Event Notification Report for May 09, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/08/2002 - 05/09/2002
EVENT NUMBERS
38908389093891138912
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 38908
Rep Org: GEORGE WASHINGTON UNIV. HOSPITAL
Licensee: G.W. UNIV. HOSPITAL
Region: 1
City: WASHINGTON DC State: DC
County:
License #: 08-30607-01
Agreement: N
Docket:
NRC Notified By: ANIS CHOWDHURG
HQ OPS Officer: JOHN MacKINNON
Licensee: G.W. UNIV. HOSPITAL
Region: 1
City: WASHINGTON DC State: DC
County:
License #: 08-30607-01
Agreement: N
Docket:
NRC Notified By: ANIS CHOWDHURG
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/09/2002
Notification Time: 16:25 [ET]
Event Date: 05/09/2002
Event Time: 10:30 [EDT]
Last Update Date: 05/17/2002
Notification Time: 16:25 [ET]
Event Date: 05/09/2002
Event Time: 10:30 [EDT]
Last Update Date: 05/17/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
MICHELE EVANS (R1)
DOUG BROADDUS (NMSS)
JOE HOLONICH (IRO)
MICHELE EVANS (R1)
DOUG BROADDUS (NMSS)
JOE HOLONICH (IRO)
PRELIMINARY ESTIMATED EXPOSURE OF 63 ROENTGEN TO THE HANDS OF A MEDICAL PHYSICIST
While using a Cordis delivery system to insert a ribbon containing Ir-192 seeds into a patient, the ribbon came out into the hands of the Medical Physicist. The screw and cap of the Cordis delivery system had been loosened and the ribbon containing the Ir-192 seeds was supposed to be pushed into patient via a catheter but somehow the ribbon containing the Ir-192 seeds ended up in the hand of the Medical Physicist. George Washington Hospital Radiation Safety Officer preliminarily estimated the minimum exposure to the Medical Physicist hand was 63 roentgens. The Medical Physicist walked 5 or 6 feet into another room where the Radiation Oncologist was located and dropped the ribbon to the floor. The Radiation Oncologist, wearing gloves, picked the ribbon up and placed it in a safe location. The Radiation Safety Officer for George Washington Hospital said that the Radiation Oncologist received a dose to his hand while carrying the ribbon. An estimated dose calculation to Radiation Oncologist hands, etc., had not been made at the time of the notification.
****UPDATE ON 5/17/02 at 11:15 FROM A. CHOWDHURY TO R. LAURA****
Further licensee investigation revealed that an actual overexposure did not occur. The initial calculations of this event were too conservative. NRC Region 1 inspectors made a site visit to review this event.
Notified R1DO (D. Holody) and NMSS (D. Cool).
While using a Cordis delivery system to insert a ribbon containing Ir-192 seeds into a patient, the ribbon came out into the hands of the Medical Physicist. The screw and cap of the Cordis delivery system had been loosened and the ribbon containing the Ir-192 seeds was supposed to be pushed into patient via a catheter but somehow the ribbon containing the Ir-192 seeds ended up in the hand of the Medical Physicist. George Washington Hospital Radiation Safety Officer preliminarily estimated the minimum exposure to the Medical Physicist hand was 63 roentgens. The Medical Physicist walked 5 or 6 feet into another room where the Radiation Oncologist was located and dropped the ribbon to the floor. The Radiation Oncologist, wearing gloves, picked the ribbon up and placed it in a safe location. The Radiation Safety Officer for George Washington Hospital said that the Radiation Oncologist received a dose to his hand while carrying the ribbon. An estimated dose calculation to Radiation Oncologist hands, etc., had not been made at the time of the notification.
****UPDATE ON 5/17/02 at 11:15 FROM A. CHOWDHURY TO R. LAURA****
Further licensee investigation revealed that an actual overexposure did not occur. The initial calculations of this event were too conservative. NRC Region 1 inspectors made a site visit to review this event.
Notified R1DO (D. Holody) and NMSS (D. Cool).
