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Event Notification Report for April 21, 1999

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/20/1999 - 04/21/1999

EVENT NUMBERS
35619356243561335614356153561635612

Power Reactor
Event Number: 35619
Facility: CALVERT CLIFFS
Region: 1     State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: BRUCE MONTGOMERY
HQ OPS Officer: FANGIE JONES
Notification Date: 04/22/1999
Notification Time: 14:36 [ET]
Event Date: 04/21/1999
Event Time: 00:00 [EDT]
Last Update Date: 04/22/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
MOHAMED SHANBAKY (R1)
Power Reactor Unit Info
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 N 0 Refueling 0 Refueling
Event Text
- VOLUNTARY FITNESS-FOR-DUTY REPORT -

A licensed operator was determined to be just below the limit by random test. The employee's access to the plant was terminated. Refer to the HOO Log for additional details.

The licensee notified the NRC Resident Inspector.


Other Nuclear Material
Event Number: 35624
Rep Org: NATIONAL INSTITUTE OF HEALTH
Licensee: NATIONAL INSTITUTE OF HEALTH
Region: 1
City: BETHERSDA   State: MD
County: MONTGOMERY
License #: 19-00296-17
Agreement: Y
Docket:
NRC Notified By: ROBERT ZOON
HQ OPS Officer: FANGIE JONES
Notification Date: 04/23/1999
Notification Time: 13:38 [ET]
Event Date: 04/21/1999
Event Time: 14:30 [EDT]
Last Update Date: 04/23/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
MOHAMED SHANBAKY (R1)
FREDERICK COMBS (NMSS)
JOSEPH GIITTER (IRO)
Event Text
AN IRRADIATOR FAILED TO PROPERLY RETURN THE SOURCE TO THE FULLY SHIELDED POSITION.

The following text is a portion of a facsimile received from the licensee:

"This is a report in accordance with condition 17.E. of license 19-00296-17 which requires that with respect to each J. L. Shepherd and Associates Mark 1 Cesium-137 Irradiator, we ' ... notify the Commission by telephone ... if ... any malfunction of the irradiator is detected.

"At approximately 2:30 p.m. April 21, 1999, a health physicist (HP) in the Radiation Safety Branch was continuing a quarterly inspection and leak test procedure which he had initiated on April 19, 1999. During this follow-up visit, he became aware of an apparent problem with a J. L. Shepherd Mark I Cesium-137 irradiator, which is located in Building 37, Room B440. This self-contained self-shielded irradiator contains approximately 3,850 Ci of Cs-137.

"The [HP] reported the results of his investigation to me at 9:15 a.m. this morning. The problem was reported to the HP on April 21 by a designated user who explained that the source failed on at least one occasion to return to the fully shielded position following an irradiation procedure. The door interlock functioned as designed, which prevented the door from being opened. Thus, this situation resulted in NO safety problem or radiation exposure.

"The HP, continuing his investigation, was able to duplicate a similar problem one additional time during the inspection. However, numerous repeated attempts to duplicate the problem did not result in a failure of the irradiator to properly stow the source. The HP did not, therefore, judge the irradiator to have malfunctioned.

"Following the HP's discussion with me this morning, it was my judgement that the problem observed could be interpreted as a malfunction of the irradiator. Therefore, effective this morning, I directed the irradiator custodian to remove this irradiator from service and to contact J. L. Shepherd for maintenance to correct this problem. At that time, I also elected to report this apparent malfunction directly to you [Judith Joustra, Chief, Nuclear Materials Safety Branch, Region 1]. Upon your advice, I am simultaneously reporting this finding to the NRC Operations Center.

"Upon receipt of the report of maintenance from the J. L. Shepherd service representative, I will forward you the explanation for the irradiator's failure to operate."

(Call the NRC operations officer for a site contact telephone number.)


Power Reactor
Event Number: 35613
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KLAY KLIMPLE
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 04/21/1999
Notification Time: 18:03 [ET]
Event Date: 04/21/1999
Event Time: 10:15 [CDT]
Last Update Date: 04/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
DALE POWERS (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation
Event Text
- FITNESS FOR DUTY REPORT -

AT 1015 CDT ON 04/21/99, A PLANT EMPLOYEE WAS DETERMINED TO BE UNDER THE INFLUENCE OF ALCOHOL DURING A RANDOM TEST. THE EMPLOYEE'S ACCESS AUTHORIZATION TO THE PLANT HAS BEEN TERMINATED. REFER TO THE HOO LOG FOR ADDITIONAL DETAILS.

THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.


Power Reactor
Event Number: 35614
Facility: INDIAN POINT
Region: 1     State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: PHIL SANTINI
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 04/21/1999
Notification Time: 22:16 [ET]
Event Date: 04/21/1999
Event Time: 21:17 [EDT]
Last Update Date: 04/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(ii)(B) - OUTSIDE DESIGN BASIS
Person (Organization):
MOHAMED SHANBAKY (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation
Event Text
- UNIT 2 OUTSIDE ITS PLANT DESIGN BASIS FOR 30 SECONDS DUE TO A FAILED TRANSFER SWITCH -

DURING A SURVEILLANCE TEST, DC CONTROL POWER TRANSFER SWITCH #EDD-2 FAILED TO TRANSFER TO THE EMERGENCY POWER SUPPLY FOR 480-VOLT BUS 2A.. PLANT OPERATORS RESTORED DC CONTROL POWER TO 480-VOLT BUS 2A FROM ITS NORMAL POWER SUPPLY IN APPROXIMATELY 30 SECONDS.

THIS LOSS OF DC CONTROL POWER TO 480-VOLT BUS 2A PLACED UNIT 2 OUTSIDE ITS PLANT DESIGN BASIS FOR 30 SECONDS.

THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR.


Power Reactor
Event Number: 35615
Facility: GINNA
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: DOUG PETERSON
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 04/21/1999
Notification Time: 22:30 [ET]
Event Date: 04/21/1999
Event Time: 20:00 [EDT]
Last Update Date: 04/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
MOHAMED SHANBAKY (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 2 Startup 2 Startup
Event Text
- INADVERTENT TDAFW PUMP START DURING A MOVATS TEST -

During the restoration of motor operated valve #MOV-3505A from Motor Operated Valve Analysis and Test System (MOVATS) test #M-64.1.2, the turbine driven auxiliary feedwater (TDAFW) pump inadvertently started. A system engineer standing near the TDAFW pump called the control room and reported that the pump was running. The control operator isolated the TDAFW system discharge to the steam generators with the discharge air operated valves, and the control room foreman directed the auxiliary operator to close the manual isolation valve which secured the steam to the TDAFW pump.

This resulted in a 2°F cooldown of the reactor coolant system (RCS) during the approximate 1 minute run of the TDAFW pump.

The licensee informed the NRC Resident Inspector.


Power Reactor
Event Number: 35616
Facility: LIMERICK
Region: 1     State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CURT WOLTON
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 04/21/1999
Notification Time: 23:19 [ET]
Event Date: 04/21/1999
Event Time: 20:25 [EDT]
Last Update Date: 04/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(v) - OFFSITE MEDICAL
Person (Organization):
MOHAMED SHANBAKY (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
Event Text
- POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED TO OFFSITE MEDICAL FACILITY -

AT 2025 ON 04/21/99, A WORKER RECEIVED AN INJURY TO HIS HAND. THE INJURY WAS SERIOUS ENOUGH THAT THE EMERGENCY MEDICAL TECHNICIAN AND HEALTH PHYSICS TECHNICIAN DID NOT REMOVE THE WORKERS GLOVE BEFORE TRANSPORTING HIM TO THE POTTSTOWN HOSPITAL FOR TREATMENT. THE HEALTH PHYSICS TECHNICIAN SUBSEQUENTLY DETERMINED THAT THE INDIVIDUAL WAS NOT CONTAMINATED.

THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR.


