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Event Notification Report for December 21, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/20/2005 - 12/21/2005

** EVENT NUMBERS **

Power Reactor	Event Number: 42069
Facility: SAINT LUCIE Region: 2 State: FL Unit: [1] [2] [ ] RX Type: [1] CE,[2] CE NRC Notified By: ALAN T. HALL HQ OPS Officer: JOE O'HARA	Notification Date: 10/24/2005 Notification Time: 00:26 [ET] Event Date: 10/23/2005 Event Time: 23:00 [EDT] Last Update Date: 12/20/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): MIKE ERNSTES (R2)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	N	0	Cold Shutdown	0	Cold Shutdown
2	N	Y	25	Power Operation	25	Power Operation

Event Text

NON-EMERGENCY EVENT DECLARED FOR LOSS OF ERDADS SYSTEM AFFECTING BOTH UNITS

"On 10/23/05 at 2300, the Unit 1 and Unit 2 emergency response data acquisition and display system's emergency response data system (ERDS) link to the NRC failed. Troubleshooting and restoration work is in progress."

The NRC Resident Inspector has been notified.

****** UPDATE ON 11/14/05 AT 1646 EST BY JOONG KO TO MACKINNON *******

"This notification is an update to previously made notification, EN# 42069. ERDS link to the NRC failed on 10/23/05, and during continuing troubleshooting efforts, Saint Lucie discovered both unit's NRC modem had failed. Due to the failure, Saint Lucie will be rescheduling Quarterly ERDS Link Test with the NRC."

NRC Resident Inspector was notified of this update by the licensee. R2DO ( Mike Ernstes) notified.

* * * UPDATE ON 12/20/05 AT 1157 EST BY D. WILLIAMS TO GOTT * * *

"This notification is an update to previously made notification, EN# 42069. The ERDS link modems have been repaired and the Quarterly ERDS Link Test has been successfully completed on the morning of 12/20/05."

NRC Resident Inspector was notified of this update by the licensee. R2DO (T. Decker) notified.

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 42161
Facility: CLINTON Region: 3 State: IL Unit: [1] [ ] [ ] RX Type: [1] GE-6 NRC Notified By: STEVEN MENG HQ OPS Officer: BILL HUFFMAN	Notification Date: 11/21/2005 Notification Time: 17:42 [ET] Event Date: 11/21/2005 Event Time: 10:42 [CST] Last Update Date: 12/20/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(B) - POT RHR INOP	Person (Organization): RICHARD SKOKOWSKI (R3)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	96	Power Operation	96	Power Operation

Event Text

DIVISION 3 EMERGENCY DIESEL GENERATOR DECLARED INOPERABLE

"The Division 3 Emergency Diesel Generator (EDG) was declared INOPERABLE following a trip during a routine monthly surveillance run. As soon as the Division 3 EDG was at full load it tripped off line (output breaker tripped). The Division 3 EDG supplies electrical power to the High Pressure Core Spray System in the event of a loss of offsite power.

"No problems occurred on the Division 3, 4160 volt, safety related bus.

"This event is being reported in accordance with 10CFR50.72(b)(3)(v)(B), Event or Condition That Could Have Prevented Fulfillment of a Safety Function for a single-train system failure.

"The NRC Resident inspector has been notified."

* * * THIS EVENT IS BEING RETRACTED ON 12/20/05 AT 1557 * * *

"Subsequent trouble-shooting and testing determined that the cause of the engine trip on 11/21/05 was an invalid high coolant temperature trip signal. This trip is bypassed during a Loss of Coolant (LOCA) initiation of the system, therefore, it was determined that the EDG would have been able to perform its safety function during a LOCA. Following a Loss of Offsite Power (LOOP), reactor water level is expected to reach Reactor Pressure Vessel (RPV) Water Level Low Low (Level 2) within 30 seconds of the initiating signal. Once Level 2 is reached, both the EDG and the LOCA Trip bypass signals are actuated. It was determined that the bypass would have occurred prior to the high coolant temperature trip. Based on the above, it was determined that the Division 3 EDG would have been fully capable of performing its safety function under both LOCA and LOOP. The Division 3 EDG was restored to an operable condition at 0214 on 11/22/05.

