Event Notification Report for September 27, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
09/24/1999 - 09/27/1999
** EVENT NUMBERS **
36220 36221 36222 36223 36224 36225 36226 36227 36228 36229 36230 36231
36232
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36220 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 09/23/1999|
| UNIT: [1] [2] [] STATE: PA |NOTIFICATION TIME: 20:15[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 09/23/1999|
+------------------------------------------------+EVENT TIME: 20:00[EDT]|
| NRC NOTIFIED BY: PHIL CHASE |LAST UPDATE DATE: 09/24/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |ROBERT SUMMERS R1 |
|10 CFR SECTION: |JOHN HANNON NRR |
|AAEC 50.72 (a) (1) (I) EMERGENCY DECLARED |CHARLES MILLER IRO |
|AESF 50.72(b)(2)(ii) ESF ACTUATION |DAN RISHE FEMA |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| PLANT ENTERED AN UNUSUAL EVENT - TOXIC GAS DETECTED IN UNIT 2 TURBINE |
| ENCLOSURE |
| |
| An Unusual Event was declared at 2000 EDT due to readings of 65 ppm hydrogen |
| sulfide (HS) and 115 ppm carbon monoxide (CO) in the Unit 2 Turbine |
| Enclosure. |
| |
| The oncoming shift reported the smell of rotten eggs when they arrived on |
| site. Inspection around the site determined the only place toxic gas was |
| detectable was in the Unit 2 Turbine Enclosure. There were no detectable |
| levels of any toxic gas existing anywhere else around the plant. |
| Inspections are on going around the plant. The Unit 2 Turbine Enclosure has |
| been evacuated after an inspection for a source of the gasses. |
| |
| The licensee isolated the control room by manually initiating chlorine |
| isolation as a precaution at 1922 EDT, this is an Engineered Safety Feature |
| activation and reportable as a 4-hour notification. |
| |
| The licensee notified the NRC Resident Inspector and the state/local |
| government agencies. |
| |
| * * * UPDATE AT 2321 EDT ON 9/23/99 BY TOM DOUGHERTY TO JOHN MacKINNON * * |
| * |
| |
| The site de-escalated from the Unusual Event at 2312 EDT. The toxic gas |
| levels were verified to be nominal 0% in all areas inside and outside the |
| power block. The source of the toxic gas is still unknown and under |
| investigation. The licensee notified the NRC Resident Inspector and the |
| state/local government agencies. The R1DO (Robert Summers), NRR EO (John |
| Hannon), IRO Manager (Charles Miller), and FEMA (Cegielski) have been |
| informed. |
| |
| * * * UPDATE AT 1429 EDT ON 9/24/99 BY STAN GAMBLE TO FANGIE JONES * * * |
| |
| The licensee submitted a written summary of the event as a follow-up per |
| their procedure guidance for NUREG-0654. The source of the gas is still |
| unknown, but the investigation continues. The summary was sent to NRC |
| Region 1. |
| |
| R1DO (Robert Summers) and NRR (Tad Marsh) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36221 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 09/24/1999|
| UNIT: [1] [] [] STATE: CA |NOTIFICATION TIME: 02:13[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/23/1999|
+------------------------------------------------+EVENT TIME: 17:52[PDT]|
| NRC NOTIFIED BY: STEVE WILSON |LAST UPDATE DATE: 09/24/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOSEPH TAPIA R4 |
|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 N 0 Hot Standby |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| A TRANSFER IN OFFSITE POWER SOURCES CAUSED THE TURBINE DRIVEN AUXILIARY |
| FEEDWATER PUMP TO AUTOMATICALLY START AND DISCHARGE WATER INTO THE STEAM |
| GENERATORS. |
| |
| During restoration of relaying in the 500 kV switchyard an actuation caused |
| the opening of the PCB breakers (Main Generator Breakers) supplying Unit 1 |
| from Auxiliary Power System). Unit 1 power automatically transferred to the |
| Start-Up power supply. The momentary loss of power during the transfer |
| caused the Turbine Driven Auxiliary Feedwater Pump to start from an ESF |
| actuation signal (12 kV Buses) and discharge into the Main Steam Generators. |
| |
| |
