Event Notification Report for January 28, 2000
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/27/2000 - 01/28/2000
EVENT NUMBERS
3665036638366393664036687
General Information or Other
Event Number: 36650
Rep Org: IL DEPARTMENT OF NUCLEAR SAFETY
Licensee: UNKNOWN
Region: 3
City: State: IL
County:
License #: GL#9223308
Agreement: Y
Docket:
NRC Notified By: STEVE COLLINS (by E MAIL)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: UNKNOWN
Region: 3
City: State: IL
County:
License #: GL#9223308
Agreement: Y
Docket:
NRC Notified By: STEVE COLLINS (by E MAIL)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/01/2000
Notification Time: 18:00 [ET]
Event Date: 01/28/2000
Event Time: 00:00 [CST]
Last Update Date: 02/01/2000
Notification Time: 18:00 [ET]
Event Date: 01/28/2000
Event Time: 00:00 [CST]
Last Update Date: 02/01/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TONY VEGEL (R3)
JOE HOLONICH (NMSS)
FRANK CONGEL (IRO)
TONY VEGEL (R3)
JOE HOLONICH (NMSS)
FRANK CONGEL (IRO)
MISSING THICKNESS GAUGE CONTAINING RADIOACTIVE SOURCE
The individual responsible for a Generally Licensed device reported on 01/28/00 that he noticed the device containing a radioactive source was missing from the facility. The device was removed by some unauthorized person or persons. He noticed it missing when he attempted to perform a test for leakage. The Illinois company changed ownership within the last two weeks. The facility location and most personnel remain the same. The radioactive source was registered with the Illinois Department of Nuclear Safety on 09/05/96 (GL #9223308). The source is 150 mCi of Am-241 in a NDC Model 103 thickness gauge with serial number 11300. This device was used to measure thickness of plastic film. The device is stainless steel approximately eight inches long and 1-1/4 to 1-1/2 inches in diameter. The SS&D sheet (CA0471D102B) indicates a maximum radiation level of 5 mR/hour at one foot with the shutter open and 185 mR/hour near contact with the shutter open. With the shutter closed, the maximum radiation level is 0.1 mR/hour at one inch and less than 0.75 mR/hour near contact.
The individual had searched the entire plant on 01/28/00, including the roof, in an attempt to locate the device. A police report has been filed.
On 02/01/00, IL Department of Nuclear Safety staff personnel performed surveys in an attempt to locate the device and its source but did not find them.
The individual responsible for a Generally Licensed device reported on 01/28/00 that he noticed the device containing a radioactive source was missing from the facility. The device was removed by some unauthorized person or persons. He noticed it missing when he attempted to perform a test for leakage. The Illinois company changed ownership within the last two weeks. The facility location and most personnel remain the same. The radioactive source was registered with the Illinois Department of Nuclear Safety on 09/05/96 (GL #9223308). The source is 150 mCi of Am-241 in a NDC Model 103 thickness gauge with serial number 11300. This device was used to measure thickness of plastic film. The device is stainless steel approximately eight inches long and 1-1/4 to 1-1/2 inches in diameter. The SS&D sheet (CA0471D102B) indicates a maximum radiation level of 5 mR/hour at one foot with the shutter open and 185 mR/hour near contact with the shutter open. With the shutter closed, the maximum radiation level is 0.1 mR/hour at one inch and less than 0.75 mR/hour near contact.
The individual had searched the entire plant on 01/28/00, including the roof, in an attempt to locate the device. A police report has been filed.
On 02/01/00, IL Department of Nuclear Safety staff personnel performed surveys in an attempt to locate the device and its source but did not find them.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 36638
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DARYL CLARK
HQ OPS Officer: STEVE SANDIN
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DARYL CLARK
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/28/2000
Notification Time: 05:14 [ET]
Event Date: 01/28/2000
Event Time: 02:40 [CST]
Last Update Date: 02/02/2000
Notification Time: 05:14 [ET]
Event Date: 01/28/2000
Event Time: 02:40 [CST]
Last Update Date: 02/02/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (R3)
MONTE PHILLIPS (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
BOTH EMERGENCY DIESEL GENERATORS INOPERABLE DURING CORE ALTERATIONS.
"On 1/28/00 at 0005 hrs, the U-2 Emergency Diesel Generator was found to be inoperable due to the diesel generator room vent fan selector switch being selected to the alternate feed. The 1/2 Emergency Diesel Generator was inoperable due to Division I electrical system refuel outage work. Core alterations were in progress.
"Per Tech Spec 3.9.B, one diesel generator must be operable in Mode 5 and when handling irradiated fuel in the secondary containment.
"The switch was aligned to the normal position, and vent fan operation was verified within approximately 15 minutes to restore the U-2 diesel generator to an operable status. An internal investigation is commencing. Although both the 1/2 and U-2 EDGs were inoperable, both diesels remained available for operation.
"This event is being reported as required by 10CFR50.72(b)(2)(iii)(D), an event which alone could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident."
The licensee informed the NRC Resident Inspector.
* * * UPDATE ON 02/02/00 AT 1841 FROM HILL TO GOULD * * * RETRACTION
The licensee has completed its evaluation and determined that the Unit 2 Emergency Diesel Generator was able to meet its intended safety function considering reasonable operator actions. Therefore, this event is not reportable with respect to 10CFR 50.72(b)(2)(iii)(D) and is hereby retracted.
The licensee notified the NRC Resident Inspector. The NRC Operations Officer notified R3DO (Tony Vegel).
