Event Notification Report for October 8, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
10/07/1999 - 10/08/1999
** EVENT NUMBERS **
36268 36269 36270 36271 36272
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|Fuel Cycle Facility |Event Number: 36268 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 10/06/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:30[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 10/06/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 17:03[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/07/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |JOHN JACOBSON R3 |
| DOCKET: 0707002 |JOHN GREEVES NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KEITH WILLIAMSON | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
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EVENT TEXT
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| INFORMATION REPORT ON RUPTURE OF CIRCULATING WATER HEADER FOLLOWED BY AN |
| OFFSITE NOTIFICATION (4-HOUR NOTIFICATION) |
| |
| The plant suffered a rupture in a 6-inch header on the plant circulating |
| water header that does not affect present plant operation. Work is in |
| progress to isolate the leak. Several thousand gallons of water have been |
| released on site, and environmental sampling of the site outfalls is |
| underway to determine if any release offsite of chlorine (water additive) |
| has taken place. |
| |
| Portsmouth personnel have notified the NRC resident inspector. |
| |
| (Call the NRC operations officer for a contact telephone number.) |
| |
| ******************** UPDATE AT 0103 ON 10/07/99 FROM ERIC SPAETH TO LEIGH |
| TROCINE ******************** |
| |
| The following text is a portion of a facsimile received from Portsmouth: |
| |
| "At approximately 1703 hrs on 10/06/99, a recirculating cooling water line |
| rupture occurred on the plant. A 6-inch line rupture caused a significant |
| increase in flow through an NPDES outfall. Monitoring has not determined a |
| permitted limit exceedance or impact to local water tributaries. However, |
| [at 0008 hrs on 10/07/99,] a courtesy notification to [the Ohio |
| Environmental Protection Agency (OEPA)] was made to advise of this upset |
| condition." |
| |
| "[This is a 4-hour] notification to the NRC due to [the] plant notifying |
| [another] government agency [ ... ]." |
| |
| "There was no loss of hazardous/radioactive material or |
| radioactive/radiological contamination exposure as a result of this event." |
| |
| Portsmouth personnel plan to notify the NRC resident inspector and the |
| Department of Energy site representative. The NRC operations center |
| notified the R3DO (Jacobson), NMSS EO (Hickey), and IRO (Miller). |
| |
| * * * UPDATE 1601 10/7/1999 FROM LARSON TAKEN BY STRANSKY * * * |
| |
| "At 1205 hours on 10/7/99 Environmental Management personnel notified the |
| Ohio Dept. of Natural Resources of an observed fish kill in a local |
| tributary (Little Beaver Creek) that was attributed to the recirculating |
| cooling water line rupture that occurred on 10/6/99. Additionally, the Ohio |
| EPA was notified at 1240 hours on 10/7/99. A press release was also issued |
| at 1600 hours on 10/7/99." |
| |
| Notified R3DO (Shear). |
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|General Information or Other |Event Number: 36269 |
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| REP ORG: STATE OF ILLINOIS |NOTIFICATION DATE: 10/07/1999|
|LICENSEE: RUSH-PRES-ST. LUKE'S MEDICAL CENTER |NOTIFICATION TIME: 00:43[EDT]|
| CITY: REGION: 3 |EVENT DATE: 10/05/1999|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: IL-01766-01 AGREEMENT: Y |LAST UPDATE DATE: 10/07/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN JACOBSON R3 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PATRICIA LARKINS (NRC) | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT OF A NOVOSTE CORPORATION BETA-CATHETER TREATMENT |
| DEVICE DRIVE MECHANISM FAILURE AT ST. LUKE'S MEDICAL CENTER (The facility's |
| location was not provided.) |
| |
| The following text is a portion of an E-mail sent to the NRC operations |
| center from the NRC Office of State Programs (Patricia Larkins) at 1650 on |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce |
| Sanza) to the NRC (Patricia Larkins) at 1409 on 10/05/99: |
| |
| "FYI. The license number is IL-01766-01" |
| |
| "-----Original Message----- From: Gulczynski, Andy |
| Sent: Tuesday, October 05, 1999 12:05 PM |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul |
| Cc: (ORS, Glen Ellyn DRM Staff) |
| Subject: Reported Drive Mechanism Failure in Novoste Corporation |
| Beta-Catheter Treatment Device " |
| |
| "Glenn Sullivan, RSO at Rush-Pres-St. Luke's Medical Center, [ ... ], just |
| called me to report an event which occurred this morning." |
| |
| "A patient was being treated with a Novoste Corporation Beta-Cath System |
| (Model SRO.S03 using Novoste Source Train 139/99 in transfer device 7Z519). |
| The device is used to treat arterial occlusions. This system contains 56 |
| mCi of Sr-90 as of April 8, 1999, contained in 16 active seeds. The source |
| 'train' contains a total of 18 seeds, two of which are 'dummies', located at |
