Event Notification Report for May 05, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/04/2003 - 05/05/2003
EVENT NUMBERS
3983039824398253982639868
Fuel Cycle Facility
Event Number: 39830
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: VANDERPOOL
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: VANDERPOOL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/06/2003
Notification Time: 15:46 [ET]
Event Date: 05/05/2003
Event Time: 19:05 [EDT]
Last Update Date: 05/06/2003
Notification Time: 15:46 [ET]
Event Date: 05/05/2003
Event Time: 19:05 [EDT]
Last Update Date: 05/06/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROGER LANKSBURY (R3)
TOM ESSIG (NMSS)
ROGER LANKSBURY (R3)
TOM ESSIG (NMSS)
AUTOCLAVE "O" RING FAILURE
On 5/5/03 at approximately 1905 hours, X-344 Operations Personnel identified visible/audible steam out leakage on Autoclave #2. Autoclave #2 was operating in Operational Mode 2 (heating) at the time of discovery. The out leakage was determined to be due to a failure of the "Q" Safety System Component "O"-Ring which seals the cylinder within the autoclave. The Autoclave Steam Supply was immediately valved off and the autoclave was opened for inspection. This inspection identified a 9/16" gap in the "O"-Ring Seal which would have degraded the seal to the point that it could not perform its designed safety function as required during Operational Mode 2 Evolutions. This incident is being reported as a Safety Equipment Failure while operating in an Applicable Mode. Immediate Radiation / Air Monitoring indicates no release of Radioactive Material occurred as a result of this incident. The Autoclave was declared inoperable by the Plant Shift Superintendent.
The NRC Resident Inspector was notified.
On 5/5/03 at approximately 1905 hours, X-344 Operations Personnel identified visible/audible steam out leakage on Autoclave #2. Autoclave #2 was operating in Operational Mode 2 (heating) at the time of discovery. The out leakage was determined to be due to a failure of the "Q" Safety System Component "O"-Ring which seals the cylinder within the autoclave. The Autoclave Steam Supply was immediately valved off and the autoclave was opened for inspection. This inspection identified a 9/16" gap in the "O"-Ring Seal which would have degraded the seal to the point that it could not perform its designed safety function as required during Operational Mode 2 Evolutions. This incident is being reported as a Safety Equipment Failure while operating in an Applicable Mode. Immediate Radiation / Air Monitoring indicates no release of Radioactive Material occurred as a result of this incident. The Autoclave was declared inoperable by the Plant Shift Superintendent.
The NRC Resident Inspector was notified.
General Information or Other
Event Number: 39824
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: STERIS-ISOMEDIX SERVICES
Region: 2
City: SPARTENBURG State: SC
County:
License #: 267
Agreement: Y
Docket:
NRC Notified By: DAVID KING
HQ OPS Officer: CHAUNCEY GOULD
Licensee: STERIS-ISOMEDIX SERVICES
Region: 2
City: SPARTENBURG State: SC
County:
License #: 267
Agreement: Y
Docket:
NRC Notified By: DAVID KING
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/05/2003
Notification Time: 16:25 [ET]
Event Date: 05/05/2003
Event Time: 11:30 [EDT]
Last Update Date: 05/05/2003
Notification Time: 16:25 [ET]
Event Date: 05/05/2003
Event Time: 11:30 [EDT]
Last Update Date: 05/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOEL MUNDAY (R2)
TOM ESSIG (NMSS)
JOEL MUNDAY (R2)
TOM ESSIG (NMSS)
MALFUNCTIONING IRRADIATOR CARRIER DOOR HINGE PIN ASSEMBLY
Steris-Isomedix Services reported to the state that they had an incident where the hinge pin assembly on the carrier door of an irradiator malfunctioned. This resulted in the door opening and jamming at the source rack which in turn left the source in a fully unshielded position. The operator then went to the hoist cables for the source rack, which is in a shielded area, moved the cables around a bit and unjammed the source rack returning the source to the fully shielded position. The amount of time taken to return the source to the fully shielded position was approximately 20-30 minutes. The licensee is shutting down all irradiators to check the hinge pin assemblies. There were no exposures.
Steris-Isomedix Services reported to the state that they had an incident where the hinge pin assembly on the carrier door of an irradiator malfunctioned. This resulted in the door opening and jamming at the source rack which in turn left the source in a fully unshielded position. The operator then went to the hoist cables for the source rack, which is in a shielded area, moved the cables around a bit and unjammed the source rack returning the source to the fully shielded position. The amount of time taken to return the source to the fully shielded position was approximately 20-30 minutes. The licensee is shutting down all irradiators to check the hinge pin assemblies. There were no exposures.
