Event Notification Report for May 12, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/11/2003 - 05/12/2003
EVENT NUMBERS
4277439841398423984339838
General Information or Other
Event Number: 42774
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM & WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Licensee: BRIGHAM & WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 08/15/2006
Notification Time: 13:24 [ET]
Event Date: 05/12/2003
Event Time: 00:00 [EDT]
Last Update Date: 08/15/2006
Notification Time: 13:24 [ET]
Event Date: 05/12/2003
Event Time: 00:00 [EDT]
Last Update Date: 08/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)
RAYMOND LORSON (R1)
CINDY FLANNERY (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information regarding a previously unreported event via facsimile:
"The Agency [MA Radiation Control Program] received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again.
"Corrective action
1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery.
2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means.
3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device."
The State provided the following information regarding a previously unreported event via facsimile:
"The Agency [MA Radiation Control Program] received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again.
"Corrective action
1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery.
2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means.
3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device."
Hospital
Event Number: 39841
Rep Org: TRIPLER ARMY MEDICAL CENTER
Licensee: TRIPLER ARMY MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-00458-04
Agreement: N
Docket:
NRC Notified By: MAJ. ARTHUR MORTON, USA
HQ OPS Officer: HOWIE CROUCH
Licensee: TRIPLER ARMY MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-00458-04
Agreement: N
Docket:
NRC Notified By: MAJ. ARTHUR MORTON, USA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/12/2003
Notification Time: 17:32 [ET]
Event Date: 05/12/2003
Event Time: 11:00 [HST]
Last Update Date: 05/12/2003
Notification Time: 17:32 [ET]
Event Date: 05/12/2003
Event Time: 11:00 [HST]
Last Update Date: 05/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
LINDA SMITH (R4)
SONIA BURGESS (R3)
MELVYN LEACH (NMSS)
MATT HAHN (IAT)
LINDA SMITH (R4)
SONIA BURGESS (R3)
MELVYN LEACH (NMSS)
MATT HAHN (IAT)
NUCLEAR MATERIAL MISSING DURING SHIPMENT
The following information was received from the licensee via facsimile:
"An order for 150 milli-curies (mCi) of iodine-131 was placed with Mallinckrodt on May 9, 2003. The package was received by the Nuclear Pharmacist,[DELETED], on May 12, 2003 and indicated that the package had 154.10 mCi of iodine-131 but was measured to contain only 54.0 mCi of iodine-131.
"At 11:00 [HST] the Nuclear Pharmacist paged me and I immediately went to the Nuclear Pharmacy laboratory. I verified that the dose calibrator was set on I-131and inquired about the package receipt procedures. The Nuclear Pharmacist indicated that the package was in excellent condition with no sign of physical damage. The package was received in a timely manner, metered and swiped without incident. The package contained two vials supposedly containing 140.00 mCi and 14.10 mCi of iodine-131 for a total of 154.10 mCi. The contents of the package appeared to be intact. The Nuclear Pharmacist combined the two vials and assayed the dose in the dose calibrator for an iodine ablation therapy but measured only 54.0 mCi of I-131.
"At 11:20 I notified Mallinckrodt of the discrepancy, and then at 11:30 I notified the NRC Operations Center to report the missing licensed material in accordance with 10 CFR Part 20.2201(a)(1)(i). I will also contact the shipper, MMS Courier, and the Army Medical Command as well as any local or state notifications that are required."
The following information was received from the licensee via facsimile:
"An order for 150 milli-curies (mCi) of iodine-131 was placed with Mallinckrodt on May 9, 2003. The package was received by the Nuclear Pharmacist,[DELETED], on May 12, 2003 and indicated that the package had 154.10 mCi of iodine-131 but was measured to contain only 54.0 mCi of iodine-131.
"At 11:00 [HST] the Nuclear Pharmacist paged me and I immediately went to the Nuclear Pharmacy laboratory. I verified that the dose calibrator was set on I-131and inquired about the package receipt procedures. The Nuclear Pharmacist indicated that the package was in excellent condition with no sign of physical damage. The package was received in a timely manner, metered and swiped without incident. The package contained two vials supposedly containing 140.00 mCi and 14.10 mCi of iodine-131 for a total of 154.10 mCi. The contents of the package appeared to be intact. The Nuclear Pharmacist combined the two vials and assayed the dose in the dose calibrator for an iodine ablation therapy but measured only 54.0 mCi of I-131.
