Event Notification Report for December 22, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/21/2003 - 12/22/2003
EVENT NUMBERS
404124041340406404084041040405
General Information or Other
Event Number: 40412
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GUIDANT CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L05178
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: MIKE RIPLEY
Licensee: GUIDANT CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L05178
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/23/2003
Notification Time: 16:58 [ET]
Event Date: 12/22/2003
Event Time: 00:00 [CST]
Last Update Date: 12/23/2003
Notification Time: 16:58 [ET]
Event Date: 12/22/2003
Event Time: 00:00 [CST]
Last Update Date: 12/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
TOM ESSIG (NMSS)
LINDA SMITH (R4)
TOM ESSIG (NMSS)
LEAKING P-32 SOURCE WIRE
The following information was received via facsimile:
"Houston licensee received an IVB [Intravascular Brachytherapy] source wire back from a hospital. Source wire was determined to be leaking upon leak test. Leaking Source, P32 IVB, approximately 85 millicuries of P-32. Leaking IVB source returned by unknown hospital in Lafayette, Louisiana to the manufacturer."
Texas Incident Report I-8086.
The following information was received via facsimile:
"Houston licensee received an IVB [Intravascular Brachytherapy] source wire back from a hospital. Source wire was determined to be leaking upon leak test. Leaking Source, P32 IVB, approximately 85 millicuries of P-32. Leaking IVB source returned by unknown hospital in Lafayette, Louisiana to the manufacturer."
Texas Incident Report I-8086.
General Information or Other
Event Number: 40413
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SOUTHWEST GENERAL HEALTH CENTER-IRELAND CANCER CENTER
Region: 3
City: MIDDLEBURG HEIGHTS State: OH
County:
License #: 02120180001
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: GERRY WAIG
Licensee: SOUTHWEST GENERAL HEALTH CENTER-IRELAND CANCER CENTER
Region: 3
City: MIDDLEBURG HEIGHTS State: OH
County:
License #: 02120180001
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: GERRY WAIG
Notification Date: 12/24/2003
Notification Time: 09:34 [ET]
Event Date: 12/22/2003
Event Time: 13:00 [EST]
Last Update Date: 12/24/2003
Notification Time: 09:34 [ET]
Event Date: 12/22/2003
Event Time: 13:00 [EST]
Last Update Date: 12/24/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)
PATRICK LOUDEN (R3)
TOM ESSIG (NMSS)
OHIO AGREEMENT STATE REPORT - RADIATION DOSE TO UNINTENDED SITE DURING BRACHYTHERAPHY TREATMENT
On 12/23/2003 at 1600 hours EST the licensee notified the Ohio Department of Health, Bureau of Radiation Protection, of the following information regarding a patient undergoing intravascular brachytheraphy treatment:
"On December 22, 2003 during a treatment with a Novoste Beta-Cath 3.5 French IVB System, the source did not travel the entire way to the treatment site and was 3 centimeters proximal to the treatment site. The immediate cause of the event was a small kink in the delivery catheter which kept the source train from traveling to the correct site, even though the kink was not substantial enough to affect the flow of sterile water used to send/retrieve the sources. The error was discovered the next day during medical physics quality checks and reported to Ohio Department of Health, Bureau of Radiation Protection. An investigation will be performed the week of December 29, 2003."
The dose to the unintended site was identified as 1840 rad (18.4 Gy) from a 0.05378 curie, Sr-90, sealed source. The attending physician has been notified. The intravascular brachytheraphy unit is a Novoste, model TDA-1040, serial number 91828.
The Ohio Department of Health, Bureau of Radiation Protection reference number for this event is 2003-126.
On 12/23/2003 at 1600 hours EST the licensee notified the Ohio Department of Health, Bureau of Radiation Protection, of the following information regarding a patient undergoing intravascular brachytheraphy treatment:
"On December 22, 2003 during a treatment with a Novoste Beta-Cath 3.5 French IVB System, the source did not travel the entire way to the treatment site and was 3 centimeters proximal to the treatment site. The immediate cause of the event was a small kink in the delivery catheter which kept the source train from traveling to the correct site, even though the kink was not substantial enough to affect the flow of sterile water used to send/retrieve the sources. The error was discovered the next day during medical physics quality checks and reported to Ohio Department of Health, Bureau of Radiation Protection. An investigation will be performed the week of December 29, 2003."