| Reactor Coolant Temperature decreased approximately 7 degrees F due to the |
| operation of the Turbine Driven Auxiliary Feedwater Pump (Tave no load is |
| 547 degrees F). The Turbine Driven Auxiliary Feedwater pump operated for |
| approximately 18 minutes before it was secured. A Reactor Operator |
| immediately closed the Turbine Driven Auxiliary Feedwater discharge valve(s) |
| to secure auxiliary feedwater to the Steam Generators, so there was very |
| little discharge of auxiliary feedwater into the Steam Generators. Reactor |
| Coolant System cooldown was mainly due to the Turbine Driven Auxiliary |
| Feedwater Turbine using the steam from the Steam Generators for its motive |
| force. |
| |
| The NRC Resident Inspector will be informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36222 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: HINES VA HOSPITAL |NOTIFICATION DATE: 09/24/1999|
|LICENSEE: HINES VA HOSPITAL |NOTIFICATION TIME: 11:16[EDT]|
| CITY: MAYWOOD REGION: 3 |EVENT DATE: 09/23/1999|
| COUNTY: STATE: IL |EVENT TIME: 12:36[CDT]|
|LICENSE#: 12-01087-07 AGREEMENT: Y |LAST UPDATE DATE: 09/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROGER LANKSBURY R3 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: L CASE | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PATIENT'S ESOPHAGUS WAS RADIATED IN 11 DIFFERENT POSITIONS BUT IT WAS LATER |
| DISCOVERED THAT THE AFTERLOADER WAS INITIALLY OFF BY 60 MILLIMETER AT THE |
| START OF THE TREATMENT. |
| |
| |
| A patient was placed in the wrong site for radioactive treatment of his |
| esophagus using a GammaMedIIi (afterloader). The patient's site was |
| initially off by 60 millimeters when the afterloader started treatment of 11 |
| positions of the patients esophagus. The patient received 5 grays to 11 |
| positions in his esophagus but each one of the doses was off from the |
| correct area to be irradiated by 60 millimeters. The patient's physician |
| was notified and the patient will be informed in writing within 15 days of |
| the error. The caller stated that the patient was not harmed by being |
| irradiated in the incorrect areas of his esophagus. The patient is |
| scheduled for a second treatment and during his next treatment the correct |
| areas will be irradiated for a total dose of 5 grays times 2 fractions to 11 |
| the positions that were not treated in the first treatment because of the 60 |
| millimeter error. The GammaMedIIi contains a 10 curie iridium-192 source. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36223 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 09/24/1999|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 11:39[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/24/1999|
+------------------------------------------------+EVENT TIME: 07:54[EDT]|
| NRC NOTIFIED BY: MIKE GWIRTZ |LAST UPDATE DATE: 09/24/1999|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT SUMMERS R1 |
|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 N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CONTAINMENT GASEOUS ACTIVITY MONITOR ALARM DURING DETENSIONING OF THE |
| REACTOR VESSEL HEAD IN PREPARATION FOR A HEAD LIFT |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "At 0754, with normal maintenance activities in progress, the 1R12A, [which |
| is] the containment gaseous activity monitor, went into alarm. The alarm |
| setpoint is two times background per technical specifications, and [it] is |
| set at 135 counts per minute. The containment purge and pressure relief |
| valves were already closed, so no actuations occurred, although this was a |
| valid signal. Other containment area monitors showed no rise in activity |
| levels other than one [local] area monitor on [the] 78 elevation which |
| showed a slight increase. No release [is in] progress. We will continue to |
| monitor levels and investigate the source of the increase." |
| |
| The licensee stated that the normal maintenance activities in progress at |
| the time of the alarm involved detensioning of the reactor vessel head in |
