Event Notification Report for October 11, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/10/2001 - 10/11/2001
EVENT NUMBERS
38384383823838038388
Hospital
Event Number: 38384
Rep Org: PARK VIEW HOSPITAL
Licensee: PARK VIEW HOSPITAL
Region: 3
City: Ft. WAYNE State: IN
County:
License #: 13-01284-02
Agreement: N
Docket:
NRC Notified By: AGNEW
HQ OPS Officer: CHAUNCEY GOULD
Licensee: PARK VIEW HOSPITAL
Region: 3
City: Ft. WAYNE State: IN
County:
License #: 13-01284-02
Agreement: N
Docket:
NRC Notified By: AGNEW
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/12/2001
Notification Time: 17:37 [ET]
Event Date: 10/11/2001
Event Time: 16:45 [CST]
Last Update Date: 10/12/2001
Notification Time: 17:37 [ET]
Event Date: 10/11/2001
Event Time: 16:45 [CST]
Last Update Date: 10/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
MICHAEL PARKER (R3)
MICHAEL PARKER (R3)
PARK VIEW HOSPITAL REPORTED A MEDICAL MISADMINISTRATION
During an intravascular bracytherapy treatment with strontium-90 to a heart artery, a possible medical misadministration occurred at the completion of the treatment. At the conclusion of this treatment, not all the sources returned to the Novoste applicator. The sources were seen to have left the vessel and heart within the appropriate time(5 sec), but they did not all return to the device. Another attempt to remove the sources was made, but was unsuccessful, so the entire treatment catheter was removed(within 18 secs) from the patient as per their emergency procedures. The physician and manufacturer of the device did not consider this as a medical misadministration, however an NRC inspector felt that it was for that additional 18 secs to remove the treatment catheter. This incident occurred 8/27/01. It was decided not to notify the patient because of the patient's condition.
During an intravascular bracytherapy treatment with strontium-90 to a heart artery, a possible medical misadministration occurred at the completion of the treatment. At the conclusion of this treatment, not all the sources returned to the Novoste applicator. The sources were seen to have left the vessel and heart within the appropriate time(5 sec), but they did not all return to the device. Another attempt to remove the sources was made, but was unsuccessful, so the entire treatment catheter was removed(within 18 secs) from the patient as per their emergency procedures. The physician and manufacturer of the device did not consider this as a medical misadministration, however an NRC inspector felt that it was for that additional 18 secs to remove the treatment catheter. This incident occurred 8/27/01. It was decided not to notify the patient because of the patient's condition.
Fuel Cycle Facility
Event Number: 38382
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: WALKER
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: WALKER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/12/2001
Notification Time: 15:32 [ET]
Event Date: 10/11/2001
Event Time: 14:44 [CDT]
Last Update Date: 10/12/2001
Notification Time: 15:32 [ET]
Event Date: 10/11/2001
Event Time: 14:44 [CDT]
Last Update Date: 10/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL PARKER (R3)
JOHN HICKEY (NMSS)
MICHAEL PARKER (R3)
JOHN HICKEY (NMSS)
24 HOUR 91-01 BULLETIN RESPONSE
Four waste drums were discovered to be incorrectly characterized based on incorrect laboratory analysis results. The incorrect analysis resulted from failure to follow a step in the procedure and violated the single point failure prevention arguments for sample characterization in NCSA 1493-33. The purpose of preventing a single point failure is to maintain double contingency for the case in which independent sample results are used to characterize and classify waste drums as "NCS Spacing Exempt."
The samples were later re-analyzed for both assay and U-235 content. The re-analysis results demonstrated that three of the four drums in question are in fact non-fissile and have been handled conservatively. The remaining drum is greater than 1%, but the U-235 mass is less than the limit for spacing exemption.
NUCLEAR CRITICALITY SAFETY CONTROLS INVOLVED AND THEIR IMPACT ON DOUBLE CONTINGENCY
Double contingency is maintained by implementing controls to ensure the samples are analyzed correctly, without common mode failures.
The first leg of double contingency is based on correctly analyzing the sample for U-235 loading. Since the procedure was violated the analysis result should not have been relied upon for NCS purposes. The control was violated. Since there are two controls on one parameter, double contingency was not maintained.
