Event Notification Report for April 30, 1999
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/29/1999 - 04/30/1999 ** EVENT NUMBERS ** 35612 35641 35648 35649 35650 35651 35652 35653 35654 35655 35656 +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35612 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: MA DEPT OF PUBLIC HEALTH RCP |NOTIFICATION DATE: 04/21/1999| |LICENSEE: AEA TECHNOLOGIES QSA, INC |NOTIFICATION TIME: 15:00[EDT]| | CITY: BURLINGTON REGION: 1 |EVENT DATE: 04/21/1999| | COUNTY: STATE: MA |EVENT TIME: 14:00[EDT]| |LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 04/29/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |MOHAMED SHANBAKY R1 | | |FREDERICK COMBS NMSS | +------------------------------------------------+JOSEPH GIITTER IRO | | NRC NOTIFIED BY: KEN TRAEGDE |DONNA MARIE PEREZ IP | | HQ OPS OFFICER: DICK JOLLIFFE |LEN WERT R2 | +------------------------------------------------+DALE POWERS R4 | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | |NOCM COMM ASST BRIEF | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - SHIPMENT OF 8 Ir-192 SOURCES (866 CURIES TOTAL) FROM BURLINGTON, MA, | | OVERDUE IN MEXICO - | | | | At 1500 EDT on 04/21/99, Ken Traegde of the Massachusetts Department of | | Public Health Radiation Control Program (RCP) located in Boston, | | Massachusetts, reported that on 04/16/99, AEA Technology QSA, Inc., located | | in Burlington, Massachusetts, shipped a Model-855 source changer loaded with | | eight Iridium-192 sources (totaling 866 curies) via Federal Express to | | Vicont S.A. De C.V. located in Toluca, Mexico. The undamaged package had a | | transport index of 1.4 (normal readings of 1.4 mR/hour at 1 meter and 55 | | mR/hour at the surface) at the time of shipment. | | | | The shipment was scheduled to arrive in Mexico on 04/17/99. As of 1400 EDT | | on 04/21/99, the recipient (Vicont S.A. De C.V.) had received the shipping | | papers but not the container. The shipper and Federal Express have launched | | a full search for the package. The Federal Express Hazardous Material | | Investigation Team has conducted a physical search of Express Depots in | | Boston, Memphis, Los Angeles, and Mexico. | | | | The license numbers are: SU-1485, 12-8361, 52-0243, 54-0237, and 58-0242. | | | | The NRC operations officer notified the Department of Transportation via the | | National Response Center (Gauthier); Report number 481132. | | | | (Contact the NRC operations officer for applicable telephone numbers.) | | | | *********************************** UPDATE AT 1345 ON 04/22/99 BY JONES | | *********************************** | | | | The NRC entered the Monitoring Phase of Normal Mode at 1345 on 04/22/99. | | The NRC operations officer notified the R1DO (Shanbaky), Region 1 (Miller), | | IRO (Congel and Giitter), NMSS (Paperiello), RCT (Weinstein), OPA (Gagner), | | EDO's office (Charleen Raddatz), and Chairman's office (Holian). The RCT | | notified the Federal Emergency Management Agency (Dan Rishe), Department of | | Energy (Thomas Yates), Environmental Protection Agency (Ms. Reddy), | | Department of Agriculture (Bob Conley), Department of Health and Human | | Services (James Raab), and Department of Transportation (Rick Boyle). | | | | *********************************** UPDATE AT 1600 ON 04/22/99 BY JONES | | *********************************** | | | | A Commissioner's Assistants Briefing was conducted at 1600 on 04/22/99. The | | following notifications were made (* office did not participate): IRO (Joe | | Giitter and Eric Weinstein), Chairman Jackson (Dan Gillen), Commissioner | | Dicus (Joel Lubenau), Commissioner Diaz (Patrick Castleman), Commissioner | | McGaffigan (Janet Schlueter), Commissioner Merrifield (JohnThoma), EDO (*Dan | | Martin), DEDE (*Jocelyn Mitchell), NMSS (Don Cool and Carl Paperiello), NMSS | | EO (Fred Combs), R1DO (Mohamed Shanbaky), OPA (Joe Gilland), CAO (Thomas | | Madden), SECY (Andrew Bates), OSP (Paul Lohaus), OIP (Ron Hauber), Region 1 | | (Felicia Hinson and Jim Wiggins, etc), and Region 2 (Doug Collins, Chuck | | Hosey, and Dick Woodruff). The briefer was Fred Combs of NMSS. | | | | At 1610, the NRC operations