Event Notification Report for May 07, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/06/1999 - 05/07/1999
EVENT NUMBERS
356883568935690356923569635708
Other Nuclear Material
Event Number: 35688
Rep Org: USAF RADIOISOTOPE COMMITTEE
Licensee: USAF RADIOISOTOPE COMMITTEE
Region: 2
City: Sumptor State: SC
County:
License #: 42-23539-01AF
Agreement: Y
Docket: 03028641
NRC Notified By: MAJOR JAMES HICKS
HQ OPS Officer: LEIGH TROCINE
Licensee: USAF RADIOISOTOPE COMMITTEE
Region: 2
City: Sumptor State: SC
County:
License #: 42-23539-01AF
Agreement: Y
Docket: 03028641
NRC Notified By: MAJOR JAMES HICKS
HQ OPS Officer: LEIGH TROCINE
Notification Date: 05/07/1999
Notification Time: 10:45 [ET]
Event Date: 05/07/1999
Event Time: 09:38 [EDT]
Last Update Date: 09/10/1999
Notification Time: 10:45 [ET]
Event Date: 05/07/1999
Event Time: 09:38 [EDT]
Last Update Date: 09/10/1999
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):
CHRIS CHRISTENSEN (R2)
BILL JONES (R4)
DON COOL (NMSS)
FRANK CONGEL (IRO)
CHRIS CHRISTENSEN (R2)
BILL JONES (R4)
DON COOL (NMSS)
FRANK CONGEL (IRO)
DISCOVERY OF A MISSING CHEMICAL AGENT MONITOR CONTAINING 15 mCi OF NICKEL-63 FROM SHAW AIR FORCE BASE LOCATED IN SUMTER, SOUTH CAROLINA
At 0938 on 05/07/99, Shaw Air Force Base (AFB) located in Sumter, South Carolina, notified the U.S. Air Force Radioisotope Committee located at Bolling AFB located in Washington D.C. of a missing chemical agent monitor (CAM) containing a 15-mCi nickel-63 source.
On 04/27/99, the base radiation safety officer (RSO) at Shaw AFB conducted an inventory of CAMs located in building #1981. The correct number of CAMs were there, but one had the wrong serial number. Examination of previous inventories shows one CAM with a different serial number. The building had been searched with no success. The 20CES/CEX RSO has no explanation for the different serial number on one CAM or where the correct CAM may be located.
It is suspected that the CAM may have been exchanged with another Air Force Unit or may have been sent off for calibration. At this time, the U.S. Air Force Radioisotope Committee believes that the CAM is still in Air Force possession. Past shipping records will be researched, and calibration labs that serve Shaw AFB will be notified. The completion time for these actions is currently estimated to be 06/07/99.
Call the NRC Operations Officer for a licensee contact telephone number.
The licensee plans to notify the NRC Region 4 office and plans to issue a 30-day written report.
*** UPDATE ON 6/11/99 @ 1242 BY HICKS TO GOULD *** INTERIM REPORT
MISSING CAM SERIAL NUMBER: CAN-C-04646
RADIOACTIVITY MATERIAL CONTAINED: 10 mCi OF Ni-63
ACTIVITY: 0.05 Ci
CHEMICAL AND PHYSICAL FORM: SOLID
A SERIAL NUMBER DISCREPANCY WAS NOTED DURING A SEMIANNUAL CAM INVENTORY CONDUCTED 4/27/99. THE PREVIOUS INVENTORY CONDUCTED 10/98 INDICATED NO DISCREPANCIES.
A DISPOSITION, OR PROBABLE DISPOSITION, OF THE MATERIAL IS UNDETERMINABLE.
THERE EXISTS THE POSSIBILITY THAT CALIBRATION SERVICES MAY HAVE SWAPPED OUT THE CAM WITH ANOTHER MONITOR. ALSO, A POLICE INVESTIGATION MAY BE REQUIRED SINCE THE DEVICE IS WORTH OVER $3,000.00.
NOTIFIED REG 2 RDO(BONSER), REG 4 RDO(ANDREWS), AND NMSS EO(COOL).
