Event Notification Report for September 20, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/19/1999 - 09/20/1999
EVENT NUMBERS
3620736201362023621436333
Fuel Cycle Facility
Event Number: 36207
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: JEFF CASTLE
HQ OPS Officer: DICK JOLLIFFE
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: JEFF CASTLE
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 09/21/1999
Notification Time: 17:10 [ET]
Event Date: 09/20/1999
Event Time: 20:18 [EDT]
Last Update Date: 09/21/1999
Notification Time: 17:10 [ET]
Event Date: 09/20/1999
Event Time: 20:18 [EDT]
Last Update Date: 09/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROGER LANKSBURY (R3)
JOHN SURMEIER (NMSS)
ROGER LANKSBURY (R3)
JOHN SURMEIER (NMSS)
- Site DOE Rep notified of the loss of one NCSA control at a DOE regulated area of the site -
At 2018 on 09/20/99, it was determined that a Nuclear Criticality Safety Approval (NCSA) requirement was violated in the X-705 West Annex which is a Department of Energy (DOE) regulated area of the Portsmouth site. This event was reportable to DOE as a loss of one NCSA control. This notification to another government agency is reportable to the NRC as a four hour event notification report.
There was no radioactive or radiological contamination exposure as a result of this event.
Portsmouth personnel notified the NRC Resident Inspector.
At 2018 on 09/20/99, it was determined that a Nuclear Criticality Safety Approval (NCSA) requirement was violated in the X-705 West Annex which is a Department of Energy (DOE) regulated area of the Portsmouth site. This event was reportable to DOE as a loss of one NCSA control. This notification to another government agency is reportable to the NRC as a four hour event notification report.
There was no radioactive or radiological contamination exposure as a result of this event.
Portsmouth personnel notified the NRC Resident Inspector.
Power Reactor
Event Number: 36201
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CHISM
HQ OPS Officer: CHAUNCEY GOULD
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CHISM
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/20/1999
Notification Time: 03:59 [ET]
Event Date: 09/20/1999
Event Time: 00:09 [EDT]
Last Update Date: 09/20/1999
Notification Time: 03:59 [ET]
Event Date: 09/20/1999
Event Time: 00:09 [EDT]
Last Update Date: 09/20/1999
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 |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 4 | Startup | 0 | Hot Standby |
THE REACTOR WAS MANUALLY SCRAMMED AT 4% POWER.
While in mode 2 at approximately 450 psig during unit 2 startup, an automatic group 1 (MSIV's, steam line drain and reactor sample valves) isolation occurred. The main steam line isolation caused reactor pressure to rise. The licensee inserted control rods and stabilized reactor pressure at approximately 950 psig. After verifying that the automatic isolation signal had cleared, the licensee equalized around and reopened the MSIV's in order to restart a reactor feed pump and restore RPV level control. When feed flow was restored, a rapid power rise was observed prompting the licensee to insert a manual reactor scram. All control rods fully inserted as expected, and no ECCS actuation occurred or safety relief valves lifted. The licensee took conservative action to insert a manual scram.
The systems affected by the automatic isolations were returned to service. Unit 2 is currently in hot shutdown. The licensee has formed an event investigation team for this event. The cause of the automatic isolation has not been positively determined, but it appears the isolation occurred when the licensee was draining the condenser pressure sensing lines for the pressure transmitters resulting in a Group 1 isolation on low condenser vacuum in accordance with 0GP-02, APPROACH TO CRITICALITY AND PRESSURIZATION OF THE REACTOR.
The Resident Inspector was notified.
While in mode 2 at approximately 450 psig during unit 2 startup, an automatic group 1 (MSIV's, steam line drain and reactor sample valves) isolation occurred. The main steam line isolation caused reactor pressure to rise. The licensee inserted control rods and stabilized reactor pressure at approximately 950 psig. After verifying that the automatic isolation signal had cleared, the licensee equalized around and reopened the MSIV's in order to restart a reactor feed pump and restore RPV level control. When feed flow was restored, a rapid power rise was observed prompting the licensee to insert a manual reactor scram. All control rods fully inserted as expected, and no ECCS actuation occurred or safety relief valves lifted. The licensee took conservative action to insert a manual scram.
The systems affected by the automatic isolations were returned to service. Unit 2 is currently in hot shutdown. The licensee has formed an event investigation team for this event. The cause of the automatic isolation has not been positively determined, but it appears the isolation occurred when the licensee was draining the condenser pressure sensing lines for the pressure transmitters resulting in a Group 1 isolation on low condenser vacuum in accordance with 0GP-02, APPROACH TO CRITICALITY AND PRESSURIZATION OF THE REACTOR.
The Resident Inspector was notified.
