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> March 1
Event Notification Report for March 1, 2004
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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/27/2004 - 03/01/2004
** EVENT NUMBERS **
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| General Information or Other |
Event Number: 40532 |
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SOIL TESTING AND ENGINEERING, INC
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 61201
Agreement: Y
Docket:
NRC Notified By: TOM PENTECOST
HQ OPS Officer: JEFF ROTTON
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Notification Date: 02/20/2004
Notification Time: 10:41 [ET]
Event Date: 02/19/2004
Event Time: 15:50 [MST]
Last Update Date: 02/27/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
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Person (Organization):
JACK WHITTEN (R4)
JOHN HICKEY (NMSS)
TOM ANDREWS (R4)
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Event Text
AGREEMENT STATE REPORT CONCERNING STOLEN GAUGE
"At 3:50 PM [MST] on 19 Feb 04 - The Department received telephone notification of a stolen gauge by Larry W. Chisman, the RSO for Soil Testing and Engineering Inc.
"The theft occurred between 11:30 AM and 2:00 PM [MST] on 19 Feb 04 in a parking lot at 314 W. Bijou, Colorado Springs, Colorado. The gauge was locked within its orange transport case which was locked within a Suburban. The windows were reported to be intact and it is unknown how entry to the vehicle was gained.
"The stolen gauge is a CPN Model MC-2, serial number M21084026. The gauge contains 10 milliCi of Cs-137 and 50 milliCi of Am-241:Be. The incident was reported to local police on the day of the theft."
* * * UPDATE ON 02/27/04 AT 11:20 BY A. COSTA * * *
This text update was reported as EN#40544 on 02/24/04 at 14:51 EST. EN#40544 has been retracted because it was a duplicate of this event notification.
"A Campbell Pacific Nuclear (CPN) Density Gauge, Model MC2, serial number M21084026 was stolen from the backseat of a privately owned chevy suburban at approximately 1300 CST on 2/19/04. The gauge contains 10 millicuries of Cs-137, and 50 millicuries of Am-241/Be. The gauge case inside the truck was not locked, but was blocked to prevent movement. Several other items were also stolen from the truck including a cellphone, wallet, and briefcase.
"The licensee reported the theft to the Colorado Springs Police Department, Case No. 04-6892, shortly after the theft was discovered. Police are investigating credit card and cellphone usage to try and track down the perpetrators."
* * * UPDATE ON 02/27/04 FROM JAMES JARVIS TO A. COSTA * * *
The Colorado Department of Health reported that Local Law Enforcement located the lost gauge, and it was returned to licensee, Soil Test and Engineering. The gauge source is intact and the licensee is leak testing the instrument as requested by the Agreement State.
Notified R4DO (Sanborn) and NMSS (Brown). |
| General Information or Other |
Event Number: 40543 |
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: ALTRU HEALTH SYSTEM
Region: 4
City: GRAND FORKS State: ND
County:
License #: 33-01599-03
Agreement: Y
Docket:
NRC Notified By: JIM KILLINGBECK
HQ OPS Officer: ERIC THOMAS
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Notification Date: 02/24/2004
Notification Time: 14:10 [ET]
Event Date: 01/28/2004
Event Time: 12:00 [MST]
Last Update Date: 02/24/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
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Person (Organization):
GARY SANBORN (R4)
JOHN HICKEY (NMSS)
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Event Text
AGREEMENT STATE REPORT OF MEDICAL EVENT
On 1/28/04, the patient was to receive a total dose of 50.4 Grays to the 'vaginal cuff' region using a 6 Curie Ir-192 sealed source. The dose was to be administered using a Microselectron Remote Afterloader HDR manufactured by Nucletron, serial number 31021.
The plan was to administer 3 radiation treatments using a catheter that is 1500 millimeters (mm) long. The treatment planning software system uses a default value of 995 mm for the catheter length. When preparing the treatment plan for the first of the 3 planned radiation treatments, the medical physicist did not notice that the catheter length in the treatment plan was incorrect (995 mm instead of the actual 1500 mm catheter that would be used). When the radiation oncologist and the medical physicist were doing a pretreatment review and ensuring that the important parameters of the planned treatment were correct, they did not check the catheter length in the treatment plan to ensure that it was correct.
