Event Notification Report for December 20, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/19/1999 - 12/20/1999
EVENT NUMBERS
36527365293653036542
Power Reactor
Event Number: 36527
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: MR. HUJET
HQ OPS Officer: DOUG WEAVER
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: MR. HUJET
HQ OPS Officer: DOUG WEAVER
Notification Date: 12/20/1999
Notification Time: 12:04 [ET]
Event Date: 12/20/1999
Event Time: 07:10 [CST]
Last Update Date: 12/20/1999
Notification Time: 12:04 [ET]
Event Date: 12/20/1999
Event Time: 07:10 [CST]
Last Update Date: 12/20/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(ii)(B) - OUTSIDE DESIGN BASIS
10 CFR Section:
50.72(b)(1)(ii)(B) - OUTSIDE DESIGN BASIS
Person (Organization):
THOMAS KOZAK (R3)
THOMAS KOZAK (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
OUTSIDE DESIGN BASIS - BOTH TRAINS OF CONTROL ROOM AIR CONDITIONING INOPERABLE
"At 0710 [CST], while attempting to rotate running equipment, the operator placed the control switch for the B Train control Room A/C to ON. Subsequently, the A Train switch was placed to OFF to allow the B Train to start. The B Train failed to start, and the A Train switch was placed back to AUTO. Further investigation determined that the A Train switch was placed to OFF greater than 20 seconds following the B switch being placed to ON. This resulted in a Trip signal being generated for the B Train unit. Therefore, both trains of Control Room A/C were out of service with the B Train Trip signal and the A Train switch in the OFF position. This condition existed for a total of 12 seconds before the A Train unit was restarted. The need to report this condition was not identified until 1025 [CST]."
The licensee will inform the NRC resident inspector.
"At 0710 [CST], while attempting to rotate running equipment, the operator placed the control switch for the B Train control Room A/C to ON. Subsequently, the A Train switch was placed to OFF to allow the B Train to start. The B Train failed to start, and the A Train switch was placed back to AUTO. Further investigation determined that the A Train switch was placed to OFF greater than 20 seconds following the B switch being placed to ON. This resulted in a Trip signal being generated for the B Train unit. Therefore, both trains of Control Room A/C were out of service with the B Train Trip signal and the A Train switch in the OFF position. This condition existed for a total of 12 seconds before the A Train unit was restarted. The need to report this condition was not identified until 1025 [CST]."
The licensee will inform the NRC resident inspector.
Fuel Cycle Facility
Event Number: 36529
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: DALE NOLE
HQ OPS Officer: DOUG WEAVER
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: DALE NOLE
HQ OPS Officer: DOUG WEAVER
Notification Date: 12/20/1999
Notification Time: 19:38 [ET]
Event Date: 12/20/1999
Event Time: 15:45 [EST]
Last Update Date: 12/20/1999
Notification Time: 19:38 [ET]
Event Date: 12/20/1999
Event Time: 15:45 [EST]
Last Update Date: 12/20/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS KOZAK (R3)
JOHN SURMEIER (NMSS)
FRANK CONGEL (IRO)
THOMAS KOZAK (R3)
JOHN SURMEIER (NMSS)
FRANK CONGEL (IRO)
OFFSITE NOTIFICATION TO DOE - MINOR OUT-GASSING OF UF6 WHILE SAMPLING CYLINDER
ON 12/20/99, AT 1545 A DEPARTMENT OF ENERGY (DOE) OFF-NORMAL OCCURRENCE WAS INITIATED REGARDING A MINOR OUT-GASSING AT THE X-343 FEED VAPORIZATION AND SAMPLING FACILITY WHILE SAMPLING A DOE CYLINDER IN AUTOCLAVE SIX. RESPONSE PERSONNEL STOPPED THE OUT-GASSING AND STABILIZED THE CYLINDER FOR COOLDOWN. THIS EVENT IS REPORTABLE DUE TO NOTIFICATION BEING MADE TO AN OUTSIDE AGENCY (DOE). THE OUT-GASSING WAS DUE TO A CRACKED BONNET NUT ON THE CYLINDER VALVE.
THE NRC RESIDENT INSPECTOR WILL BE INFORMED.
ON 12/20/99, AT 1545 A DEPARTMENT OF ENERGY (DOE) OFF-NORMAL OCCURRENCE WAS INITIATED REGARDING A MINOR OUT-GASSING AT THE X-343 FEED VAPORIZATION AND SAMPLING FACILITY WHILE SAMPLING A DOE CYLINDER IN AUTOCLAVE SIX. RESPONSE PERSONNEL STOPPED THE OUT-GASSING AND STABILIZED THE CYLINDER FOR COOLDOWN. THIS EVENT IS REPORTABLE DUE TO NOTIFICATION BEING MADE TO AN OUTSIDE AGENCY (DOE). THE OUT-GASSING WAS DUE TO A CRACKED BONNET NUT ON THE CYLINDER VALVE.
THE NRC RESIDENT INSPECTOR WILL BE INFORMED.
