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Event Notification Report for September 2, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/01/2004 - 09/02/2004

** EVENT NUMBERS **

General Information or Other	Event Number: 40990
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: CHILDREN'S HOSPITAL Region: 4 City: NEW ORLEANS State: LA County: License #: LA-1448-L01 Agreement: Y Docket: NRC Notified By: SCOTT BLACKWELL (fax) HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 08/27/2004 Notification Time: 09:35 [ET] Event Date: 08/05/2004 Event Time: [CDT] Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): WILLIAM JOHNSON (R4) TOM ESSIG (NMSS)

Event Text

INCORRECT DOSE ADMINISTERED TO A PATIENT

A misadministration occurred on August 5, 2004. The patient was an uncooperative 20 year old Down's Syndrome who was to be injected with 20 mCi of Tc-99m MDP for a bone scan. While attempting to restrain the patient the technologist mistakenly reached for and injected a 4.2 mCi DMSA renal scan dose. The patient was notified of the error and subsequently injected with the correct dose. The misadministration did not exceed the 5 rems effective dose equivalent or the 50 rems dose equivalent to any organ. The technologist was been counseled to obtain assistance when performing such administrations in the future.

General Information or Other	Event Number: 40991
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: BAYOU TESTERS Region: 4 City: AMEILA State: LA County: License #: LA-7112-L01 Agreement: Y Docket: NRC Notified By: SCOTT BLACKWELL (fax) HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 08/27/2004 Notification Time: 10:01 [ET] Event Date: 07/01/2004 Event Time: [CDT] Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): WILLIAM JOHNSON (R4) TOM ESSIG (NMSS)

Event Text

LICENSEE REPORTED FAILURE OF A RADIOGRAPHY CAMERA

On July 1, 2004 while Bayou Testers was performing quarterly inspections, they noticed that the case on a INC-100 industrial radiography camera was split open. The exposure devise was taken out of operation and sent to Source Production and Equipment (SPEC). The devise contained approximately 10 Ci of Ir-192. SPEC informed the licensee that the cause of the case splitting was corrosion of the depleted uranium shield, which caused it to swell and tear the weld. SPEC informed the licensee that this occurrence was not unusual.

General Information or Other	Event Number: 40992
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: DOW CHEMICAL Region: 4 City: PLAQUEMINE State: LA County: License #: LA-2002-L02 Agreement: Y Docket: NRC Notified By: SCOTT BLACKWELL (fax) HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 08/27/2004 Notification Time: 11:09 [ET] Event Date: 07/20/2004 Event Time: [CDT] Last Update Date: 08/27/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): WILLIAM JOHNSON (R4) TOM ESSIG (NMSS)

Event Text

POSSIBLE RADIATION EXPOSURE FROM A LEVEL DETECTION DEVICE

It has been determined that during a painting and insulation replacement: job on the exterior of the D-15 vessel at the Solvents Plant at Dow's Plaquemine manufacturing complex, a radiation shield was not locked out on a 500 mCi Cs-137 radiation source used for level detection. The zone of potential exposure was approximately 3 inches wide by 14 inches long on the external top of the tank. The work that was being performed was in such a manner that there could have been a possibility of hand or arm exposure. During the six day period it was determined that up to 16 persons had the potential to be exposed while completing the insulation replacement. A conservative estimate of 5 minutes total continuous exposure time over this period at a distance of 5 inches from the source yield a potential exposure of 421 mrems. A two minute total continuous exposure at a distance of 14 inches would yield a potential exposure of 31 mrems. The cause of the incident was failure to lock out a radiation shield prior to commencement of work. Lock out procedures for the facility have been reviewed and strengthened to prevent reoccurrence. Medical screening was performed on all potentially exposed personnel and the results were reviewed with the personnel. No effects were observed.

General Information or Other	Event Number: 41000
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: SOUTHERN REGIONAL MEDICAL CENTER Region: 1 City: RIVERDALE State: GA County: License #: 1039-1 Agreement: Y Docket: NRC Notified By: ROD HARRELL HQ OPS Officer: JEFF ROTTON	Notification Date: 08/30/2004 Notification Time: 14:49 [ET] Event Date: 07/01/2004 Event Time: [EDT] Last Update Date: 08/30/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PAMELA HENDERSON (R1) E. WILLIAM BRACH (NMSS)

Event Text

GEORGIA AGREEMENT STATE REPORT - MEDICAL EVENT

On July 01, 2004 the licensee had three patients scheduled for I-131 treatments. Two patients were scheduled to receive less than 33 milliCuries and one patient was scheduled to receive 100 milliCuries. One of the patients scheduled to receive less than 33 milliCuries was administered 100 milliCuries instead. The patient was allowed to leave the facility without the proper instructions being given. The authorized user who signed the written directive was at the facility when the dose was administered. The temporary RSO was at South Fulton Hospital and he was notified. The patient was notified and was given the proper instructions prior to release and the referring physician was notified.

On 07/19/04, a written copy of this event was received by the [Georgia] Department [of Natural Resources], including measures taken to prevent recurrence. Incident was not discovered by licensee until after patient had left with her children. On 7/26/04, the Department received report from the medical physicist consultant hired by licensee that no overexposures or affects from radiation would have been received by patient's children.

