Event Notification Report for September 08, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/07/1999 - 09/08/1999
EVENT NUMBERS
3614236139361543613436135361363613736138
General Information or Other
Event Number: 36142
Rep Org: KANSAS DEPT OF HEALTH
Licensee: UNIVERSITY OF KANSAS MEDICAL CENTER
Region: 4
City: KANSAS CITY State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RONALD FRASS (FAX)
HQ OPS Officer: WILLIAM POERTNER
Licensee: UNIVERSITY OF KANSAS MEDICAL CENTER
Region: 4
City: KANSAS CITY State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RONALD FRASS (FAX)
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 09/09/1999
Notification Time: 17:33 [ET]
Event Date: 09/08/1999
Event Time: 11:45 [CDT]
Last Update Date: 09/09/1999
Notification Time: 17:33 [ET]
Event Date: 09/08/1999
Event Time: 11:45 [CDT]
Last Update Date: 09/09/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
JOSIE PICCONE (NMSS)
GARY SANBORN (R4)
JOSIE PICCONE (NMSS)
POTENTIAL MEDICAL MISADMINISTRATION.
A patient was administered 5.4 millicuries of Indium-111. The patient was supposed to receive a dose of Chromium-51 for a blood volume test. The preliminary investigation indicates a dose of 14 rads (cGy) to the spleen and less than 5 rads whole body. The University of Kansas Medical Center (KUMC) RSO was not available when the potential misadministration occurred, and informed the Kansas Department Of Health And Environment (KDHE) upon her return to the office. The KDHE and KUMC investigations have commenced. At this time, KUMC has no further information regarding this event.
A patient was administered 5.4 millicuries of Indium-111. The patient was supposed to receive a dose of Chromium-51 for a blood volume test. The preliminary investigation indicates a dose of 14 rads (cGy) to the spleen and less than 5 rads whole body. The University of Kansas Medical Center (KUMC) RSO was not available when the potential misadministration occurred, and informed the Kansas Department Of Health And Environment (KDHE) upon her return to the office. The KDHE and KUMC investigations have commenced. At this time, KUMC has no further information regarding this event.
Power Reactor
Event Number: 36139
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: ANDRE DALL'AU
HQ OPS Officer: STEVE SANDIN
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: ANDRE DALL'AU
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/08/1999
Notification Time: 23:12 [ET]
Event Date: 09/08/1999
Event Time: 22:30 [EDT]
Last Update Date: 09/09/1999
Notification Time: 23:12 [ET]
Event Date: 09/08/1999
Event Time: 22:30 [EDT]
Last Update Date: 09/09/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(v) - OTHER ASMT/COMM INOP
10 CFR Section:
50.72(b)(1)(v) - OTHER ASMT/COMM INOP
Person (Organization):
ROBERT HAAG (R2)
ROBERT HAAG (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 4 | N | Y | 100 | Power Operation | 100 | Power Operation |
BOTH UNITS EXPERIENCED A TEMPORARY LOSS OF THE EMERGENCY RESPONSE DATA SYSTEM.
"DISCOVERED @ 2230 ERDADS AND ERDS STOPPED UPDATING DATA @ 2200. ERDS CALLED OUT OF SERVICE AND TROUBLESHOOTING UNDERWAY TO DETERMINE CAUSE. UNKNOWN AT THIS TIME IF FAILURE ASSOCIATED WITH Y2K. SYSTEM STARTED UPDATING DUE TO TROUBLESHOOTING ACTIVITIES @ 2305."
THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR.
* * * UPDATE 0313 9/9/1999 FROM DALL'AU TAKEN BY STRANSKY * * *
"ERDS and ERDADS powered and declared functional at 2330 9/8/99. All troubleshooting and testing complete with ERDS and ERDADS declared back in service at 0250 9/9/99. Intermittent disk failures of the primary computer, not any Y2K related failures, were determined to be the cause of the loss of data."
The NRC resident inspector will be informed of this update. Notified R2DO (Haag).