| preparation for a head lift. The unit is not currently in a technical |
| specification limiting condition for operation as a result of this event due |
| to the current mode of operation (Refueling). |
| |
| The licensee plans to notify the NRC resident inspector and the Lower |
| Alloways Creek Township. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36224 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 09/24/1999|
|LICENSEE: RONE ENGINEERS |NOTIFICATION TIME: 11:52[EDT]|
| CITY: DALLAS REGION: 4 |EVENT DATE: 09/23/1999|
| COUNTY: STATE: TX |EVENT TIME: 11:00[CDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 09/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOSEPH TAPIA R4 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JAMES OGDEN | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE |
| |
| "Another stolen Troxler Gauge Model 3401, Serial Number 9934, with two |
| sources: 1) 7.8 mCi Cs-137, Serial Number 40-7404 and 2) 40 mCi AmBe-241, |
| Serial Number 46-1316. |
| |
| "Stolen Dallas, Texas, 09/23/99 at approximately 11:00 a.m. from Rone |
| Engineers, 11234 Goodnight Lane, Dallas, Texas 75229, (817) 831-6211. |
| Stolen from company pickup truck. Lock cut and chain and device removed |
| from truck while driver/operator at lunch. |
| |
| "Note: This is the 7th gauge stolen/missing in the Dallas/North Texas area |
| since March 1999. Two more in the Houston area since October 1998. Posting |
| notice to all Texas Licensees using MD gauges on BRC Website and in our |
| Radiation Report (Winter Edition) concerning increased security needs for |
| users of gauges." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36225 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WESTVACO BLEACHBOARD DIVISION |NOTIFICATION DATE: 09/24/1999|
|LICENSEE: OHMART |NOTIFICATION TIME: 15:39[EDT]|
| CITY: COVINGTON REGION: 2 |EVENT DATE: 09/23/1999|
| COUNTY: STATE: VA |EVENT TIME: 11:00[EDT]|
|LICENSE#: 45-01568-01 AGREEMENT: N |LAST UPDATE DATE: 09/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |THOMAS DECKER R2 |
| |KEVIN RAMSEY (FAX) NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RAYMOND HUNDLEY | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 10 CFR PART 21 REPORT - FAILURE, SOURCE SHUTTER STUCK OPEN |
| |
| During the performance of the six month surveillances of sources, one |
| source's shutter was discovered to be stuck open. The device is an Ohmart |
| SH-F2-0, serial number 4612GK, with a sealed source of 1000 mCi of Cs-137. |
| There is no indication of what the problem might be, no rust or apparent |
| damage. The shutter mechanism could not be moved manually. |
| |
| The manufacturer was contacted and they directed the licensee to lubricate |
| the shutter and if that did not free up the shutter mechanism, they would |
| send representatives to the site. |
| |
| The device is used on the manufacturing line, it is a fixed installation. |
| There is little or no safety implications to personnel as installed. |
| |
| * * * UPDATE AT 1626 EDT ON 9/24/99 BY RAYMOND HUNDLEY TO FANGIE JONES * * |
| * |
| |
| The shutter mechanism was treated with lubricating oil and it was freed. |
| The device is working properly. A written report will follow within 30 |
| days. |
| |
| R2DO (Thomas Decker) and NMSS (Kevin Ramsey) have been contacted. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36226 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 09/24/1999|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 15:40[EDT]|
| RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 09/24/1999|
+------------------------------------------------+EVENT TIME: 14:00[CDT]|
| NRC NOTIFIED BY: PAUL SALGADO |LAST UPDATE DATE: 09/25/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROGER LANKSBURY R3 |
|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 99 Power Operation |99 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| VENTILATION DAMPER FOUND TO FAIL OPEN INSTEAD OF CLOSED |
| |
| "During an engineering review of an industry event it was determined that a |
