Event Notification Report for October 04, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/03/2001 - 10/04/2001
EVENT NUMBERS
38358383553834838349383503835138346
General Information or Other
Event Number: 38358
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: AMEC EARTH & ENVIRONMENT
Region: 4
City: UNIVERSITY PLACE State: WA
County:
License #: WN-1093-1
Agreement: Y
Docket:
NRC Notified By: TERRY FRAZEE
HQ OPS Officer: FANGIE JONES
Licensee: AMEC EARTH & ENVIRONMENT
Region: 4
City: UNIVERSITY PLACE State: WA
County:
License #: WN-1093-1
Agreement: Y
Docket:
NRC Notified By: TERRY FRAZEE
HQ OPS Officer: FANGIE JONES
Notification Date: 10/05/2001
Notification Time: 17:31 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/05/2001
Notification Time: 17:31 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/05/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
JOHN DAVIDSON (IAT)
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
JOHN DAVIDSON (IAT)
AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following is the faxed report:
City and state: Spokane, WA
License number: WN-l093-1
Type of license: Portable Gauge
Date of event: October 4, 2001
Location of Event: University Place, WA
ABSTRACT: A Troxler portable gauge was stolen from a pick-up parked at a residence. An authorized user was returning home late from a job site and knowing he had to go back early the next morning requested permission from the licensee's Radiation Safety Officer to take the gauge home and secure it there. The authorized user's home was closer than the licensee's storage location. Permission was given and the gauge, a Troxler model 3440, serial number 31199, was locked and chained in the bed of the pick-up. The pick-up, which did not have a canopy, was parked in the residence's drive way on the evening of October 4. The authorized user discovered early the next morning that the chain had been cut and the gauge stolen. Neighbors reported hearing noises about 11:45 PM that night. The theft was reported to the local police, the licensee's corporate RSO and to the Department. A reward is being offered for the gauge which contains 10 millicuries of cesium 137 and 50 millicuries of americium 241/beryllium.
What is the notification or reporting criteria involved? WAC 246-221-240 (Reports of stolen, lost or missing radiation sources.)
The following is the faxed report:
City and state: Spokane, WA
License number: WN-l093-1
Type of license: Portable Gauge
Date of event: October 4, 2001
Location of Event: University Place, WA
ABSTRACT: A Troxler portable gauge was stolen from a pick-up parked at a residence. An authorized user was returning home late from a job site and knowing he had to go back early the next morning requested permission from the licensee's Radiation Safety Officer to take the gauge home and secure it there. The authorized user's home was closer than the licensee's storage location. Permission was given and the gauge, a Troxler model 3440, serial number 31199, was locked and chained in the bed of the pick-up. The pick-up, which did not have a canopy, was parked in the residence's drive way on the evening of October 4. The authorized user discovered early the next morning that the chain had been cut and the gauge stolen. Neighbors reported hearing noises about 11:45 PM that night. The theft was reported to the local police, the licensee's corporate RSO and to the Department. A reward is being offered for the gauge which contains 10 millicuries of cesium 137 and 50 millicuries of americium 241/beryllium.
What is the notification or reporting criteria involved? WAC 246-221-240 (Reports of stolen, lost or missing radiation sources.)
Hospital
Event Number: 38355
Rep Org: AVERA McKENNAN HOSPITAL
Licensee: AVERA McKENNAN HOSPITAL
Region: 4
City: FREEMAN State: SD
County:
License #:
Agreement: N
Docket:
NRC Notified By: MARK EWING
HQ OPS Officer: FANGIE JONES
Licensee: AVERA McKENNAN HOSPITAL
Region: 4
City: FREEMAN State: SD
County:
License #:
Agreement: N
Docket:
NRC Notified By: MARK EWING
HQ OPS Officer: FANGIE JONES
Notification Date: 10/05/2001
Notification Time: 16:50 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2001
Notification Time: 16:50 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
SPILL OF TECHNETIUM IN PUBLIC AREA
The mobile lab of Avera McKennan Hospital was on site at the Freeman Hospital, Freeman, S.D. when a cracked vial containing 250 mCi of Technetium leaked on to the floor of the kitchen. The area was secured and the only exposure/contamination was the shoes of the medical technician transporting the vial. A containment area was established and gross cleanup was completed on 10/4/01. The area was checked again this morning and further evaluation will be taken tomorrow, 10/6/01, after 8:00 PM, which will be greater than ten half-lives.