"DISCOVERED @ 2230 ERDADS AND ERDS STOPPED UPDATING DATA @ 2200. ERDS CALLED OUT OF SERVICE AND TROUBLESHOOTING UNDERWAY TO DETERMINE CAUSE. UNKNOWN AT THIS TIME IF FAILURE ASSOCIATED WITH Y2K. SYSTEM STARTED UPDATING DUE TO TROUBLESHOOTING ACTIVITIES @ 2305."
THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR.
* * * UPDATE 0313 9/9/1999 FROM DALL'AU TAKEN BY STRANSKY * * *
"ERDS and ERDADS powered and declared functional at 2330 9/8/99. All troubleshooting and testing complete with ERDS and ERDADS declared back in service at 0250 9/9/99. Intermittent disk failures of the primary computer, not any Y2K related failures, were determined to be the cause of the loss of data."
The NRC resident inspector will be informed of this update. Notified R2DO (Haag).
Other Nuclear Material
Event Number: 36154
Rep Org: TACOM - ROCK ISLAND
Licensee: TACOM - ROCK ISLAND
Region: 4
City: Barstow State: CA
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: TIM MOHS
HQ OPS Officer: JOHN MacKINNON
Licensee: TACOM - ROCK ISLAND
Region: 4
City: Barstow State: CA
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: TIM MOHS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/13/1999
Notification Time: 16:49 [ET]
Event Date: 09/08/1999
Event Time: 20:00 [PDT]
Last Update Date: 09/13/1999
Notification Time: 16:49 [ET]
Event Date: 09/08/1999
Event Time: 20:00 [PDT]
Last Update Date: 09/13/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(4)(ii) - DAMAGED LNM/CONTAINER
10 CFR Section:
30.50(b)(4)(ii) - DAMAGED LNM/CONTAINER
Person (Organization):
JOHN PELLET (R4)
GARY SHEAR (R3)
WAYNE HODGES (NMSS)
JOHN PELLET (R4)
GARY SHEAR (R3)
WAYNE HODGES (NMSS)
FIRE CONTROL DEVICES USED FOR AIMING A 198 HOWITZER WERE DAMAGED CAUSING A RELEASE OF TRITIUM AND CONTAMINATION OF THE FIRE CONTROL DEVICES.
On September 8, 1999 at approximately 2000 PDT a 198 Howitzer was damaged. Some of the fire control devices used for aiming the Howitzer were damaged. It is estimated that between 3 to 4 curies of tritium were released from the damaged fire control devices. A survey was performed on the damaged fire control devices and surface contamination on the damaged fire control devices from tritium was a couple of million disintegrations per minute. Ten Marines from camp Pendleton who cleaned up the contamination were bioassayed after the cleanup. The bioassay results on these individuals are still pending. The contaminated fire control devices are now located at the US Marine Corp Logistic Base located outside of Barstow, California. The Howitzer was damaged on Interstate 15 just outside of Barstow, California.
On September 8, 1999 at approximately 2000 PDT a 198 Howitzer was damaged. Some of the fire control devices used for aiming the Howitzer were damaged. It is estimated that between 3 to 4 curies of tritium were released from the damaged fire control devices. A survey was performed on the damaged fire control devices and surface contamination on the damaged fire control devices from tritium was a couple of million disintegrations per minute. Ten Marines from camp Pendleton who cleaned up the contamination were bioassayed after the cleanup. The bioassay results on these individuals are still pending. The contaminated fire control devices are now located at the US Marine Corp Logistic Base located outside of Barstow, California. The Howitzer was damaged on Interstate 15 just outside of Barstow, California.
Power Reactor
Event Number: 36134
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM GOLDEN
HQ OPS Officer: BOB STRANSKY
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM GOLDEN
HQ OPS Officer: BOB STRANSKY
Notification Date: 09/08/1999
Notification Time: 10:27 [ET]
Event Date: 09/08/1999
Event Time: 06:10 [CDT]
Last Update Date: 09/08/1999
Notification Time: 10:27 [ET]
Event Date: 09/08/1999
Event Time: 06:10 [CDT]
Last Update Date: 09/08/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT HAAG (R2)
ROBERT HAAG (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HPCI SYSTEM DECLARED INOPERABLE
The high pressure coolant injection (HPCI) system was declared inoperable after a unit operator observed that the HPCI system flow controller, located on the control panel, had failed downscale. The licensee has begun troubleshooting activities to determine the nature of the controller failure. The NRC resident inspector has been informed of this event by the licensee.