*** UPDATE ON 9/10/99 AT 1316 FROM HICKS (FAX) TO POERTNER ***
The investigative officer concluded a one-for-one swap out of a CAM must have occurred. There is no supporting documentation, but numerically this unit is in possession of 5 CAMS which is consistent with the quantity always on hand. They believe the CAM was exchanged with one belonging to a unit deployed overseas. The investigation is closed.
Notified R4DO (SANBORN), R2DO (HAAG), and NMSS (PICCONE).
At 0938 on 05/07/99, Shaw Air Force Base (AFB) located in Sumter, South Carolina, notified the U.S. Air Force Radioisotope Committee located at Bolling AFB located in Washington D.C. of a missing chemical agent monitor (CAM) containing a 15-mCi nickel-63 source.
On 04/27/99, the base radiation safety officer (RSO) at Shaw AFB conducted an inventory of CAMs located in building #1981. The correct number of CAMs were there, but one had the wrong serial number. Examination of previous inventories shows one CAM with a different serial number. The building had been searched with no success. The 20CES/CEX RSO has no explanation for the different serial number on one CAM or where the correct CAM may be located.
It is suspected that the CAM may have been exchanged with another Air Force Unit or may have been sent off for calibration. At this time, the U.S. Air Force Radioisotope Committee believes that the CAM is still in Air Force possession. Past shipping records will be researched, and calibration labs that serve Shaw AFB will be notified. The completion time for these actions is currently estimated to be 06/07/99.
Call the NRC Operations Officer for a licensee contact telephone number.
The licensee plans to notify the NRC Region 4 office and plans to issue a 30-day written report.
*** UPDATE ON 6/11/99 @ 1242 BY HICKS TO GOULD *** INTERIM REPORT
MISSING CAM SERIAL NUMBER: CAN-C-04646
RADIOACTIVITY MATERIAL CONTAINED: 10 mCi OF Ni-63
ACTIVITY: 0.05 Ci
CHEMICAL AND PHYSICAL FORM: SOLID
A SERIAL NUMBER DISCREPANCY WAS NOTED DURING A SEMIANNUAL CAM INVENTORY CONDUCTED 4/27/99. THE PREVIOUS INVENTORY CONDUCTED 10/98 INDICATED NO DISCREPANCIES.
A DISPOSITION, OR PROBABLE DISPOSITION, OF THE MATERIAL IS UNDETERMINABLE.
THERE EXISTS THE POSSIBILITY THAT CALIBRATION SERVICES MAY HAVE SWAPPED OUT THE CAM WITH ANOTHER MONITOR. ALSO, A POLICE INVESTIGATION MAY BE REQUIRED SINCE THE DEVICE IS WORTH OVER $3,000.00.
NOTIFIED REG 2 RDO(BONSER), REG 4 RDO(ANDREWS), AND NMSS EO(COOL).
*** UPDATE ON 9/10/99 AT 1316 FROM HICKS (FAX) TO POERTNER ***
The investigative officer concluded a one-for-one swap out of a CAM must have occurred. There is no supporting documentation, but numerically this unit is in possession of 5 CAMS which is consistent with the quantity always on hand. They believe the CAM was exchanged with one belonging to a unit deployed overseas. The investigation is closed.
Notified R4DO (SANBORN), R2DO (HAAG), and NMSS (PICCONE).
Power Reactor
Event Number: 35689
Facility: HATCH
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: EDWEN URQUHART
HQ OPS Officer: BOB STRANSKY
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: EDWEN URQUHART
HQ OPS Officer: BOB STRANSKY
Notification Date: 05/07/1999
Notification Time: 11:09 [ET]
Event Date: 05/07/1999
Event Time: 08:21 [EDT]
Last Update Date: 05/07/1999
Notification Time: 11:09 [ET]
Event Date: 05/07/1999
Event Time: 08:21 [EDT]
Last Update Date: 05/07/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
CHRIS CHRISTENSEN (R2)
CHRIS CHRISTENSEN (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 53 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM DUE TO LOSS OF EHC PRESSURE
An automatic reactor scram occurred due to high reactor vessel pressure (1080 psig) after the main turbine stop and control valves drifted closed. All control rods inserted following the scram, and all systems functioned as expected. Neither the HPCI nor RCIC systems started, as reactor vessel water level did not decrease to the automatic actuation setpoint. The licensee reported that an operator inadvertently isolated the main turbine electrohydraulic control (EHC) system oil supply while tagging out the standby EHC oil pump, causing the turbine stop and control valves to drift closed.