"At 11:20 I notified Mallinckrodt of the discrepancy, and then at 11:30 I notified the NRC Operations Center to report the missing licensed material in accordance with 10 CFR Part 20.2201(a)(1)(i). I will also contact the shipper, MMS Courier, and the Army Medical Command as well as any local or state notifications that are required."
Fuel Cycle Facility
Event Number: 39842
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: THOMAS WHITE
HQ OPS Officer: HOWIE CROUCH
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: THOMAS WHITE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/12/2003
Notification Time: 23:08 [ET]
Event Date: 05/12/2003
Event Time: 09:00 [CDT]
Last Update Date: 05/12/2003
Notification Time: 23:08 [ET]
Event Date: 05/12/2003
Event Time: 09:00 [CDT]
Last Update Date: 05/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SONIA BURGESS (R3)
MELVYN LEACH (NMSS)
SONIA BURGESS (R3)
MELVYN LEACH (NMSS)
LOSS OF ONE OF TWO CONTROLS ON MODERATION
NRC BULLETIN 91-01 24 HOUR NOTIFICATION
The following information was received from the licensee via facsimile:
"At 0900 on 5/12/03, the Plant Shift Superintendent (PSS) was notified that differential pressure transmitter inputs for three Freezer/Sublimers, U/2(Unit # 2) C/B (Cell B), U3 C/B and U/4 C/B located in C-337, were installed incorrectly. The transmitter (PDT-338) measures the differential pressure between the R-114 (freon) and the Recirculating Cooling Water (RCW). NCSA CAS-001 requires that the pressure differential between the R-114 and RCW pressures be such that the R-114 pressure is at least 2.0 psia above the RCW pressure. This would preclude the introduction of a moderator (RCW) into the process side of the system. The correct configuration of these inputs has the pressure tap on the inlet line to the condenser/reboiler. For Freezer/Sublimers U/2 C/B, U/3 C/B and U/4 C/B the pressure tap is located on the outlet line from the condenser/reboiler. As installed, the low differential pressure-alarm may not come in until after the R-114 pressure and RCW pressure at the inlet of the Condenser/Reboiler have exceeded the NCS limit. At 1040 on 5/12/03, the PSS was notified by Nuclear Criticality Safety that one of the two controls on moderation had been lost.
The System Engineer identified four additional Freezer/Sublimers, two in C-331 and two in C-335, with the same problem. These Freezer/Sublimer units were out-of-service and the RCW had been drained prior to the walk-down. ,
SAFETY SIGNIFICANCS OF EVENTS:
Although high side Condenser/Reboiler pressure readings could not be taken due to incorrect installation of an AQ-NCS pressure instrument, the integrity of the F/S tubes has been maintained. All of the Condenser/Reboilers had the RCW drained by 1345 hours on 5-12-03. thus re-establishing double contingency.
POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(s) OF HOW CRITICALITY COULD OCCUR)
In order for a criticality to be possible, an unsafe mass of uranium would have to be present within the Freezer/Sublimer unit and a moderator would have to enter through the Freezer/Sublimer and Condenser/Reboiler tubes.
CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,ETC.)
Double contingency is maintained by implementing two controls on moderation.
ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
For the 20 MW Freezer/Sublimers, less than a safe mass of uranium, at less than or equal to (LEU) U235.
For the 10 MW Freezer/Sublimers, less than a safe mass of uranium, at less than or equal to (LEU) U235
NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIFNCIES
The first leg of double contingency relies on Freezer/Sublimer and Condenser/Reboiler tube integrity. Since high UF6 pressure alarms or other operational indicators, caused by leaking R-114 into the Freezer/Sublimer, have not been received on the Freezer/Sublimer units, the integrity of the Freezer/Sublimer tubes has been maintained. Therefore, this leg of double contingency was maintained.
The second leg of double contingency relies on the differential pressure between the R-114 and RCW, controlling the differential pressure such that the R-114 is maintained at least 2.0 psi above the RCW precludes the introduction of RCW to the process side of the unit. Monitoring the RCW pressure on the outlet to the Condenser/Reboiler, instead of the inlet, does not give correct differential pressure readings. Therefore. This leg of double contingency was not maintained.