Power Reactor
Event Number: 36202
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CAMERON CAMPBELL
HQ OPS Officer: DICK JOLLIFFE
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CAMERON CAMPBELL
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 09/20/1999
Notification Time: 17:53 [ET]
Event Date: 09/20/1999
Event Time: 14:35 [EDT]
Last Update Date: 09/20/1999
Notification Time: 17:53 [ET]
Event Date: 09/20/1999
Event Time: 14:35 [EDT]
Last Update Date: 09/20/1999
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):
ROBERT SUMMERS (R1)
ROBERT SUMMERS (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 82 | Power Operation | 82 | Power Operation |
- Channel 'B' manual half scram signal received due to an electrical short in the reactor protection system logic -
A channel 'B' manual half scram signal was received during modification installation when drilling activities inadvertently contacted a wire in the reactor protection system (RPS) logic. The shorted wire resulted in a blown fuse which deenergized power to the channel 'B' manual half scram logic. The outboard scram discharge volume vent valves and drain valve shut per design on receipt of the channel 'B' manual half scram signal.
The damaged RPS wire has been repaired and the fuse has been replaced. The channel 'B' manual half scram signal has been reset and the outboard scram discharge volume vent valves and drain valve have been reopened per station procedures by 1638. The channel 'B' manual half scram signal and subsequent reset had no impact on plant operation.
The licensee informed the NRC Resident Inspector.
A channel 'B' manual half scram signal was received during modification installation when drilling activities inadvertently contacted a wire in the reactor protection system (RPS) logic. The shorted wire resulted in a blown fuse which deenergized power to the channel 'B' manual half scram logic. The outboard scram discharge volume vent valves and drain valve shut per design on receipt of the channel 'B' manual half scram signal.
The damaged RPS wire has been repaired and the fuse has been replaced. The channel 'B' manual half scram signal has been reset and the outboard scram discharge volume vent valves and drain valve have been reopened per station procedures by 1638. The channel 'B' manual half scram signal and subsequent reset had no impact on plant operation.
The licensee informed the NRC Resident Inspector.
General Information or Other
Event Number: 36214
Rep Org: TEXAS BUREAU OF RADIATION CONTROL
Licensee: TEAM CONSULTANTS
Region: 4
City: DALLAS State: TX
County:
License #: L04012 (TX)
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS, TBRC
HQ OPS Officer: DICK JOLLIFFE
Licensee: TEAM CONSULTANTS
Region: 4
City: DALLAS State: TX
County:
License #: L04012 (TX)
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS, TBRC
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 09/22/1999
Notification Time: 23:00 [ET]
Event Date: 09/20/1999
Event Time: 12:00 [CDT]
Last Update Date: 09/22/1999
Notification Time: 23:00 [ET]
Event Date: 09/20/1999
Event Time: 12:00 [CDT]
Last Update Date: 09/22/1999
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):
JOSEPH TAPIA (R4)
JOHN SURMEIER (NMSS)
JOSEPH TAPIA (R4)
JOHN SURMEIER (NMSS)
- Troxler moisture density gauge stolen from company parking facility -
On 09/20/99, Texas licensee, Team Consultants, Dallas, TX, notified Texas Bureau of Radiation Control (TBRC) that a Troxler moisture density gauge, #3411B, was stolen on 09/20/99 from the back of a pickup truck that was parked in the licensee's parking facility. Reportedly, the gauge was locked and left unattended for only 10 minutes. The licensee notified the local police and the Dallas Fire Department. TBRC is obtaining additional information and investigating this theft. [TBRC Incident #7511].
(Call the NRC operations officer for a contact telephone number.)
On 09/20/99, Texas licensee, Team Consultants, Dallas, TX, notified Texas Bureau of Radiation Control (TBRC) that a Troxler moisture density gauge, #3411B, was stolen on 09/20/99 from the back of a pickup truck that was parked in the licensee's parking facility. Reportedly, the gauge was locked and left unattended for only 10 minutes. The licensee notified the local police and the Dallas Fire Department. TBRC is obtaining additional information and investigating this theft. [TBRC Incident #7511].
(Call the NRC operations officer for a contact telephone number.)