General Information or Other
Event Number: 35612
Rep Org: MA DEPT OF PUBLIC HEALTH RCP
Licensee: AEA TECHNOLOGIES QSA, INC
Region: 1
City: BURLINGTON   State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEN TRAEGDE
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 04/21/1999
Notification Time: 15:00 [ET]
Event Date: 04/21/1999
Event Time: 14:00 [EDT]
Last Update Date: 05/07/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
MOHAMED SHANBAKY (R1)
FREDERICK COMBS (NMSS)
JOSEPH GIITTER (IRO)
DONNA MARIE PEREZ (IP)
LEN WERT (R2)
Event Text
- SHIPMENT OF 8 Ir-192 SOURCES (866 CURIES TOTAL) FROM BURLINGTON, MA, OVERDUE IN MEXICO -

At 1500 EDT on 04/21/99, Ken Traegde of the Massachusetts Department of Public Health Radiation Control Program (RCP) located in Boston, Massachusetts, reported that on 04/16/99, AEA Technology QSA, Inc., located in Burlington, Massachusetts, shipped a Model-855 source changer loaded with eight Iridium-192 sources (totaling 866 curies) via Federal Express to Vicont S.A. De C.V. located in Toluca, Mexico. The undamaged package had a transport index of 1.4 (normal readings of 1.4 mR/hour at 1 meter and 55 mR/hour at the surface) at the time of shipment.

The shipment was scheduled to arrive in Mexico on 04/17/99. As of 1400 EDT on 04/21/99, the recipient (Vicont S.A. De C.V.) had received the shipping papers but not the container. The shipper and Federal Express have launched a full search for the package. The Federal Express Hazardous Material Investigation Team has conducted a physical search of Express Depots in Boston, Memphis, Los Angeles, and Mexico.

The license numbers are: SU-1485, 12-8361, 52-0243, 54-0237, and 58-0242.

The NRC operations officer notified the Department of Transportation via the National Response Center (Gauthier); Report number 481132.

(Contact the NRC operations officer for applicable telephone numbers.)

*********************************** UPDATE AT 1345 ON 04/22/99 BY JONES ***********************************

The NRC entered the Monitoring Phase of Normal Mode at 1345 on 04/22/99. The NRC operations officer notified the R1DO (Shanbaky), Region 1 (Miller), IRO (Congel and Giitter), NMSS (Paperiello), RCT (Weinstein), OPA (Gagner), EDO's office (Charleen Raddatz), and Chairman's office (Holian). The RCT notified the Federal Emergency Management Agency (Dan Rishe), Department of Energy (Thomas Yates), Department of Agriculture (Bob Conley), Department of Health and Human Services (James Raab), and Environmental Protection Agency and Department of Transportation via the National Response Center (Ms. Reddy).

*********************************** UPDATE AT 1600 ON 04/22/99 BY JONES ***********************************

A Commissioner's Assistants Briefing was conducted at 1600 on 04/22/99. The following notifications were made (* office did not participate): IRO (Joe Giitter and Eric Weinstein), Chairman Jackson (Dan Gillen), Commissioner Dicus (Joel Lubenau), Commissioner Diaz (Patrick Castleman), Commissioner McGaffigan (Janet Schlueter), Commissioner Merrifield (JohnThoma), EDO (*Dan Martin), DEDE (*Jocelyn Mitchell), NMSS (Don Cool and Carl Paperiello), NMSS EO (Fred Combs), R1DO (Mohamed Shanbaky), OPA (Joe Gilland), CAO (Thomas Madden), SECY (Andrew Bates), OSP (Paul Lohaus), OIP (Ron Hauber), Region 1 (Felicia Hinson and Jim Wiggins, etc), and Region 2 (Doug Collins, Chuck Hosey, and Dick Woodruff). The briefer was Fred Combs of NMSS.

At 1610, the NRC operations officer played a tape of briefing for EDO (Dan Martin) and DEDE (Jocelyn Mitchell).

****************************** UPDATE AT 1230 ON 04/23/99 BY TROCINE AND JONES ******************************

A conference call was conducted at 1230 on 04/23/99 to update the status of this event. The following NRC offices participated (among others): IRO (Himes), NMSS (Brach, Combs, and Cook), Region 1 (Lloyd), Region 2 (Collins and Woodruff), Region 4 (Andrews), OPA (Hayden), OIP (Lieberman), OSP (Lohaus), and EDO (Raddatz). In addition, the following agencies participated: Department of Transportation (Rick Boyle), Massachusetts Department of Public Health RCP (Ken Traegde), Federal Express (Scott Mugno, Pat Oppenheimer, and Roy Parker), State of Tennessee (Alan Grewe), Tennessee Division of Radiation Health (Eddy Nanney), AEA Technology QSA, Inc. (Eric Okvist), and Environmental Protection Agency located in Atlanta (Paul Wagner).