Even though the moderation parameter was maintained through integrity of the Freezer/Sublimer and Condenser/Reboiler tubes, double contingency Is based on two controls on moderation. Thus, double contingency was not maintained.
CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLFMENTED:
1. Drain Condenser/Reboiler RCW for the affected Freezer/Sublimer units. Completed at 1345 on 5-12-03.
2. Correct the installation of the pressure taps In accordance with the approved Engineering drawings. Complete prior to returning Freezer/Sublimors to service
The NRC Resident Inspector was notified of this event by the licensee.
NRC BULLETIN 91-01 24 HOUR NOTIFICATION
The following information was received from the licensee via facsimile:
"At 0900 on 5/12/03, the Plant Shift Superintendent (PSS) was notified that differential pressure transmitter inputs for three Freezer/Sublimers, U/2(Unit # 2) C/B (Cell B), U3 C/B and U/4 C/B located in C-337, were installed incorrectly. The transmitter (PDT-338) measures the differential pressure between the R-114 (freon) and the Recirculating Cooling Water (RCW). NCSA CAS-001 requires that the pressure differential between the R-114 and RCW pressures be such that the R-114 pressure is at least 2.0 psia above the RCW pressure. This would preclude the introduction of a moderator (RCW) into the process side of the system. The correct configuration of these inputs has the pressure tap on the inlet line to the condenser/reboiler. For Freezer/Sublimers U/2 C/B, U/3 C/B and U/4 C/B the pressure tap is located on the outlet line from the condenser/reboiler. As installed, the low differential pressure-alarm may not come in until after the R-114 pressure and RCW pressure at the inlet of the Condenser/Reboiler have exceeded the NCS limit. At 1040 on 5/12/03, the PSS was notified by Nuclear Criticality Safety that one of the two controls on moderation had been lost.
The System Engineer identified four additional Freezer/Sublimers, two in C-331 and two in C-335, with the same problem. These Freezer/Sublimer units were out-of-service and the RCW had been drained prior to the walk-down. ,
SAFETY SIGNIFICANCS OF EVENTS:
Although high side Condenser/Reboiler pressure readings could not be taken due to incorrect installation of an AQ-NCS pressure instrument, the integrity of the F/S tubes has been maintained. All of the Condenser/Reboilers had the RCW drained by 1345 hours on 5-12-03. thus re-establishing double contingency.
POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(s) OF HOW CRITICALITY COULD OCCUR)
In order for a criticality to be possible, an unsafe mass of uranium would have to be present within the Freezer/Sublimer unit and a moderator would have to enter through the Freezer/Sublimer and Condenser/Reboiler tubes.
CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,ETC.)
Double contingency is maintained by implementing two controls on moderation.
ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
For the 20 MW Freezer/Sublimers, less than a safe mass of uranium, at less than or equal to (LEU) U235.
For the 10 MW Freezer/Sublimers, less than a safe mass of uranium, at less than or equal to (LEU) U235
NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIFNCIES
The first leg of double contingency relies on Freezer/Sublimer and Condenser/Reboiler tube integrity. Since high UF6 pressure alarms or other operational indicators, caused by leaking R-114 into the Freezer/Sublimer, have not been received on the Freezer/Sublimer units, the integrity of the Freezer/Sublimer tubes has been maintained. Therefore, this leg of double contingency was maintained.
The second leg of double contingency relies on the differential pressure between the R-114 and RCW, controlling the differential pressure such that the R-114 is maintained at least 2.0 psi above the RCW precludes the introduction of RCW to the process side of the unit. Monitoring the RCW pressure on the outlet to the Condenser/Reboiler, instead of the inlet, does not give correct differential pressure readings. Therefore. This leg of double contingency was not maintained.
Even though the moderation parameter was maintained through integrity of the Freezer/Sublimer and Condenser/Reboiler tubes, double contingency Is based on two controls on moderation. Thus, double contingency was not maintained.
CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLFMENTED:
1. Drain Condenser/Reboiler RCW for the affected Freezer/Sublimer units. Completed at 1345 on 5-12-03.
2. Correct the installation of the pressure taps In accordance with the approved Engineering drawings. Complete prior to returning Freezer/Sublimors to service
The NRC Resident Inspector was notified of this event by the licensee.
