Event Notification Report for September 30, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/29/2003 - 09/30/2003
EVENT NUMBERS
4020840209402104156141608
Power Reactor
Event Number: 40208
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: STEENBERGEN
HQ OPS Officer: ERIC THOMAS
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: STEENBERGEN
HQ OPS Officer: ERIC THOMAS
Notification Date: 09/30/2003
Notification Time: 22:52 [ET]
Event Date: 09/30/2003
Event Time: 21:34 [EDT]
Last Update Date: 09/30/2003
Notification Time: 22:52 [ET]
Event Date: 09/30/2003
Event Time: 21:34 [EDT]
Last Update Date: 09/30/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (R3)
GENE IMBRO (NRR)
JULIO LARA (R3)
GENE IMBRO (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | N | 0 | Hot Standby | 0 | Hot Standby |
VALID SPECIFIED SYSTEM ACTUATION
At 2134 EDT on 9/30/03, a reactor trip occurred on RPS (Reactor Protection System) shutdown high pressure. The plant was in Mode 3 performing a cooldown to Mode 4. RCS (Reactor Coolant System) pressure was 1788 psig on the cooldown pressure indicator.
Group 1 safety rods were withdrawn prior to the trip. All other safety and regulating rods were already fully inserted.
All systems performed as required, and the plant is stable in Mode 3. RCS pressure is 1755 psig, and RCS temperature is 526 degrees F.
The licensee notified the NRC Resident Inspector.
At 2134 EDT on 9/30/03, a reactor trip occurred on RPS (Reactor Protection System) shutdown high pressure. The plant was in Mode 3 performing a cooldown to Mode 4. RCS (Reactor Coolant System) pressure was 1788 psig on the cooldown pressure indicator.
Group 1 safety rods were withdrawn prior to the trip. All other safety and regulating rods were already fully inserted.
All systems performed as required, and the plant is stable in Mode 3. RCS pressure is 1755 psig, and RCS temperature is 526 degrees F.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 40209
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: SALGADO
HQ OPS Officer: JOHN MacKINNON
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: SALGADO
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/30/2003
Notification Time: 23:11 [ET]
Event Date: 09/30/2003
Event Time: 20:14 [CDT]
Last Update Date: 09/30/2003
Notification Time: 23:11 [ET]
Event Date: 09/30/2003
Event Time: 20:14 [CDT]
Last Update Date: 09/30/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (R3)
JULIO LARA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 85 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM ON LOW REACTOR VESSEL WATER LEVEL.
Dresden Unit 2 automatically scrammed on low reactor vessel water level after "2C" reactor feed pump tripped (1 of 2 running). All systems responded as required (all rods fully inserted). Investigation into reactor feed pump trip cause has begun.
The NRC Resident Inspector will be notified of this event by the licensee.
Dresden Unit 2 automatically scrammed on low reactor vessel water level after "2C" reactor feed pump tripped (1 of 2 running). All systems responded as required (all rods fully inserted). Investigation into reactor feed pump trip cause has begun.
The NRC Resident Inspector will be notified of this event by the licensee.
Power Reactor
Event Number: 40210
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: MIKE HIMEBAUCH
HQ OPS Officer: GERRY WAIG
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: MIKE HIMEBAUCH
HQ OPS Officer: GERRY WAIG
Notification Date: 10/01/2003
Notification Time: 00:43 [ET]
Event Date: 09/30/2003
Event Time: 20:50 [EDT]
Last Update Date: 10/20/2003
Notification Time: 00:43 [ET]
Event Date: 09/30/2003
Event Time: 20:50 [EDT]
Last Update Date: 10/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)
JULIO LARA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 84 | Power Operation |
PLANT SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS DUE TO INOPERABLE CONTROL CENTER HVAC
"With the plant in Mode 1 and 100% reactor power at 2043 [EDT] on September 30, 2003, while shifting divisions of Control Center HVAC (CCHVAC), the Division 1 chiller failed to start and Division 1 CCHVAC was declared INOPERABLE. At 2050, a restart of Division 2 CCHVAC was attempted and the Division 2 chiller failed to start. Division 2 CCHVAC was declared INOPERABLE, and the plant entered LCO 3.0.3 as required by LCO 3.7.4 Condition D. Plant shutdown was initiated at 2146. Division 1 CCHVAC was declared OPERABLE at 2315, and LCO 3.0.3 was exited. Plant shutdown was terminated at 2315 with the reactor at 84% power. Division 2 CCHVAC remains INOPERABLE and under investigation, with plant operating under LCO 3.7.4 Condition A. Plans are to return to 100% reactor power. All ECCS systems remained OPERABLE during this event.