Power Reactor	Event Number: 41003
Facility: INDIAN POINT Region: 1 State: NY Unit: [2] [ ] [ ] RX Type: [2] W-4-LP,[3] W-4-LP NRC Notified By: BRAIN ROKES HQ OPS Officer: JOHN MacKINNON	Notification Date: 09/01/2004 Notification Time: 07:46 [ET] Event Date: 09/01/2004 Event Time: 00:05 [EDT] Last Update Date: 09/01/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL	Person (Organization): PAMELA HENDERSON (R1) TERRY REIS (NRR)

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

Event Text

MANUAL REACTOR TRIP DUE TO OSCILLATING STEAM GENERATOR WATER LEVEL

"On September 1, 2004, at 00:01 hours, operations noticed the 22 Main Feedwater (FW) regulating valve operating erratically and FW and 22 Steam Generator (SG) level oscillating. Operators placed the 22 Main FW regulating valve in manual and attempted to control FW flow and SG level but were unsuccessful. A Nuclear Plant Operator (NPO) in the plant reported water hammer in the Auxiliary Building that contains the FW regulating valves. At 00:05 hours operations initiated a manual trip of the reactor based on the degrading condition with FW flow and SG level. All control rods fully inserted and safety equipment operated as expected. Auxiliary Feedwater started as expected, the Emergency Diesel Generators did not start and offsite power remained available. The plant is in Hot (Standby) at Normal Temperature and Pressure and there was no radiation release. The 22 Main FW regulating valve was discovered to be partially stuck open. At 00:19 hours operations isolated the 22 FW flow path by closing the 22 FW line motor operated valve (MOV) BFD 5-1. The condition is under investigation and a post trip review is being conducted." State of NY was notified of this event by the licensee.

The NRC Resident Inspector was notified of this event by the licensee.

* * * UPDATE AT 1113 ON 9/1/04 FROM B. ROKES TO W. GOTT * * *

"After further review of the reporting guidelines and discussion with the NRC R1, Licensing concluded the event notification should be reported under 10CFR50.72 (b)(1)(iv)(B) for a 4-hour report. A Condition Report was initiated for the late notification."

Notified NRR (Reis) and R1DO (Henderson).

Power Reactor	Event Number: 41004
Facility: VERMONT YANKEE Region: 1 State: VT Unit: [1] [ ] [ ] RX Type: [1] GE-4 NRC Notified By: DAVID HALLOUQUIST HQ OPS Officer: JEFF ROTTON	Notification Date: 09/01/2004 Notification Time: 14:14 [ET] Event Date: 07/31/2004 Event Time: 13:56 [EDT] Last Update Date: 09/01/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION	Person (Organization): PAMELA HENDERSON (R1) TERRY REIS (NRR)

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

INVALID PCIS ACTUATION

"This notification is being made in accordance with 10CFR50.73(a)(2)(iv)(A) to provide the NRC with information pertaining to the invalid Primary Containment Isolation System (PCIS) Group III actuation signal that affected containment isolation valves in more than one system.

"On July 31, 2004 at 1356 [EDT] with the reactor at full power, the power supply that provides power to the Reactor Protection System (RPS) Channel 'A' of the Reactor Building Ventilation Exhaust Rad Monitor and RPS Channel 'A' of the Refuel Floor Rad Monitor was momentarily lost causing an invalid PCIS Group III actuation. Operators immediately verified the plant response to the loss of RPS 'A', backed up the Group III actuation manually, walked down the control room panels, shifted RPS 'A' bus to the alternate power supply, secured 'A' RPS MG set and restored the affected plant equipment to a normal line-up. The following systems were observed to have performed as follows:

"The PCIS functioned successfully providing a complete Group III isolation. Both trains of the Standby Gas Treatment System started and operated as designed.

"The PCIS Group Ill isolation involved isolation of valves in the following systems:

Drywell Air Purge and Vent, Drywell and Suppression Chamber Main Exhaust, Suppression Chamber Purge
and Vent, Containment Air Compressor Suction Valve, Exhaust to Standby Gas Treatment, Containment Purge
Supply and Makeup, Containment Air Sampling, Air Dilution Subsystem Valves, Vent Subsystem Valves, and
Containment Air Dilution Vent System MOV VG-22 A/B.

"Repairs were subsequently made to the 'A' RPS power supply and the system was returned to normal status. This event has been entered into Entergy Nuclear Vermont Yankee's Corrective Action Program."

The licensee will notify the NRC Resident Inspector.

Power Reactor	Event Number: 41005
Facility: MONTICELLO Region: 3 State: MN Unit: [1] [ ] [ ] RX Type: [1] GE-3 NRC Notified By: ROBERT SCHREIFELS HQ OPS Officer: STEVE SANDIN	Notification Date: 09/01/2004 Notification Time: 17:12 [ET] Event Date: 09/01/2004 Event Time: 12:45 [CDT] Last Update Date: 09/01/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION	Person (Organization): JULIO LARA (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

UNANALYZED CONDITION DUE TO APPENDIX R CRITERIA NOT SATISFIED FOR SAFE SHUTDOWN EQUIPMENT

"Unanalyzed condition due to missing fire barrier and inadequate separation involving power supply cables for RHR and Core Spray pumps. During a review of the site Appendix R program, NMC Engineering personnel discovered that the credited Monticello Division I RHR Pump and Core Spray Pump power cables pass through a Division II fire area. A fire in this room could potentially damage both divisions of post-fire safe shutdown equipment.

"This condition is reportable under 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety due to the lack of required separation of post-fire safe shutdown trains. As a compensatory action an hourly fire watch has been established in accordance with the Monticello Fire Protection Program.

"The licensee informed the NRC Resident Inspector."

The licensee is continuing their evaluation to determine the extent of the condition.