General Information or Other
Event Number: 36530
Rep Org: LONGVIEW INSPECTIONS
Licensee: LONGVIEW INSPECTIONS
Region: 3
City: BROOMFIELD State: WI
County:
License #: 4227593-01
Agreement: N
Docket:
NRC Notified By: WALLANDER
HQ OPS Officer: CHAUNCEY GOULD
Licensee: LONGVIEW INSPECTIONS
Region: 3
City: BROOMFIELD State: WI
County:
License #: 4227593-01
Agreement: N
Docket:
NRC Notified By: WALLANDER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 12/21/1999
Notification Time: 10:36 [ET]
Event Date: 12/20/1999
Event Time: 17:00 [CST]
Last Update Date: 12/21/1999
Notification Time: 10:36 [ET]
Event Date: 12/20/1999
Event Time: 17:00 [CST]
Last Update Date: 12/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
Person (Organization):
THOMAS KOZAK (R3)
BRIAN SMITH EO (NMSS)
JOHN DAVIDSON IAT (NMSS)
RON ALBERT IAT (NRR)
THOMAS KOZAK (R3)
BRIAN SMITH EO (NMSS)
JOHN DAVIDSON IAT (NMSS)
RON ALBERT IAT (NRR)
POSSIBLE INTENTIONAL OVEREXPOSURE OF AN EMPLOYEE'S TLD BADGE
THE LICENSEE REPORTED THAT A RADIOGRAPHER'S TLD BADGE WAS OVEREXPOSED FOR THE MONTH OF OCTOBER. THE READING FROM THE TLD WAS 77 REM. (NORMAL READINGS RANGE FROM 100 mREM-300 mREM.) THEY HAVE STARTED AN INVESTIGATION AND HAVE COMMENCED INTERVIEWS WITH INDIVIDUALS THAT WORKED WITH THIS PERSON. SINCE THE WORK HAS BEEN COMPLETED, ALL OF THE WORKERS WERE LAID OFF, AND THEY STILL HAVE ADDITIONAL PERSONS TO LOCATE AND INTERVIEW.
(CALL THE NRC OPERATIONS OFFICER FOR PRELIMINARY CONCLUSIONS AND A LICENSEE CONTACT TELEPHONE NUMBER.)
THE LICENSEE REPORTED THAT A RADIOGRAPHER'S TLD BADGE WAS OVEREXPOSED FOR THE MONTH OF OCTOBER. THE READING FROM THE TLD WAS 77 REM. (NORMAL READINGS RANGE FROM 100 mREM-300 mREM.) THEY HAVE STARTED AN INVESTIGATION AND HAVE COMMENCED INTERVIEWS WITH INDIVIDUALS THAT WORKED WITH THIS PERSON. SINCE THE WORK HAS BEEN COMPLETED, ALL OF THE WORKERS WERE LAID OFF, AND THEY STILL HAVE ADDITIONAL PERSONS TO LOCATE AND INTERVIEW.
(CALL THE NRC OPERATIONS OFFICER FOR PRELIMINARY CONCLUSIONS AND A LICENSEE CONTACT TELEPHONE NUMBER.)
General Information or Other
Event Number: 36542
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: HCA L.W. BLAKE HOSPITAL
Region: 2
City: BRADENTON State: FL
County:
License #: 1072-1
Agreement: Y
Docket:
NRC Notified By: ADAMS (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: HCA L.W. BLAKE HOSPITAL
Region: 2
City: BRADENTON State: FL
County:
License #: 1072-1
Agreement: Y
Docket:
NRC Notified By: ADAMS (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 12/27/1999
Notification Time: 14:14 [ET]
Event Date: 12/20/1999
Event Time: 12:00 [EST]
Last Update Date: 12/27/1999
Notification Time: 14:14 [ET]
Event Date: 12/20/1999
Event Time: 12:00 [EST]
Last Update Date: 12/27/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
CHRIS CHRISTENSEN (R2)
CHARLES HAUGHNEY (NMSS)
CHRIS CHRISTENSEN (R2)
CHARLES HAUGHNEY (NMSS)
MEDICAL MISADMINISTRATION AT THE HCA L.W. BLAKE HOSPITAL IN BRADENTON, FL
THE FLORIDA BUREAU OF RADIATION CONTROL REPORTED A MISADMINISTRATION AT THE HCA L.W. BLAKE HOSPITAL IN BRADENTON, FL. THIS OCCURRED ON 12/20/99 WHEN A PATIENT WAS SCHEDULED FOR A THERAPEUTIC TREATMENT WITH 15 mCi OF I-131. THE PATIENT INSTEAD WAS GIVEN A DIAGNOSTIC DOSE OF I-123 (300 µCi). THE ERROR WAS DISCOVERED ON 12/27/99, AND THE STATE WAS NOTIFIED THE SAME DAY. THE PHYSICIAN AND PATIENT HAVE BEEN NOTIFIED, AND THERE ARE NO ADVERSE HEALTH EFFECTS EXPECTED. THE PHYSICIAN WHO ORDERED THE THERAPY TREATMENT IS APPARENTLY NOT AN AUTHORIZED USER AT THIS FACILITY. A WRITTEN REPORT WILL BE PROVIDED WITHIN 15 DAYS.
(CALL THE NRC OPERATIONS OFFICER FOR CONTACT TELEPHONE NUMBERS.)
THE FLORIDA BUREAU OF RADIATION CONTROL REPORTED A MISADMINISTRATION AT THE HCA L.W. BLAKE HOSPITAL IN BRADENTON, FL. THIS OCCURRED ON 12/20/99 WHEN A PATIENT WAS SCHEDULED FOR A THERAPEUTIC TREATMENT WITH 15 mCi OF I-131. THE PATIENT INSTEAD WAS GIVEN A DIAGNOSTIC DOSE OF I-123 (300 µCi). THE ERROR WAS DISCOVERED ON 12/27/99, AND THE STATE WAS NOTIFIED THE SAME DAY. THE PHYSICIAN AND PATIENT HAVE BEEN NOTIFIED, AND THERE ARE NO ADVERSE HEALTH EFFECTS EXPECTED. THE PHYSICIAN WHO ORDERED THE THERAPY TREATMENT IS APPARENTLY NOT AN AUTHORIZED USER AT THIS FACILITY. A WRITTEN REPORT WILL BE PROVIDED WITHIN 15 DAYS.
(CALL THE NRC OPERATIONS OFFICER FOR CONTACT TELEPHONE NUMBERS.)