The high pressure coolant injection (HPCI) system was declared inoperable after a unit operator observed that the HPCI system flow controller, located on the control panel, had failed downscale. The licensee has begun troubleshooting activities to determine the nature of the controller failure. The NRC resident inspector has been informed of this event by the licensee.
Other Nuclear Material
Event Number: 36135
Rep Org: METOREX
Licensee: METOREX
Region: 1
City: EWING State: NJ
County:
License #: 29-30342-01
Agreement: N
Docket:
NRC Notified By: JOHN PATTERSON
HQ OPS Officer: BOB STRANSKY
Licensee: METOREX
Region: 1
City: EWING State: NJ
County:
License #: 29-30342-01
Agreement: N
Docket:
NRC Notified By: JOHN PATTERSON
HQ OPS Officer: BOB STRANSKY
Notification Date: 09/08/1999
Notification Time: 11:10 [ET]
Event Date: 09/08/1999
Event Time: 00:00 [EDT]
Last Update Date: 09/13/1999
Notification Time: 11:10 [ET]
Event Date: 09/08/1999
Event Time: 00:00 [EDT]
Last Update Date: 09/13/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
TOM MOSLAK (R1)
JOSIE PICCONE (NMSS)
TOM MOSLAK (R1)
JOSIE PICCONE (NMSS)
PACKAGE CONTAINING RADIOACTIVE SOURCES LOST DURING SHIPMENT
Mr. Patterson of Metorex contacted the NRC Headquarters Operations Center to report that a package containing a device with two radioactive sources (60 mCi of Cm-244 and 30 mCi of Am-241) has been lost during shipment by Federal Express. The package left Metorex on 8/3/99, but failed to arrive at Envirosafe Services of Oregon, OH as of 8/26/99. The package was last scanned by Federal Express on 8/16/99 in Northwood, OH. The licensee has been in contact with the RSO for Federal Express (Dr. Roy Parker) regarding this shipment.
* * * UPDATE AT 1006 EDT ON 9/13/99 BY JOHN PATTERSON TO FANGIE JONES * * *
The missing package has been located by Federal Express and will be delivered to Envirosafe Services. Region 1 (Pam Henderson) has been notified by Metorex. The NRC operations officer notified R1DO (Niel Della Greca) and NMSS EO (Wayne Hodges).
Mr. Patterson of Metorex contacted the NRC Headquarters Operations Center to report that a package containing a device with two radioactive sources (60 mCi of Cm-244 and 30 mCi of Am-241) has been lost during shipment by Federal Express. The package left Metorex on 8/3/99, but failed to arrive at Envirosafe Services of Oregon, OH as of 8/26/99. The package was last scanned by Federal Express on 8/16/99 in Northwood, OH. The licensee has been in contact with the RSO for Federal Express (Dr. Roy Parker) regarding this shipment.
* * * UPDATE AT 1006 EDT ON 9/13/99 BY JOHN PATTERSON TO FANGIE JONES * * *
The missing package has been located by Federal Express and will be delivered to Envirosafe Services. Region 1 (Pam Henderson) has been notified by Metorex. The NRC operations officer notified R1DO (Niel Della Greca) and NMSS EO (Wayne Hodges).
