to take five weeks. The alternate TSC will remain operable and available, so no loss of TSC function will occur due to the maintenance activity. This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity results in a loss of an emergency response facility for the duration of the evolution. The NRC Resident Inspector was notified and state and local notifications will be made.
The TSC was returned to service at 1100 EDT on 05/04/05. The NRC Resident Inspector was notified. The Reg 2 RDO (Lesser) was notified. |
| ENS 41871 | 26 July 2005 14:27:00 | Licensee reported that two 50 millicurie Cs-137 sources, used in level measuring devices, were found to be missing from a magnesium oxide producing facility that had been closed for two years. It was determined that two sources were missing after a review of their registration around the April-May time period. Since then, they located one of the two sources, brand new, in a crate on a shelf at the facility. They located the non-nuclear part of the device (the receiver) on a hopper which was at a scrap yard on site, but the sending unit (the nuclear part) was missing. They continued looking for the sender, but could not find it.
The single source which is still lost is a TN Technologies Model 5200 gauge containing 200 millicuries Cs-137 not 50 millicuries. Notified Reg 3 RDO (Mark Ring) and NMSS EO (Joe Giitter)
Two NRC Inspectors visited the closed facility with a radiation detector and located the missing device in a parts warehouse at the facility. It was on a shelf and had turned rusty and was unidentifiable. The device was isolated in another building with the other device that had been found. Notified Reg 3 RDO (Mark Ring), NMSS EO (Joe Giitter) and TAS(E-MAIL) |
| ENS 41631 | 24 April 2005 21:39:00 | At 2130 hours on 04/24/2005 the Unit 1 SPDS system will be removed from service for planned maintenance (cable rework). The duration of work is expected to be 32 hours (scheduled for completion at 0530 hours on 04/26/2005). ERDS will remain operable during the work window but several points will not be available. For example 23 of 58 ERDS points will be unavailable while SPDS is out of service. However, the ERDS system will still be operable and transmit the remaining points. Loss of Emergency Assessment Capability - A review of the ability of the Emergency organization to function without SPDS was performed. Alternate sources for many of the points in SPDS were identified and are contained on an Emergency Plan format in PICSY (plant integrated computer system). Those points not available from PICSY can be obtained from the control room. With these compensatory actions and the communications in place between the facilities, there will not be a major loss of emergency assessment capability. Since the Unit 1-SPDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii). The NRC Resident Inspector was notified. |
| ENS 41628 | 23 April 2005 14:58:00 | On April 23, 2005, at 10:45 hours St. Lucie Plant last the ERDADS NRC Data Link capability. The System Engineer reports that the ERDADS periphery switch failed to swap to the "A" CPU from the "B" CPU on a auto failover that occurred at 10:45. The switch has been manually swapped and the Data Link has been restored. A work order has been prepared to investigate and repair the cause for this failure. The NRC resident Inspector was notified. |
| ENS 41624 | 22 April 2005 14:01:00 | A contract foreman tested positive for alcohol during a for-cause alcohol test. The employee had not performed any work and was not allowed access to the site. The employee's access to the site was terminated. The NRC Resident Inspector was informed. |
| ENS 41626 | 22 April 2005 18:56:00 | A licensee employee, trained by the device manufacturer, was performing a device inspection (inventory/shutter check/leak test) for one of the licensee's non-portable gauging devices (Ohmart Corporation Model SH-F2, serial number 2296CG) containing 7.4 gigabecquerels (200 millicuries) of cesium-137 (sealed source model number A-2102). A screw broke off while the employee was closing the device shutter. Because the screw broke off, the shutter could not be closed. The licensee plans to follow the manufacturer's procedures for this particular incident as per the manufacturer's training and instruction. This device will either be repaired by an individual specifically licensed by the Executive Secretary, the U.S. Nuclear Regulatory Commission, or an Agreement state to perform such service, or the licensee will return this device to the manufacturer. Event date was March 2005 and reporting date was April 21,2005. Utah event report # UT-05-0003 |
| ENS 41620 | 21 April 2005 15:05:00 | The following information was provided by the State via facsimile: On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital. The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing. The licensee has developed, an action plan for this event based on possible causes: 1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule. 2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician. 3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education. A voluntary MedWatch form was sent in to the FDA. Wisconsin Radiation Protection Section plans on investigating this event. State Event Report ID # 24. |