officer played a tape of briefing for EDO (Dan | | Martin) and DEDE (Jocelyn Mitchell). | | | | ****************************** UPDATE AT 1230 ON 04/23/99 BY TROCINE AND | | JONES ****************************** | | | | A conference call was conducted at 1230 on 04/23/99 to update the status of | | this event. The following NRC offices participated (among others): IRO | | (Himes), NMSS (Brach, Combs, and Cook), Region 1 (Lloyd), Region 2 (Collins | | and Woodruff), Region 4 (Andrews), OPA (Hayden), OIP (Lieberman), OSP | | (Lohaus), and EDO (Raddatz). In addition, the following agencies | | participated: Department of Transportation (Rick Boyle), Massachusetts | | Department of Public Health RCP (Ken Traegde), Federal Express (Scott Mugno, | | Pat Oppenheimer, and Roy Parker), State of Tennessee (Alan Grewe), Tennessee | | Division of Radiation Health (Eddy Nanney), AEA Technology QSA, Inc. (Eric | | Okvist), and Environmental Protection Agency located in Atlanta (Paul | | Wagner). | | | | During this conference call, representatives of Federal Express reported | | that they are confident that the shipment of eight Iridium-192 sources left | | Boston. They issued an 'all-points' search order, faxed a description to | | all 'logical' locations, and conducted repeat physical searches in Memphis, | | Boston, and Mexico, all without locating the shipment to date. (The Los | | Angeles depot was not searched as had been reported on 04/21/99.) | | Massachusetts and Tennessee health authorities conducted radiological | | surveys in Boston and Memphis on 04/22/99 with negative results. | | | | Rick Boyle of the Department of Transportation notified the competent | | authority in Mexico, and Federal Express requested a detailed search of the | | Customs facilities in Mexico City. | | | | The next conference call is scheduled for 1230 EDT on Wednesday, 04/28/99. | | | | ************************* UPDATE AT 1333 ON 04/26/99 FROM TRAEGDE TO TROCINE | | ************************* | | | | At 0619 EDT on 04/26/99, Federal Express confirmed that the serial number on | | a Model-855, Type-B package found at the Stansted Airport (located outside | | of London, England) matched the serial number for the missing package | | containing the eight Iridium-192 sources. The Massachusetts Department of | | Public Health RCP was informed of this discovery by AEA Technology QSA, | | Inc., at 0933 EDT on 04/26/99. The package was reported to be intact and | | undisturbed. The carrier (Federal Express) contacted the shipper (AEA | | Technology QSA, Inc.), and the shipper requested that the package be | | forwarded to its intended destination. Accordingly, the package will be | | shipped from Stansted Airport to Toluca, Mexico, via Memphis, Tennessee. | | Federal Express informed the Massachusetts Department of Public Health RCP | | that the package is expected to arrive in Memphis, Tennessee, by tomorrow | | morning (04/27/99). | | | | The Massachusetts Department of Public Health RCP notified NRC Region 1 | | (Duncan White). The NRC Operations Officer notified the R1DO (Anderson); | | R2DO (Wert); R4DO (Graves); NMSS (Combs); IRO (Giitter, Miller, and Congel); | | RCT (Bailey). | | | | *********************************** UPDATE AT 1600 ON 04/26/99 BY TROCINE | | *********************************** | | | | A conference call was conducted at 1600 on 04/26/99 to update the status of | | this event. The following NRC offices participated (*office did not | | participate): IRO (Giitter), RCT (Bailey), NMSS (Brach and Cool), Region 1 | | (Kinneman), Region 2 (Hosey), Region 4 (*Graves), Region 1 Public Affairs | | (*Screnci and *Sheehan), HQ OPA (Beecher), OIP (Lieberman), OSP (Bolling and | | Lohaus), and EDO (Raddatz). In addition, the following agencies | | participated: Massachusetts Department of Public Health RCP (Ken Traegde), | | State of Tennessee (Alan Grewe and Mike Mobley), and Tennessee Division of | | Radiation Health (Eddy Nanney). | | | | Based upon the information discussed during this conference call (reference | | the 1333 04/26/99 update above), the NRC exited the Monitoring Phase of | | Normal Mode at 1615 on 04/26/99. | | | | The NRC