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
Page Last Reviewed/Updated Wednesday, March 24, 2021