General Information or Other
Event Number: 38909
Rep Org: ROCKWELL AUTOMATION
Licensee: ROCKWELL AUTOMATION
Region: 2
City: FLOWERY BRANCH State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES THIGPEN
HQ OPS Officer: RICH LAURA
Licensee: ROCKWELL AUTOMATION
Region: 2
City: FLOWERY BRANCH State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES THIGPEN
HQ OPS Officer: RICH LAURA
Notification Date: 05/09/2002
Notification Time: 16:30 [ET]
Event Date: 05/09/2002
Event Time: 00:00 [EDT]
Last Update Date: 05/17/2002
Notification Time: 16:30 [ET]
Event Date: 05/09/2002
Event Time: 00:00 [EDT]
Last Update Date: 05/17/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
VERN HODGE (NRR)
VERN HODGE (NRR)
PART 21 ISSUE ON ELECTRIC MOTORS
Rockwell Automations report a potential defect involving insufficient slot fill in electric motor windings used to drive fan assemblies. They have contacted Hayden Company located in New Philadelphia, Ohio who was supplied with these motors. The motors may be in use at commercial nuclear power plants.
***UPDATE Curt Pratt to Mike Norris 5/16/02 13:59 EDT***
This update listed the Licensees that have these motors: Davis Besse, Oconee and Braidwood.
Notified NRR (Hodges) , Reg 2 RDO(Fredrickson) and Reg 3 RDO(Gardner).
****UPDATE J. Thigpen to R. Laura on 5/17/02 at 13:19 by fax*****
The licensee identified 1 additional motor and the customer was the same as the others.
Notified NRR (Hodges)
Rockwell Automations report a potential defect involving insufficient slot fill in electric motor windings used to drive fan assemblies. They have contacted Hayden Company located in New Philadelphia, Ohio who was supplied with these motors. The motors may be in use at commercial nuclear power plants.
***UPDATE Curt Pratt to Mike Norris 5/16/02 13:59 EDT***
This update listed the Licensees that have these motors: Davis Besse, Oconee and Braidwood.
Notified NRR (Hodges) , Reg 2 RDO(Fredrickson) and Reg 3 RDO(Gardner).
****UPDATE J. Thigpen to R. Laura on 5/17/02 at 13:19 by fax*****
The licensee identified 1 additional motor and the customer was the same as the others.
Notified NRR (Hodges)
Power Reactor
Event Number: 38911
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JESSE COLVIN
HQ OPS Officer: RICH LAURA
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JESSE COLVIN
HQ OPS Officer: RICH LAURA
Notification Date: 05/09/2002
Notification Time: 21:02 [ET]
Event Date: 05/09/2002
Event Time: 17:50 [CDT]
Last Update Date: 05/09/2002
Notification Time: 21:02 [ET]
Event Date: 05/09/2002
Event Time: 17:50 [CDT]
Last Update Date: 05/09/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANTON VEGEL (R3)
ANTON VEGEL (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 96 | Power Operation | 96 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF CONTROL ROOM HVAC AT DRESDEN
"At 1750 hours on May 9, 2002 the B Control Room HVAC Refrigeration and Condensing Unit (RCU) would not stay running during surveillance testing. The B RCU is a single train system and therefore is reportable per SAF 1.8 & LS-AA-1400, Event Reporting Guidelines Section 3.2.7. The B RCU is required to operate during a design basis accident to remove the heat from the Main Control Room. The Air Filtration Unit (AFU) of CREVS remains operable. This places both units in a 30 day LCORA per Tech Spec 3.7.5. Required Action A. 1."
Train "A" is not fully qualified but is available to maintain proper control room temperatures.
The NRC Resident Inspector was notified.
"At 1750 hours on May 9, 2002 the B Control Room HVAC Refrigeration and Condensing Unit (RCU) would not stay running during surveillance testing. The B RCU is a single train system and therefore is reportable per SAF 1.8 & LS-AA-1400, Event Reporting Guidelines Section 3.2.7. The B RCU is required to operate during a design basis accident to remove the heat from the Main Control Room. The Air Filtration Unit (AFU) of CREVS remains operable. This places both units in a 30 day LCORA per Tech Spec 3.7.5. Required Action A. 1."