The dose to the unintended site was identified as 1840 rad (18.4 Gy) from a 0.05378 curie, Sr-90, sealed source. The attending physician has been notified. The intravascular brachytheraphy unit is a Novoste, model TDA-1040, serial number 91828.
The Ohio Department of Health, Bureau of Radiation Protection reference number for this event is 2003-126.
Power Reactor
Event Number: 40406
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD BRABEC
HQ OPS Officer: JEFF ROTTON
Region: 4 State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD BRABEC
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/22/2003
Notification Time: 11:39 [ET]
Event Date: 12/22/2003
Event Time: 08:27 [CST]
Last Update Date: 12/22/2003
Notification Time: 11:39 [ET]
Event Date: 12/22/2003
Event Time: 08:27 [CST]
Last Update Date: 12/22/2003
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):
LINDA SMITH (R4)
LINDA SMITH (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 99 | Power Operation | 0 | Hot Standby |
REACTOR TRIP DUE TO MAIN TURBINE TRIP
"At 0827 on 12/22/2003, Comanche Peak Unit Two (2) tripped due to a turbine trip > 50%. The turbine trip was caused by ingestion of a small metallic cover plate into the main generator exciter housing, as witnessed by maintenance personnel. A small fire ensued, which self-extinguished in five (5) minutes. An Aux Feedwater auto start (ESF actuation) occurred due to normal post-trip steam generator shrink. The turbine-driven and both motor-driven aux feedwater pumps started as designed.
"All control rods inserted into the core upon trip. The local electrical grid is stable. The number one (1) steam generator atmospheric relief valve cycled as designed upon the secondary pressure transient.
"The number three (3) Reactor Coolant Pump tripped during the transfer of power sources post-trip.
"Unit 1 was not affected by the trip. Unit 2 is stable in Mode 3. Damage assessment is in progress which will determine future (near-term) plant mode of operation."
RCPs are in operation transferring decay heat to the steam generators. Decay heat removal is through the MSIVs to the main condenser using the turbine steam dump valves. Both motor-driven AFW pumps are running to maintain Steam Generator levels. The trip of the number (3) Reactor Coolant Pump is being investigated.
The licensee notified the NRC Resident Inspector.
"At 0827 on 12/22/2003, Comanche Peak Unit Two (2) tripped due to a turbine trip > 50%. The turbine trip was caused by ingestion of a small metallic cover plate into the main generator exciter housing, as witnessed by maintenance personnel. A small fire ensued, which self-extinguished in five (5) minutes. An Aux Feedwater auto start (ESF actuation) occurred due to normal post-trip steam generator shrink. The turbine-driven and both motor-driven aux feedwater pumps started as designed.
"All control rods inserted into the core upon trip. The local electrical grid is stable. The number one (1) steam generator atmospheric relief valve cycled as designed upon the secondary pressure transient.
"The number three (3) Reactor Coolant Pump tripped during the transfer of power sources post-trip.
"Unit 1 was not affected by the trip. Unit 2 is stable in Mode 3. Damage assessment is in progress which will determine future (near-term) plant mode of operation."
RCPs are in operation transferring decay heat to the steam generators. Decay heat removal is through the MSIVs to the main condenser using the turbine steam dump valves. Both motor-driven AFW pumps are running to maintain Steam Generator levels. The trip of the number (3) Reactor Coolant Pump is being investigated.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 40408
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM WELSH
HQ OPS Officer: MIKE RIPLEY
Region: 4 State: CA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM WELSH
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/22/2003
Notification Time: 14:39 [ET]
Event Date: 12/22/2003
Event Time: 11:22 [PST]
Last Update Date: 12/23/2003
Notification Time: 14:39 [ET]
Event Date: 12/22/2003
Event Time: 11:22 [PST]
Last Update Date: 12/23/2003
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
LINDA SMITH (R4)
DAVID SKEEN (NRR)
RICHARD WESSMAN (IRO)
DAN SULLIVAN (FEMA)
JOHN FROST (DHS)
LINDA SMITH (R4)
DAVID SKEEN (NRR)
RICHARD WESSMAN (IRO)
DAN SULLIVAN (FEMA)
JOHN FROST (DHS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF UNUSUAL EVENT - EARTHQUAKE
At 1116 PST on 12/22/03, an earthquake was felt on-site measuring 0.04g on plant seismic instrumentation. The licensee declared an Unusual Event at 1122 PST per EAL 18 (greater than 0.01g) . Both Units 1 and 2 continue to operate at 100% power. The local electrical grid is stable and all Emergency Diesel Generators are fully operable. A number of plant tank level were momentarily alarmed. The Unit 2 Main Turbine Electro-Hydraulic Control (EHC) pump tripped and was successfully restarted.
