United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 1999

Event Notification Report for December 27, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           12/23/1999 - 12/27/1999

                              ** EVENT NUMBERS **

36535  36536  36537  36538  36539  36540  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36535       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  OHIO BUREAU OF RADIATION PROTECTION  |NOTIFICATION DATE: 12/23/1999|
|LICENSEE:  SYNCOR                               |NOTIFICATION TIME: 08:49[EST]|
|    CITY:                           REGION:  3  |EVENT DATE:        12/23/1999|
|  COUNTY:  SENECA                    STATE:  OH |EVENT TIME:        08:30[EST]|
|LICENSE#:  02500490001           AGREEMENT:  Y  |LAST UPDATE DATE:  12/23/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK RING            R3      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  MIKE SNEE                    |JOHN COOK            NMSS    |
|  HQ OPS OFFICER:  FANGIE JONES                 |WHITE                DOE     |
+------------------------------------------------+REDDY                DOT     |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|NTRA                     TRANSPORTATION EVENT   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A VEHICLE ACCIDENT CARRYING TECHNETIUM-99M  |
|                                                                              |
| The Ohio Bureau of Radiation Protection (BRP) received a notification        |
| concerning an accident involving a Syncor truck in Seneca County, Ohio.  The |
| truck is on fire, and there is a possible fatality involved.  The truck was  |
| being used to deliver technetium-99m to area hospitals and used to pick up   |
| waste.  The report indicates that waste containers are strewn across the     |
| highway.  Emergency Medical and Fire Department personnel have responded,    |
| and the highway patrol was en route to the scene.  The Ohio BRP is sending a |
| team to the accident site, which is located about 100 miles from their       |
| offices.  Syncor is also sending representatives to the accident site.       |
|                                                                              |
| * * * UPDATE AT 1145 EST ON 12/23/99 FROM MIKE SNEE TO FANGIE JONES * * *    |
|                                                                              |
| Two Ohio BRP representatives, the radiation safety officer from the Syncor   |
| facility in Holland, Ohio, and an Ohio Public Utility Commission HAZMAT      |
| expert are on the scene as well as personnel from the state police and the   |
| county emergency management agency.  The Ohio BRP has received the following |
| updated information on the accident:                                         |
|                                                                              |
| The accident involved a head on collision of two vehicles, and both vehicles |
| are currently located on the side of the road.  The accident resulted in     |
| both drivers being killed.  A county coroner is en route the scene, and the  |
| scene has been cordoned off by the state police.  The accident occurred on   |
| state route 635 and county road 38 in Seneca County, Ohio.  The cause of the |
| accident is under investigation.  The weather in the area is currently clear |
| and cold with no snow on the ground.                                         |
|                                                                              |
| There were 12 ammo boxes (which were used to transport radioactive           |
| materials) in the Syncor truck.  Two boxes had doses (technetium-99m) that   |
| had yet to be delivered.  Both of these boxes were intact and have been      |
| recovered.  Approximately eight ammo boxes broke open and were scattered     |
| around the scene.  These boxes contained waste material (most of which had   |
| already decayed or had significantly decayed).  Most of the boxes have been  |
| recovered.  However, there are a few lead pigs that were inside the ammo     |
| boxes that opened up, and there are some syringes on the scene that have not |
| yet been recovered.  One of the ammo boxes was in the fire and burned up.    |
| The lead pigs in this box were charred, but both were intact.  This box has  |
| also been recovered.  Therefore, the radioactive hazard at the scene is very |
| minimal.  The Ohio BRP representatives at the scene plan to continue         |
| searching the area for any other syringes or radioactive material that may   |
| still be on the ground.  At the time of this update, recovery efforts for    |
| the radioactive material had stopped in order to allow for removal of the    |
| drivers from the vehicles.                                                   |
|                                                                              |
| The NRC operations officer notified the R3DO (Ring), NMSS (Cool), and IRO    |
| (Miller).                                                                    |
|                                                                              |
| (Call the NRC operations officer for contact information.)                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36536       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 12/23/1999|
|    UNIT:  [2] [] []                 STATE:  NY |NOTIFICATION TIME: 14:36[EST]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        12/23/1999|
+------------------------------------------------+EVENT TIME:        13:45[EST]|
| NRC NOTIFIED BY:  SANTINI                      |LAST UPDATE DATE:  12/23/1999|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD CONTE        R1      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       99       Power Operation  |99       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DURING PERFORMANCE OF THE CABLE SPREADING ROOM (CSR) HALON SYSTEM            |
| SURVEILLANCE, APPROXIMATELY ONE-HALF OF THE CSR FIRE DAMPERS FAILED TO       |
| CLOSE.                                                                       |
|                                                                              |