| ENS 41770 | 14 June 2005 13:45:00 | At 1515 hours on April 15, 2005, while conducting excess flow check valve testing in conjunction with a reactor vessel pressure test during a scheduled refueling outage, Unit 1 received an invalid Anticipated Transient Without Scram (ATWS) Channel A trip signal and invalid reactor Lo-Lo water level trips on the A and C channels for ECCS. The operating Reactor Recirculation pump (1 A) tripped and both Emergency Diesel Generators (Unit 1 and Unit 0) auto-started and ran unloaded. RCIC received an initiation signal, which resulted in proper valve repositioning for the system but no injection due to the steam supply being isolated to support the reactor vessel pressure test. In addition, all appropriate running equipment tripped due to load shedding. Reactor pressure was 787 psig at the time of the event and no pressure transient or vessel injection occurred. All equipment responded to the actuation as expected for plant conditions. The excess flow check valve testing was stopped and the reactor vessel pressure test was terminated as a result of this invalid actuation. It was subsequently determined that a leaking drain valve at the instrument rack where the excess flow check valve testing was being performed caused a slow depressurization of the high-pressure side sensing line for the level transmitters associated with ATWS Channel A and the A and C channels for ECCS, resulting in an erroneous level signal and the invalid actuation. The instrument rack drain valve is scheduled for replacement. The NRC Resident Inspector was notified |
| ENS 41586 | 11 April 2005 11:03:00 | Individual received laceration to right leg while working in Unit 1 Reactor Building. Individual transported to Oconee Hospital at 0949 with potential contamination. Radiation Protection conducted survey at 1046 in hospital and found no indication of contamination in wounded of individual. The licensee notified the NRC Resident Inspector |
| ENS 41582 | 9 April 2005 04:53:00 | On 04/09/05 at approximately 00:50 an automatic reactor scram occurred on Brunswick Unit 2. The Reactor Protection System (RPS) actuated on low reactor water level (LL1). All control rods inserted from the RPS signal. The LL1 signal also provided a Group 2 (floor and equipment drain isolation valves), 6 (monitoring and sampling isolation valves) and 8 (shutdown cooling isolation valves) isolation signal for the respective containment Isolation valves. Reactor low level 2 (LL2) resulted in a Reactor Core Isolation Cooling (RCIC) system actuation and injection into the reactor. The High Pressure Coolant Injection (HPCI) system actuated but did not inject because reactor water level recovered. The Reactor Water Cleanup system (RWCU) isolated (Group 3 isolation). Secondary Containment isolated and the Standby Gas Treatment (SBGT) system initiated. An Alternate Rod Insertion signal was received and the Reactor Recirculation Pumps tripped as designed. An investigation is in progress to determine the cause of the reactor level transient. Safety systems and isolations functioned as designed. The NRC Resident Inspector was notified. |
| ENS 41591 | 12 April 2005 09:35:00 | Report # MA050006 AEA Technology QSA Inc is reporting a potentially lost radioactive material shipment. The shipment contains two Type A packages each containing a 1 Ci AmBe source US model number AMN. PE2. The source serial numbers are 1865NN and 1858NN. The sources were shipped from AEA Technology on 30 Mar 05 and were designated to leave on a flight to Australia on 2 Apr 05 with arrival scheduled on 5 Apr 2005. AEA was notified on 7 Apr 05 that the shipment had not arrived. The shipment was sent to Surtech Systems Pty Ltd, in Wangara Perth, WA 6055 Australia. Indication from the airline (Qantas) in New York (JFK) that the packages were on the plane, however the airline in Perth cannot confirm that (they) have the packages. Discussions with the carrier and freight forwarders indicate that they have so far been unsuccessful in locating the packages. A conference call is currently being arranged between all parties to try and locate the packages. The sources were finally found today (04/12/04) at a Qantas airlines facility in Melbourne, Australia. |
| ENS 41721 | 20 May 2005 11:20:00 | Kellogg's did an extensive inventory of the exit signs at their facility in the past couple months. They determined that nine exit signs are missing, that were listed on a previous inventory. They believe that the signs are now in the local landfill because a number of remodeling projects have been done at Kellogg's. They have communicated with staff and contractors the importance of maintaining control of these devices. Kellogg's is also looking into alternative methods for providing exit signage". Type of sign - Radioluminescent sign Manufacturer - SRB Technologies Inc Model # BXU20SW Serial Numbers - 217791, 217808, 217845, 217897, 217903, 217949, 217950, 217951, 218307 Each sign measured 17.51 Ci tritium |
| ENS 41516 | 23 March 2005 22:29:00 | Unit 4 reactor was manually tripped from 20 percent power per 4 - GOP - 103 "Power Operation to Hot Standby" (normal shutdown procedure), during a load reduction to take the unit off line. The reason for the load reduction was an oil leak of approximately 100 drops per minute on the "4B" steam generator feed pump. The reactor was tripped when directed by 4 - GOP - 103. All rods fully inserted, no relief valves lifted, and all other systems functioned normally. The licensee notified the NRC Resident Inspector.