The NRC Resident Inspector has been informed of this notification by the licensee.
An automatic reactor scram occurred due to high reactor vessel pressure (1080 psig) after the main turbine stop and control valves drifted closed. All control rods inserted following the scram, and all systems functioned as expected. Neither the HPCI nor RCIC systems started, as reactor vessel water level did not decrease to the automatic actuation setpoint. The licensee reported that an operator inadvertently isolated the main turbine electrohydraulic control (EHC) system oil supply while tagging out the standby EHC oil pump, causing the turbine stop and control valves to drift closed.
The NRC Resident Inspector has been informed of this notification by the licensee.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 35690
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: LANGE
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: LANGE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/07/1999
Notification Time: 12:41 [ET]
Event Date: 05/07/1999
Event Time: 09:50 [EDT]
Last Update Date: 05/13/1999
Notification Time: 12:41 [ET]
Event Date: 05/07/1999
Event Time: 09:50 [EDT]
Last Update Date: 05/13/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES LINVILLE (R1)
JAMES LINVILLE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 59 | Power Operation | 59 | Power Operation |
THE LICENSEE DECLARED THE HIGH PRESSURE CORE SPRAY (HPCS) SYSTEM INOPERABLE AND ENTERED A 14-DAY LCO ACTION STATEMENT.
THE HPCS SYSTEM FAILED TO MEET THE CHANNEL CHECK CRITERIA AND WAS DECLARED INOPERABLE, BUT FUNCTIONAL. TWO TRIP UNITS WERE FOUND NOT TO BE WITHIN THE 13-INCH LIMIT FOR LEVEL INITIATION INSTRUMENTATION. (THEY MEASURED 15 INCHES.) A WORK ORDER HAS BEEN GENERATED TO CORRECT THE PROBLEM BEFORE THE TIME CLOCK EXPIRES FOR THE LCO ACTION STATEMENT. THE REACTOR IS CURRENTLY IN SINGLE LOOP OPERATION AT 59% POWER.
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.
***RETRACTION ON 04/13/99 AT 1651 EDT FROM ROY GREEN TAKEN BY MACKINNON***
IT HAS BEEN DETERMINED THAT THE CHANNEL CHECK CRITERIA WERE MET AND THAT THE HIGH PRESSURE CORE SPRAY SYSTEM WAS, THEREFORE, NOT INOPERABLE. PROCEDURAL GUIDANCE THAT LED TO THE INOPERABLE DETERMINATION HAS BEEN CHANGED AFTER ENGINEERING PROVIDED THE NECESSARY JUSTIFICATION.
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE R1DO (JOHN CARUSO) WAS NOTIFIED BY THE NRC OPERATIONS OFFICER.
THE HPCS SYSTEM FAILED TO MEET THE CHANNEL CHECK CRITERIA AND WAS DECLARED INOPERABLE, BUT FUNCTIONAL. TWO TRIP UNITS WERE FOUND NOT TO BE WITHIN THE 13-INCH LIMIT FOR LEVEL INITIATION INSTRUMENTATION. (THEY MEASURED 15 INCHES.) A WORK ORDER HAS BEEN GENERATED TO CORRECT THE PROBLEM BEFORE THE TIME CLOCK EXPIRES FOR THE LCO ACTION STATEMENT. THE REACTOR IS CURRENTLY IN SINGLE LOOP OPERATION AT 59% POWER.
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.
***RETRACTION ON 04/13/99 AT 1651 EDT FROM ROY GREEN TAKEN BY MACKINNON***
IT HAS BEEN DETERMINED THAT THE CHANNEL CHECK CRITERIA WERE MET AND THAT THE HIGH PRESSURE CORE SPRAY SYSTEM WAS, THEREFORE, NOT INOPERABLE. PROCEDURAL GUIDANCE THAT LED TO THE INOPERABLE DETERMINATION HAS BEEN CHANGED AFTER ENGINEERING PROVIDED THE NECESSARY JUSTIFICATION.