The first radiation treatment was conducted, but instead of the radiation source traveling approximately 1500 mm in the catheter and providing radiation treatment to the 'vaginal cuff' region on the patient, it traveled only about 995 mm, and never entered the patient's body. When the medical physicist began to plan the second of the three radiation treatments, he noticed the error in the treatment plan for the first treatment. The radiation oncologist notified the patient on the same day the error was discovered.
The records of all patients previously treated by this medical physicist and radiation oncologist were reviewed to determine if a similar error had occurred during any other high dose rate remote afterloader treatments, but no other errors of this type were found. To prevent future errors, both the medical physicist and the radiation oncologist have reviewed the treatment planning software and have agreed on a program of formal cross checking of the pretreatment printout that would include verifying that the catheter length specified in the treatment plan is correct. |
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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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| General Information or Other |
Event Number: 40544 |
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SOIL TESTING AND ENGINEERING, INC.
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 612-01
Agreement: Y
Docket:
NRC Notified By: LARRY CHISMAN
HQ OPS Officer: ERIC THOMAS
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Notification Date: 02/24/2004
Notification Time: 14:51 [ET]
Event Date: 02/19/2004
Event Time: 13:00 [MST]
Last Update Date: 02/27/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
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Person (Organization):
GARY SANBORN (R4)
E. WILLIAM BRACH (NMSS)
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Event Text
AGREEMENT STATE REPORT
A Campbell Pacific Nuclear (CPN) Density Gauge, Model MC2, serial number M21084026 was stolen from the backseat of a privately owned chevy suburban at approximately 1300 CST on 2/19/04. The gauge contains 10 millicuries of Cs-137, and 50 millicuries of Am-241/Be. The gauge case inside the truck was not locked, but was blocked to prevent movement. Several other items were also stolen from the truck including a cellphone, wallet, and briefcase.
The licensee reported the theft to the Colorado Springs Police Department, Case No. 04-6892, shortly after the theft was discovered. Police are investigating credit card and cellphone usage to try and track down the perpetrators.
* * * RETRACTION ON 02/27/04 AT 11:20 BY A. COSTA * * *
This event notification is a duplication of event notification number 40532. The information contained herein will be shown as an update to EN#40532. |
| Power Reactor |
Event Number: 40554 |
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GORDON ROBINSON
HQ OPS Officer: STEVE SANDIN
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Notification Date: 02/28/2004
Notification Time: 02:02 [ET]
Event Date: 02/28/2004
Event Time: 00:54 [EST]
Last Update Date: 02/28/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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Person (Organization):
TODD JACKSON (R1)
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| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
N |
Y |
18 |
Power Operation |
18 |
Power Operation |
| 2 |
N |
Y |
100 |
Power Operation |
100 |
Power Operation |
Event Text
OFFSITE NOTIFICATION TO STATE BASED ON MEDICAL TRANSPORT OF INJURED WORKER
"At 00:54 AM EST, the Main Control Room was notified than an individual had fallen approx. 12 feet from scaffolding. An ambulance was requested to the site, and arrived on site at 01:20. The individual is not contaminated and was transported to a local hospital at 01:40. PEMA [Pennsylvania Emergency Management Agency] was notified of the incident."
The licensee informed the NRC Resident Inspector. |
| Power Reactor |
Event Number: 40555 |
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KEN LEFFEL
HQ OPS Officer: BILL GOTT
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Notification Date: 02/28/2004
Notification Time: 15:47 [ET]
Event Date: 02/03/2004
Event Time: [CST]
Last Update Date: 02/28/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
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Person (Organization):
MONTE PHILLIPS (R3)
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| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
N |
Y |
25 |
Power Operation |
25 |
Power Operation |
Event Text
DEAD FISH FOUND AT CLINTON POWER STATION
The licensee provided the following in accordance with their operating license Appendix B, Environmental Protection Plan.