The licensee provided the following information via facsimile (licensee text in quotes): Upon review, the manual reactor trip from 20 percent power is not reportable in accordance with 10 CFR 50.72(b)(2)(iv)(13) since it was part of the pre-planned sequence of reactor shutdown steps contained in procedure 4-GOP-103, "Power Operation to Hot Standby." In addition, the reactor shutdown was not required by Technical Specifications. The NRC Resident Inspector will be notified of this retraction. |
| ENS 41513 | 22 March 2005 12:25:00 | A plant shutdown to mode 3( 0% power) was started at 1102 on 3/22/05. The shutdown was required per T.S. 3.3-1 Table 3.3-1, item 19, action 9. Reactor trip breaker "A" is inoperable. T.S.3.3.1, Table 3.3-1 item 19, action requires a shutdown to mode 3 within 6 hours. Plant must be in mode 3 by 1622 EST on 3-22-05. They are currently troubleshooting on the reactor trip breaker. The NRC Resident Inspector was notified. |
| ENS 41510 | 21 March 2005 22:34:00 | The following information was provided by the licensee by fax. At approximately 17:00 on March 21, 2005, while performing required surveillance testing on the Unit 3 HPCI system, the HPCI Condensate Storage Tank (CST) suction valve (MO-3-23-17) failed to close after the HPCI Torus suction valves (MO-3-23-57 & MO-3-23-58) were full open. Failure of the CST suction valve MO-3-23-17 to close when a Torus suction path was established, required entry into Technical Specification 3.3.5.1 for loss of initiation function for CST level low and Torus level high (Functions 3d, 3e). The loss of initiation function under Technical Specification 3.3.5.1 required that the HPCI system be declared inoperable in one (1) hour after discovery. HPCI was initially declared inoperable at 16:41 for surveillance testing. HPCI inoperability has been maintained as of that time. Pursuant to 10CFR 50.72(b)(3), this notification is being made due to Unit 3 HPCI inoperability, which prevents fulfillment of a Safety Function. Initial troubleshooting hints that the cause of the failure may be due to a limit switch malfunction. The NRC Resident Inspector was notified. |
| ENS 41509 | 21 March 2005 18:25:00 | The following information was provided by the licensee On 3-21-05 the Plant Computer system was removed from service at 0753 for scheduled maintenance. The system was not verified restored until 1558. This is in excess of the eight hours allowed by 10CFR50.72(b)(3)(xiii). The Plant Computer system supplies the Safety Parameter Display System (SPDS) function, which is required for Emergency Assessment Capability. The Plant Computer is currently operable. This event did not effect the plant operations. The unit is stable in Mode 1 at 100% power. The NRC Resident inspector has been informed. |
| ENS 41508 | 21 March 2005 12:20:00 | On 3/21/05 at 1045, the Control Room was notified of a fuel oil spill. The event was believed to have occurred on Saturday, 3/19/05 between 1900 and 0300. The amount of fuel oil ( Grade 2 Diesel) that was spilled was approximately 219 gallons and dispersed over a distance of about 1 mile. The cause of the spill was possibly due to a valve left open on the tanker after making a fuel delivery. The long trail of oil was made as the tanker left the site. The spill is contained and being cleaned up at this time. The area will be excavated and transported to Redland Construction. The location of the fuel oil spill occurred outside of the Nuclear Plant protected area at the new fossil plant. Construction site. DERM (Department of Environmental Resources Management) will be notified by Turkey Point Land Utilization representative. The NRC Resident Inspector will be notified. |
| ENS 41702 | 17 May 2005 11:24:00 | On March 19, 2005, during refueling Outage 2R17, it was identified that a Flex-wedge disc intended for installation in a Containment Sump isolation valve, did not have a machined slot around the disc edge, as required by the purchase specifications. A feature of the flex-wedge design is to allow the disc faces to flex, thereby reducing the potential for thermal binding. The discrepancy was identified during pre-installation inspection; therefore, the disc was not installed in the plant. Considering that extensive machining and handling of the disc is necessary during installation, it is extremely unlikely that the discrepancy could have gone undetected. The outboard containment sump isolation valve is normally closed and receives a Recirculation Actuation Signal (RAS) to open when the Refueling Water Tank volume is depleted (post-LOCA) in order to shift the Emergency Core Cooling System (ECCS) suction to the sump. Had the subject disc been installed in this valve, the discrepancy could have resulted in thermal binding of the disc, thereby rendering a complete train of ECCS inoperable upon initiation of a RAS. The subject disc was manufactured by Crane - Aloyco, and was delivered to Arkansas Nuclear One in 1991. This condition was determined to be reportable pursuant to 10CFR21 on 5/17/2005. |