| During performance of surveillance test PT-EM19, "Cable Spreading Room (CSR) |
| Halon System," approximately one-half of the CSR fire dampers (FD-02, 03, 06 |
| and 07) failed to close on a Halon fire suppression system actuation.        |
| Damper closure upon Halon system actuation is required to ensure that a      |
| proper concentration of Halon is achieved in the CSR to suppress a fire.     |
| With the dampers not fully closed, Halon concentration cannot be ensured as  |
| described in the Fire Protection Program Plan.  Damper closure by other      |
| means such as heat was not affected by this condition.  Appendix R safe      |
| shutdown capabilities were not affected.  The apparent cause of this failure |
| was incorrect wiring which has been corrected.  Subsequent attempts to close |
| these dampers via Halon system actuation were successful, but investigation  |
| into the source of the incorrect wiring is ongoing.  This surveillance is    |
| performed every 24 months.  After the surveillance test was performed last   |
| time, a modification was performed on the Transformer Deluge System.  The    |
| wiring problem which caused only one-half of the dampers to close came from  |
| the Transformer Deluge System.  The licensee is investigating the cause of   |
| this wiring problem.                                                         |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36537       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 12/24/1999|
|    UNIT:  [] [2] []                 STATE:  SC |NOTIFICATION TIME: 03:02[EST]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        12/24/1999|
+------------------------------------------------+EVENT TIME:        02:07[EST]|
| NRC NOTIFIED BY:  NEIL CONSTANCE               |LAST UPDATE DATE:  12/24/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE MALLETT        R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       77       Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REACTOR TRIP ON HIGH REACTOR COOLANT SYSTEM PRESSURE  (Refer to event #36532 |
| for a similar event that occurred on 12/21/99.)                              |
|                                                                              |
| "Unit 2 tripped on RCS high pressure at 0207 [EST].  The RPS setpoint of     |
| 2345 psig was exceeded, resulting in an RPS actuation and tripping all CRD   |
| breakers.  The initiating event was a spurious closure of all main turbine   |
| intercept/reheat stop valves and main turbine control valves.  The plant is  |
| stable in Mode 3, with a trip investigation in progress."                    |
|                                                                              |
| No primary power-operated relief valves (setpoint 2405 psig) or code safety  |
| valves lifted.  Secondary side code safeties lifted as expected on the trip, |
| and all valves shut with the turbine bypass valves in operation to remove    |
| decay heat to the main condenser.  Main feedwater is maintaining steam       |
| generator level.                                                             |
|                                                                              |
| The NRC resident inspector was notified.                                     |
|                                                                              |
| (Call the NRC operations officer for additional information.)                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36538       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  STATE OF CALIFORNIA                  |NOTIFICATION DATE: 12/24/1999|
|LICENSEE:  UC  SAN DIEGO                        |NOTIFICATION TIME: 14:59[EST]|
|    CITY:  SAN DIEGO                REGION:  4  |EVENT DATE:        08/12/1999|
|  COUNTY:                            STATE:  CA |EVENT TIME:        00:00[PST]|
|LICENSE#:  1339-37               AGREEMENT:  Y  |LAST UPDATE DATE:  12/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  K . HANNER                   |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RESEARCH STUDENT AT THE UNIVERSITY OF CALIFORNIA RECEIVED AND EXTREMITY DOSE |
| OF 61.65 REM TO HER LEFT INDEX FINGER.                                       |
|                                                                              |
| The event occurred between April of 1999 and June 1999 at the University of  |
| California in San Diego.  The individual was observed holding a petri dish   |
| with her left index finger over the unshielded portion of the dish.  The     |
| radioactive element in the petri dish was P-32.  Her film badge was          |
| processes on August 12, 1999, and it was discovered that her left index      |
| finger had received a dose of 61.65 Rem.  The State of California Department |
| of Health Services Radiological Health Branch was notified of this event on  |
| 10/14/99.  There were no adverse health affects to the individual.  The      |
| State of California Department of Health Services Radiological Health Branch |
| event number assigned to this incident is 10-14-99.                          |
|                                                                              |
| (Call the NRC operations officer for additional information.)                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36539       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 12/25/1999|
|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 07:45[EST]|
|   RXTYPE: [1] GE-3                             |EVENT DATE:        12/25/1999|
+------------------------------------------------+EVENT TIME:        07:00[EST]|
| NRC NOTIFIED BY:  BRIAN SULLIVAN               |LAST UPDATE DATE:  12/25/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD CONTE        R1      |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(1)(ii)     DEGRAD COND DURING OP  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOW SWITCHGEAR ROOM TEMPERATURE DUE TO DEGRADED HEATING, VENTILATION, AND    |
| AIR  CONDITIONING (HVAC) COMPONENTS IN CONJUNCTION WITH COLD WEATHER         |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "[The] 'A' switchgear room temperature [was] outside the [final safety       |