Hospital
Event Number: 36136
Rep Org: McLAREN REGIONAL MEDICAL CENTER
Licensee: McLAREN REGIONAL MEDICAL CENTER
Region: 3
City: FLINT State: MI
County:
License #: 21-04171-04
Agreement: N
Docket:
NRC Notified By: DOUGLAS SOUTHWELL
HQ OPS Officer: FANGIE JONES
Licensee: McLAREN REGIONAL MEDICAL CENTER
Region: 3
City: FLINT State: MI
County:
License #: 21-04171-04
Agreement: N
Docket:
NRC Notified By: DOUGLAS SOUTHWELL
HQ OPS Officer: FANGIE JONES
Notification Date: 09/08/1999
Notification Time: 11:47 [ET]
Event Date: 09/08/1999
Event Time: 08:00 [EDT]
Last Update Date: 09/08/1999
Notification Time: 11:47 [ET]
Event Date: 09/08/1999
Event Time: 08:00 [EDT]
Last Update Date: 09/08/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MONTE PHILLIPS (R3)
JOSIE PICCONE (NMSS)
JOSEPH GIITTER (IRO)
MONTE PHILLIPS (R3)
JOSIE PICCONE (NMSS)
JOSEPH GIITTER (IRO)
HOSPITAL RECEIVED PACKAGE THAT EXCEEDED REGULATORY LIMITS
During the receipt inspection of a package, containing Technetium-99m Myoview, it was determined that a surface survey reading was greater than the limit of a White 1 tag, the reading was 1.1 mR/hr. A wipe reading had a maximum of 23.75 dpm. The hospital contacted the source pharmacy (Mallinckrodt of Saginaw, MI) who asked them to open the package for inspection. The hospital opened the package and performed a wipe test of the contents and the inside of the container. The results were negative with a maximum wipe of 62.5 dpm. A surface survey determined that one of the pigs had a surface reading of 2 mR/hr, the pharmacy asked the hospital to mark it so that it could be discarded when it is returned. They believe that the pig has developed a crack which makes it unusable. The dose of Technetium-99m Myoview was not damaged.
The hospital has notified NRC Region 3 DNMS (Debra Piskura).
During the receipt inspection of a package, containing Technetium-99m Myoview, it was determined that a surface survey reading was greater than the limit of a White 1 tag, the reading was 1.1 mR/hr. A wipe reading had a maximum of 23.75 dpm. The hospital contacted the source pharmacy (Mallinckrodt of Saginaw, MI) who asked them to open the package for inspection. The hospital opened the package and performed a wipe test of the contents and the inside of the container. The results were negative with a maximum wipe of 62.5 dpm. A surface survey determined that one of the pigs had a surface reading of 2 mR/hr, the pharmacy asked the hospital to mark it so that it could be discarded when it is returned. They believe that the pig has developed a crack which makes it unusable. The dose of Technetium-99m Myoview was not damaged.
The hospital has notified NRC Region 3 DNMS (Debra Piskura).
Power Reactor
Event Number: 36137
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: LAVATO
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: LAVATO
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/08/1999
Notification Time: 14:52 [ET]
Event Date: 09/08/1999
Event Time: 13:05 [EDT]
Last Update Date: 09/08/1999
Notification Time: 14:52 [ET]
Event Date: 09/08/1999
Event Time: 13:05 [EDT]
Last Update Date: 09/08/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(vi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(vi) - OFFSITE NOTIFICATION
Person (Organization):
TOM MOSLAK (R1)
TOM MOSLAK (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 |
THE LICENSEE NOTIFIED THE MARYLAND DEPARTMENT OF THE ENVIRONMENT THAT THEY HAD EXCEEDED THEIR NATIONAL POLLUTION DISCHARGE ELIMINATION SYSTEM (NPDES) PERMIT LIMITS
THEY DISCOVERED THAT TOTAL SUSPENDED SOLIDS IN A COMPOSITE SAMPLE OF EFFLUENT FROM THE SEWAGE TREATMENT PLANT WAS 68 MG/LITER, WHICH EXCEEDS THE NPDES PERMIT DAILY MAXIMUM VALUE OF 45 MG/LITER. THE STATE WAS BEING NOTIFIED BY THE CHEMISTRY DEPARTMENT.
THE RESIDENT INSPECTOR WAS NOTIFIED.
THEY DISCOVERED THAT TOTAL SUSPENDED SOLIDS IN A COMPOSITE SAMPLE OF EFFLUENT FROM THE SEWAGE TREATMENT PLANT WAS 68 MG/LITER, WHICH EXCEEDS THE NPDES PERMIT DAILY MAXIMUM VALUE OF 45 MG/LITER. THE STATE WAS BEING NOTIFIED BY THE CHEMISTRY DEPARTMENT.