"The NRC Senior Resident Inspector has been notified."

Notified R3DO (H. Peterson).

Power Reactor	Event Number: 42206
Facility: OCONEE Region: 2 State: SC Unit: [1] [2] [3] RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP NRC Notified By: STEPHAN C. NEWMAN HQ OPS Officer: JOE O'HARA	Notification Date: 12/15/2005 Notification Time: 12:19 [ET] Event Date: 12/15/2005 Event Time: 09:30 [EST] Last Update Date: 12/20/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): THOMAS DECKER (R2)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	100	Power Operation	100	Power Operation
2	N	Y	100	Power Operation	100	Power Operation
3	N	Y	100	Power Operation	100	Power Operation

Event Text

LOSS OF EMERGENCY SIREN POWER

"On December 15, 2005, at 0930 hours, it was determined that approximately 17 of 65 Oconee Nuclear Station emergency sirens, located in Pickens and Oconee Counties, failed to send a feedback signal when checked. It is postulated that these sirens are inoperable due to a loss of power attributed to severe icing conditions currently being experienced in both counties. At the time of discovery, current weather conditions were a steady light rain with a temperature of 33 degrees F.

"Duke is currently attempting to restore power to the affected sirens but does not expect to have all of the inoperable sirens back in service until later in the day. During the loss of siren period, a compensatory means of notifying the public has been put into place to include routing of local law enforcement personnel to the affected areas for public notification should an emergency occur at the station. Because more than 25% of the sirens were unavailable as a result of this event, this event constitutes a major loss of notification capability; consequently, this event is reported as an eight -hour notification in accordance with 10CFR50.72(b)(3)(xiii) reporting criteria.

"The licensee notified the NRC Resident Inspector and applicable station personnel.

"Initial Safety Significance: None. Compensatory measures have been put into place to ensure that the members of the public located in the affected areas are appropriately notified by local law enforcement personnel. All three Oconee units remain operable in Mode 1 (100 percent Power) and are unaffected by this condition.

"Corrective Action(s): Duke will attempt to have all of the inoperable sirens restored as soon as possible and will maintain the compensatory action in-place until full restoration has been completed."

* * * UPDATE ON 12/16/05 AT 1620 FROM JOHN COLLINS TO JOE O'HARA* * *

"On December 15, 2005, at 0930 hours, it was determined that approximately 17 of 65 Oconee Nuclear Station emergency sirens, located in Pickens and Oconee Counties, failed to send a feedback signal when checked. It is postulated that these sirens are inoperable due to a loss of power attributed to severe icing conditions currently being experienced in both counties. At the time of discovery, current weather conditions were a steady light rain with a temperature of 33 degrees F.

"Throughout the day and night of December 15th, additional sirens were lost. A maximum number of 40 sirens were eventually lost.

"On December 16th, 2005, at 0815 Emergency Planning contacted Oconee and Pickens County to assess the siren outage due to ice storm on 12-15-05 and the results of the assessment were that Pickens County still had 17 sirens out of service and Oconee County still had 9 sirens out of service due to the ice storm. The ONS resident NRC inspector was notified this morning at 0818 of the siren issue and all of his questions and concerns were answered. Duke Power Company Community Affairs was also notified.

"On December 16th, 2005, at 1509, Emergency Planning contacted Oconee and Pickens County. The results were that Pickens County still has 11 sirens out of service and Oconee County still has 2 sirens out of service due to the ice storm. This reduces the total number of sirens out of service to less than the threshold considered a major loss of offsite response capability per the 10CFR 50.72 notification requirements.

"Duke is currently attempting to restore power to all the affected sirens. Power is expected to be restored to the entire service area by Sunday.

"During the loss of siren period, a compensatory means of notifying the public was put into place to include routing of local law enforcement personnel to the affected areas for public notification should an emergency occur at the station.

"Initial Safety Significance: 12-16-05, Safety Significance has not changed. None. Compensatory measures have been put into place to ensure that the members of the public located in the affected service areas are appropriately notified by local law enforcement personnel. All three Oconee units remain operable in Mode 1 (100 percent power) and are unaffected by this condition.