| design flaw of a ventilation damper that feeds the Aux electric equipment |
| room fails open instead of failing closed. With this valve failing open it |
| introduces 15000 CFM of air to the AEER and causes it to become positive in |
| pressure with respect to the control room emergency zone. This allows a |
| leak path into the control room and can affect the dose to the control room |
| operators. Compensatory measures are being planned that will gag closed |
| this damper to rectify the problem." |
| |
| The gagging of the damper is the temporary fix, a long term fix is being |
| investigated. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| * * * RETRACTED AT 1927 EDT ON 9/25/99 BY BRIAN SAMPSON TO FANGIE JONES * * |
| * |
| |
| Upon further review of the damper operation by Dresden Operations and |
| Engineering personnel, it was determined that the damper in question will |
| fail closed, which is the desired position for post-accident conditions. |
| Therefore the condition is not outside design basis, and is not reportable. |
| This event report is retracted. |
| |
| The licensee notified the NRC Resident Inspector. The R3DO (Roger |
| Lanksbury) has been notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36227 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 09/24/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 17:15[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 09/24/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:30[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 09/24/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |ROGER LANKSBURY R3 |
| DOCKET: 0707002 |JOHN SURMEIER NMSS |
+------------------------------------------------+CHARLES MILLER IRO |
| NRC NOTIFIED BY: RICK LARSON | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 4 HOUR NRC 91-01 BULLETIN REPORT |
| |
| "ON 9/24/99 AT 1330 AN ANALYSIS OF A TACKY TEXTURED SUBSTANCE FOUND IN THE |
| SIDE PURGE PIPING DURING REPAIRS TO THIS SYSTEM REVEALS A URANIUM COMPOUND |
| THAT IS UNPRECEDENTED IN CASCADE OPERATIONS. THE COMPOUND UO2CL(OH).2H2O |
| HAS A H/U RATIO OF 5. THE ASSUMED PROCESS MODERATION CONDITION FOR |
| NCSA-PLANT 062.AO2 HAS BEEN EXCEEDED, RESULTING IN A LOSS OF ONE LEG OF |
| DOUBLE CONTINGENCY. THE OTHER LEG OF DOUBLE CONTINGENCY (MASS CONTROL) HAS |
| BEEN MAINTAINED. |
| |
| "THIS IS REPORTABLE PER NRC BL 91-01 FOR 'OCCURRENCE OF ANY UNANTICIPATED OR |
| UNANALYZED EVENT FOR WHICH THE CORRECTIVE ACTIONS TO RE-ESTABLISH DOUBLE |
| CONTINGENCY ARE NOT READILY IDENTIFIABLE.. |
| |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: |
| |
| "THE PRESENCE OF UO2CL(0H).2H2O (H/U = 5) RESULTS IN THE LOSS OF MODERATION |
| CONTROL IN THE SECTION OF THE SIDE PURGE PIPING WHERE THE COMPOUND IS |
| PRESENT (i.e., THE ASSUMED NORMAL MODERATION PROCESS CONDITION WAS |
| EXCEEDED.) THE PREDOMINANT ENRICHMENT OF URANIUM-BEARING MATERIAL INSIDE THE |
| PIPE IS APPROXIMATELY 6%. HOWEVER, THERE ARE NO GREATER THAN SAFE MASS |
| DEPOSITS IN THE AREA NEAR THIS MATERIAL, NOR IS THERE A POTENTIAL FOR |
| DEPOSIT MOVEMENT (e.g., VIA FLAKING) WHICH COULD CREATE A GREATER THAN SAFE |
| MASS DEPOSIT. THEREFORE, MASS CONTROL IS STILL MAINTAINED, AND A |
| CRITICALITY CANNOT OCCUR WITHOUT THE ADDITION OF MORE URANIUM MASS. THIS IS |
| HIGHLY UNLIKELY IF NOT INCREDIBLE BECAUSE THE SIDE PURGE CASCADE PIPING IS |
| CURRENTLY ISOLATED FROM THE OPERATING CASCADE, AND IS AT A HIGHER PRESSURE |
| THAN THE SURROUNDING OPERATING EQUIPMENT. THE FORMATION OF THIS COMPOUND |
| WAS ONLY POSSIBLE BECAUSE OF THE CONDITIONS PRESENT DURING THE X-326 FIRE; |
| THEREFORE, OTHER CASCADE EQUIPMENT IS NOT IMPACTED BY THE PRESENCE OF THIS |
| COMPOUND. BASED ON THIS. IT IS CONCLUDED THAT THE SAFETY SIGNIFICANCE OF |
| THIS EVENT IS LOW. |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR); |
| |
| "THE ONLY WAY THAT A CRITICALITY COULD OCCUR IS IF ADDITIONAL URANIUM MASS |
| IS ADDED TO THE SIDE PURGE PIPE, CREATING A GREATER THAN SAFE MASS DEPOSIT. |
| AS DISCUSSED ABOVE, THIS IS HIGHLY UNLIKELY IF NOT INCREDIBLE BECAUSE THE |