Plant walk-down inspections are in progress. The licensee notified the NRC Resident Inspector.
The National Earthquake Information center reports that the earthquake measured 6.5 R and was centered approximately 5 miles Northeast of San Simeon, CA or approximately 35 miles Northwest of the Diablo Canyon site.
* * * UPDATE ON 12/23/03 @ 1526 BY HENDERSON TO GOULD * * *
The licensee terminated the NOUE at 1212 PST following a 24 hour period after the earthquake. It was determined that the probability of an earthquake at this point is no greater than it was prior to the earthquake that occurred on 12/22/03.
The licensee notified the NRC Resident Inspector.
Notified R4DO (Smith), NRR EO (Reis), DIRO Manager (Nieh), FEMA (Eaches) and DHS (Bozzo).
At 1116 PST on 12/22/03, an earthquake was felt on-site measuring 0.04g on plant seismic instrumentation. The licensee declared an Unusual Event at 1122 PST per EAL 18 (greater than 0.01g) . Both Units 1 and 2 continue to operate at 100% power. The local electrical grid is stable and all Emergency Diesel Generators are fully operable. A number of plant tank level were momentarily alarmed. The Unit 2 Main Turbine Electro-Hydraulic Control (EHC) pump tripped and was successfully restarted.
Plant walk-down inspections are in progress. The licensee notified the NRC Resident Inspector.
The National Earthquake Information center reports that the earthquake measured 6.5 R and was centered approximately 5 miles Northeast of San Simeon, CA or approximately 35 miles Northwest of the Diablo Canyon site.
* * * UPDATE ON 12/23/03 @ 1526 BY HENDERSON TO GOULD * * *
The licensee terminated the NOUE at 1212 PST following a 24 hour period after the earthquake. It was determined that the probability of an earthquake at this point is no greater than it was prior to the earthquake that occurred on 12/22/03.
The licensee notified the NRC Resident Inspector.
Notified R4DO (Smith), NRR EO (Reis), DIRO Manager (Nieh), FEMA (Eaches) and DHS (Bozzo).
Power Reactor
Event Number: 40410
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAMON RITTER
HQ OPS Officer: MIKE RIPLEY
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAMON RITTER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/22/2003
Notification Time: 16:43 [ET]
Event Date: 12/22/2003
Event Time: 15:30 [EST]
Last Update Date: 12/22/2003
Notification Time: 16:43 [ET]
Event Date: 12/22/2003
Event Time: 15:30 [EST]
Last Update Date: 12/22/2003
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):
RAYMOND LORSON (R1)
RAYMOND LORSON (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 |
OFFSITE NOTIFICATION
"FPL Energy Seabrook notified the EPA and NHDES [New Hampshire Department of Environmental Services] this afternoon [12/22/03] at 3:30 pm of unusually high impingement of small fish during the last two weeks caused by a series of strong storms. This notification was made under FPL Energy's Seabrook NPDES permit Part 1.A.24.e.
"Most of the fish were small and included silversides, winter flounder, windowpane flounder, cod, smelt, and several other species.
"The biomass of the fish was relatively small."
The licensee notified the NRC Resident Inspector.
"FPL Energy Seabrook notified the EPA and NHDES [New Hampshire Department of Environmental Services] this afternoon [12/22/03] at 3:30 pm of unusually high impingement of small fish during the last two weeks caused by a series of strong storms. This notification was made under FPL Energy's Seabrook NPDES permit Part 1.A.24.e.
"Most of the fish were small and included silversides, winter flounder, windowpane flounder, cod, smelt, and several other species.
"The biomass of the fish was relatively small."
The licensee notified the NRC Resident Inspector.