NRC Region 4 (Bob Brown) has been notified by the hospital chief technician.
The mobile lab of Avera McKennan Hospital was on site at the Freeman Hospital, Freeman, S.D. when a cracked vial containing 250 mCi of Technetium leaked on to the floor of the kitchen. The area was secured and the only exposure/contamination was the shoes of the medical technician transporting the vial. A containment area was established and gross cleanup was completed on 10/4/01. The area was checked again this morning and further evaluation will be taken tomorrow, 10/6/01, after 8:00 PM, which will be greater than ten half-lives.
NRC Region 4 (Bob Brown) has been notified by the hospital chief technician.
Power Reactor
Event Number: 38348
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] B&W-L-LP
NRC Notified By: RICKY RAWLS
HQ OPS Officer: FANGIE JONES
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] B&W-L-LP
NRC Notified By: RICKY RAWLS
HQ OPS Officer: FANGIE JONES
Notification Date: 10/04/2001
Notification Time: 15:59 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2001
Notification Time: 15:59 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CHARLES CASTO (R2DO)
CHARLES CASTO (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
SMALL PRESSURE BOUNDARY LEAK IDENTIFIED WHILE SHUTDOWN
"At 0809 on October 4, 2001, Crystal River Unit 3 (CR-3) was in MODE 6 shutdown for refueling operation. CR-3 has identified a small defect in the reactor coolant system (RCS) pressure boundary. An RCS leak was suspected due to elevated radioactivity levels detected in the nuclear services closed cycle cooling water (SW) system since June 2001. Testing was conducted on-line in MODE 1 and could not determine the source of the leakage. Additional testing in MODE 6 has identified the seal area heat exchanger on the 1B reactor coolant pump (RCP-1B) as the most likely source of the leakage. The defect allowed a small amount of leakage to occur from the RCS to the SW system during the previous operating cycle. A definitive leak location could not be identified due to the extremely small size of the leak. However, since all components in the RCP heat exchanger are included as part of the class 1 RCS pressure boundary, this defect is reportable under 10 CFR 50.72(b)(3)(ii)(A). CR-3 was shutdown in MODE 6 at the time of the discovery. The RCP heat exchanger will be repaired prior to returning to power operation."
The leak rate has been determined to be 0.02 gpm which exceeds the Technical Specification limit of 'No Pressure Boundary Leakage' and it appears to be a long term development.
The licensee notified the NRC Resident Inspector.
"At 0809 on October 4, 2001, Crystal River Unit 3 (CR-3) was in MODE 6 shutdown for refueling operation. CR-3 has identified a small defect in the reactor coolant system (RCS) pressure boundary. An RCS leak was suspected due to elevated radioactivity levels detected in the nuclear services closed cycle cooling water (SW) system since June 2001. Testing was conducted on-line in MODE 1 and could not determine the source of the leakage. Additional testing in MODE 6 has identified the seal area heat exchanger on the 1B reactor coolant pump (RCP-1B) as the most likely source of the leakage. The defect allowed a small amount of leakage to occur from the RCS to the SW system during the previous operating cycle. A definitive leak location could not be identified due to the extremely small size of the leak. However, since all components in the RCP heat exchanger are included as part of the class 1 RCS pressure boundary, this defect is reportable under 10 CFR 50.72(b)(3)(ii)(A). CR-3 was shutdown in MODE 6 at the time of the discovery. The RCP heat exchanger will be repaired prior to returning to power operation."
