Event Notification Report for November 4, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/01/2002 - 11/04/2002
** EVENT NUMBERS **
39327 39328 39329 39337 39338 39339 39340
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|General Information or Other |Event Number: 39327 |
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| REP ORG: FLORIDA BUREAU OF RADIATION CONTROL |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: ROBERT BOISSONEAULT ONCOLOGY INSTITUT|NOTIFICATION TIME: 13:04[EST]|
| CITY: LACANTO REGION: 2 |EVENT DATE: 10/22/2002|
| COUNTY: STATE: FL |EVENT TIME: [EDT]|
|LICENSE#: 2155-1 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KERRY LANDIS R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHARLES ADAMS | |
| HQ OPS OFFICER: MIKE RIPLEY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT |
| |
| "On 10-22-02 the patient was undergoing the first of six fraction therapy |
| using a HDR source in the cervix. The source was misplaced by approximately |
| 2 centimeters. The dose received was 800 Rem instead of the prescribed dose |
| of 500 Rem. On 10-28-02 the error was discovered during planning for the |
| second fraction, and it was reported the same day. The patient and physician |
| have been notified. No long term health effect is expected and the |
| prescribed treatment is continuing. Licensee will submit a letter of |
| explanation within 15 days. Florida is continuing it's investigation." |
| |
| Florida Incident No. FL02-161 |
| Isotope used was 9.961 Curies Ir-192. |
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|General Information or Other |Event Number: 39328 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: ALPHA TESTING, INC. |NOTIFICATION TIME: 13:44[EST]|
| CITY: DALLAS REGION: 4 |EVENT DATE: 10/28/2002|
| COUNTY: STATE: TX |EVENT TIME: 06:30[CST]|
|LICENSE#: L03411 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JAMES H. OGDEN Jr. | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - STOLEN NUCLEAR DENSITY GAUGE |
| |
| |
| "A company technician returned to the office at 6:30 a.m. after an extended |
| job in Brundidge, Alabama. He was in the office to return to operations at |
| the Dallas, office and was beginning to unload his truck and return his |
| equipment to the office. He unlocked his gauge (Troxler Model 3411B, Serial |
| # 6819) and placed it on the tailgate of the truck. He walked into the |
| office to get a chain and lock to secure the gauge in the company storage |
| cabinet. He walked back to the truck to get the gauge and discovered that |
| the gauge and the concrete air meter were missing from the truck. He |
| contacted the dispatcher, who had not yet arrived at the office, to notify |
| the company RSO. Notifications were made to the Bureau of Radiation |
| Control, the Dallas Police Department (Police Report # 823204L - a copy has |
| not been received yet), and three local nuclear gauge repair centers |
| (Richardson & Associated, Component Sales - Houston, and Troxler Labs, |
| Arlington). The gauge has not been located. Source Serial #'s are: Cs-137, |
| 10 millicuries, S/N CC3975, and AmBE-241, 40 millicuries, S/N CCA3132. The |
| BRC is still investigating the incident." |
| |
| "Company truck with Logo, Texas Licensee # 5ND G59" |
| |
| "Texas Incident No.: I-7945" |
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|General Information or Other |Event Number: 39329 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: WOODWARD REGIONAL HOSPITAL |NOTIFICATION TIME: 15:19[EST]|
| CITY: WOODWARD REGION: 4 |EVENT DATE: 10/28/2002|
| COUNTY: STATE: OK |EVENT TIME: 15:00[CST]|
|LICENSE#: OK-21269-01 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: M. BRODERICK | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
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EVENT TEXT
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| FOLLOW-UP PATIENT GIVEN INCORRECT PREP DRUG |
| |
| |
| Woodward Regional Hospital was doing an Iodine-131 follow-up scan for |
| residual Thyroid on cancer patient. A nurse injected the patient with the |
| incorrect prep drug, non radioactive drug, prior to the patient being |
| administered 4 millicuries of Iodine-131. The caller believes that the |
| patient was given the incorrect prep drug on October 28, 2002 and today, |
| October 29, 2002, was administered the 4 millicuries of Iodine-131 before |
| given the scan. After the scan was performed it was discovered that the |
| patient was given the incorrect prep drug for the scan. The State of |
| Oklahoma is investigating this event. |
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|Power Reactor |Event Number: 39337 |
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| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 11/01/2002|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 17:52[EST]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 11/01/2002|
+------------------------------------------------+EVENT TIME: 15:08[EST]|
| NRC NOTIFIED BY: QUENTIN HICKS |LAST UPDATE DATE: 11/01/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID SILK R1 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| DEGRADED PLANT CONDITION DUE TO LOSS OF SAFETY RELATED OFFSITE POWER |
| |
| "This report is being filed per 10CFR50.72.b.3. This is an eight hour |
| notification of a degraded plant condition based on a loss of safety related |
| offsite power. |
| |
| "At 1508 hours, Central New York Power Control notified Nine Mile Point Unit |
| 1 control room staff that a Low Contingency Voltage alarm had been received. |
| Per plant procedures NMP1 entered a 24-hour shutdown Limiting Condition of |
| Operation per Technical Specification 3.6.3. Power Control's Load Flow |
| Computer program that monitors the 115 kV grid for NMP1, determined that |
| there is insufficient voltage (based on the grid loading) to supply NMP1 |