| the beginning and the end of the source train. The sources are driven in to |
| and out of the catheter using saline solution (water pressure). This system |
| is an 'all or nothing' system, meaning all the seeds are used in each |
| treatment." |
| |
| "At the conclusion of today's treatment, the staff could not visually verify |
| the presence of all the sources within the machine. They immediately |
| removed the catheter from the patient; surveyed the patient, the catheter, |
| and the room; and found no sources present. They then connected the |
| catheter to the machine and activated the drive mechanism. Six active |
| sources and one dummy source came out, which they placed into a shielded |
| container. They activated the drive mechanism again and 9 active sources, |
| and one dummy source came out. (This left one source unaccounted for.) |
| They then surveyed the machine and confirmed the presence of the last source |
| within the machine, though they do not know exactly where it is located." |
| |
| "The patient suffered no adverse effects and received no unplanned exposure |
| as a result of this event." |
| |
| "Glenn Sullivan is preparing a written report, which will be sent to our |
| Department." |
| |
| (Call the NRC operations officer for a licensee contact name and telephone |
| number.) |
| |
| ******************** UPDATE AT 0044 ON 10/07/88 BY LEIGH TROCINE |
| ******************** |
| |
| The following text is a portion of an E-mail sent to the NRC operations |
| center from the NRC Office of State Programs (Patricia Larkins) at 1651 on |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce |
| Sanza) to the NRC (Patricia Larkins) at 1432 on 10/05/99: |
| |
| "-----Original Message----- From: Gulczynski, Andy |
| Sent: Tuesday, October 05, 1999 1:31 PM |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul |
| Cc: (ORS, Glen Ellyn DRM Staff) |
| Subject: Update to Novoste Corporation Beta Cath Event" |
| |
| "Glenn Sullivan called again to inform us that a Novoste Corporation |
| Representative will be at Rush-Pres-St. Luke's Medical Center tomorrow to |
| investigate the cause of this event. Glenn will keep us informed of any |
| new |
| developments. " |
| |
| The NRC operations officer notified the R3DO (Jacobson) and NMSS EO |
| (Hickey). |
| |
| ******************** UPDATE AT 0045 ON 10/07/88 BY LEIGH TROCINE |
| ******************** |
| |
| The following text is a portion of an E-mail sent to the NRC operations |
| center from the NRC Office of State Programs (Patricia Larkins) at 1653 on |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce |
| Sanza) to the NRC (Patricia Larkins) at 1436 on 10/06/99: |
| |
| "-----Original Message----- From: Gulczynski, Andy |
| Sent: Wednesday, October 06, 1999 1:35 PM |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul |
| Cc: (ORS, Glen Ellyn DRM Staff); Merrihew, George |
| Subject: Update on Novoste Beta-Cath System" |
| |
| "Glenn Sullivan called me with an update to the Novoste Beta-Cath source |
| drive mechanism failure:" |
| |
| "Novoste service personnel were there today and dismantled the machine. |
| They found the missing source in the 'belly' of the machine stuck to a |
| magnet. They don't know how or why yet. They left the sources with Glenn |
| and took the machine to their facility to perform tests on it, presumably to |
| figure out the root cause(s) of the failure." |
| |
| "One of the sources involved in the event appeared to be damaged. All of |
| the sources were leak tested and none, including the damaged one, were |
| leaking. Glenn said that he would package the sources and ship them to the |
| supplier." |
| |
| "A written report from Glenn Sullivan will be sent to our Department." |
| |
| The NRC operations officer notified the R3DO (Jacobson) and NMSS EO |
| (Hickey). |
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|Fuel Cycle Facility |Event Number: 36270 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 10/07/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 01:03[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 10/06/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 21:10[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/07/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |JOHN JACOBSON R3 |
| DOCKET: 0707002 |JOHN HICKEY NMSS |
+------------------------------------------------+CHARLES MILLER IRO |
| NRC NOTIFIED BY: ERIC SPAETH | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| NRC BULLETIN 91-01 RESPONSE (4-HOUR REPORT) |
| |
| The following text is a portion of a facsimile received from Portsmouth: |
| |
| "On 10/06/99 at 2110 hrs, the Plant Shift Superintendent (PSS) was notified |
| by NCS Engineering, that an Nuclear Criticality Safety Approval (NCSA) |
| requirement was not being maintained in the X-333 process building during a |
| maintenance evolution. Maintenance personnel, while working on seal exhaust |
| pumps, removed the filter from the demister without prior non-destructive |
| analysis (NDA) being completed." |
| |
| "Requirement #12 of NCSA-033_016.AO1 states in part [that] seal exhaust |
| pumps/demisters shall be drained of oil then NDA measured for U-235 content |
| prior to removal." |
| |
| "At the direction of the [PSS,] the requirements for an NCS anomalous |