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE R1DO (JOHN CARUSO) WAS NOTIFIED BY THE NRC OPERATIONS OFFICER.
Fuel Cycle Facility
Event Number: 35692
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: BEASLEY
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: BEASLEY
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/07/1999
Notification Time: 23:00 [ET]
Event Date: 05/07/1999
Event Time: 13:45 [CDT]
Last Update Date: 05/07/1999
Notification Time: 23:00 [ET]
Event Date: 05/07/1999
Event Time: 13:45 [CDT]
Last Update Date: 05/07/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MONTE PHILLIPS (R3)
JOHN GREEVES (NMSS)
MONTE PHILLIPS (R3)
JOHN GREEVES (NMSS)
PRIMARY CONDENSATE ALARM RECEIVED AT THE C-337-A FACILITY.
A PRIMARY CONDENSATE ALARM WAS RECEIVED ON THE C-337-A #1 EAST AUTOCLAVE WATER INVENTORY CONTROL (WIC) SYSTEM. THE WIC SYSTEM IS REQUIRED TO BE OPERABLE WHILE HEATING IN MODE 5 ACCORDING TO TECHNICAL SAFETY REQUIREMENT #2.2.4.2. THE AUTOCLAVE WAS CHECKED ACCORDING TO THE ALARM RESPONSE PROCEDURE, AND SUBSEQUENTLY REMOVED FROM SERVICE AND DECLARED INOPERABLE. TROUBLESHOOTING WAS INITIATED AND IS CONTINUING IN ORDER TO DETERMINE THE REASON FOR THE ALARM.
THE NRC RESIDENT INSPECTOR WAS INFORMED.
A PRIMARY CONDENSATE ALARM WAS RECEIVED ON THE C-337-A #1 EAST AUTOCLAVE WATER INVENTORY CONTROL (WIC) SYSTEM. THE WIC SYSTEM IS REQUIRED TO BE OPERABLE WHILE HEATING IN MODE 5 ACCORDING TO TECHNICAL SAFETY REQUIREMENT #2.2.4.2. THE AUTOCLAVE WAS CHECKED ACCORDING TO THE ALARM RESPONSE PROCEDURE, AND SUBSEQUENTLY REMOVED FROM SERVICE AND DECLARED INOPERABLE. TROUBLESHOOTING WAS INITIATED AND IS CONTINUING IN ORDER TO DETERMINE THE REASON FOR THE ALARM.
THE NRC RESIDENT INSPECTOR WAS INFORMED.
General Information or Other
Event Number: 35696
Rep Org: NEW YORK CITY DEPART OF HEALTH
Licensee: BROWNING FERRIS INDUSTRIES
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BORRI (NYC DPT OF HEALTH)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: BROWNING FERRIS INDUSTRIES
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BORRI (NYC DPT OF HEALTH)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/10/1999
Notification Time: 11:47 [ET]
Event Date: 05/07/1999
Event Time: 08:00 [EDT]
Last Update Date: 05/10/1999
Notification Time: 11:47 [ET]
Event Date: 05/07/1999
Event Time: 08:00 [EDT]
Last Update Date: 05/10/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CURTIS COWGILL (R1)
FRED COMBS (NMSS)
CURTIS COWGILL (R1)
FRED COMBS (NMSS)
LANDFILL REJECTED HOSPITAL SOLID WASTE CONTAINING 300 MILLICURIES OF TECHNETIUM-99m
BROWNING FERRIS INDUSTRIES (BFI) RECEIVED A LOAD OF SOLID WASTE FROM CITY HOSPITAL CENTER AT ELMHURST IN NEW YORK CITY AND TOOK IT TO THEIR TRANSFER STATION IN BROOKLYN, NY. THE WASTE WAS THEN MOVED TO A LANDFILL IN COMSTOCK, PA WHERE IT WAS REJECTED AND RETURNED TO THE BFI FACILITY IN BROOKLYN ON 05/07/99. THE WASTE CONTAINED APPROXIMATELY 300 MILLICURIES OF TECHNETIUM-99m. THE WASTE IS BEING RETURNED TO THE HOSPITAL. THE CITY IS INVESTIGATING THIS INCIDENT.
