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 +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35402 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Fuel Cycle Facility |Event Number: 35403 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35404 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35405 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35406 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35407 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35408 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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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Page Last Reviewed/Updated Thursday, March 25, 2021