| condition were initiated, and the area was boundaried off." |
| |
| "There was no loss of hazardous/radioactive material or |
| radioactive/radiological contamination exposure as a result of this event." |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: An NDA measurement was not obtained; |
| however, the demister was drained of oil. Therefore, an unsafe mass is not |
| anticipated. The maximum enrichment for the seal exhaust is 3% U-235. |
| Spacing was maintained; therefore, the overall safety [significance] is low. |
| (At the enrichment involved, the component is a favorable geometry)." |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): In order for criticality to occur, a spacing |
| violation would have to occur as well as a failure to NDA the equipment |
| prior to removal." |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| Spacing [was] maintained. Mass [was] assumed [to be] lost." |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE OF CRITICAL MASS): The equipment removed was only a |
| part [of] the seal exhaust pump demister; therefore, a large mass is not |
| anticipated. The enrichment was at 3% in the form of UF4 with oil." |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: NDA was not performed on seal demisters |
| prior to removal. The NDA is required to demonstrate that the component is |
| less than a safe mass. Spacing between components was maintained." |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: |
| At the direction of the [PSS,] the requirements for an NCS anomalous |
| condition were initiated, and the [area was] boundaried off. The filters |
| removed will be scheduled to have NDA measurements performed." |
| |
| Portsmouth personnel stated that this event was a 4-hour notification |
| because it involved a loss of one of two criticality controls without |
| re-establishment within 4 hours. |
| |
| Portsmouth personnel notified the NRC resident inspector and the Department |
| of Energy site representative. |
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|Other Nuclear Material |Event Number: 36271 |
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| REP ORG: WEST VIRGINIA UNIVERSITY |NOTIFICATION DATE: 10/07/1999|
|LICENSEE: WEST VIRGINIA UNIVERSITY |NOTIFICATION TIME: 14:22[EDT]|
| CITY: MORGANTOWN REGION: 2 |EVENT DATE: 10/04/1999|
| COUNTY: STATE: WV |EVENT TIME: [EDT]|
|LICENSE#: 47-23035-01 AGREEMENT: N |LAST UPDATE DATE: 10/07/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRIAN BONSER R2 |
| |DON COOL NMSS |
+------------------------------------------------+JOHN DAVIDSON IAT |
| NRC NOTIFIED BY: KEN DOUGLASS |BARRY MANILLI IAT |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| TRITIUM-FILLED EXIT SIGNS STOLEN FROM CREATIVE ARTS CENTER BUILDING |
| |
| On 10/4/1999, a University administrative assistant noticed that a |
| tritium-filled exit sign had been stolen from a hallway in the creative arts |
| building. Upon further investigation, the licensee determined that up to |
| five other signs were also missing from the building. The campus police were |
| notified, and a public safety report was filed. The licensee believes that |
| the signs were stolen during the weekend of 10/2-3/1999. The licensee is |
| currently researching specific information regarding the signs (model number |
| and activity). |
| |
| The licensee may make a press release regarding this event. |
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|Other Nuclear Material |Event Number: 36272 |
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| REP ORG: COGEMA MINING INC. |NOTIFICATION DATE: 10/07/1999|
|LICENSEE: COGEMA MINING INC. |NOTIFICATION TIME: 16:04[EDT]|
| CITY: MILLS REGION: 4 |EVENT DATE: 10/05/1999|
| COUNTY: STATE: WY |EVENT TIME: [MDT]|
|LICENSE#: SUA-1341 AGREEMENT: N |LAST UPDATE DATE: 10/07/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |JOHN GREEVES NMSS |
+------------------------------------------------+JOE HOLONICH NMSS |
| NRC NOTIFIED BY: JOHN VASELIN | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MONITOR WELL PLACED IN EXCURSION STATUS |
| |
| "A routine biweekly water sample collected on October 5, 1999 from monitor |
| well MW89, exceeded 2 of its 3 upper control limits (UCLs). A confirmation |
| sample was collected on this date, which also exceeded 2 of its 3 UCLs. |
| Monitor well MW89 has been placed on excursion status as per license Section |
| 11.2 and its sampling frequency is increased to weekly. MW89 is a perimeter |
| ore zone monitor well located approximately 500 feet south of the Mine Unit |
| 2 boundary, at the Christensen Mine, Campbell County Wyoming. The nearest |
| community is Linch, Wyoming, approximately 15 miles to the southeast. Note |
| that mining has been completed in Mine Unit 2 and it is currently on standby |
| status, awaiting for the second phase of groundwater restoration to begin." |
| |
| Data collected from the well, and the respective upper control limits are |
| listed below: |
| |
| Chloride Conductivity Alkalinity Uranium |
| Date mg/l umhos/cm2 mg/l |
| mg/l U3O8 |
| |
| 10-5-99 17.5 756 123.6 |
| <0.4 |
| 10-7-99 17.1 740 121.9 |
| <0.4 |
| |
| Limits --> 13.6 823 121.3 |
| none |
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