The leak rate has been determined to be 0.02 gpm which exceeds the Technical Specification limit of 'No Pressure Boundary Leakage' and it appears to be a long term development.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 38349
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DANNY WILLIAMSON
HQ OPS Officer: FANGIE JONES
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DANNY WILLIAMSON
HQ OPS Officer: FANGIE JONES
Notification Date: 10/04/2001
Notification Time: 16:10 [ET]
Event Date: 10/04/2001
Event Time: 09:13 [CDT]
Last Update Date: 10/04/2001
Notification Time: 16:10 [ET]
Event Date: 10/04/2001
Event Time: 09:13 [CDT]
Last Update Date: 10/04/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CLAUDE JOHNSON (R4)
CLAUDE JOHNSON (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
OPERATING LICENSE CONDITION VIOLATION (POTENTIAL MAXIMUM POWER LEVEL VIOLATION)
"This report is being made as required by River Bend Station license condition 2.E. River Bend is reporting a potential violation of the maximum power level as authorized in license condition 2.C.1.
"This event is similar to event numbers 38337 and 38340 reported by two other BWR plants Based on the General Electric (GE) report titled, 'Impact of Steam Generator Carryover Fraction on Process Computer Heat Balance Calculations, September 2001.' It is possible that River Bend may have exceeded the maximum power level on some occasions in the past by approximately three megawatts thermal.
"River Bend Station is currently in a refueling outage, so no immediate actions are necessary. This condition has been entered into the station's corrective action program to further evaluate the applicability of this condition and to develop an appropriate response before returning to power operations.
"The licensee notified the NRC resident inspector."
(Refer to event numbers 38330, 38337, 38340, 38344, 38445, 38347, 38356, and 38357 for similar events at Fermi, Perry, Hope Creek, Grand Gulf, Columbia Generating Station, Limerick 2, Clinton, and Limerick 1.)
"This report is being made as required by River Bend Station license condition 2.E. River Bend is reporting a potential violation of the maximum power level as authorized in license condition 2.C.1.
"This event is similar to event numbers 38337 and 38340 reported by two other BWR plants Based on the General Electric (GE) report titled, 'Impact of Steam Generator Carryover Fraction on Process Computer Heat Balance Calculations, September 2001.' It is possible that River Bend may have exceeded the maximum power level on some occasions in the past by approximately three megawatts thermal.
"River Bend Station is currently in a refueling outage, so no immediate actions are necessary. This condition has been entered into the station's corrective action program to further evaluate the applicability of this condition and to develop an appropriate response before returning to power operations.
"The licensee notified the NRC resident inspector."
(Refer to event numbers 38330, 38337, 38340, 38344, 38445, 38347, 38356, and 38357 for similar events at Fermi, Perry, Hope Creek, Grand Gulf, Columbia Generating Station, Limerick 2, Clinton, and Limerick 1.)
Hospital
Event Number: 38350
Rep Org: RAPID CITY REGIONAL HOSPITAL
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY State: SD
County:
License #:
Agreement: N
Docket:
NRC Notified By: ERIC HENDEE
HQ OPS Officer: FANGIE JONES
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY State: SD
County:
License #:
Agreement: N
Docket:
NRC Notified By: ERIC HENDEE
HQ OPS Officer: FANGIE JONES
Notification Date: 10/04/2001
Notification Time: 16:58 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2001
Notification Time: 16:58 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
MEDICAL MISADMINISTRATION - UNDERDOSE
Today, 10/4/01, when the dose for a second treatment was being prepared, it was discovered that the first dose was not as large as prescribed. The first dose administered on 9/27/01 should have been 750 centigray and was only 400 to 500 centigray. The attending physician has been notified and the patient will be notified. A correcting dose, an additional fraction, will be given to correct the underdose. No adverse affects are expected by this misadministration.
The dosage is administered with a high dose rate machine, Nucletron Microselectron.
The Radiation Safety Officer contacted NRC Region 4 (Richard Leonardi).
Today, 10/4/01, when the dose for a second treatment was being prepared, it was discovered that the first dose was not as large as prescribed. The first dose administered on 9/27/01 should have been 750 centigray and was only 400 to 500 centigray. The attending physician has been notified and the patient will be notified. A correcting dose, an additional fraction, will be given to correct the underdose. No adverse affects are expected by this misadministration.