The second leg of double contingency is based on independently analyzing the sample correctly for U-235 loading. Since the procedure was violated the independent analysis result should not have been relied upon for NCS purposes. The control was violated. Since there are two controls on one parameter, double contingency was not maintained.
Since double contingency is based on two controls on one parameter, double contingency was not maintained.
Potential Critical Pathways:
In order for a criticality to be possible, the mass in multiple waste drums would each have to be greater than the safe mass determined for that container size and these waste drums would have to be stored together or re-containerized into unfavorable geometry drums.
Safety Significance:
Double contingency for characterizing and storing "NCS Spacing Exempt" waste are based on determination of U-235 mass in the drum. Both of these controls were lost. However, based on re-analysis results the drums are in fact non-fissile or spacing exempt.
EXCLUSION ZONE AND POSTiNG:
Control the area around the drum and post as follows according to CP2-EG-N51031;
Do not move fissile/potentially fissile material into or within this area without NCS and PSS approval.
NCS-INC-01 -025
CORRECTIVE ACTIONS:
1. Re-characterize the drum according to CP4-EW-WM2100 based upon the re-analysis results.
2. Remove the ropes and postings
The NRC Resident Inspector was informed and the DOE Representative will be notified.
Four waste drums were discovered to be incorrectly characterized based on incorrect laboratory analysis results. The incorrect analysis resulted from failure to follow a step in the procedure and violated the single point failure prevention arguments for sample characterization in NCSA 1493-33. The purpose of preventing a single point failure is to maintain double contingency for the case in which independent sample results are used to characterize and classify waste drums as "NCS Spacing Exempt."
The samples were later re-analyzed for both assay and U-235 content. The re-analysis results demonstrated that three of the four drums in question are in fact non-fissile and have been handled conservatively. The remaining drum is greater than 1%, but the U-235 mass is less than the limit for spacing exemption.
NUCLEAR CRITICALITY SAFETY CONTROLS INVOLVED AND THEIR IMPACT ON DOUBLE CONTINGENCY
Double contingency is maintained by implementing controls to ensure the samples are analyzed correctly, without common mode failures.
The first leg of double contingency is based on correctly analyzing the sample for U-235 loading. Since the procedure was violated the analysis result should not have been relied upon for NCS purposes. The control was violated. Since there are two controls on one parameter, double contingency was not maintained.
The second leg of double contingency is based on independently analyzing the sample correctly for U-235 loading. Since the procedure was violated the independent analysis result should not have been relied upon for NCS purposes. The control was violated. Since there are two controls on one parameter, double contingency was not maintained.
Since double contingency is based on two controls on one parameter, double contingency was not maintained.
Potential Critical Pathways:
In order for a criticality to be possible, the mass in multiple waste drums would each have to be greater than the safe mass determined for that container size and these waste drums would have to be stored together or re-containerized into unfavorable geometry drums.
Safety Significance:
Double contingency for characterizing and storing "NCS Spacing Exempt" waste are based on determination of U-235 mass in the drum. Both of these controls were lost. However, based on re-analysis results the drums are in fact non-fissile or spacing exempt.
EXCLUSION ZONE AND POSTiNG:
Control the area around the drum and post as follows according to CP2-EG-N51031;
Do not move fissile/potentially fissile material into or within this area without NCS and PSS approval.
NCS-INC-01 -025
CORRECTIVE ACTIONS:
1. Re-characterize the drum according to CP4-EW-WM2100 based upon the re-analysis results.
2. Remove the ropes and postings
The NRC Resident Inspector was informed and the DOE Representative will be notified.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 38380
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GROFF
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GROFF
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/11/2001
Notification Time: 17:56 [ET]
Event Date: 10/11/2001
Event Time: 14:20 [EDT]
Last Update Date: 10/26/2001
Notification Time: 17:56 [ET]
Event Date: 10/11/2001
Event Time: 14:20 [EDT]
Last Update Date: 10/26/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL PARKER (R3)
MICHAEL PARKER (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONDITION OF LICENSE REPORT DUE TO UNAVAILABLE EMERGENCY LIGHTING
On October 11, 2001, following a fire protection program self assessment, it was determined that emergency lighting was unavailable in two required locations. Actions in these areas are required steps of procedure 20.000.18 "Control of Plant from Dedicated Shutdown Panel."
The inability to perform steps in 20.000.18 constitutes a reportable condition under Fermi 2 License Condition 2.F as a violation of "Modifications for Fire Protection" as described in License Condition 2.C(9).
