Event Notification Report for August 24, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/23/2001 - 08/24/2001
EVENT NUMBERS
38231382323823338234
General Information or Other
Event Number: 38231
Rep Org: ROSEMOUNT NUCLEAR INSTRUMENTS INC
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS INC
Region: 3
City: EDEN PRAIRIE State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: CLEVELAND
HQ OPS Officer: CHAUNCEY GOULD
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS INC
Region: 3
City: EDEN PRAIRIE State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: CLEVELAND
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/24/2001
Notification Time: 12:46 [ET]
Event Date: 08/24/2001
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2001
Notification Time: 12:46 [ET]
Event Date: 08/24/2001
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RONALD GARDNER (R3)
BILL JONES (R4)
VERN HODGE (NRR)
RONALD GARDNER (R3)
BILL JONES (R4)
VERN HODGE (NRR)
PART 21 FOR A POTENTIAL NONCONFORMANCE RELATED TO REMOTE DIAPHRAGM SEALS
Pursuant to 10CFR Part 21 Paragraph 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you of a potential nonconformance related to two model 1159 remote diaphragm seals. The two remote diaphragm seals are connected to a single Rosemount nuclear qualified transmitter with serial number 0521038. The two remote diaphragm seals are used to measure differential process pressure or liquid level while preventing the process fluid from contacting the transmitter diaphragm. The remote seals contain discrepant fill fluid screws. The fill fluid screws are part of the pressure boundary of the remote seal system. The nonconformance was due to an oversight during assembly, which has been corrected.
The material specification for the qualified fill screws is 416 SST. The unqualified fill screws are 416 SST with a ball tip that is AISA E52100. The ball tip allows multiple insertions. The qualified screw does not possess the bearing feature.
1.0 Affected customer - Grand Gulf
2.0 Identification of items supplied - Model 1159 Remote Diaphragm Seals
3.0 Identification of firm supplying the Item - Rosemount Nuclear Instruments, Inc.
4.0 Nature of the failure and potential safety hazard:
This notification relates to two Model 1159 Remote Diaphragm Seals, which contain discrepant fill fluid seal screws. These screws are part of the pressure boundary of the remote diaphragm seal system.
This notification is not applicable to other remote diaphragm seal systems.
RNII has determined that there is no safety impact related to plant applications. RNII does not feel Licensees with installed Model 1159 Remote Diaphragm Seals need to address this issue.
5.0 The corrective action which is taken, the name of the individual or organization responsible for that action and the length of time taken to complete that action:
RNII immediately contacted the affected customer, and the nonconforming seals were returned to RNII prior to installation into the customer's facility. The unit will be reworked to conform to the qualification requirements.
RNII internal corrective actions:
1. Revised the non-standard filling procedure for remote seals to ensure that qualified fill screws are installed during the filling process.
2. Training of engineering, manufacturing and quality personnel involved in the preparation, review and approval of non-standard procedures and processes to reemphasize the need to specifically address the material requirements.
6.0 Any advice related to the potential failure of the item:
This notification applies to a single transmitter with two Model 1159C20A Remote Diaphragm Seals. This unit was returned to RNII prior to installation; therefore, does not pose a potential failure.
Pursuant to 10CFR Part 21 Paragraph 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you of a potential nonconformance related to two model 1159 remote diaphragm seals. The two remote diaphragm seals are connected to a single Rosemount nuclear qualified transmitter with serial number 0521038. The two remote diaphragm seals are used to measure differential process pressure or liquid level while preventing the process fluid from contacting the transmitter diaphragm. The remote seals contain discrepant fill fluid screws. The fill fluid screws are part of the pressure boundary of the remote seal system. The nonconformance was due to an oversight during assembly, which has been corrected.
The material specification for the qualified fill screws is 416 SST. The unqualified fill screws are 416 SST with a ball tip that is AISA E52100. The ball tip allows multiple insertions. The qualified screw does not possess the bearing feature.
1.0 Affected customer - Grand Gulf
2.0 Identification of items supplied - Model 1159 Remote Diaphragm Seals
3.0 Identification of firm supplying the Item - Rosemount Nuclear Instruments, Inc.
4.0 Nature of the failure and potential safety hazard:
This notification relates to two Model 1159 Remote Diaphragm Seals, which contain discrepant fill fluid seal screws. These screws are part of the pressure boundary of the remote diaphragm seal system.
This notification is not applicable to other remote diaphragm seal systems.
RNII has determined that there is no safety impact related to plant applications. RNII does not feel Licensees with installed Model 1159 Remote Diaphragm Seals need to address this issue.
5.0 The corrective action which is taken, the name of the individual or organization responsible for that action and the length of time taken to complete that action:
RNII immediately contacted the affected customer, and the nonconforming seals were returned to RNII prior to installation into the customer's facility. The unit will be reworked to conform to the qualification requirements.
RNII internal corrective actions:
1. Revised the non-standard filling procedure for remote seals to ensure that qualified fill screws are installed during the filling process.
2. Training of engineering, manufacturing and quality personnel involved in the preparation, review and approval of non-standard procedures and processes to reemphasize the need to specifically address the material requirements.
6.0 Any advice related to the potential failure of the item:
This notification applies to a single transmitter with two Model 1159C20A Remote Diaphragm Seals. This unit was returned to RNII prior to installation; therefore, does not pose a potential failure.