| SIDE PURGE. CASCADE PIPING IS CURRENTLY ISOLATED FROM THE OPERATING |
| CASCADE, AND IS AT A HIGHER PRESSURE THAN THE SURROUNDING OPERATING |
| EQUIPMENT. THEREFORE, A VALVING ERROR WOULD HAVE TO OCCUR AT THE SAME TIME |
| AS A MAJOR CASCADE UPSET CAUSING INCREASED PRESSURES IN THE SURROUNDING |
| OPERATING CASCADE EQUIPMENT. IN ORDER FOR THE MORE MASS TO ENTER THIS |
| PIPE. |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| |
| "MASS MAINTAINED, MODERATION-LOST |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE OF CRITICAL MASS): |
| |
| "THE PREDOMINANT ENRICHMENT OF THE MATERIAL IN THE PIPE IS APPROXIMATELY 6%. |
| THE COMPOUND OF CONCERN IS IN THE FORM OF UO2CL(OH).2H2O (H/U=5). THE MASS |
| OF THE LARGEST DEPOSIT IN THE AREA IS APPROXIMATELY 159 GRAMS 235U, WHICH IS |
| WELL BELOW A SAFE MASS OF 740 GRAMS 235U. THE SAFE MASS ASSUMES 6% |
| ENRICHMENT OPTIMUM SPHERICAL GEOMETRY OPTIMUM MODERATION, AND FULL |
| REFLECTION, AND INCLUDES A SAFETY MARGIN OF APPROXIMATELY A FACTOR OF 2 FROM |
| THE ACTUAL CRITICAL MASS. |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: |
| |
| "THE NCSA PROVIDES CONTROLS ON MASS AND MODERATION. THE PRESENCE OF |
| UO2CL(OH).2H2O (H/U=5) RESULTS TS IN A LOSS OF CONTROL OF THE PROCESS |
| CONDITION. MASS CONTROLS WERE MAINTAINED. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: |
| |
| "THE FOLLOWING CORRECTIONS ACTIONS ARE BEING TAKEN: AREA WILL REMAIN |
| BOUNDARIED, NCSA-PLANT 062 MAINTENANCE ACTIVITIES WILL REMAIN SUSPENDED, AND |
| NCS WILL DEVELOP AN NCSA TO COVER THIS OPERATION." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36228 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WASHINGTON DEPARTMENT OF HEALTH |NOTIFICATION DATE: 09/24/1999|
|LICENSEE: WHEELABRATOR |NOTIFICATION TIME: 18:55[EDT]|
| CITY: SPOKANE REGION: 4 |EVENT DATE: 09/09/1999|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 09/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LAWRENCE YANDELL R4 |
| |JOHN SURMEIER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TERRY FRAZEE | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| WASTE-TO-ENERGY FACILITY HAD RADIATION ALARM ON INCOMING LOAD |
| |
| Agreement State Event Report #WA-99-025 |
| |
| The following text is a portion of E-mail received from the Washington |
| Department of Health, Division of Radiation Protection: |
| |
| "A waste-to-energy facility in Spokane reported a radiation alarm on an |
| incoming load of residential waste. The facility separated the load, |
| finding a plastic bag with "kitty litter" reading about 8 mR/hr on contact. |
| They notified DOH and isolated the material in their locked storage area. On |
| September 15, 1999, DOH staff identified the offending radionuclide to be |
| I-131 and confirmed that the contents appeared to be cat litter. There was |
| no accompanying waste that could identify the origin of the waste. It is |
| presumed that a local cat was receiving |
| treatment for a thyroid condition and had been released to its owner with a |
| small amount of residual radioactivity (only a few microcuries were present |
| in the litter). The material is being held for decay. |
| |
| "Activity and Isotope(s) involved: An unknown (but small) amount of I-131" |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36229 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WASHINGTON DEPARTMENT OF HEALTH |NOTIFICATION DATE: 09/24/1999|
|LICENSEE: UNIVERSITY OF WASHINGTON HOSPITAL |NOTIFICATION TIME: 19:02[EDT]|
| CITY: SEATTLE REGION: 4 |EVENT DATE: 09/17/1999|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: WN-C001-1 AGREEMENT: Y |LAST UPDATE DATE: 09/24/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LAWRENCE YANDELL R4 |
| |JOHN SURMEIER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT VERELLEN | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THREE I-125 BRACHYTHERAPY SOURCES LOST |
| |
| Agreement State Event Report #WA-99-027 |
| |
| The following text is a portion of E-mail received from the Washington |