"The NRC Resident Inspector has been notified. This report is being made pursuant to 10 CFR 50.72(b)(2)(i) and 10 CFR 50.72(b)(3)(v)(D)."
* * * UPDATE 1428 EDT ON 10/20/03 FROM JEFF YEAGER TO S. SANDIN * * *
The licensee is retracting the notification required per 10 CFR 50.72(b)(3)(v) based on the following:
"At 2050 hours on September 30,2003 with the plant operating at 100 percent reactor power air conditioning chillers for both divisions of the Control Center Air Conditioning System failed to start. Technical Specification (TS) LCO 3.0.3 was entered as directed by LCO 3.7.4, Control Center Air Conditioning System, Condition D.1 and a plant shutdown initiated at 2146 hours. Notification was made in accordance with 10 CFR 50.72(b)(2)(i), a Plant Shutdown Required by Technical Specifications. The chiller for Division 1 Control Center Air Conditioning System was started after approximately one hour and subsequently declared operable at 2315 hours. TS 3.0.3 was exited and power reduction was terminated at 84 percent reactor power.
"Notification was also made in accordance with 10 CFR 50.72(b)(3)(v), Event or Condition that Could Have Prevented Fulfillment of a Safety Function. Investigation revealed an oil pressure permissive was not met for start of the chiller due to a small amount of air leaking into a pressure switch while shutdown. This delayed meeting the oil pressure permissive for starting the chiller. Subsequent start attempts removed the air, allowing the pressure permissive to be met and the chiller to be restarted. This restart of the chiller was accomplished from the main control room in accordance with plant procedures. Therefore, Division 1 Control Center Air Conditioning was capable of performing its intended function. This condition is therefore not reportable under 10 CFR 50.72(b)(3)(v). The original notification, Event Number 40210, is retracted."
The licensee informed the NRC Resident Inspector. Notified R3DO (Jim Creed).
"With the plant in Mode 1 and 100% reactor power at 2043 [EDT] on September 30, 2003, while shifting divisions of Control Center HVAC (CCHVAC), the Division 1 chiller failed to start and Division 1 CCHVAC was declared INOPERABLE. At 2050, a restart of Division 2 CCHVAC was attempted and the Division 2 chiller failed to start. Division 2 CCHVAC was declared INOPERABLE, and the plant entered LCO 3.0.3 as required by LCO 3.7.4 Condition D. Plant shutdown was initiated at 2146. Division 1 CCHVAC was declared OPERABLE at 2315, and LCO 3.0.3 was exited. Plant shutdown was terminated at 2315 with the reactor at 84% power. Division 2 CCHVAC remains INOPERABLE and under investigation, with plant operating under LCO 3.7.4 Condition A. Plans are to return to 100% reactor power. All ECCS systems remained OPERABLE during this event.
"The NRC Resident Inspector has been notified. This report is being made pursuant to 10 CFR 50.72(b)(2)(i) and 10 CFR 50.72(b)(3)(v)(D)."
* * * UPDATE 1428 EDT ON 10/20/03 FROM JEFF YEAGER TO S. SANDIN * * *
The licensee is retracting the notification required per 10 CFR 50.72(b)(3)(v) based on the following:
"At 2050 hours on September 30,2003 with the plant operating at 100 percent reactor power air conditioning chillers for both divisions of the Control Center Air Conditioning System failed to start. Technical Specification (TS) LCO 3.0.3 was entered as directed by LCO 3.7.4, Control Center Air Conditioning System, Condition D.1 and a plant shutdown initiated at 2146 hours. Notification was made in accordance with 10 CFR 50.72(b)(2)(i), a Plant Shutdown Required by Technical Specifications. The chiller for Division 1 Control Center Air Conditioning System was started after approximately one hour and subsequently declared operable at 2315 hours. TS 3.0.3 was exited and power reduction was terminated at 84 percent reactor power.