| analysis report] design temperature limit of 60F.  [The] temperature        |
| decreased to 59F due to degraded [heating, ventilation, and air             |
| conditioning (HVAC)] components.  No known operability issues have been      |
| identified."                                                                 |
|                                                                              |
| The licensee stated that the temperature in the 'A' switchgear room has      |
| returned to 60F but that cold weather is expected again tonight.  The       |
| licensee is currently in the process of repairing the degraded HVAC          |
| components.                                                                  |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36540       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 12/26/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 15:57[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        12/26/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        05:45[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  12/26/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MARK RING            R3      |
|  DOCKET:  0707002                              |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  SPAETH                       |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ATTENDANT HAD TO EVACUATE AREA BEFORE THREE PIPE FLANGES TO A CELL WERE      |
| COVERED TO PREVENT MODERATION INTRUSION.  (NRC Bulletin 91-01 24-hour        |
| notification)                                                                |
|                                                                              |
| AT 0545 hours on 12/26/99, an emergency response was initiated in the X-333  |
| process building due to a report of smoke coming from a piece of process     |
| equipment., i.e., a seal exhaust pump (vacuum pump).  All personnel in the   |
| building were required to evacuate "see & flee" to a safe area until the     |
| emergency condition was mitigated.                                           |
|                                                                              |
| The "see & flee" took place while a maintenance evolution was ongoing that   |
| required a Nuclear Criticality Safety (NCS) required attendant to be         |
| present.  The "see & flee" resulted in the attendant being required to       |
| evacuate the work area with piping flanges uncovered (left three large       |
| compressor pipe openings uncovered to cell #33-8-9 after one of its          |
| compressors had been removed).                                               |
|                                                                              |
| This violated requirement #4 of NCSA-PLANT062.A02 which states,              |
| "openings/penetrations made during, or as a result of, maintenance           |
| activities will be covered to minimize the potential for moderation          |
| collection and moist air exposure when unattended."  This constitutes the    |
| loss of one NCS control (moderation) with mass and interaction controls      |
| maintained throughout this event.                                            |
|                                                                              |
| Moderation control was reestablished at 0655 hours by covering the openings  |
| under the direction of the Incident Commander and concurrence of NCS         |
| personnel.                                                                   |
|                                                                              |
| There was no loss of hazardous/ radioactive/material or                      |
| radioactive/radiological exposure as a result of this event.                 |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENT:  The safety significance of this event is      |
| extremely low.  The limited amount of time the flanges were uncovered and    |
| unattended did not allow any more moisture to enter than if work had         |
| continued and the equipment had been attended for the entire period.  Lack   |
| of attending personnel during the "see & flee" simply removed the ability to |
| mitigate an unlikely event involving the entrance of liquid water (or other  |
| moderator) into the equipment.                                               |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW            |
| CRITICALITY COULD OCCUR):  If the equipment had been mis-categorized and     |
| actually contained greater than the minimum critical mass of uranium (more   |
| than 900 pounds of uranyl fluoride, UO2F2, at 1.908 wt% enrichment) and      |
| liquid water entered the exposed openings, a critical configuration might    |
| have formed inside the cascade equipment.                                    |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
| The controlled parameters include mass and moderation.                       |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF CRITICAL MASS):  The exact amount is unknown;      |
| however, the cell was categorized as "uncomplicated handling" which means    |
| the cell has less than the safe mass (approximately 400 pounds uranyl        |
| fluoride, UO2F2, at 1.908 wt% enrichment).  The form would be uranyl         |
| fluoride.                                                                    |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:  By leaving the exposed flanges unattended, |
| control #4 of NCSA-PLANT062.A02 which requires, "openings/penetrations made  |
| during maintenance activities shall be covered to minimize the potential for |
| moderation collection and moist air exposure when unattended.                |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY AND WHEN EACH WAS IMPLEMENTED:          |
| Moderation control was reestablished at 0655 hours on 12/26/99, under the    |
| direction of Incident Commander, by covering the opening.                    |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the certificate     |
| holder.                                                                      |
+------------------------------------------------------------------------------+