Fuel Cycle Facility
Event Number: 40405
Facility: HONEYWELL INTERNATIONAL, INC.
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: DARREN MAYS
HQ OPS Officer: JEFF ROTTON
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: DARREN MAYS
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/22/2003
Notification Time: 05:00 [ET]
Event Date: 12/22/2003
Event Time: 03:00 [CST]
Last Update Date: 12/22/2003
Notification Time: 05:00 [ET]
Event Date: 12/22/2003
Event Time: 03:00 [CST]
Last Update Date: 12/22/2003
Emergency Class: SITE AREA EMERGENCY
10 CFR Section:
40.35(f) - EMERGENCY DECLARED
10 CFR Section:
40.35(f) - EMERGENCY DECLARED
Person (Organization):
THOMAS DECKER (R2)
RICHARD WESSMAN (IRO)
JOHN HICKEY (NMSS)
LUIS REYES (RA)
MARTY VIRGILLIO (ET)
THOMAS DECKER (R2)
RICHARD WESSMAN (IRO)
JOHN HICKEY (NMSS)
LUIS REYES (RA)
MARTY VIRGILLIO (ET)
SITE AREA EMERGENCY DECLARED DUE TO UF6 RELEASE
At 0245 CST, a small release of UF6 occurred lasting approximately 45 minutes. At 0300 CST the licensee declared a Site Area Emergency. The release has been terminated at the time of the notification. All personnel were evacuated within a 1 mile radius. At the time of notification, the evacuated personnel were allowed to return to their homes. The local sheriff has responded to the scene. NRC HQ and Region 2 NRC personnel are responding and a NRC Inspector is in transit to the site. The NRC entered Monitoring phase of Normal Mode at 0515 EST. The Acting NRC Chairman (Commissioner Merrifield) has been informed. There is no indication at this time of any malevolent activity.
Initial reports indicated that there were no injuries at the plant, but three individuals offsite were taken to the hospital. Two have been released, and the third is being evaluated further prior to release. About 25 people offsite were temporarily evacuated and some 75 persons remained sheltered for a time in their homes. The licensee is evaluating the amount of material released.
Licensee notified State of Illinois. NRC Headquarters also notified DHS-DOE (Mike Wyatt)
The licensee terminated the Site Area Emergency at 0650 CST on 12/22/03. The release is over, the plant is stable and the licensee is in the recovery mode. The NRC exited the Monitoring Phase of the Normal Mode for this event at 1230 ET.
Notified DIRO (S. Frant), NMSS EO (F. Brown), R2DO (T. Decker), USDA (L. Jensen), HHS (J. Little), EPA (Rawls), DHS (Frost), FEMA (D. Barden) regarding exiting Monitoring Phase of the Normal Mode.
At 0245 CST, a small release of UF6 occurred lasting approximately 45 minutes. At 0300 CST the licensee declared a Site Area Emergency. The release has been terminated at the time of the notification. All personnel were evacuated within a 1 mile radius. At the time of notification, the evacuated personnel were allowed to return to their homes. The local sheriff has responded to the scene. NRC HQ and Region 2 NRC personnel are responding and a NRC Inspector is in transit to the site. The NRC entered Monitoring phase of Normal Mode at 0515 EST. The Acting NRC Chairman (Commissioner Merrifield) has been informed. There is no indication at this time of any malevolent activity.
Initial reports indicated that there were no injuries at the plant, but three individuals offsite were taken to the hospital. Two have been released, and the third is being evaluated further prior to release. About 25 people offsite were temporarily evacuated and some 75 persons remained sheltered for a time in their homes. The licensee is evaluating the amount of material released.
Licensee notified State of Illinois. NRC Headquarters also notified DHS-DOE (Mike Wyatt)
The licensee terminated the Site Area Emergency at 0650 CST on 12/22/03. The release is over, the plant is stable and the licensee is in the recovery mode. The NRC exited the Monitoring Phase of the Normal Mode for this event at 1230 ET.
Notified DIRO (S. Frant), NMSS EO (F. Brown), R2DO (T. Decker), USDA (L. Jensen), HHS (J. Little), EPA (Rawls), DHS (Frost), FEMA (D. Barden) regarding exiting Monitoring Phase of the Normal Mode.