"At approximately 2100 hrs. on 2/27/04, the Illinois Department of Natural Resources (IDNR) contacted Exelon corporate environmental personnel and informed them there was a fish loss on Clinton Lake. Corporate personnel notified Clinton Power Station personnel at 2130 hrs.
"An inspection on the lake shoreline on 2/28/04 occurred from 0800 to 1200 hrs by station personnel.
"The inspection revealed a total of several hundred deceased fish over several locations. The species predominantly observed were gizzard shad. As followup, the final tally of fish affected will be determined after further communication by CPS environmental personnel working with IDNR.
"The fish appeared have been deceased 3-5 weeks, based on observed decomposition. This 3-5 week time period closely coincides with Clinton Power Station's shutdown on 2/3/04 for refueling outage C1R09."
The Licensee notified the NRC Resident Inspector. |
| Power Reactor |
Event Number: 40556 |
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: STEVE BANKS
HQ OPS Officer: BILL GOTT
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Notification Date: 02/29/2004
Notification Time: 11:46 [ET]
Event Date: 02/29/2004
Event Time: [MST]
Last Update Date: 02/29/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
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Person (Organization):
GARY SANBORN (R4)
BILL BATEMAN (NRR)
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| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 3 |
N |
N |
0 |
Hot Standby |
0 |
Hot Standby |
Event Text
BORIC ACID RESIDUE FOUND ON PRESSURIZER HEATER SLEEVE
"The following event description is based on information currently available. If through subsequent reviews of this event, additional Information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On February 29, 2004, at approximately 05:21 Mountain Standard Time (MST) engineering personnel performing preplanned visual examinations of reactor coolant system (RCS) piping in accordance with procedure requirements discovered boric acid residue on the A03 pressurizer heater sleeve. The heater sleeve is an alloy 600 penetration. The visual observation was characterized as a small white buildup of boron residue around the heater sleeve as the sleeve enters the pressurizer bottom head. There does not appear to be residue running down the outside of the sleeve. There were no signs of dripping, spraying, puddles of liquid, or liquid running down the nozzle or pressurizer. The residue appeared dry.
"Technical Specifications (TS) Limiting Condition for Operation (LCO) 3.4.14 permits no reactor coolant system (RCS) pressure boundary leakage and therefore, the discovery of leakage (presumed boric acid residue) from the pressurizer heater sleeve was a degradation of a principal safety barrier. Therefore, the ENS notification of this event is in accordance with 10CFR50.72(b)(3)(ii). The control room personnel entered LCO 3.4.14 Condition B and are taking action to place the plant In Mode 5 within 36 hours. The Unit had been shutdown and was being maintained in Mode 3 while troubleshooting a turbine-generator excitation problem. At the time of discovery, the RCS was at approximately 565 degrees F and 2245 psia.
"An investigation of this event will be conducted in accordance with the PVNGS corrective action program.
"No ESF actuations occurred and none were required. There were no structures, systems, or components that were inoperable at the time of discovery that contributed to this condition. There were no failures that rendered a train of a safety system inoperable and no failures of components with multiple functions were involved. 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 licensee notified the NRC Resident Inspector. |
| Power Reactor |
Event Number: 40557 |
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: CHAUNCEY GOULD
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Notification Date: 03/01/2004
Notification Time: 04:17 [ET]
Event Date: 02/29/2004
Event Time: 20:11 [EST]
Last Update Date: 03/01/2004
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Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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Person (Organization):
CHARLES R. OGLE (R2)
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| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
Y |
96 |
Power Operation |
96 |
Power Operation |
Event Text
UNIT 2 AUTOMATIC FEEDWATER ISOLATION SYSTEM (AFIS) DECLARED INOPERABLE
The licensee reported that both digital trains of the automatic feedwater isolation system were declared inoperable when one channel's input failed to zero and about the same time the second channel showed a shift in readouts which was fairly significant that they also declared it inoperable. These two channels have a shared neutral bus and it is believed that there may be a loose connection somewhere in the circuit. They are currently troubleshooting the problem. Plant will initiate a unit shutdown if the problem cannot be corrected by 0600 @ 03/01/04 (12-hour LCO A/S).
The NRC Resident Inspector will be notified. |
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