| ENS 41496 | 15 March 2005 22:48:00 | The following was provided by the licensee: While reviewing Nuclear Regulatory Commission's (NRC) memorandum regarding Task Interface Agreement (TIA), TIA 2001-02,'Design Basis Assumptions For Non-Seismic Piping Failures at Prairie Island Plant,' Kewaunee staff determined that the Kewaunee plant design for flooding events may not mitigate the consequences of piping system failures. As a minimum, and as a consequence of assuming failure of non-seismically qualified piping systems as prescribed in the TIA, water has been assumed to collect in the turbine building from a circulating water system piping failure that would result in substantial damage to Engineered Safeguards (ESF) and Safe Shutdown (SS) plant equipment, most notably electrical equipment. As a consequence of high water level in the turbine building, water could flow into the ESF equipment rooms that contain the Auxiliary Feedwater pumps, Emergency Diesel Generators and both the 480 volt and 4160 volt electrical switchgear. Water is assumed to flow into the equipment rooms by way of leakage past non-water-tight doors and the plant's unchecked floor-drain system. The expected water levels In the safeguards and electrical equipment rooms are assumed to increase to the point of causing multiple trains of both ESF and SS equipment to be unavailable to safely shutdown the plant. Kewaunee's primary mitigation strategy to combat flooding events is to recognize the event and initiate manual actions to open doors/ barriers. Opening the barriers to flooding directs the water out of the turbine building through the safeguards equipment rooms and returns it to the lake. Normally the manual actions would be expected to be performed before water level accumulates to a point of causing equipment damage. However, under the seismic failure assumptions, water levels are assumed to accumulate faster than the plant's ability to identify and react in order to assure protection of equipment required to initiate and complete a safe plant shutdown. Coincidental to the condition being reported, the plant had recently implemented additional precautionary measures to combat internal flooding events that lesson the significance of the condition being reported. Temporary pumping equipment, temporary sandbag barriers and additional personnel have been staged to minimize the consequences of previously questioned flooding events. Furthermore, a number of plant equipment design changes are being processed to further improve Kewaunee's defenses against internal flooding events. However, given the event being reported, the full scope of any additional actions is still to be determined. The NRC Resident Inspector was notified. |
| ENS 41482 | 11 March 2005 17:06:00 | As part of the Cycle 6 refueling outage, inspections are being performed in accordance with Technical Specification (TS) 5.7.2.12, 'Steam Generator (SG) Tube Surveillance Program.' Based on a review of the inspection results to date, it was established at approximately 14:29 EST on March 11, 2005, that greater than 1 percent of the inspected SG tubes must be repaired. In accordance with the criteria stated in TS 5.7.2.12 and the inspection findings, the four SGs must be classified as C-3. The current inspection results do not meet the criteria specified for steam generator tube degradation in Revision 2 of NUREG 1022, 'Event Reporting Guidelines 10 CFR 50.72 and 10 CFR 50.73.' However, for the C-3 classification, WBN TS Table 5.7.2,12-1, 'SG Tube Inspection Supplemental Sampling Requirements,' requires that the results of the inspection be reported under 10 CFR 50.72. At this time, the submittal of a Licensee Event Report in accordance with 10 CFR 50.73 is not planned. The NRC Resident Inspector was notified. |
| ENS 41481 | 10 March 2005 19:06:00 | The licensee had a Troxler gauge model 3400 serial # 31101 with 8 millicuries Cs - 137 and 40 millicuries Am - 241:Be stolen from their storage building on their parking lot in Miami. The theft was considered a general burglary and was given a Miami Dade police report number of 7088G-D. No reward notice has yet been made. |
| ENS 41480 | 10 March 2005 18:15:00 | At approximately 15:45 a hydraulic line ruptured on a 90-ton mobile crane located outside of the Unit 2 Turbine Building. Approximately 50 gallons of hydraulic oil leaked onto the surrounding pavement. Barriers and absorption materials were positioned around the spill area and no oil was released to soil or the river. Required offsite notifications included the NYS Department of Environmental Conservation and the Westchester County (NY) Department of Health. The licensee notified the NRC Resident Inspector |