Train "A" is not fully qualified but is available to maintain proper control room temperatures.
The NRC Resident Inspector was notified.
Power Reactor
Event Number: 38912
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RONALD WILLIAMS
HQ OPS Officer: RICH LAURA
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: RONALD WILLIAMS
HQ OPS Officer: RICH LAURA
Notification Date: 05/10/2002
Notification Time: 14:20 [ET]
Event Date: 05/09/2002
Event Time: 14:30 [CDT]
Last Update Date: 05/10/2002
Notification Time: 14:20 [ET]
Event Date: 05/09/2002
Event Time: 14:30 [CDT]
Last Update Date: 05/10/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK SHAFFER (R4)
MARK SHAFFER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
LICENSE CONDITION VIOLATION OF THERMAL POWER AT WATERFORD 3
"During initial installation of the LEFM Check-Plus ultrasonic feedwater flow measuring system installed as part of the Appendix K Power Uprate Project at Waterford 3, it was noted that the three available reactor core calorimetric thermal power indications calculated by the Core Operating Limits Supervisory System (COLSS) were not in agreement. This disagreement was noted on 4/20/02. These thermal power indications consist of: Main Steam venturi Secondary Calorimetric (MSBSCAL), Feedwater Flow venturi Secondary Calorimetric (FWBSCAL) and the Calorimetric indication generated by the newly installed LEEM Check-Plus ultrasonic flow measuring system (USBSCAL). The LEFM Check-Plus ultrasonic flow measuring system was certified for use on May 9, 2002.
"Preliminary information indicates the mismatch in indication is likely the result of biases factored into the MSBSCAL indication as well as possible degradation of the secondary side of the plant over time since August 1997. These biases, based on the most accurate USBSCAL indication, are approximately 0.22% power beyond the accepted power measurement uncertainty of 1.68% power for the MSBSCAL. indication. Thus, Waterford 3 may have operated at average power levels in excess of the 100% licensed power limit since approximately August 1997.
"Waterford 3 is currently in Mode 1 at 99.9% power using FWBSCAL, the most conservative indication of reactor power. This report is being made per Waterford 3 License Condition 2.F for potential violation of License Condition 2.C.1, "Maximum Power Level." The investigation for this condition is ongoing".
The NRC resident inspector was notified.
"During initial installation of the LEFM Check-Plus ultrasonic feedwater flow measuring system installed as part of the Appendix K Power Uprate Project at Waterford 3, it was noted that the three available reactor core calorimetric thermal power indications calculated by the Core Operating Limits Supervisory System (COLSS) were not in agreement. This disagreement was noted on 4/20/02. These thermal power indications consist of: Main Steam venturi Secondary Calorimetric (MSBSCAL), Feedwater Flow venturi Secondary Calorimetric (FWBSCAL) and the Calorimetric indication generated by the newly installed LEEM Check-Plus ultrasonic flow measuring system (USBSCAL). The LEFM Check-Plus ultrasonic flow measuring system was certified for use on May 9, 2002.
"Preliminary information indicates the mismatch in indication is likely the result of biases factored into the MSBSCAL indication as well as possible degradation of the secondary side of the plant over time since August 1997. These biases, based on the most accurate USBSCAL indication, are approximately 0.22% power beyond the accepted power measurement uncertainty of 1.68% power for the MSBSCAL. indication. Thus, Waterford 3 may have operated at average power levels in excess of the 100% licensed power limit since approximately August 1997.
"Waterford 3 is currently in Mode 1 at 99.9% power using FWBSCAL, the most conservative indication of reactor power. This report is being made per Waterford 3 License Condition 2.F for potential violation of License Condition 2.C.1, "Maximum Power Level." The investigation for this condition is ongoing".
The NRC resident inspector was notified.