Other Nuclear Material
Event Number: 39843
Rep Org: NUCOR STEEL
Licensee: NUCOR STEEL
Region: 3
City: CRAWFORDSVILLE State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: JEFF JORDAN
HQ OPS Officer: HOWIE CROUCH
Licensee: NUCOR STEEL
Region: 3
City: CRAWFORDSVILLE State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: JEFF JORDAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/13/2003
Notification Time: 13:14 [ET]
Event Date: 05/12/2003
Event Time: 15:00 [CST]
Last Update Date: 05/13/2003
Notification Time: 13:14 [ET]
Event Date: 05/12/2003
Event Time: 15:00 [CST]
Last Update Date: 05/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
SONIA BURGESS (R3)
FRED BROWN (NMSS)
SONIA BURGESS (R3)
FRED BROWN (NMSS)
METAL THICKNESS GAUGE SHUTTER ASSEMBLY DAMAGED
On 5/12/03 at 1500 CST, the shutter assembly on an IMS model TIAS-04 metal thickness gauge became stuck and resulted in shutter assembly bolts shearing. The gauge contains 50 curies of Cs-137. The licensee safed the gauge by isolating air to the air-operated gauge. The manufacturer was contacted and is currently on-site repairing the gauge. Additionally, during the incident, the assistant RSO walked below the gauge without having his radiation detection meter. Ion chambers mounted in the gauge area were reading zero at the time. Area monitors mounted in the area were not in alarm. The RSO has sent the assistant RSO's film badge out for processing.
The licensee has contacted Region 3 personnel (Sandy Frazier and Debbie Piskura).
On 5/12/03 at 1500 CST, the shutter assembly on an IMS model TIAS-04 metal thickness gauge became stuck and resulted in shutter assembly bolts shearing. The gauge contains 50 curies of Cs-137. The licensee safed the gauge by isolating air to the air-operated gauge. The manufacturer was contacted and is currently on-site repairing the gauge. Additionally, during the incident, the assistant RSO walked below the gauge without having his radiation detection meter. Ion chambers mounted in the gauge area were reading zero at the time. Area monitors mounted in the area were not in alarm. The RSO has sent the assistant RSO's film badge out for processing.
The licensee has contacted Region 3 personnel (Sandy Frazier and Debbie Piskura).
Power Reactor
Event Number: 39838
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: EDDIE BYARS
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: EDDIE BYARS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/12/2003
Notification Time: 03:28 [ET]
Event Date: 05/12/2003
Event Time: 01:02 [EDT]
Last Update Date: 05/12/2003
Notification Time: 03:28 [ET]
Event Date: 05/12/2003
Event Time: 01:02 [EDT]
Last Update Date: 05/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
PAUL FREDRICKSON (R2)
PAUL FREDRICKSON (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 |
AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO MAIN GENERATOR OUTPUT BREAKER OPENING
Main Generator output breaker opened after receiving Main Generator voltage regulator # 1 (core 1) & # 2 (core 2) alarms causing an automatic turbine trip followed by an automatic reactor trip (first out annunciator was over temperature differential temperature). All rods fully inserted into the core. Both motor driven auxiliary feedwater pumps were manually started to maintain reactor coolant temperature and proper steam generator water levels. Steam is being dumped to the main condenser. Emergency Operating procedure 1.0 entered and then Emergency Operating procedure 1.1, Reactor Recovery Procedure was entered. All emergency core cooling systems and the emergency diesel generators are fully operable if needed. The licensee believes that the main generator exciter breaker opened before the main generator output breaker opened. No work was going on in the area of the main generator when the output breaker opened.
The NRC Resident Inspector was notified of this event by the licensee.
Main Generator output breaker opened after receiving Main Generator voltage regulator # 1 (core 1) & # 2 (core 2) alarms causing an automatic turbine trip followed by an automatic reactor trip (first out annunciator was over temperature differential temperature). All rods fully inserted into the core. Both motor driven auxiliary feedwater pumps were manually started to maintain reactor coolant temperature and proper steam generator water levels. Steam is being dumped to the main condenser. Emergency Operating procedure 1.0 entered and then Emergency Operating procedure 1.1, Reactor Recovery Procedure was entered. All emergency core cooling systems and the emergency diesel generators are fully operable if needed. The licensee believes that the main generator exciter breaker opened before the main generator output breaker opened. No work was going on in the area of the main generator when the output breaker opened.
The NRC Resident Inspector was notified of this event by the licensee.