"Notification was also made in accordance with 10 CFR 50.72(b)(3)(v), Event or Condition that Could Have Prevented Fulfillment of a Safety Function. Investigation revealed an oil pressure permissive was not met for start of the chiller due to a small amount of air leaking into a pressure switch while shutdown. This delayed meeting the oil pressure permissive for starting the chiller. Subsequent start attempts removed the air, allowing the pressure permissive to be met and the chiller to be restarted. This restart of the chiller was accomplished from the main control room in accordance with plant procedures. Therefore, Division 1 Control Center Air Conditioning was capable of performing its intended function. This condition is therefore not reportable under 10 CFR 50.72(b)(3)(v). The original notification, Event Number 40210, is retracted."
The licensee informed the NRC Resident Inspector. Notified R3DO (Jim Creed).
Hospital
Event Number: 41561
Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County: LANCASTER
License #: 37-11866-04
Agreement: N
Docket:
NRC Notified By: TONY MONTAGNESE
HQ OPS Officer: HOWIE CROUCH
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County: LANCASTER
License #: 37-11866-04
Agreement: N
Docket:
NRC Notified By: TONY MONTAGNESE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/04/2005
Notification Time: 15:01 [ET]
Event Date: 09/30/2003
Event Time: 00:00 [EST]
Last Update Date: 04/07/2005
Notification Time: 15:01 [ET]
Event Date: 09/30/2003
Event Time: 00:00 [EST]
Last Update Date: 04/07/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE 21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE 21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JAMES NOGGLE (R1)
JOHN HICKEY (NMSS)
JAMES NOGGLE (R1)
JOHN HICKEY (NMSS)
MEDICAL EVENT NOTIFICATION
In September, 2003, a patient at Lancaster General Hospital's Health Campus was undergoing Co-60 gamma knife treatment. In preparation for the treatment, the patient was immobilized to ensure that the gamma knife was accurately aimed at the treatment site. During the treatment, the patient became uncomfortable and asked to move. He was told to move only his legs, but he shifted his body. As a result, the patient shifted 7cm away from the gamma knife. Licensee was unable to calculate dose to unintended site. There were no adverse effects to the patient.
* * * UPDATE FROM LICENSEE (MONTAGNES) TO NRC (HUFFMAN) AT 1048 EDT ON 4/07/05 * * *
The following additional details were provided on the event. The licensee also is reporting this as a 10 CRF Part 21 report.
The Licensee reported an incident involving component of a Leksell Model 23004 Type B Gamma Knife unit (Elekta AB, Stockholm, Sweden). The specific components involved are the "z-bars". During the treatment with this device, a patient's head is secured into a head frame in preparation for irradiation treatment of deep head disease. This head frame is then also secured to a helmet and couch assembly to ensure immobilization during treatment. In, order to localize the therapeutic radiation beam to a precise location, the frame is able to be adjusted in the X, Y, or Z directions. In the "Z" direction, there are metal bars that are adjusted to a desired position, then locked into place by the treatment staff with a number of screens.
During the case which lead to the incident, a large patient is believed to have made an exaggerated movement during treatment, against staff instructions, as a means of alleviating some discomfort. At the conclusion of the treatment, the staff noted that the patient's position - as indicated by the z-bars - had slipped caudally by approximately 7 cm.
The incident occurred on September 30, 2003 in the Lancaster General Gamma Knife Center, 2102 Harrisburg Pike, Lancaster, Pennsylvania, 17603. Although this original incident occurred on September 30, 2003, this report is only being filed now as a result of an investigation by the NRC that concluded on April 5, 2005.
R1DO (Noggle) and NMSS (Essig) notified.
In September, 2003, a patient at Lancaster General Hospital's Health Campus was undergoing Co-60 gamma knife treatment. In preparation for the treatment, the patient was immobilized to ensure that the gamma knife was accurately aimed at the treatment site. During the treatment, the patient became uncomfortable and asked to move. He was told to move only his legs, but he shifted his body. As a result, the patient shifted 7cm away from the gamma knife. Licensee was unable to calculate dose to unintended site. There were no adverse effects to the patient.
