Event Notification Report for February 26, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/25/1999 - 02/26/1999
** EVENT NUMBERS **
35402 35403 35404 35405 35406 35407 35408
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|Power Reactor |Event Number: 35402 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 02/25/1999|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 09:03[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 02/25/1999|
+------------------------------------------------+EVENT TIME: 08:05[EST]|
| NRC NOTIFIED BY: ERIC OLSON |LAST UPDATE DATE: 02/25/1999|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RICHARD BARKLEY R1 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| DISCOVERY OF EMERGENCY DIESEL GENERATOR BUILDING TEMPERATURE LESS THAN |
| DESIGN DUE AN ONGOING SEVERE WINTER STORM (Refer to event numbers 33658 and |
| 33938 for previous similar occurrences reported to the NRC Operations Center |
| by Pilgrim 1.) |
| |
| The design temperature for the building that houses the emergency diesel |
| generators is 60�F. However, at 0805 on 02/25/99, it was discovered that |
| temperature for the area that houses the 'A' emergency diesel generator was |
| 59�F. This was due to an ongoing severe winter storm with winds out of the |
| northeast which introduced cold air to the emergency diesel generator |
| building. Temperature returned to 60�F at approximately 0830, but it is |
| expected that it may decrease below the design temperature throughout the |
| storm as long as the winds are coming out of the northeast. |
| |
| The licensee stated that this problem has occurred in the past and |
| referenced Licensee Event Report (LER) 98-004-01. Corrective actions for |
| this LER involved changing the emergency diesel generator building design |
| temperature to 40�F. This design change is currently being processed but |
| has not yet been approved. |
| |
| The licensee currently has an engineering evaluation in place to justify |
| emergency diesel generator operability with building temperatures as low as |
| 40�F. Therefore, both emergency diesel generators are considered to be |
| operable, and the unit is not currently in a technical specification |
| limiting condition for operation as a result of this issue. |
| |
| The licensee notified the NRC resident inspector. |
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|Fuel Cycle Facility |Event Number: 35403 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 02/25/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 11:13[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 02/24/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 12:05[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 02/25/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |BRUCE JORGENSEN R3 |
| DOCKET: 0707002 |DON COOL, NMSS EO |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RICK LARSON | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| DISCOVERY OF MINOR UF6 LEAKAGE IN THE X-330 BUILDING AND CONFIRMED VALID |
| CASCADE AUTOMATIC DATA PROCESSING (CADP) ACTUATION (24-HOUR REPORT) |
| |
| The following text is a portion of a facsimile received from Portsmouth: |
| |
| "At approximately 1205 hours on 02/24/99, operations personnel investigating |
| a smokehead alarm that occurred at 1005 found visible evidence of minor UF6 |
| leakage on a valve in the evacuation header for position 3 of the liquid |
| withdrawal station at tails. Finding this visible evidence of UF6 leakage |
| confirmed that the actuation of the CADP UF6 smoke detection safety system |
| was valid. This discovery concludes the investigation that was started on |
| 02/22/99 to determine if three smokehead alarm actuations that occurred on |
| 02/19/99 were actual or invalid signals. When the alarms were initially |
| received, operations personnel responded and performed an investigation in |
| accordance with response procedures. Their initial inspections did not |
| reveal any evidence of UF6 leakage which would indicate the alarm actuations |
| were valid. On 02/22/99, additional actions were taken to investigate the |
| alarms which included isolating sections of piping near the smokeheads. |
| Visual inspections and leak tests performed on this section of piping did |
| not reveal any evidence of UF6 leakage. On 02/24/99, with the suspected |
| section of piping isolated, another alarm was received. This led the |
| operations personnel to re-inspect equipment which did not previously show |
| any evidence of leakage. This inspection revealed evidence of minor leakage |
| which was not previously visible. This evidence confirmed that a valid CADP |
| actuation had occurred." |
| |
| "This is reportable to the NRC as a valid actuation of a 'Q' safety system |
| in accordance with the Safety Analysis Report, Section 6.9." |
| |
| "There was no loss of hazardous/radioactive material or |
| radioactive/radiological contamination exposure as a result of this event." |