"Corrective Action(s): Duke will attempt to have all the inoperable sirens restored as soon as possible and will maintain the compensatory action in-place until full restoration has been completed."

The R2DO(Decker) had been notified.

***** UPDATE ON 12/20/05 AT 1610 EST FROM RANDY TODD TO MACKINNON ******

"This update (December 20, 2005) is to report that all sirens have now been returned to service and tested.

"Duke has completed repairs to restore and test all sirens. Full restoration has been completed."

R2DO (Paul Fredrickson) notified.

NRC Resident Inspector will be notified of this update by the licensee.

General Information or Other	Event Number: 42207
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: UNIVERSITY OF CHICAGO HOSPITAL Region: 3 City: CHICAGO State: IL County: License #: IL-01678-02 Agreement: Y Docket: NRC Notified By: DAREN PERRERO HQ OPS Officer: MIKE RIPLEY	Notification Date: 12/15/2005 Notification Time: 12:26 [ET] Event Date: 09/12/2005 Event Time: [CST] Last Update Date: 12/15/2005
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): SONIA BURGESS (R3) SANDRA WASTLER (NMSS)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via email:

"On December 14, 2005 the licensee's Radiation Safety Officer, [name deleted], called the Division and forwarded information describing a medical misadministration that involved a brachytherapy dose that was greater than 10 percent from the intended treatment. The misadministration had occurred some months ago. The event was discovered as a result of a review of past treatments during an attempt to understand, what appeared to be, anomalies for certain cases.

"In a particular case on September 12, 2005, a patient began treatment for cervical cancer with a 'Fletcher Suit' manual brachytherapy afterloader using Cs-137 sealed sources. A transposition error was made in the digitization of the patient's lateral film used to construct the applicator's position and thus the positions of the radiation sources relative to the locations of the dose calculation points. Therefore, the digital locations used for mapping and treatment planning of points 'right A' and 'left A' relative to the sources were incorrectly determined.

"These calculated points used in the treatment planning were located in a region of lower dose rate within the tumor than the true anatomical 'A points', at which the prescription should have been defined. As a result, the prescription/final treatment plan used incorrect lower dose rate points and called for the use of an erroneously high source loading. Based on a retrospective analysis, instead of the calculated average dose rate of 0.545 Gy/hr for the erroneous 'A points', the actual delivered averaged dose rate to the true 'A points' was 0.74 Gy/hr. This resulted in an average dose of 54.3 Gy delivered to the true points A instead of the planned 40.0 Gy. The dose to the other points, namely rectum and bladder, were calculated correctly because their location did not involve the digitization step in which the transposition error occurred. These doses, which were calculated correctly, were all within acceptable limits. Only the tumor dose was in excess of the intended dose.

"This event occurred because of a misunderstanding concerning use of the new treatment planning system (TPS) that was being introduced into the clinic. The TPS allows digitizing either a right or left lateral film for locating the sources, bladder and rectal points for calculating doses. However the location of target point 'A', which is used for dose prescription, must be determined manually. Therefore a separate program is used which requires digitizing the source applicator on AP and lateral films to localize these points. In this additional step, the orientation of the lateral film on the digitizer was reversed left to right from what the program required, resulting in sign reversal of the anterior-posterior coordinate of the left and right 'A points'. This error was discovered in December, when looking into why positions of calculated points sometimes appeared unusual. This error was not caught at the time of the original implants.

"Once this potential source of dose discrepancy was discovered, the licensee reviewed all the patients whose dosimetry plans were determined with the new TPS since treatments were first initiated some three months ago. Three total patients were identified. The magnitude of the effect was found to also depend upon the orientation of the applicator in the patient. Only the case described above had those adverse complications which resulted in a medical event. A review of the two additional dosimetry plans showed that due to the orientation of the apparatus in the patient, the dose to the true prescription point was less than 5% greater than the planned dose. The clinical consequences for the patient concerned in this report are being evaluated by physicians.