* * * UPDATE FROM LICENSEE (MONTAGNES) TO NRC (HUFFMAN) AT 1048 EDT ON 4/07/05 * * *
The following additional details were provided on the event. The licensee also is reporting this as a 10 CRF Part 21 report.
The Licensee reported an incident involving component of a Leksell Model 23004 Type B Gamma Knife unit (Elekta AB, Stockholm, Sweden). The specific components involved are the "z-bars". During the treatment with this device, a patient's head is secured into a head frame in preparation for irradiation treatment of deep head disease. This head frame is then also secured to a helmet and couch assembly to ensure immobilization during treatment. In, order to localize the therapeutic radiation beam to a precise location, the frame is able to be adjusted in the X, Y, or Z directions. In the "Z" direction, there are metal bars that are adjusted to a desired position, then locked into place by the treatment staff with a number of screens.
During the case which lead to the incident, a large patient is believed to have made an exaggerated movement during treatment, against staff instructions, as a means of alleviating some discomfort. At the conclusion of the treatment, the staff noted that the patient's position - as indicated by the z-bars - had slipped caudally by approximately 7 cm.
The incident occurred on September 30, 2003 in the Lancaster General Gamma Knife Center, 2102 Harrisburg Pike, Lancaster, Pennsylvania, 17603. Although this original incident occurred on September 30, 2003, this report is only being filed now as a result of an investigation by the NRC that concluded on April 5, 2005.
R1DO (Noggle) and NMSS (Essig) notified.
Other Nuclear Material
Event Number: 41608
Rep Org: DEPT OF NAVY RADIATION SAFETY CMTE
Licensee: DEPT OF NAVY RADIATION SAFETY CMTE
Region: 1
City: CRYSTAL CITY State: VA
County:
License #: 45-93645-01NA
Agreement: N
Docket:
NRC Notified By: COMMANDER FRAGOSA
HQ OPS Officer: JOHN KNOKE
Licensee: DEPT OF NAVY RADIATION SAFETY CMTE
Region: 1
City: CRYSTAL CITY State: VA
County:
License #: 45-93645-01NA
Agreement: N
Docket:
NRC Notified By: COMMANDER FRAGOSA
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/18/2005
Notification Time: 10:48 [ET]
Event Date: 09/30/2003
Event Time: 12:00 [EST]
Last Update Date: 04/18/2005
Notification Time: 10:48 [ET]
Event Date: 09/30/2003
Event Time: 12:00 [EST]
Last Update Date: 04/18/2005
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):
DAVID SILK (R1)
JOHN HICKEY (NMSS)
TAS (VIA EMAIL)
DAVID SILK (R1)
JOHN HICKEY (NMSS)
TAS (VIA EMAIL)
CHEMICAL AGENT DETECTORS MISSING FROM DEPARTMENT OF NAVY INVENTORY
A representative for the Navy's master material license reported two chemical agent detectors were missing since their last audit on 9/30/2003. One detector was a Automatic Chemical Agent Detector Alarms (ACADA) which has 230 microcuries of Am241 with a surface exposure of 0.4 millirem/hr. The identification number is SSND -NR-1065-D-101-E. The other detector was a hand held vapor detector containing a 10 microCurie Ni63 source with identification number SSND-NR-0399-D-101-E.
The licensee was informed by a supply room person that the detectors were assigned to the USS Fletcher on 9/30/03, and have not been accounted for since.
A representative for the Navy's master material license reported two chemical agent detectors were missing since their last audit on 9/30/2003. One detector was a Automatic Chemical Agent Detector Alarms (ACADA) which has 230 microcuries of Am241 with a surface exposure of 0.4 millirem/hr. The identification number is SSND -NR-1065-D-101-E. The other detector was a hand held vapor detector containing a 10 microCurie Ni63 source with identification number SSND-NR-0399-D-101-E.
The licensee was informed by a supply room person that the detectors were assigned to the USS Fletcher on 9/30/03, and have not been accounted for since.