THE RESIDENT INSPECTOR WAS NOTIFIED.
Power Reactor
Event Number: 36138
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JONES
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JONES
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/08/1999
Notification Time: 15:42 [ET]
Event Date: 09/08/1999
Event Time: 14:05 [EDT]
Last Update Date: 09/08/1999
Notification Time: 15:42 [ET]
Event Date: 09/08/1999
Event Time: 14:05 [EDT]
Last Update Date: 09/08/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(ii) - DEGRAD COND DURING OP
10 CFR Section:
50.72(b)(1)(ii) - DEGRAD COND DURING OP
Person (Organization):
TOM MOSLAK (R1)
ELINOR ADENSAM (NRR)
JOSEPH GIITTER (IRO)
TOM MOSLAK (R1)
ELINOR ADENSAM (NRR)
JOSEPH GIITTER (IRO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 80 | Power Operation | 80 | Power Operation |
THE PLANT HAD REACTOR COOLANT LEAKAGE >25 GPM.
IN PREPARATION FOR RESIN SLUICING OPERATIONS ON THE "12" MIXED BED DEMINERLIZER, THE DEMINERLIZER WAS ISOLATED AND TAGGED. WHILE THE DEMINERLIZER WAS BEING DRAINED, IT WAS IDENTIFIED THAT THE ISOLATION VALVE WAS LEAKING BY FOR TWO MINUTES AT A REACTOR COOLANT SYSTEM LEAKRATE OF APPROXIMATELY 80 GPM. UPON IDENTIFICATION, THE LEAK WAS IMMEDIATELY ISOLATED. TOTAL DISCHARGE WAS APPROXIMATELY 200 GALLONS TO THE PLANT'S RADIOACTIVE WASTE SYSTEM. THE PLANT VENT RADIATION MONITOR "1R16" WAS IN ALARM AND HAS SINCE CLEARED THE ALARM SETPOINT. AT 1445 IT WAS IDENTIFIED THAT THIS DISCHARGE EXCEEDED THE UNUSUAL EVENT CRITERIA OF 25 GPM FOR IDENTIFIED LEAKAGE AND THE MAXIMUM PLANT VENT RELEASE RATE WAS APPROXIMATELY 835 MICROCURIES/SEC. PLANT CONDITIONS ARE STABLE AND AN INVESTIGATION IS ONGOING. THERE IS NO RELEASE AT THIS TIME AND THE APPROXIMATE RELEASE RATE WAS ABOUT 1% OF LIMITS.
THE RESIDENT INSPECTOR WAS NOTIFIED
IN PREPARATION FOR RESIN SLUICING OPERATIONS ON THE "12" MIXED BED DEMINERLIZER, THE DEMINERLIZER WAS ISOLATED AND TAGGED. WHILE THE DEMINERLIZER WAS BEING DRAINED, IT WAS IDENTIFIED THAT THE ISOLATION VALVE WAS LEAKING BY FOR TWO MINUTES AT A REACTOR COOLANT SYSTEM LEAKRATE OF APPROXIMATELY 80 GPM. UPON IDENTIFICATION, THE LEAK WAS IMMEDIATELY ISOLATED. TOTAL DISCHARGE WAS APPROXIMATELY 200 GALLONS TO THE PLANT'S RADIOACTIVE WASTE SYSTEM. THE PLANT VENT RADIATION MONITOR "1R16" WAS IN ALARM AND HAS SINCE CLEARED THE ALARM SETPOINT. AT 1445 IT WAS IDENTIFIED THAT THIS DISCHARGE EXCEEDED THE UNUSUAL EVENT CRITERIA OF 25 GPM FOR IDENTIFIED LEAKAGE AND THE MAXIMUM PLANT VENT RELEASE RATE WAS APPROXIMATELY 835 MICROCURIES/SEC. PLANT CONDITIONS ARE STABLE AND AN INVESTIGATION IS ONGOING. THERE IS NO RELEASE AT THIS TIME AND THE APPROXIMATE RELEASE RATE WAS ABOUT 1% OF LIMITS.
THE RESIDENT INSPECTOR WAS NOTIFIED