The dosage is administered with a high dose rate machine, Nucletron Microselectron.
The Radiation Safety Officer contacted NRC Region 4 (Richard Leonardi).
Other Nuclear Material
Event Number: 38351
Rep Org: US AIR FORCE
Licensee: US AIR FORCE
Region: 4
City: CANNON AFB State: NM
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: CRAIG REFOSCO
HQ OPS Officer: FANGIE JONES
Licensee: US AIR FORCE
Region: 4
City: CANNON AFB State: NM
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: CRAIG REFOSCO
HQ OPS Officer: FANGIE JONES
Notification Date: 10/04/2001
Notification Time: 18:09 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2001
Notification Time: 18:09 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2001
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):
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
CLAUDE JOHNSON (R4)
PATRICIA HOLAHAN (NMSS)
REPORT OF 2 MISSING EXIT SIGNS CONTAINING TRITIUM AT CANNON AFB
Two exit signs containing 20 curies of tritium each were discovered missing from building 1258 at Cannon Air Force Base, New Mexico. The signs were in place on 9/26/01 during a previous inspection. The signs are manufactured by SRB Technologies and the serial numbers are 192167 and 192168. There will be a formal investigation conducted.
Two exit signs containing 20 curies of tritium each were discovered missing from building 1258 at Cannon Air Force Base, New Mexico. The signs were in place on 9/26/01 during a previous inspection. The signs are manufactured by SRB Technologies and the serial numbers are 192167 and 192168. There will be a formal investigation conducted.
General Information or Other
Event Number: 38346
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0196-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: FANGIE JONES
Licensee: LAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0196-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: FANGIE JONES
Notification Date: 10/04/2001
Notification Time: 14:11 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/04/2001
Notification Time: 14:11 [ET]
Event Date: 10/04/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/04/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CLAUDE JOHNSON (R4)
FRED BROWN (NMSS)
CLAUDE JOHNSON (R4)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT - DAMAGED GAUGE
1. Event Report ID No.: NV-01-006
2. License No.: 00-11-0196-01
3. Licensee: Las Valley Water District
4. Event time, date, location: Las Vegas, NV, October 1, 2001
5. Event type (e.g. misadministration, lost source, overexposure, etc.): Slightly damaged portable gauge. Cause of the incident was lack of attention to detail.
6. Any notifications i.e. other agencies, patient, press release, FBI, etc.: N/A
7. Event description: release, isotope, activity, exposure(s), dose, contamination level, equipment malfunction model, serial No., etc.: A portable gauge fell off the bed of a slow moving transporting pickup and was slightly damaged. The gauge was not carried in it's shipping container at the time of the incident, The source was in the safe, shielded position at the time of the incident. The gauge has been surveyed and leak tested and has been shipped to the manufacturer for repair. The gauge was a Troxler Model 3440, s/n 22284 containing 10 mCi of Cs-137 and 40 mCi of Am-241 :Be.
8. Transport vehicle description, if known: Company pickup.
1. Event Report ID No.: NV-01-006
2. License No.: 00-11-0196-01
3. Licensee: Las Valley Water District
4. Event time, date, location: Las Vegas, NV, October 1, 2001
5. Event type (e.g. misadministration, lost source, overexposure, etc.): Slightly damaged portable gauge. Cause of the incident was lack of attention to detail.
6. Any notifications i.e. other agencies, patient, press release, FBI, etc.: N/A
7. Event description: release, isotope, activity, exposure(s), dose, contamination level, equipment malfunction model, serial No., etc.: A portable gauge fell off the bed of a slow moving transporting pickup and was slightly damaged. The gauge was not carried in it's shipping container at the time of the incident, The source was in the safe, shielded position at the time of the incident. The gauge has been surveyed and leak tested and has been shipped to the manufacturer for repair. The gauge was a Troxler Model 3440, s/n 22284 containing 10 mCi of Cs-137 and 40 mCi of Am-241 :Be.
8. Transport vehicle description, if known: Company pickup.