| |
| Portsmouth personnel notified the NRC resident inspector and the Department |
| of Energy site representative. |
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|Hospital |Event Number: 35404 |
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| REP ORG: INDIANA UNIVERSITY MEDICAL CENTER |NOTIFICATION DATE: 02/25/1999|
|LICENSEE: INDIANA UNIVERSITY MEDICAL CENTER |NOTIFICATION TIME: 11:21[EST]|
| CITY: INDIANAPOLIS REGION: 3 |EVENT DATE: 02/24/1999|
| COUNTY: MARION STATE: IN |EVENT TIME: 12:17[CST]|
|LICENSE#: 13-02752-03 AGREEMENT: N |LAST UPDATE DATE: 02/25/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE JORGENSEN R3 |
| |DON COOL, NMSS EO |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARK RICHARD | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION INVOLVING RECEIPT OF A BRACHYTHERAPY DOSE THAT WAS |
| 24% LOW |
| |
| On 10/29/98, a patient at Indiana University Medical Center located in |
| Indianapolis, IN, was being treated with a three-channel, low-dose-rate, |
| brachytherapy device containing Cesium-137 sources in the form of small |
| pellets. When nurses entered the room to attend the patient, the sources |
| were retracted, and there were problems resuming the treatment. The |
| problems were initially believed to be the result of a power problem. The |
| on-call medical physicist was contacted, power problem recovery steps were |
| followed, and the treatment was resumed. The following morning, a resident |
| physician noticed that only one of the three channels on the brachytherapy |
| device was actually operating (treating the patient) and that the sources in |
| the other two channels were still in the shielded position. Therefore, the |
| problem was the result of a pellet problem rather than a power problem and |
| different recovery steps should have been followed. The medical physicist |
| was contacted, and the treatment resumed. When the patient was informed |
| that the treatment time would need to be lengthened to compensate for the |
| delay in reactivating two of the three channels, the patient refused the |
| additional treatment. The prescribed dose was 2,500 centigray, and the |
| patient actually received 1,900 centigray. |
| |
| On 11/09/98, the licensee sent an Incident Report to NRC Region III (Bob |
| Gattone). NRC Region III sent a Technical Assistance Request to NRC |
| Headquarters regarding reportability, and a response stating that this |
| incident was reportable was received by licensee via facsimile at 1217 CST |
| on 02/24/99. |
| |
| (Call the NRC Operations Center for a site contact telephone number.) |
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|Hospital |Event Number: 35405 |
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| REP ORG: METCALF INSTITUTE OF RAD ONCOLOGY |NOTIFICATION DATE: 02/25/1999|
|LICENSEE: HOSPITAL CENTER AT ORANGE |NOTIFICATION TIME: 11:49[EST]|
| CITY: ORANGE REGION: 1 |EVENT DATE: 02/25/1999|
| COUNTY: ESSEX STATE: NJ |EVENT TIME: 09:55[EST]|
|LICENSE#: 29-03038-02 AGREEMENT: N |LAST UPDATE DATE: 02/25/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| |DON COOL (EO) NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DR. JOSE BARBA | |
| HQ OPS OFFICER: HENRY BAILEY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: | |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SOURCE DRAWER FAILURE ON AN ATC Co-60 MACHINE |
| |
| THE METCALF INSTITUTE OF RADIATION AT THE HOSPITAL CENTER AT ORANGE LOCATED |
| IN ORANGE, NJ, REPORTED AN INCIDENT WHERE A PATIENT WAS EXPOSED FOR 15 TO 20 |
| SECONDS WHEN THE SOURCE DRAWER ON AN ATC Co-60 MACHINE FAILED. SEVERAL |
| ATTENDING PERSONNEL ALSO WERE EXPOSED FOR 5 TO 10 SECONDS. THE SOURCE |
| STRENGTH WAS 6,000 CURIES. NO DOSAGE CALCULATIONS HAD BEEN PERFORMED AT THE |
| TIME OF THIS EVENT NOTIFICATION. |
| |
| A SIMULATION FILM WAS BEING TAKEN IN PREPARATION FOR A TREATMENT ON THE |
| PATIENT. THE SOURCE FAILED TO RETURN TO THE SHIELDED POSITION EVEN WHEN THE |
| EMERGENCY STOP WAS ACTUATED. THE ROOM WAS SEALED AND LOCKED, AND THE SOURCE |
| DRAWER WAS THEN CLOSED REMOTELY. ALL OPERATIONS WITH THIS MACHINE HAVE BEEN |
| SUSPENDED. |
| |
| THE LICENSEE NOTIFIED NRC REGION I (DR. NEELAM BHALLA) AND PLANS TO SUBMIT A |
| WRITTEN REPORT TO THE NRC. |
| |
| (CALL THE NRC OPERATIONS CENTER FOR A LICENSEE CONTACT TELEPHONE NUMBER.) |
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|General Information or Other |Event Number: 35406 |
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| REP ORG: PYCO, INC. |NOTIFICATION DATE: 02/25/1999|
|LICENSEE: PYCO, INC. |NOTIFICATION TIME: 17:03[EST]|
| CITY: PENNDEL REGION: 1 |EVENT DATE: 02/25/1999|
| COUNTY: STATE: PA |EVENT TIME: 17:03[EST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 02/25/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROBERT HAAG R2 |
| |VERN HODGE (via fax) NRR |
+------------------------------------------------+RICHARD BARKLEY R1 |