Hospital
Event Number: 38232
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01728-01
Agreement: N
Docket:
NRC Notified By: PAUL SMITH
HQ OPS Officer: CHAUNCEY GOULD
Licensee: PROVIDENCE HOSPITAL
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01728-01
Agreement: N
Docket:
NRC Notified By: PAUL SMITH
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/24/2001
Notification Time: 15:03 [ET]
Event Date: 08/24/2001
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2001
Notification Time: 15:03 [ET]
Event Date: 08/24/2001
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
JAMES NOGGLE (R1)
SUSAN FRANT (NMSS)
JAMES NOGGLE (R1)
SUSAN FRANT (NMSS)
PROVIDENCE HOSPITAL REPORTED MEDICAL MISADMINISTRATIONS OCCURRING BETWEEN 1996 AND 2000
The hospital reported that during the period from 8/7/96 to 10/18/00 fourteen medical misadministrations of strontium-90 occurred during clinical procedures using a strontium-90 eye applicator. The same ophthalmologist was the operator of the applicator during all fourteen incidences. It appears that there was a misinterpretation of what the affect the shield had on the radiation reaching the eye. There was a supposition that the use of the shield reduced the radiation to the eye by a minimum of 50% and up to 80%. Therefore, the amount of administration time for the procedures was doubled. The amount of radiation given(in the range of 3,000 rads) was well within the therapeutic range for the procedure, but it was not what the physician had written. The amount of rads given was doubled of what was prescribed.
The hospital reported that during the period from 8/7/96 to 10/18/00 fourteen medical misadministrations of strontium-90 occurred during clinical procedures using a strontium-90 eye applicator. The same ophthalmologist was the operator of the applicator during all fourteen incidences. It appears that there was a misinterpretation of what the affect the shield had on the radiation reaching the eye. There was a supposition that the use of the shield reduced the radiation to the eye by a minimum of 50% and up to 80%. Therefore, the amount of administration time for the procedures was doubled. The amount of radiation given(in the range of 3,000 rads) was well within the therapeutic range for the procedure, but it was not what the physician had written. The amount of rads given was doubled of what was prescribed.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 38233
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: FISHER
HQ OPS Officer: CHAUNCEY GOULD
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: FISHER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/24/2001
Notification Time: 17:05 [ET]
Event Date: 08/24/2001
Event Time: 13:05 [PDT]
Last Update Date: 09/17/2001
Notification Time: 17:05 [ET]
Event Date: 08/24/2001
Event Time: 13:05 [PDT]
Last Update Date: 09/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
BILL JONES (R4)
BILL JONES (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
SAFEGUARDS SYSTEM DEGRADATION RELATED TO AREA BOUNDARY
IMMEDIATE COMPENSATORY MEASURES TAKEN UPON TO DISCOVERY
THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED
CONTACT THE HEADQUARTERS OPERATION CENTER FOR ADDITIONAL DETAILS.
* * * RETRACTED AT 1407 EDT ON 9/17/2001 BY MICHAEL FERRY TO FANGIE JONES * * *
The licensee retracted this notification after further review of the event particulars. The licensee notified the NRC Resident Inspector. The R4DO (John Pellet) has been notified.
IMMEDIATE COMPENSATORY MEASURES TAKEN UPON TO DISCOVERY
THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED
CONTACT THE HEADQUARTERS OPERATION CENTER FOR ADDITIONAL DETAILS.
* * * RETRACTED AT 1407 EDT ON 9/17/2001 BY MICHAEL FERRY TO FANGIE JONES * * *
The licensee retracted this notification after further review of the event particulars. The licensee notified the NRC Resident Inspector. The R4DO (John Pellet) has been notified.
Power Reactor
Event Number: 38234
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT DORMAN
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT DORMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/25/2001
Notification Time: 00:34 [ET]
Event Date: 08/24/2001
Event Time: 23:07 [EDT]
Last Update Date: 08/25/2001
Notification Time: 00:34 [ET]
Event Date: 08/24/2001
Event Time: 23:07 [EDT]
Last Update Date: 08/25/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EDWARD MCALPINE (R2)
EDWARD MCALPINE (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
LOSS OF EXCITATION TO THE MAIN GENERATOR RESULTS IN A REACTOR TRIP.
Unit 1 was operating at approximately 100% power. While the main generator rectifier bank # 1 was being placed back in service after repairs when the main generator had a loss of excitation to the generator resulting in a generator trip, turbine trip and reactor trip. All rods fully inserted into the core. An investigation is in progress to determine when excitation was lost when attempting to place main generator rectifier bank # 1 back in service. An Auxiliary Feedwater Actuation Signal was generated on Lo-Lo Steam Generator Water Levels and AMSAC. Both Motor Driven Feedwater Pumps and the Turbine Driven Auxiliary Feedwater Pump started. The plant is currently stable in mode 3 (Hot Standby). An evaluation is in progress to determine what work will be done with the unit shut down and to develop a schedule for returning to power operation.
The NRC Resident Inspector was notified of this event by the licensee.
Unit 1 was operating at approximately 100% power. While the main generator rectifier bank # 1 was being placed back in service after repairs when the main generator had a loss of excitation to the generator resulting in a generator trip, turbine trip and reactor trip. All rods fully inserted into the core. An investigation is in progress to determine when excitation was lost when attempting to place main generator rectifier bank # 1 back in service. An Auxiliary Feedwater Actuation Signal was generated on Lo-Lo Steam Generator Water Levels and AMSAC. Both Motor Driven Feedwater Pumps and the Turbine Driven Auxiliary Feedwater Pump started. The plant is currently stable in mode 3 (Hot Standby). An evaluation is in progress to determine what work will be done with the unit shut down and to develop a schedule for returning to power operation.
The NRC Resident Inspector was notified of this event by the licensee.