Power Reactor
Event Number: 39825
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: HALLIDAY
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: HALLIDAY
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/05/2003
Notification Time: 17:44 [ET]
Event Date: 05/05/2003
Event Time: 14:45 [EDT]
Last Update Date: 05/05/2003
Notification Time: 17:44 [ET]
Event Date: 05/05/2003
Event Time: 14:45 [EDT]
Last Update Date: 05/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE COBEY (R1)
EUGENE COBEY (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 |
OFF SITE NOTIFICATION DUE TO LOSS OF 35 POUNDS OF FREON R-22.
The licensee discovered that approximately 35 lbs of freon R-22 was missing from a plant refrigeration system. The State of New York requires the licensee to notify the National Response Center, New York State Department of Environmental Conservation and Oswego County Emergency Management Office of R-22 leaks to air >1 lb in any 24 hour period. The system currently tested tight, however an investigation is showing there was probably an acute release >1 lb during recent maintenance activities.
The licensee notified the NRC Resident Inspector, the State, local agencies and other Government Agencies.
The licensee discovered that approximately 35 lbs of freon R-22 was missing from a plant refrigeration system. The State of New York requires the licensee to notify the National Response Center, New York State Department of Environmental Conservation and Oswego County Emergency Management Office of R-22 leaks to air >1 lb in any 24 hour period. The system currently tested tight, however an investigation is showing there was probably an acute release >1 lb during recent maintenance activities.
The licensee notified the NRC Resident Inspector, the State, local agencies and other Government Agencies.
Power Reactor
Event Number: 39826
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: HARRISON
HQ OPS Officer: CHAUNCEY GOULD
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: HARRISON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/05/2003
Notification Time: 23:48 [ET]
Event Date: 05/05/2003
Event Time: 20:41 [EDT]
Last Update Date: 05/05/2003
Notification Time: 23:48 [ET]
Event Date: 05/05/2003
Event Time: 20:41 [EDT]
Last Update Date: 05/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOEL MUNDAY (R2)
JOEL MUNDAY (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 |
LOST ERDS DUE TO COMPUTER MALFUNCTION
"Loss of ERDS communication Link from 20:41 [EDT] until 22:26 [EDT] 5/5/03. Computer displayed hard disk error. Rebooted machine; error corrected. Re-established ERDS Link."
The NRC Resident Inspector will be notified by the licensee.
"Loss of ERDS communication Link from 20:41 [EDT] until 22:26 [EDT] 5/5/03. Computer displayed hard disk error. Rebooted machine; error corrected. Re-established ERDS Link."
The NRC Resident Inspector will be notified by the licensee.
General Information or Other
Event Number: 39868
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA UNIVERSITY MEDICAL CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-21035-01
Agreement: Y
Docket:
NRC Notified By: PAM BISHOP
HQ OPS Officer: MIKE RIPLEY
Licensee: OKLAHOMA UNIVERSITY MEDICAL CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-21035-01
Agreement: Y
Docket:
NRC Notified By: PAM BISHOP
HQ OPS Officer: MIKE RIPLEY
Notification Date: 05/20/2003
Notification Time: 19:13 [ET]
Event Date: 05/05/2003
Event Time: 00:00 [CDT]
Last Update Date: 05/20/2003
Notification Time: 19:13 [ET]
Event Date: 05/05/2003
Event Time: 00:00 [CDT]
Last Update Date: 05/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TROY PRUETT (R4)
JOHN HICKEY (NMSS)
TROY PRUETT (R4)
JOHN HICKEY (NMSS)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The licensee reported a medical misadministration involving High Dose Rate brachytherapy MammoSite treatment to a 70-year old female. Upon administering the first of ten planned fractions it was noticed that the Ir-192 source did not reach the center of the balloon but was near the periphery 30 millimeters from the center. The patient dose was reassessed and it was determined that the dose to the target area was less than planned (56% of the planned dose). The patient and the patient's physician were notified. It has been determined that there were no adverse effects to the patient. Corrective actions will address four factors contributing to the misadministration: wrong orientation of the patient during a CT scan; delays in issuing the treatment plan due to a computer network failure; mis-communications regarding the specified treatment plan; and similarities between CT-based and radiographic-based printouts.
The licensee reported a medical misadministration involving High Dose Rate brachytherapy MammoSite treatment to a 70-year old female. Upon administering the first of ten planned fractions it was noticed that the Ir-192 source did not reach the center of the balloon but was near the periphery 30 millimeters from the center. The patient dose was reassessed and it was determined that the dose to the target area was less than planned (56% of the planned dose). The patient and the patient's physician were notified. It has been determined that there were no adverse effects to the patient. Corrective actions will address four factors contributing to the misadministration: wrong orientation of the patient during a CT scan; delays in issuing the treatment plan due to a computer network failure; mis-communications regarding the specified treatment plan; and similarities between CT-based and radiographic-based printouts.