During this conference call, representatives of Federal Express reported that they are confident that the shipment of eight Iridium-192 sources left Boston. They issued an 'all-points' search order, faxed a description to all 'logical' locations, and conducted repeat physical searches in Memphis, Boston, and Mexico, all without locating the shipment to date. (The Los Angeles depot was not searched as had been reported on 04/21/99.) Massachusetts and Tennessee health authorities conducted radiological surveys in Boston and Memphis on 04/22/99 with negative results.

Rick Boyle of the Department of Transportation notified the competent authority in Mexico, and Federal Express requested a detailed search of the Customs facilities in Mexico City.

The next conference call is scheduled for 1230 EDT on Wednesday, 04/28/99.

************************* UPDATE AT 1333 ON 04/26/99 FROM TRAEGDE TO TROCINE *************************

At 0619 EDT on 04/26/99, Federal Express confirmed that the serial number on a Model-855, Type-B package found at the Stansted Airport (located outside of London, England) matched the serial number for the missing package containing the eight Iridium-192 sources. The Massachusetts Department of Public Health RCP was informed of this discovery by AEA Technology QSA, Inc., at 0933 EDT on 04/26/99. The package was reported to be intact and undisturbed. The carrier (Federal Express) contacted the shipper (AEA Technology QSA, Inc.), and the shipper requested that the package be forwarded to its intended destination. Accordingly, the package will be shipped from Stansted Airport to Toluca, Mexico, via Memphis, Tennessee. Federal Express informed the Massachusetts Department of Public Health RCP that the package is expected to arrive in Memphis, Tennessee, by tomorrow morning (04/27/99).

The Massachusetts Department of Public Health RCP notified NRC Region 1 (Duncan White). The NRC Operations Officer notified the R1DO (Anderson); R2DO (Wert); R4DO (Graves); NMSS (Combs); IRO (Giitter, Miller, and Congel); RCT (Bailey).

*********************************** UPDATE AT 1600 ON 04/26/99 BY TROCINE ***********************************

A conference call was conducted at 1600 on 04/26/99 to update the status of this event. The following NRC offices participated (*office did not participate): IRO (Giitter), RCT (Bailey), NMSS (Brach and Cool), Region 1 (Kinneman), Region 2 (Hosey), Region 4 (*Graves), Region 1 Public Affairs (*Screnci and *Sheehan), HQ OPA (Beecher), OIP (Lieberman), OSP (Bolling and Lohaus), and EDO (Raddatz). In addition, the following agencies participated: Massachusetts Department of Public Health RCP (Ken Traegde), State of Tennessee (Alan Grewe and Mike Mobley), and Tennessee Division of Radiation Health (Eddy Nanney).

Based upon the information discussed during this conference call (reference the 1333 04/26/99 update above), the NRC exited the Monitoring Phase of Normal Mode at 1615 on 04/26/99.

The NRC operations officer notified the IRO (Giitter, Miller, and Congel); RCT (Bailey); NMSS EO (Cool); NMSS (Brach); Region 1 (Kinneman); Region 2 (Hosey); R1DO (Anderson); R2DO (Wert); R4DO (Graves); OPA (Beecher); OIP (Lieberman); OSP (Bolling and Lohaus); and EDO (Raddatz). The RCT notified the Federal Emergency Management Agency (Butch Steindurf), Department of Energy (Kevin Moore), Department of Agriculture (George Bickerton), Department of Health and Human Services (E.K. Gray), and Environmental Protection Agency and Department of Transportation via the National Response Center (Gauthier).

**** UPDATE AT 1505 ON 04/29/99 FROM DAKUBU TAKEN BY WEAVER ****

Dr. Dakubu of the Massachusetts Department of Public Health Radiation Control Program informed the NRC Operations Center that the sources arrived safely at their intended destination in Mexico on 04/28/98. The NRC Operations Officer informed the R1DO (Cliff Anderson) and NMSS EO (Larry Camper).

**** UPDATE AT 0900 ON 04/30/99 BY JOLLIFFE ****

The sources arrived in Mexico on 04/28/99 (not 04/28/98, as specified above).

**** UPDATE AT 1209 ON 05/07/99 BY TROCINE ****

This event has been updated to correct the notifications made to other agencies.