operations officer notified the IRO (Giitter, Miller, and Congel); | | RCT (Bailey); NMSS EO (Cool); NMSS (Brach); Region 1 (Kinneman); Region 2 | | (Hosey); R1DO (Anderson); R2DO (Wert); R4DO (Graves); OPA (Beecher); OIP | | (Lieberman); OSP (Bolling and Lohaus); and EDO (Raddatz). The RCT notified | | the Federal Emergency Management Agency (Dan Rishe), Department of Energy | | (Thomas Yates), Environmental Protection Agency (Ms. Reddy), Department of | | Agriculture (Bob Conley), Department of Health and Human Services (James | | Raab), and Department of Transportation (Rick Boyle). | | | | **** UPDATE AT 1505 ON 4/29/99, BY DAKUBU TAKEN BY WEAVER **** | | | | Dr. Dakubu of the Massachusetts Department of Public Health Radiation | | Control Program (RCP) informed the Ops Center that the sources arrived | | safely at their intended destination in Mexico on 4/28/98. The HOO informed | | the R1DO (Anderson) and NMSS (Camper). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35641 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 04/27/1999| | UNIT: [] [2] [3] STATE: IL |NOTIFICATION TIME: 17:53[EDT]| | RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 04/27/1999| +------------------------------------------------+EVENT TIME: 15:55[CDT]| | NRC NOTIFIED BY: DAVID THRONE |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JOHN MADERA R3 | |10 CFR SECTION: | | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | |2 N Y 99 Power Operation |99 Power Operation | |3 N Y 99 Power Operation |99 Power Operation | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY OF A SAFEGUARDS SYSTEM DEGRADATION RELATED TO THE PERIMETER AREA | | (1-HOUR REPORT) | | | | Security personnel discovered a safeguard system degradation related to the | | perimeter area. Immediate compensatory actions were taken upon discovery. | | (Contact the NRC operations officer for additional details.) | | | | The licensee plans to notify the NRC resident inspector. | | | | * * * UPDATE AT 2007 ON 4/29/99 BY BORING TAKEN BY WEAVER * * * | | | | The licensee is retracting this event based on further review and concluding | | that the event did not constitute a reportable condition. This conclusion | | is based on the fact that compensatory measures were re-established within | | specified time standards. The licensee will inform the NRC resident | | inspector. The HOO notified the R3DO (Madera). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35648 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [] [] STATE: GA |NOTIFICATION TIME: 00:45[EDT]| | RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/28/1999| +------------------------------------------------+EVENT TIME: 18:00[EDT]| | NRC NOTIFIED BY: BRUCE BUTLER |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |AL BELISLE R2 | |10 CFR SECTION: | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 16 Power Operation |16 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - HPCI SYSTEM INOPERABLE DUE TO TRIPPED BAROMETRIC CONDENSER VACUUM PUMP | | BREAKER - | | | | AT 1800 ON 04/28/99, WITH UNIT 1 AT 16% POWER, THE HIGH PRESSURE COOLANT | | INJECTION (HPCI) SYSTEM BAROMETRIC CONDENSER VACUUM PUMP TRIPPED DURING A | | TECH SPEC SURVEILLANCE TEST. PLANT OPERATORS WERE UNABLE TO RESET THE | | VACUUM PUMP CIRCUIT BREAKER AND SHUT THE HPCI SYSTEM DOWN AND DECLARED IT | | INOPERABLE. MAINTENANCE ELECTRICIANS RESET THE VACUUM PUMP CIRCUIT BREAKER | | THERMAL OVERLOADS RESTORING POWER TO THE VACUUM PUMP. MAINTENANCE | | ELECTRICIANS REPLACED THE HPCI SYSTEM VACUUM PUMP CONTROL SWITCH BECAUSE THE | | SWITCH HAS RECENTLY EXPERIENCED PROBLEMS NOT RETURNING TO ITS MID POSITION, | | AS DESIGNED. THE LICENSEE IS CONTINUING TO INVESTIGATE THE CAUSE OF THE | | VACUUM PUMP TRIP. | | | | TECH SPEC LCO ACTION STATEMENT 3.5.1 REQUIRES THE LICENSEE TO VERIFY THE | | OPERABILITY OF THE REACTOR CORE ISOLATION COOLING (RCIC) SYSTEM AND RESTORE | | THE HPCI SYSTEM TO OPERABLE STATUS WITHIN 14 DAYS OR SHUT UNIT 1 DOWN. AT | | 1925, THE LICENSEE VERIFIED THE OPERABILITY OF THE RCIC SYSTEM. | | | | THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35649 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [] [] STATE: LA |NOTIFICATION TIME: 02:06[EDT]| | RXTYPE: [1] GE-6 |EVENT DATE: 04/28/1999| +------------------------------------------------+EVENT TIME: 21:51[CDT]| | NRC NOTIFIED BY: RUSS GODWIN |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |DAVID GRAVES R4 | |10 CFR SECTION: | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Refueling |0 Refueling | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - Fuel Building inoperable due to loss of vacuum in Fuel Building due to an | | open Fuel Building/Annulus door - | | | | At 2151 CDT on 04/28/99, with the plant in Operational Condition 5 in a | | refueling outage, the Fuel Building was determined to be inoperable. At the | | time, fuel inspection activities were in progress in the Fuel Building. | | | | The Fuel Building was rendered inoperable when a Fuel Building/Annulus door | | was opened. The door was opened to allow entry of personnel for completion | | of required testing of lighting circuits. The control room staff was alerted | | to this condition when the "Fuel Building Pressure High" alarm was received. | | Upon receipt of the alarm, the Control Room Supervisor directed that fuel | | handling activities be suspended. Fuel handling activities were immediately | | suspended and not resumed until the door was closed to reestablish Fuel | | Building integrity. | | | | The fuel inspection activities in progress consisted of removing single fuel | | pins from an irradiated bundle. The irradiated bundle was located in the | | fuel preparation machine. | | | | The Fuel Building/Annulus door was required to be closed to maintain the | | leak tightness of the Fuel Building. Plant staff personnel are continuing to | | evaluate this event. However, as a result of the open door, the Fuel | | Building may not have been able to perform its design function. | | | | The licensee informed the NRC Resident Inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Fuel Cycle Facility |Event Number: 35650 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/29/1999| | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 08:28[EDT]| | COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/28/1999| | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:15[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/29/1999| | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION | |LICENSE#: GDP-1 AGREEMENT: Y |JOHN MADERA R3 | | DOCKET: 0707001 |FREDERICK COMBS NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: ERIC WALKER | | | HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 24-HOUR NRC BULLETIN 91-01 REPORT | | | | The following is text from a facsimile submitted to the Operations Center: | | | | "During a walk-down of C-710, room 6, a group of small chemical traps with | | tags indicating less than 5 pounds of uranium were discovered in violation | | of NCSA GEN-10 two foot spacing requirement for UH pieces of equipment. | | These items were improperly categorized as spacing exempt based on the size | | criteria of having dimensions in all directions greater than that of a 5.5 | | gallon drum. Fifty-three items would be required prior to exceeding the UH | | mass at 2.0 wt. % U235. Similar incidents involving the violation were also | | discovered in C-710, room 2. C-409, and C-720. GEN-l0 states that UH items | | must be spaced a minimum of two feet edge-to--edge from other UH items to | | preclude the accumulation of an unsafe uranium mass. | | | | "This event is being categorized as a 24 hour event in accordance with | | Safety Analysis Report Table 6.9-1, Criterion A4.a and Bulletin 91-01, | | Supplement 1. | | | | "SAFETY SIGNIFICANCE OF EVENTS: | | | | "Although the amount of Fissile material present is far below safe mass for | | each item, double contingency was not maintained because the items were not | | handled as UH and properly spaced. | | | | "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW | | CRITICALITY COULD OCCUR: | | | | "In order for a criticality to be possible, greater than 104 of these items | | which contain less than 5 pounds of uranium each would need to be | | accumulated. | | | | "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): | | | | "Interaction and mass | | | | "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS | | LIMIT AND % WORST CASE CRITICAL MASS): | | | | "Variable amount. 