| Department of Health, Division of Radiation Protection: |
| |
| "THE LICENSEE REPORTED THE LOSS OF THREE I-125 BRACHY SOURCES, AMERSHAM |
| MODEL 6720, 0.529 MICROCURIE EACH [1.587 MICROCURIES TOTAL]. THE SOURCES |
| COME FROM THE MANUFACTURER IN A SET OF TEN SEEDS (SOURCES) IN A DICYL |
| SUTURE. FOR THE APPROPRIATE NUMBER OF SEEDS TO MEET THE INDIVIDUALIZED |
| TREATMENT PLAN IT IS COMMON FOR THE SUTURE TO BE TRIMMED. IN THIS CASE |
| THREE SEEDS WERE TRIMMED BUT WERE UNACCOUNTED FOR DURING A SOURCE COUNT |
| PERFORMED ON THE 17 SEPT. 1999. UPON DISCOVERY OF THE MISSING SOURCES THE |
| LICENSEE HAS PERFORMED SURVEY OF ALL POSSIBLE AREAS WITHIN THE HOSPITAL BUT |
| DID NOT FIND THEM. THEY REPORT THAT THE SOURCES WERE PROBABLY LOST, MIXED |
| WITH SOME OF THE OPERATING ROOM MATERIALS, WHICH HAD BEEN AUTOCLAVED AND |
| DISPOSED OF IN A DUMPSTER WHICH HAD BEEN PICKED UP BEFORE THEY WERE AWARE OF |
| THE MISSING SOURCES. AN INVESTIGATION IS ONGOING MORE DETAILS WILL BE |
| FORTHCOMING." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36230 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 09/25/1999|
| UNIT: [1] [2] [] STATE: CA |NOTIFICATION TIME: 12:41[EDT]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 09/24/1999|
+------------------------------------------------+EVENT TIME: 20:10[PDT]|
| NRC NOTIFIED BY: CLAY WILLIAMS |LAST UPDATE DATE: 09/25/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LAWRENCE YANDELL R4 |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| 24 HOUR REPORT UNDER CONDITION OF LICENSE REGARDING FOR UNUSUAL FISH KILL |
| |
| A periodic heat treatment, the temperature of the intake structure is raised |
| in order to limit biological fouling. After the heat treatment a fish kill |
| was discovered. The total weight, 4800 pounds, is greater than the |
| reporting limit of 4500 pounds. |
| |
| The licensee notified the NRC Resident Inspection. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36231 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 09/26/1999|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 00:52[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/25/1999|
+------------------------------------------------+EVENT TIME: 23:30[EDT]|
| NRC NOTIFIED BY: S. SAUER |LAST UPDATE DATE: 09/26/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT SUMMERS R1 |
|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 N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CONTAINMENT VENTILATION ISOLATION |
| |
| An automatic containment ventilation isolation (CVI) was initiated by the |
| containment air particulate monitor (1R11A). The containment purge system |
| was in service at the time, and the system isolated as designed. The |
| licensee is currently evaluating the cause of this isolation, and is |
| obtaining and analyzing grab samples to determine whether an increase in |
| particulate activity may have occurred. |
| |
| The NRC resident inspector will be informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36232 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 09/26/1999|
| UNIT: [] [2] [] STATE: GA |NOTIFICATION TIME: 06:45[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/26/1999|
+------------------------------------------------+EVENT TIME: 03:30[EDT]|
| NRC NOTIFIED BY: CHARLIE MEYER |LAST UPDATE DATE: 09/26/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |THOMAS DECKER R2 |
|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 Y 93 Power Operation |93 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH TRAINS OF THE SAFETY INJECTION SYSTEM DECLARED INOPERABLE |
| |
| Both trains of the safety injection (SI) system were declared inoperable due |
| to the discovery of excessive volumes of air from both SI pump casings. The |
| air was discovered during performance of the monthly ECCS flow path |
| verification surveillance procedure. Both pumps were subsequently vented and |
| declared operable at 0610 9/26/1999. The licensee is investigating the cause |
| of the entrapped air. |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021