General Information or Other
Event Number: 36333
Rep Org: KS DEPT of HEALTH & ENVIRONMENT
Licensee: CUSHING MEMORIAL HOSPITAL
Region: 4
City: LEAVENWORTH State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JUSTIN SPENCE
HQ OPS Officer: DICK JOLLIFFE
Licensee: CUSHING MEMORIAL HOSPITAL
Region: 4
City: LEAVENWORTH State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JUSTIN SPENCE
HQ OPS Officer: DICK JOLLIFFE
Notification Date: 10/22/1999
Notification Time: 16:13 [ET]
Event Date: 09/20/1999
Event Time: 12:30 [CDT]
Last Update Date: 10/22/1999
Notification Time: 16:13 [ET]
Event Date: 09/20/1999
Event Time: 12:30 [CDT]
Last Update Date: 10/22/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
CHARLEY HAUGHNEY (NMSS)
LINDA SMITH (R4)
CHARLEY HAUGHNEY (NMSS)
- AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION -
A POTENTIAL MEDICAL MISADMINISTRATION INVOLVING AN INCORRECT CHEMICAL FORM OF TECHNETIUM-99 OCCURRED ON 09/22/99. AT 1230 CDT, THE PATIENT WAS ADMINISTERED 25.8 MILLICURIES OF WHAT MAY HAVE BEEN TECHNETIUM-99 DTPA. THE PATIENT WAS SCHEDULED TO RECEIVE A DOSE OF TECHNETIUM-99 MYOVIEW FOR A HEART SCAN. AN IMAGE OF THE KIDNEYS AND
BLADDER WERE PRESENTED, BUT NO HEART IMAGE. THE RADIOLOGIST/RSO WAS IMMEDIATELY INFORMED. THE RADIOLOGIST CONFIRMED THE FINDINGS OF THE TECHNICIAN. THE LABEL FOR THE DOSE STATES THE RADIOPHARMACEUTICAL WAS A MYOVIEW DOSE. THE RADIOPHARMACY FROM WHICH THE DOSE WAS RECEIVED BELIEVES THAT THE CORRECT SUBSTANCE WAS ADMINISTERED. THE PATIENT AND PHYSICIAN WERE INFORMED THAT THE INCORRECT RADIOPHARMACEUTICAL HAD BEEN ADMINISTERED, AND THE CORRECT PROCEDURE WAS PERFORMED ON 09/23/99. DURING THE WEEK OF 10/04/99, THE CONSULTING PHYSICIST TO THE HOSPITAL WAS INFORMED. ON 10/17/99, THE PHYSICIST SENT A REPORT TO THE LICENSEE. IT WAS DETERMINED THAT THE CHEMICAL FORM OF THE RADIOPHARMACEUTICAL WAS PROBABLY DTPA. THE DOSE OF 25 MILLICURIES RESULTED IN A DOSE OF: TOTAL BODY 0.75 RAD, BLADDER 7.00 RAD, KIDNEYS 0.53 RAD, OVARIES 0.50 RAD, UTERUS 0.93 RAD, AND TESTES 0.35 RAD. THE CONSULTANT INSTRUCTED THE LICENSEE TO NOTIFY THE STATE OF KANSAS AND FILE A WRITTEN REPORT TO THE STATE OF KANSAS WITHIN 15 DAYS.
AT 0930 CDT ON 10/22/99, CUSHING MEMORIAL HOSPITAL TELEPHONED THE KANSAS RADIATION CONTROL PROGRAM IN ORDER TO INFORM THE AGENCY OF THE EVENT DESCRIBED ABOVE. THE KANSAS RADIATION CONTROL PROGRAM INITIATED AN INVESTIGATION.
A POTENTIAL MEDICAL MISADMINISTRATION INVOLVING AN INCORRECT CHEMICAL FORM OF TECHNETIUM-99 OCCURRED ON 09/22/99. AT 1230 CDT, THE PATIENT WAS ADMINISTERED 25.8 MILLICURIES OF WHAT MAY HAVE BEEN TECHNETIUM-99 DTPA. THE PATIENT WAS SCHEDULED TO RECEIVE A DOSE OF TECHNETIUM-99 MYOVIEW FOR A HEART SCAN. AN IMAGE OF THE KIDNEYS AND
BLADDER WERE PRESENTED, BUT NO HEART IMAGE. THE RADIOLOGIST/RSO WAS IMMEDIATELY INFORMED. THE RADIOLOGIST CONFIRMED THE FINDINGS OF THE TECHNICIAN. THE LABEL FOR THE DOSE STATES THE RADIOPHARMACEUTICAL WAS A MYOVIEW DOSE. THE RADIOPHARMACY FROM WHICH THE DOSE WAS RECEIVED BELIEVES THAT THE CORRECT SUBSTANCE WAS ADMINISTERED. THE PATIENT AND PHYSICIAN WERE INFORMED THAT THE INCORRECT RADIOPHARMACEUTICAL HAD BEEN ADMINISTERED, AND THE CORRECT PROCEDURE WAS PERFORMED ON 09/23/99. DURING THE WEEK OF 10/04/99, THE CONSULTING PHYSICIST TO THE HOSPITAL WAS INFORMED. ON 10/17/99, THE PHYSICIST SENT A REPORT TO THE LICENSEE. IT WAS DETERMINED THAT THE CHEMICAL FORM OF THE RADIOPHARMACEUTICAL WAS PROBABLY DTPA. THE DOSE OF 25 MILLICURIES RESULTED IN A DOSE OF: TOTAL BODY 0.75 RAD, BLADDER 7.00 RAD, KIDNEYS 0.53 RAD, OVARIES 0.50 RAD, UTERUS 0.93 RAD, AND TESTES 0.35 RAD. THE CONSULTANT INSTRUCTED THE LICENSEE TO NOTIFY THE STATE OF KANSAS AND FILE A WRITTEN REPORT TO THE STATE OF KANSAS WITHIN 15 DAYS.
AT 0930 CDT ON 10/22/99, CUSHING MEMORIAL HOSPITAL TELEPHONED THE KANSAS RADIATION CONTROL PROGRAM IN ORDER TO INFORM THE AGENCY OF THE EVENT DESCRIBED ABOVE. THE KANSAS RADIATION CONTROL PROGRAM INITIATED AN INVESTIGATION.