"Four Cs-137 sealed sources with a total activity of 178 mCi were inserted into the patient. The planned averaged point A dose was 40.0 Gy and the actual administered dose was 54.3 Gy. Other than the 'point A' dose, no other dose calculation points were outside of the treatment specifications. The physicians are reviewing the revised dosimetry plans to determine if there will be any increased risk of complications for this patient. The clinical consequences for the patient concerned in this report are being evaluated by physicians. The dose at the various calculation points were:

"Dose points/Planned Dose (Gy/hr)/Actual Dose (Gy/hr)
Right A/0.56/0.74, Left A/0.530.74, Right B/0.18/0.18, Left B/0.17/0.17, r-rectum/0.33/0.37, s-rectum/0.35/0.39, t-rectum/0.31/0.32, u-rectum/0.21/0.21, B-bladder/0.47/0.43.

"This matter will be included during an pending routine inspection which will be conducted in the next 30 days.

"Corrective Actions:
Action Number / Corrective Action: 1 PROCEDURE MODIFIED 2 PERSONNEL RECEIVED ADDITIONAL TRAINING

"Patient Information: Patient Number: 1 Patient Informed: N Date Informed:
Therapeutic BRACHY, MANUAL AFTERLOADER
Organ: CERVIX
Dose: 5430 rad 54.3 Gy % Dose Exceeds Prescribed: 36
% Dose is Less Than Prescribed:
Effect on Patient: UNKNOWN Administered By: PHYSICIAN
Dose to Family: 0 rem 0 Sv Dose to Newborn: 0 rem 0 Sv Dose to Fetus: 0 rem 0 Sv
Source of Radiation: Due to the nature of the event, this matter was reported to the U.S. NRC Operations Center on December 15, 2005. It was assigned event number 42207
Source Number: 1
Form of Radioactive: SEALED SOURCE Radionuclide or Voltage (kVp/MeV): CS-137
Source Use: BRACHYTHERAPY Activity: .178 Ci 6.586 GBq
Manufacturer: Model Number: Serial Number: Device/Associated Equipment: Device Number: 1
Device Name: MANUAL AFTERLOADER Model Number: Manufacturer: UNKNOWN Serial Number:
Reporting Requirement: 32 IAC 335.1080 - Any administration of radioactive materials that results in a 'reportable event' (misadministration), licensee shall notify the agency by telephone NLT next day after licensee ascertains and confirms that a 'reportable event' has occurred.
Mode Reported: Written"

Illinois Item No. IL-050073

General Information or Other	Event Number: 42209
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: UNIVERSITY OF DAYTON Region: 3 City: DAYTON State: OH County: License #: 03620580000 Agreement: Y Docket: NRC Notified By: STEPHEN JAMES HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 12/16/2005 Notification Time: 14:16 [ET] Event Date: 05/18/2004 Event Time: [EST] Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): SONIA BURGESS (R3) BECK KARAS (NMSS) E-MAIL (TAS)

Event Text

OHIO AGREEMENT STATE REPORT - LOSS OF TRITIUM FOIL SOURCE

The State provided the following information via email:

"Licensee had submitted license renewal application. RFI from ODH requested info on disposition of sources to be removed from the license. One H-3 foil source from a Varian Aerograph ECD was reported as having been disposed of on May 18, 2004. When asked to produce documentation, the licensee went back to their copy of the waste shipping manifest to find reference to the H-3 source. However, this source was not referenced on the manifest as being included in the shipment on the licensee's copy. The licensee has contacted the waste broker to investigate whether this source had been included in the waste shipment. Source was purchased in the late 1970's and was removed from service and placed in storage in the late 1990's. The source is now calculated to have an activity of 232 millicuries. The licensee will file a written report to ODH as required by Ohio regulations."

This source was part of an electron capture detector, Varian model 02-1681-01.

Ohio Item Number: OH050008

Notified the R3DO (Burgess), NMSS (Karas) and TAS (via E-mail).

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.

