Event Notification Report for June 25, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/24/1999 - 06/25/1999
** EVENT NUMBERS **
35855 35856 35857 35858 35859
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 35855 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 06/24/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 05:18[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 06/23/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 20:50[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 06/24/1999|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |MIKE JORDAN R3 |
| DOCKET: 0707001 |ROBERT PIERSON NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MATT MAURER | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24 HOUR REPORT - SAFETY SYSTEM ACTUATION |
| |
| "At 2050 CDT on 6/23/99, C-333A Autoclave Position 1 North received a High |
| Autoclave Steam Pressure Alarm while in Technical Specification Requirement |
| mode 5. The Autoclave Steam Pressure Control System is required to be |
| operable while in mode 5 per LCO 2.2,3.3. An Increase in autoclave steam |
| pressure was observed by the Autoclave Steam Pressure Control System and the |
| system isolated the steam from the autoclave as designed. The autoclave was |
| placed in mode 2 and the cause of the safety system actuation is being |
| investigated." |
| |
| The NRC Resident Inspector has been notified of this event. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 35856 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: U.S. VETERANS ADMINISTRATION |NOTIFICATION DATE: 06/24/1999|
|LICENSEE: DURHAM VA HOSPITAL |NOTIFICATION TIME: 15:00[EDT]|
| CITY: DURHAM REGION: 2 |EVENT DATE: 05/28/1999|
| COUNTY: STATE: NC |EVENT TIME: 12:00[EDT]|
|LICENSE#: 32-01134-01 AGREEMENT: Y |LAST UPDATE DATE: 06/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |AL BELISLE R2 |
| |FRED COMBS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: LYNNE McGUIRE | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LOSS OF IODINE-125 SEEDS INTO SANITARY SEWER |
| |
| "On May 28, 1999, two I-125 sources, with a combined activity of 0.584 mCi, |
| were lost from the Medical Center. The seeds had been implanted into a |
| patient's prostate earlier in the day. The patient had been instructed to |
| save his urine so that any seeds passed in the urine could be recovered. An |
| instruction sheet was posted on the door, directing that all urine, trash |
| and linen be saved, and nurses had been trained for the procedure. A nurse |
| called nuclear medicine to report that two seeds were in the urine |
| container. When nuclear medicine personnel arrived to recover the seeds, |
| the urine had been flushed into the sanitary sewer by another staff member |
| on the floor. |
| |
| "The toilet and urine container were surveyed with a portable low-energy |
| gamma detector, and no residual activity was detected. The sources are |
| presumed to have gone into the sewer, and assuming the seeds remain covered |
| by water, no significant exposure is expected to any individual member of |
| the public. On June 1, 1999, the loss of the sources was reported by phone |
| to the VA National Health Physics Program. |
| |
| "In order to prevent recurrence of this type of incident, the nurses on ward |
| 7A have been retrained in the proper procedures. In the future, implant |
| patient rooms will be posted with larger signs saying 'hold urine, trash, |
| linen'." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35857 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 06/24/1999|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 17:05[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 06/24/1999|
+------------------------------------------------+EVENT TIME: 15:41[EDT]|
| NRC NOTIFIED BY: ROY GREEN |LAST UPDATE DATE: 06/24/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR SCRAM WITH PARTIAL LOSS OF OFFSITE POWER |
| |
| An automatic reactor scram occurred due to low reactor vessel water level. |
| The low level condition was caused by the failure of a feedwater level |
| controller. All control rods inserted following the scram. Offsite power |
| line #5 failed to transfer following the scram, causing the following ESF |
| actuations to occur: reactor building ventilation isolation, standby gas |
| treatment system initiation, Division 1 and 3 emergency diesel generator |
| (EDG) initiation, and control room special filter train initiation. In |
| addition, operators manually closed the main steam isolation valves (MSIVs) |
| in response to decreasing condenser vacuum caused by a loss of power to the |
| offgas system. The unit is currently in Hot Shutdown, with reactor vessel |
| water level being controlled by the reactor core isolation cooling (RCIC) |
| system, and decay heat being removed via the safety/relief valves (SRVs). |
| The licensee plans to take the unit to Cold Shutdown. |
| |
| The licensee is currently troubleshooting the offsite power line #5 in order |
| to restore power to affected systems. |
| The NRC resident inspector has been informed of this event. |
| |
| * * * Update at 2244 on 06/24/99 from Trombley taken by Stransky * * * |
| |
| Scram recovery activities are continuing. Offsite power line #5 has been |
| restored, and the Division 1 EDG has been secured. The licensee is |
| currently in the process of securing the Division 3 EDG. Operators |
| experienced some problems with the RCIC flow controller and have taken |
| manual control of the system [see related EN 35859]. The NRC Operations |
| Officer notified R1DO (Glenn Meyer). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 35858 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ALASKA REGIONAL HOSPITAL |NOTIFICATION DATE: 06/24/1999|
|LICENSEE: ALASKA REGIONAL HOSPITAL |NOTIFICATION TIME: 19:27[EDT]|
| CITY: ANCHORAGE REGION: 4 |EVENT DATE: 06/24/1999|
| COUNTY: STATE: AK |EVENT TIME: 12:00[YDT]|
|LICENSE#: 50-18244-01 AGREEMENT: N |LAST UPDATE DATE: 06/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOSEPH TAPIA R4 |
| |ROBERT PIERSON NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BRADLEY CRUZ | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATIONS CAUSED BY INCORRECT REPLACEMENT PART IN |
| APPLICATOR |
| |
| The licensee reported that four medical misadministrations occurred due to |
| the installation of an incorrect replacement part into an applicator that is |
| used in conjunction with a brachytherapy device. The affected part is an |
| insert for a "Duiclos mini ovoid" applicator (manufacturer unknown), |
| purchased from the Radiation Products Design catalog. The supplied |
| replacement part looks similar to the original one, but is slightly shorter |
| (the parts are not imprinted with any identification number). Due to the |
| differing dimensions, treatments given using the applicator result in the |
| source being placed at a slightly different axial location than intended, |
| resulting in less than prescribed doses to the treatment area. The |
| misadministrations are characterized as follows: (1) patient prescribed |
| 3000 rads (cGy), received 1874 rads; (2) patient prescribed 3000 rads, |
| received 2035 rads; (3) patient prescribed 2500 rads, received 1822 rads; |
| (4) patient prescribed 3000 rads, received 2004 rads. This condition was |
| discovered when an x-ray indicated that the source was slightly out of |
| position. |
| |
| The licensee plans to contact the vendor in order to obtain the correct |
| insert for the applicator. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35859 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 06/24/1999|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 22:44[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 06/24/1999|
+------------------------------------------------+EVENT TIME: 22:07[EDT]|
| NRC NOTIFIED BY: WALT TROMBLEY |LAST UPDATE DATE: 06/24/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Shutdown |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| RCIC SYSTEM DECLARED INOPERABLE |
| |
| The Unit 2 reactor core isolation cooling (RCIC) system was declared |
| inoperable after operators noticed swings of 200-300 gpm in the system flow |
| rate. The system is currently being used to provide level control to the |
| reactor vessel following a scram [see related EN 35857]. The system flow |
| rate stabilized after operators placed the RCIC flow controller in manual, |
| so the licensee considers the system to be inoperable but functional. The |
| licensee is continuing to cool down Unit 2. The licensee plans to inform |
| the NRC resident inspector of this report. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021