Short term corrective action is to revise the procedure steps to obtain portable lighting prior to exiting the plant. Long term corrective actions are being evaluated.
The NRC Resident Inspector was notified.
* * * RETRACTION ON 10/26/01 AT 1315 ET REPORTED BY KEVIN DAHM TAKEN BY MACKINNON * * *
Upon further evaluation, it has been determined that License Condition 2.C (9) was not violated. The steps in question in the CTG 11-1 Control Building and in the EDG-11 Switchgear Room can be completed successfully with the current lighting configuration; and therefore, there is no adverse affect on the ability to achieve and maintain safe shutdown. License Condition 2.C (9) is thus met, and this condition is not reportable under License Condition 2.F. The original notification, Event Number 38380, is retracted. R3DO (Brent Clayton) notified.
The NRC Resident Inspector was notified of this retraction by the licensee.
On October 11, 2001, following a fire protection program self assessment, it was determined that emergency lighting was unavailable in two required locations. Actions in these areas are required steps of procedure 20.000.18 "Control of Plant from Dedicated Shutdown Panel."
The inability to perform steps in 20.000.18 constitutes a reportable condition under Fermi 2 License Condition 2.F as a violation of "Modifications for Fire Protection" as described in License Condition 2.C(9).
Short term corrective action is to revise the procedure steps to obtain portable lighting prior to exiting the plant. Long term corrective actions are being evaluated.
The NRC Resident Inspector was notified.
* * * RETRACTION ON 10/26/01 AT 1315 ET REPORTED BY KEVIN DAHM TAKEN BY MACKINNON * * *
Upon further evaluation, it has been determined that License Condition 2.C (9) was not violated. The steps in question in the CTG 11-1 Control Building and in the EDG-11 Switchgear Room can be completed successfully with the current lighting configuration; and therefore, there is no adverse affect on the ability to achieve and maintain safe shutdown. License Condition 2.C (9) is thus met, and this condition is not reportable under License Condition 2.F. The original notification, Event Number 38380, is retracted. R3DO (Brent Clayton) notified.
The NRC Resident Inspector was notified of this retraction by the licensee.
General Information or Other
Event Number: 38388
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KRAZAN and ASSOCIATES
Region: 4
City: CLOVIS State: CA
County:
License #: 4247-01
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: FANGIE JONES
Licensee: KRAZAN and ASSOCIATES
Region: 4
City: CLOVIS State: CA
County:
License #: 4247-01
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: FANGIE JONES
Notification Date: 10/15/2001
Notification Time: 13:02 [ET]
Event Date: 10/11/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/15/2001
Notification Time: 13:02 [ET]
Event Date: 10/11/2001
Event Time: 00:00 [PDT]
Last Update Date: 10/15/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILL JONES (R4)
BRIAN SMITH (NMSS)
BILL JONES (R4)
BRIAN SMITH (NMSS)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
"Thursday, 10/11/01 a Krazan and Associates employee, after working late took his portable moisture density gauge to his residence on Floyd Road in Modesto, California. The gauge was reportedly locked and chained to the rear of his pickup truck , but was not covered. The gauge chain was reportedly cut and the gauge was stolen sometime between 9:00 PM and 6:00 AM on October 12, 2001 by unknown persons. The gauge was a Troxler 3440 Serial Number 231711 containing approximately 10 millicuries of cesium 137 and 40 millicuries of americium 241. The RSO indicated he will be placing an ad in the local newspaper offering a reward for the gauge. The RSO indicated that he has counseled his employee for breaking company rules by taking the gauge to his residence which is against company policy and California regulations."
"Thursday, 10/11/01 a Krazan and Associates employee, after working late took his portable moisture density gauge to his residence on Floyd Road in Modesto, California. The gauge was reportedly locked and chained to the rear of his pickup truck , but was not covered. The gauge chain was reportedly cut and the gauge was stolen sometime between 9:00 PM and 6:00 AM on October 12, 2001 by unknown persons. The gauge was a Troxler 3440 Serial Number 231711 containing approximately 10 millicuries of cesium 137 and 40 millicuries of americium 241. The RSO indicated he will be placing an ad in the local newspaper offering a reward for the gauge. The RSO indicated that he has counseled his employee for breaking company rules by taking the gauge to his residence which is against company policy and California regulations."