General Information or Other	Event Number: 42210
Rep Org: ARIZONA RADIATION REGULATORY AGENCY Licensee: QUALITY TESTING, LLC Region: 4 City: TEMPE State: AZ County: License #: AZ 7-491 Agreement: Y Docket: NRC Notified By: AUBREY GODWIN HQ OPS Officer: MIKE RIPLEY	Notification Date: 12/16/2005 Notification Time: 16:20 [ET] Event Date: 12/16/2005 Event Time: 09:30 [MST] Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CLAUDE JOHNSON (R4) BECK KARAS (NMSS) E-MAIL (TAS) MEXICO (E-MAIL) ()

Event Text

ARIZONA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

"At approximately 9:30 AM December 16, 2005, the Agency was informed by the Licensee that a Troxler Model 3411B Portable Gauge, SN 17964 had been stolen from the back of an employee's pick up truck. The theft occurred between 2:00 - 4:30 AM December 16, 2005. The gauge contains 8 mCi (millicuries) of Cesium-137 and 40 mCi (millicuries) AM:Be-241.

"Phoenix PD is investigating and has issued report number 2005-52380969

"The Licensee is offering a $500.00 reward for the recovery of the truck and sources. A press release is to be made.

"The Agency continues to investigate.

"The states of CA, NV, CO, UT, and NM and Mexico and U.S. NRC and FBI are being notified of this event."

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.

Power Reactor	Event Number: 42212
Facility: BYRON Region: 3 State: IL Unit: [1] [2] [ ] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: STEVEN BOOMGARDEN HQ OPS Officer: BILL GOTT	Notification Date: 12/20/2005 Notification Time: 18:13 [ET] Event Date: 12/20/2005 Event Time: 17:12 [CST] Last Update Date: 12/20/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): HIRONORI PETERSON (R3) MICHAEL TSCHILTZ (NRR) ELIOT BRENNER (PAO) TAS email ()

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	100	Power Operation	100	Power Operation
2	N	Y	100	Power Operation	100	Power Operation

Event Text

OFFSITE NOTIFICATION - PRESS RELEASE

"This notification is being made in accordance with 10CFR50.72(b)(2)(xi) due to a press release being issued. On 12/19/05 at 14:46 CST, a licensee employee was leaving the station and received a gunshot wound to the left leg/ankle while walking between the Byron Main Access Facility and the Byron Pre Access Facility. Onsite personnel provided first aid assistance, and an offsite ambulance responded to the scene. The injured individual was transported to St. Anthony's Hospital in Rockford, Illinois. The injured individual is in stable condition and is expected to make a full recovery. The Ogle County Sheriff's Office is conducting an investigation into the event. Byron Security Firing Range activities were in progress at the time of the event and were suspended immediately upon notification of the injury. A press release is being issued due to media attention related to this event. The NRC Resident Inspector has been notified, as well as NRC personnel from Region III and NRC Headquarters."

Power Reactor	Event Number: 42213
Facility: BEAVER VALLEY Region: 1 State: PA Unit: [1] [2] [ ] RX Type: [1] W-3-LP,[2] W-3-LP NRC Notified By: A.W. HARTNER HQ OPS Officer: JOE O'HARA	Notification Date: 12/20/2005 Notification Time: 23:34 [ET] Event Date: 12/20/2005 Event Time: 21:15 [EST] Last Update Date: 12/20/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): BRIAN MCDERMOTT (R1)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	100	Power Operation	100	Power Operation
2	N	Y	100	Power Operation	100	Power Operation

Event Text

MINOR CHEMICAL SPILL

"Notified the Pennsylvania Department of Environmental Protection ( PA DEP) at 2115 of an onsite chemical leak, some of which ended up being discharged to the environment (Ohio River). A small hydrazine spill onsite was directed to the onsite chemical waste sump. The chemical waste sump was at that time being reprocessed to the water treating clarifier. The clarifier effluent is directed to filters and eventually to the onsite reverse osmosis unit and demineralizer train. The waste effluent of the reverse osmosis unit is directed to the clarifier settling basin, which in turn is routed directly to the Ohio river. The chemical analysis of the clarifier settling basin indicated 132 ppb hydrazine.

"The information reported to the PA DEP essentially stated that BVPS had a minor onsite chemical spill that is not EPA reportable. However, since hydrazine was detected in outfall 103 (The clarifier settling basin) under the requirements of the National Pollutant Discharge Elimination System (NPDES) permit we are required to report this to the PA DEP. We do not expect harm to the environment. No offsite emergency response is required."

The licensee notified the NRC Resident Inspector.