| ECCS loads during a LOCA. |
| |
| "NMP1 has started its DIV 1 emergency diesel generator (EDG). DIV 1 ECCS bus |
| is currently being supplied by the DIV 1 EDG. Plant operators are currently |
| starting the DIV 2 EDG; it will supply DIV 2 ECCS bus. |
| |
| "Power is still available for other non-safety related buses from offsite, |
| however for safety related buses it is considered degraded." |
| |
| The Licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39338 |
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 11/01/2002|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 18:26[EST]|
| RXTYPE: [1] CE |EVENT DATE: 11/01/2002|
+------------------------------------------------+EVENT TIME: 11:58[CST]|
| NRC NOTIFIED BY: RANDY CADE |LAST UPDATE DATE: 11/01/2002|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLAUDE JOHNSON R4 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
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| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| UNANALYZED CONDITION FOR PRESSURIZER LEVEL TRANSMITTER CABLE SEPARATION |
| |
| "During an internal (Self Assessment) Fire Protection Program Review, |
| documentation discrepancies were found related to Pressurizer Level |
| Transmitters LT-101Y and LT-101X (Normal Operating Level Indications) and |
| LT-106 (Cold Calibrated Shutdown Indication). The information did not |
| provide adequate documentation to ensure Appendix R cable separation was met |
| in Containment. A field verification was performed and confirmed that |
| Appendix R cable separation for the above mentioned Pressurizer Level |
| transmitters may not exist. The Plant engineering Department is continuing |
| to evaluate the situation and a Plant Review Committee (PRC) meeting is |
| planned for later this evening to review Engineering's conclusions." |
| |
| "Currently the affected transmitters are operable and this issue relates to |
| Appendix R Licensing Documentation only." |
| |
| The Licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39339 |
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| FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 11/01/2002|
| UNIT: [] [2] [] STATE: NC |NOTIFICATION TIME: 22:12[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 11/01/2002|
+------------------------------------------------+EVENT TIME: 16:41[EST]|
| NRC NOTIFIED BY: DON BAIN |LAST UPDATE DATE: 11/01/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KERRY LANDIS R2 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
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| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| HPCI INOPERABLE DUE TO INDICATED HIGH DIFFERENTIAL PRESSURE ALARM |
| |
| "On November 1, 2002 at 16:41 hours, a High Pressure Coolant Injection |
| (HPCI) Steam Line Break high differential pressure alarm was received, which |
| caused a HPCI Steam Isolation System 'A' signal, closure of the 2-E41-F003, |
| HPCI Steam Supply Outboard Isolation Valve, and a closure signal to the |
| normally closed 2-E41-F041, Torus Suction Valve. Temperature indications, |
| inspection of associated trip instrumentation, and local inspection |
| confirmed that all temperatures for the HPCI system were normal and no |
| steam or line break was present. The high differential pressure alarm |
| cleared at 16:49 hours. |
| |
| "Investigation is currently in progress and drifting of a differential |
| pressure transmitter is suspected. |
| |
| "This event is reportable in accordance with 10CFR50.72(b)(3)(v)(D) since |
| the HPCI system is needed to mitigate the consequences of an accident. |
| |
| "INITIAL SAFETY SIGNIFICANCE EVALUATION |
| "The Reactor Core Isolation Cooling (RCIC) system is operable and Unit 2 has |
| entered the Technical Specification action statement to restore the HPCI |
| system in 14 days. Therefore, this event poses minimal safety significance. |
| |
| "CORRECTIVE ACTIONS |
| "Initial actions were taken to verify no evidence of a steam leak using |
| available indications and an inspection of HPCI steam lines, Further |
| investigation is in progress on the associated differential pressure |
| transmitter." |
| |
| The Licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39340 |
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| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 11/02/2002|
| UNIT: [] [2] [] STATE: CA |NOTIFICATION TIME: 08:38[EST]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 11/02/2002|
+------------------------------------------------+EVENT TIME: 03:16[PST]|
| NRC NOTIFIED BY: BOB CONOSCENTI |LAST UPDATE DATE: 11/02/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLAUDE JOHNSON R4 |
|10 CFR SECTION: | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 100 Power Operation |0 Hot Standby |
| | |
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EVENT TEXT
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| UNIT 2 REACTOR TRIP ON LOW STEAM GENERATOR WATER LEVEL |
| |
| The San Onofre Unit 2 reactor tripped from full power on reactor protection |
| system (RPS) actuation due to low steam generator (SG) 2E089 water level. |
| The low SG water level was caused by the momentary closure of main feedwater |
| regulator valve 2-FV-1111. The momentary valve closure caused the #1 SG |
| water level to drop to the ESFAS/reactor trip setpoint of 21% (NR) resulting |
| in RPS actuation, automatic auxiliary feedwater system initiation, and the |
| trip of both main feedwater pumps. The auxiliary feedwater system was used |
| to restore and maintain SG water levels after the reactor trip. All control |
| rods fully inserted into the reactor and all plant systems responded to the |
| event as expected. The plant is currently stable in hot standby conditions. |
| |
| The licensee notified the NRC Resident Inspector. |
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