| NRC NOTIFIED BY: WILLIAM SZARY | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 10 CFR PART 21 REPORT REGARDING FAULTY RESISTANCE TEMPERATURE DETECTORS |
| (RTD) |
| |
| The following text is a portion of a facsimile received from PYCO, Inc.: |
| |
| "A deviation has been detected in that a limited number of 200 OHM DUPLEX |
| RTD assemblies have been fabricated by PYCO using THIN-FILM RTD sensors |
| instead of the WIRE-WOUND RTD sensors specified for the assembly. RTD |
| assemblies fabricated using wire-wound sensors have been tested and |
| qualified by PYCO for nuclear use under our nuclear qualification test |
| program. RTD assemblies fabricated using thin-film sensors have not been |
| tested by PYCO to IEEE-323 and IEEE-344 requirements." |
| |
| "Externally, thin-film and wire-wound RTDs have the same physical |
| appearance, shape, and electrical characteristics. Both the wire-wound and |
| thin-film sensors meet the requirements of the International Industrial |
| Standard IEC-751, 'Industrial Platinum Resistance Thermometer Sensors'." |
| |
| These RTDs have been sold to Carolina Power and Light and South Carolina |
| Electric and Gas for use at the Robinson, Brunswick, and Summer plants. |
| |
| (Call the NRC Operations Center for a contact telephone number.) |
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|Power Reactor |Event Number: 35407 |
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| FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 02/25/1999|
| UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 18:41[EST]|
| RXTYPE: [3] CE |EVENT DATE: 02/25/1999|
+------------------------------------------------+EVENT TIME: 14:18[CST]|
| NRC NOTIFIED BY: BILL MCKINNEY |LAST UPDATE DATE: 02/25/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ELMO COLLINS R4 |
|10 CFR SECTION: | |
|ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3 N N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| PRESSURIZER NOZZLE LEAKAGE DISCOVERED DURING REFUELING OUTAGE |
| |
| During a visual inspection, evidence of reactor coolant system leakage was |
| found on two inconel instrument nozzles located on the top head of the |
| pressurizer. The leakage was in the annulus area where the nozzle |
| penetrates the pressurizer head. The nozzles are welded on the inner |
| diameter of the pressurizer and are joined to instrument valves RC-310 and |
| RC-311. |
| |
| The NRC resident inspector has been informed of this notification by the |
| licensee. |
+------------------------------------------------------------------------------+
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|Hospital |Event Number: 35408 |
+------------------------------------------------------------------------------+
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| REP ORG: GREATER LA MEDICAL CENTER |NOTIFICATION DATE: 02/25/1999|
|LICENSEE: VA MEDICAL SYSTEM |NOTIFICATION TIME: 19:50[EST]|
| CITY: LOS ANGELES REGION: 4 |EVENT DATE: 02/24/1999|
| COUNTY: STATE: CA |EVENT TIME: [PST]|
|LICENSE#: 04-00181-12 AGREEMENT: Y |LAST UPDATE DATE: 02/25/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ELMO COLLINS R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ED LEIDHOLDT | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|IBBE 30.50(b)(2)(i) ACCID MIT EQUIP FAILS | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MALFUNCTION OF DOOR INTERLOCK FOR TELETHERAPY UNIT |
| |
| On 02/24/99, while conducting a test of the treatment room door interlock |
| associated with a Co-60 teletherapy unit, the treatment timer stopped and |
| the source retracted when the door was opened (expected), but the timer then |
| restarted and the source became exposed again after the door was closed (not |
| expected). The source then retracted once again after the treatment timer |
| expired. The treatment timer should not have restarted until manually |
| directed to do so from the operator console. The teletherapy unit is a |
| Theratronix model T-780, |
| containing 3,500 Ci of Co-60. A vendor technician responded to the site but |
| was unable to reproduce the event. However, the licensee reported that the |
| technician was able to reproduce a similar problem by bumping the door very |
| slightly and allowing it to quickly reclose. The licensee also reported |
| that the hand pendant associated with the treatment couch recently |
| malfunctioned (in a reproducible way) until the machine was switched off and |
| then back on, when the malfunction ceased. The technician was unable to |
| reproduce this malfunction. |
| |
| The unit appears to be working properly at this time although the licensee |
| has locked the treatment room until all radiation therapists can be briefed |
| on the potential for this malfunction. |
| |
| No patients or personnel were in the room at the time of the test. |
| |
| (Call the NRC Operations Center for contact names and telephone numbers.) |
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