BROWNING FERRIS INDUSTRIES (BFI) RECEIVED A LOAD OF SOLID WASTE FROM CITY HOSPITAL CENTER AT ELMHURST IN NEW YORK CITY AND TOOK IT TO THEIR TRANSFER STATION IN BROOKLYN, NY. THE WASTE WAS THEN MOVED TO A LANDFILL IN COMSTOCK, PA WHERE IT WAS REJECTED AND RETURNED TO THE BFI FACILITY IN BROOKLYN ON 05/07/99. THE WASTE CONTAINED APPROXIMATELY 300 MILLICURIES OF TECHNETIUM-99m. THE WASTE IS BEING RETURNED TO THE HOSPITAL. THE CITY IS INVESTIGATING THIS INCIDENT.
General Information or Other
Event Number: 35708
Rep Org: KANSAS DEPT OF HEALTH & ENVIROMENT
Licensee: VIA CHRISTI REGIONAL MEDICAL CTR
Region: 4
City: WICHITA State: KS
County: SEDGWICK
License #: 19-C030-01
Agreement: Y
Docket:
NRC Notified By: FRAASS
HQ OPS Officer: CHAUNCEY GOULD
Licensee: VIA CHRISTI REGIONAL MEDICAL CTR
Region: 4
City: WICHITA State: KS
County: SEDGWICK
License #: 19-C030-01
Agreement: Y
Docket:
NRC Notified By: FRAASS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/12/1999
Notification Time: 18:11 [ET]
Event Date: 05/07/1999
Event Time: 10:00 [CDT]
Last Update Date: 05/12/1999
Notification Time: 18:11 [ET]
Event Date: 05/07/1999
Event Time: 10:00 [CDT]
Last Update Date: 05/12/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHARLES CAIN (R4)
JOE HOLONICH (NMSS)
FRANK CONGEL (IRO)
CHARLES CAIN (R4)
JOE HOLONICH (NMSS)
FRANK CONGEL (IRO)
ON 05/12/99, THE VIA CHRISTI REGIONAL MEDICAL CENTER NOTIFIED THE KANSAS RADIATION CONTROL PROGRAM THAT A PROBABLE MEDICAL MISADMINISTRATION OCCURRED ON 05/07/99 AT 1000 CDT.
A 28-YEAR-OLD FEMALE, WHO IS APPARENTLY 19 WEEKS PREGNANT, WAS GIVEN A THERAPEUTIC DOSE OF I-131 (11.8 MILLICURIES). THE CENTER'S RADIATION SAFETY OFFICER CONTACTED REAC/TS, AND THE ONCOLOGIST WHO REQUESTED THE STUDY HAS ALREADY BEEN CONTACTED BY A PHYSICIAN FROM REAC/TS. A SECOND CONFERENCE CALL IS SCHEDULED WITH THE PATIENT'S OB/GYN PHYSICIAN. THE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT HAS BEGUN AN INVESTIGATION INTO THIS INCIDENT.
CONTACT THE OPERATIONS CENTER FOR THE STATE CONTACT'S TELEPHONE NUMBER.
A 28-YEAR-OLD FEMALE, WHO IS APPARENTLY 19 WEEKS PREGNANT, WAS GIVEN A THERAPEUTIC DOSE OF I-131 (11.8 MILLICURIES). THE CENTER'S RADIATION SAFETY OFFICER CONTACTED REAC/TS, AND THE ONCOLOGIST WHO REQUESTED THE STUDY HAS ALREADY BEEN CONTACTED BY A PHYSICIAN FROM REAC/TS. A SECOND CONFERENCE CALL IS SCHEDULED WITH THE PATIENT'S OB/GYN PHYSICIAN. THE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT HAS BEGUN AN INVESTIGATION INTO THIS INCIDENT.
CONTACT THE OPERATIONS CENTER FOR THE STATE CONTACT'S TELEPHONE NUMBER.