2.0 wt. % U235, in the form of UO2F2, with a process limit | | of approximately 600 lbs. at 2.0 wt. % U235 | | | | "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION | | OF THE FAILURES OR DEFICIENCIES: | | | | "The two process conditions relied on in this scenario for double | | contingency are mass and interaction. | | | | "The first leg of double contingency is based on limiting the mass of | | uranium at 2.0 wt. % U235 to 264 pounds of uranium. This Is controlled by | | quantifying the mass of each item using Independent NDAs/visual inspections. | | Each Individual item contains less than 5 pounds of uranium: therefore, this | | control was not violated. The total mass of all the items placed together at | | each location is less than the UH mass limit. | | | | "The second leg of double contingency is based on limiting Interaction | | between UK Items. This is controlled by maintaining minimum two-foot | | edge-to--edge spacing between UH items. Spacing was not maintained between | | the items: therefore, this requirement was violated and the process | | condition was lost, | | | | "Since a control relied upon for double contingency was violated, double | | contingency was lost." | | | | The NRC resident inspector has been informed of this notification. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35651 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [] [] STATE: SC |NOTIFICATION TIME: 11:17[EDT]| | RXTYPE: [1] W-3-LP |EVENT DATE: 04/29/1999| +------------------------------------------------+EVENT TIME: 09:28[EDT]| | NRC NOTIFIED BY: APRIL RICE |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |AL BELISLE R2 | |10 CFR SECTION: | | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Refueling |0 Refueling | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - DEATH OF A CONTRACT EMPLOYEE - | | | | At 0928 on 04/29/99, South Carolina Electric & Gas Company was notified that | | a Fluor Daniel contract employee had passed away. The individual had fallen | | unconscious earlier in the day while on a break and had been evacuated to a | | local hospital (Richland County Memorial Hospital). The individual was not | | contaminated and this event is not attributed to a work related injury. The | | exact cause of death is not known at this time. Local officials (e.g. the | | Fairfield County coroner) and the NRC Resident Inspector have been notified. | | The licensee does not plan to issue a press release at this time. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35652 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TERRE HAUTE REGIONAL HOSPITAL |NOTIFICATION DATE: 04/29/1999| |LICENSEE: TERRE HAUTE REGIONAL HOSPITAL |NOTIFICATION TIME: 11:23[EDT]| | CITY: TERRE HAUTE REGION: 3 |EVENT DATE: 04/19/1999| | COUNTY: STATE: IN |EVENT TIME: [CST]| |LICENSE#: 13-09649-01 AGREEMENT: N |LAST UPDATE DATE: 04/29/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |JOHN MADERA R3 | | |DON COOL NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: CHRIS NEWLIN | | | HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - RADIATION OVERDOSE DURING A BREAST CANCER TREATMENT - | | | | A HOSPITAL TECHNICIAN LEFT A 30 DEGREE WEDGE OUT OF A COBALT TELETHERAPY | | MACHINE WHICH RESULTED IN A 33% RADIATION OVERDOSE TO A PATIENT DURING A | | BREAST CANCER TREATMENT. THE OVERDOSE OCCURRED DURING A DAILY TREATMENT FOR | | FIVE CONSECUTIVE DAYS (04/19-23/99). THERE WAS NO ADVERSE IMPACT TO THE | | PATIENT. THE PATIENT'S DOSE WILL BE REDUCED OVER THE NEXT 15 TREATMENTS. | | THE PATIENT'S DOCTOR PLANS TO INFORM THE PATIENT LATER TODAY. | | | | HOSPITAL PERSONNEL PLAN TO SUBMIT A WRITTEN REPORT TO NRC REGION 3 WITHIN 15 | | DAYS. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35653 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: NORTH ANNA REGION: 2 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [2] [] STATE: VA |NOTIFICATION TIME: 12:11[EDT]| | RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 04/29/1999| +------------------------------------------------+EVENT TIME: 12:05[EDT]| | NRC NOTIFIED BY: RICHARD WESLEY |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |AL BELISLE R2 | |10 CFR SECTION: | | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 100 Power Operation |100 Power Operation | |2 N Y 100 Power Operation |100 Power Operation | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MAINTENANCE ON TECHNICAL SUPPORT CENTER POWER SUPPLY | | | | Planned maintenance is being performed on the TSC electrical supply which | | results in a loss of the electrical service to the TSC for more than one | | hour. The maintenance is expected to last four hours and started at 1205 on | | 4/29/99. | | | | The licensee will notify the NRC resident inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35654 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: BRAIDWOOD REGION: 3 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 14:14[EDT]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/29/1999| +------------------------------------------------+EVENT TIME: 07:58[CDT]| | NRC NOTIFIED BY: GREG BAKER |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JOHN MADERA R3 | |10 CFR SECTION: | | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 100 Power Operation |100 Power Operation | |2 N N 0 Refueling |0 Refueling | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A CONTRACT SUPERVISOR WAS DETERMINED TO BE UNDER THE INFLUENCE OF ALCOHOL | | DURING A FOR-CAUSE TEST. THE EMPLOYEE'S ACCESS TO THE SITE HAS BEEN | | TERMINATED. CONTACT THE OPERATIONS CENTER FOR ADDITIONAL DETAILS. THE | | LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35655 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 04/29/1999| | UNIT: [1] [2] [] STATE: CA |NOTIFICATION TIME: 16:21[EDT]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/29/1999| +------------------------------------------------+EVENT TIME: 12:45[PDT]| | NRC NOTIFIED BY: DAVID PATTY |LAST UPDATE DATE: 04/29/1999| | HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |DAVID GRAVES R4 | |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 | |2 N Y 50 Power Operation |50 Power Operation | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MISSED SURVEILLANCE ON POWER RANGE LOWER POWER TRIP | | | | Technical Specification 4.3.1.2 Surveillance Requirement for Reactor Trip | | System Response Time for the Power Range Low Set Point Trip for was | | performed during initial startup testing. It has not been performed since | | 1975 on Unit 1 and 1984 on Unit 2. This function is required to be operable | | in Mode 2 and in Mode 1 below P-10 (10% power). Each unit has been in Modes | | 1 and 2 many times without a current response time test. The next time each | | unit goes below P-10, Technical Specification 4.0.3 Action will be applied | | (the surveillance will be performed). | | | | The licensee notified the NRC resident inspector. | | | | This discrepancy was discovered during an engineering department review of | | Standard Technical Specifications. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Other Nuclear Material |Event Number: 35656 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TRIAD ENGINEERING |NOTIFICATION DATE: 04/29/1999| |LICENSEE: TRIAD ENGINEERING |NOTIFICATION TIME: 18:52[EDT]| | CITY: WINCHESTER REGION: 2 |EVENT DATE: 04/29/1999| | COUNTY: STATE: VA |EVENT TIME: 16:00[EDT]| |LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 04/29/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |AL BELISLE R2 | | |FREDERICK COMBS NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: DENNIS CHAMBERS | | | HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STOLEN TROXLER GAUGE | | | | A TROXLER moisture density gauge was stolen from a work site in Fairfax, VA. | | The gauge was in the back of a pickup truck when the truck was stolen late | | in the afternoon of 4/29/99. A report has been filed with the police. | | The gauge contains Cs-137 and Am-241. The gauge was a model 3411B, the | | first character of the serial number was not clearly legible on the | | paperwork, but ended with the numbers 929. | +------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021