| ENS 41514 | 22 March 2005 13:50:00 | The following information was provided by the licensee by fax. On 17 March 2005, the TACOM-RI RSO received a call from the Ft. Sill RSO informing the licensee that he discovered 3 ea broken M1A1 collimators (nsn 1240-00-332-1780 sealed source registration no. NR-155-S-102-S). Each M1A1 collimator contains a 10 curie sealed source lamp. One collimator (s/n 933) was discovered in a training area. After this collimator was discovered, the Ft Sill RSO immediately proceeded to inspect all M1A1 collimators found in the 3/30th Field Artillery, sections 2nd, 3rd, and 6th. As a result of this inspection, the RSO discovered two additional broken M1A1 collimators, (s/n's 8644, 4116). The RSO immediately took survey wipes of the collimators and areas where they were located. There was no physical damage on the exterior of the devices or cases containing the devices. Physical damage was observed of the tritium sealed source cell itself, however exterior lenses were intact on all three collimators. It could not be determined how the damage occurred. Leak tests were performed on the three collimators with the following results s/n 933 (837,000 dpm or 3.7E-4 millicuries), s/n 8644 (6,950 dpms or 3.1E-7 millicuries), and s/n 4116 (26,300 dpms or 1.2E-5 millicuries). Only Collimator s/n 933 exceeded reportable limits (110,000 DPM). The RSO secured the purging and training areas upon discovery of the broken devices and conducted area survey in the purging area, conex trailers (where collimators are stored) and training area. None of the areas surveyed had removable tritium contamination in excess of 5,000 dpms. Tritium bioassay samples were taken on individuals (approx 10) who may have actually handled the broken M1A1 collimators. Bioassay samples will be analyzed at the US Army lab, CHPPM Aberdeen, MD. At the time of this report, the bioassay results were not available, The Ft Sill RSO has secured the three collimators in a low-level rad waste storage site for future disposal. |
| ENS 41452 | 1 March 2005 02:51:00 | The following details were provided by the licensee via fax as part of their telephonic notification: Manual reactor scram due to high turbine generator vibration during a planned Unit 1 power reduction to Mode 2 to perform maintenance to replace the vent line piping on 11 MSR drain tank. The manual reactor scram was initiated per AOP-7E, section V, 'High Turbine Vibration' trip criteria when bearing #5 exceeded 12 mils vibration. This event meets NUREG-1022 Rev. 2, Section 3.2.6 'System Actuation' Part 50.72(b)(2)(iv)(B) 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' All rods fully inserted and no ECCS or relief valve actuations occurred. Heat sink is the condenser and turbine bypass valves. The NRC resident inspector was notified. |
| ENS 41488 | 14 March 2005 13:13:00 | The licensee reported that during inventory an old (20 years old) Troxler gauge model 3411-B serial # 7520 was found missing from its case which was stored in the storage area at their office. This gauge had not been used for a number of years since it was broken. It contains 8 millicuries Cs-137 and 40 millicuries Am-241-Be. The last inventory was 12/06/04 and at that time it is believed the device was in the case, but they are not sure the case was opened to verify. They are continuing the search and have reported it to the DC Police Dept (report # 029650). |
| ENS 41446 | 27 February 2005 01:26:00 | The following information, in addition to the phone report, was obtained from the licensee via facsimile: Fort Calhoun Station Unit 1 experienced a reactor trip from 16.1% Reactor Power on a Loss of Turbine Load during a scheduled plant shutdown for a refueling outage. The turbine generator was tripped offline at 2101 per refueling outage schedule. A feedwater transient occurred (cause being investigated) during turbine testing, resulting in power rising rapidly from 12.6% to 16.1% . At which point the reactor tripped on loss of load due to being greater than 15% power with all turbine stop valves closed. All plant equipment functioned as designed. A Reactor Coolant System (RCS) cooldown resulted due to a feedwater transient. Main Feedwater was isolated, which terminated the cooldown. Auxiliary Feedwater (AFW) was established with the diesel driven auxiliary feed pump. Emergency Boration was manually initiated due to the RCS cooldown and secured after shutdown margin verification. Plant is currently stable in mode 3. This report is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) for an event that resulted in an event that resulted in an unplanned RPS actuation while the reactor was critical. All rods fully inserted, no ECCS actuation and no relief valves lifted. Steam generators are being used for heat sink. The NRC resident Inspector was notified |