"On 1/28/00 at 0005 hrs, the U-2 Emergency Diesel Generator was found to be inoperable due to the diesel generator room vent fan selector switch being selected to the alternate feed. The 1/2 Emergency Diesel Generator was inoperable due to Division I electrical system refuel outage work. Core alterations were in progress.
"Per Tech Spec 3.9.B, one diesel generator must be operable in Mode 5 and when handling irradiated fuel in the secondary containment.
"The switch was aligned to the normal position, and vent fan operation was verified within approximately 15 minutes to restore the U-2 diesel generator to an operable status. An internal investigation is commencing. Although both the 1/2 and U-2 EDGs were inoperable, both diesels remained available for operation.
"This event is being reported as required by 10CFR50.72(b)(2)(iii)(D), an event which alone could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident."
The licensee informed the NRC Resident Inspector.
* * * UPDATE ON 02/02/00 AT 1841 FROM HILL TO GOULD * * * RETRACTION
The licensee has completed its evaluation and determined that the Unit 2 Emergency Diesel Generator was able to meet its intended safety function considering reasonable operator actions. Therefore, this event is not reportable with respect to 10CFR 50.72(b)(2)(iii)(D) and is hereby retracted.
The licensee notified the NRC Resident Inspector. The NRC Operations Officer notified R3DO (Tony Vegel).
Power Reactor
Event Number: 36639
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: QUENTIN HICKS
HQ OPS Officer: BOB STRANSKY
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: QUENTIN HICKS
HQ OPS Officer: BOB STRANSKY
Notification Date: 01/28/2000
Notification Time: 16:25 [ET]
Event Date: 01/28/2000
Event Time: 13:31 [EST]
Last Update Date: 01/28/2000
Notification Time: 16:25 [ET]
Event Date: 01/28/2000
Event Time: 13:31 [EST]
Last Update Date: 01/28/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(vi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(vi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN ROGGE (R1)
JOHN ROGGE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO WILDLIFE KILL
The licensee notified the New York Department of Environmental Conservation and the U.S. Fish and Wildlife Service regarding the death of 101 blue billed ducks. The ducks were discovered after the circulating water system was realigned from reverse flow to normal flow. The NRC resident inspector will be informed of this event by the licensee.
The licensee notified the New York Department of Environmental Conservation and the U.S. Fish and Wildlife Service regarding the death of 101 blue billed ducks. The ducks were discovered after the circulating water system was realigned from reverse flow to normal flow. The NRC resident inspector will be informed of this event by the licensee.
Power Reactor
Event Number: 36640
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: GETZ
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: MD
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: GETZ
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/29/2000
Notification Time: 00:45 [ET]
Event Date: 01/28/2000
Event Time: 22:00 [EST]
Last Update Date: 01/31/2000
Notification Time: 00:45 [ET]
Event Date: 01/28/2000
Event Time: 22:00 [EST]
Last Update Date: 01/31/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iii)(C) - POT UNCNTRL RAD REL 50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(iii)(C) - POT UNCNTRL RAD REL 50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN ROGGE (R1)
JOHN ROGGE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
ECCS VENT SYSTEM FAILED SURVEILLANCE DUE TO PROBLEMS WITH THE CHARCOAL FILTERS.
UPON THE COMPLETION OF MAINTENANCE PERFORMED ON THE 11 AND 12 ECCS PUMP ROOM VENT FANS, IT WAS DETERMINED THAT THE CHARCOAL FILTERS DID NOT SEAT PROPERLY DURING A CHARCOAL TEST (STPM-547-1) RESULTING IN THE TEST CRITERIA NOT BEING MET. SEVERAL LOOSE NUTS WERE DISCOVERED ON THE CHARCOAL TRAY HOLD-DOWN FASTENERS. THE NUTS WERE TIGHTENED, AND THE SURVEILLANCE WAS PERFORMED SATISFACTORILY. THE LICENSEE IS INVESTIGATING WHY THE NUTS WERE LOOSE SINCE THE FILTERS WERE NOT INVOLVED IN MAINTENANCE PERFORMED.
THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE.
*************** UPDATE AT 0335 ON 01/31/00 FROM LEO GREGORY GETZ TO LEIGH TROCINE ***************
The licensee called to change its internal event report number and to provide the following updated information. In an effort to check for a common mode problem, the licensee checked the Unit 2 charcoal filters on 01/29/00. They all tested satisfactorily.
The licensee notified the NRC resident inspector. The NRC operations officer notified the R1DO (Rogge).
UPON THE COMPLETION OF MAINTENANCE PERFORMED ON THE 11 AND 12 ECCS PUMP ROOM VENT FANS, IT WAS DETERMINED THAT THE CHARCOAL FILTERS DID NOT SEAT PROPERLY DURING A CHARCOAL TEST (STPM-547-1) RESULTING IN THE TEST CRITERIA NOT BEING MET. SEVERAL LOOSE NUTS WERE DISCOVERED ON THE CHARCOAL TRAY HOLD-DOWN FASTENERS. THE NUTS WERE TIGHTENED, AND THE SURVEILLANCE WAS PERFORMED SATISFACTORILY. THE LICENSEE IS INVESTIGATING WHY THE NUTS WERE LOOSE SINCE THE FILTERS WERE NOT INVOLVED IN MAINTENANCE PERFORMED.
THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE.
*************** UPDATE AT 0335 ON 01/31/00 FROM LEO GREGORY GETZ TO LEIGH TROCINE ***************
The licensee called to change its internal event report number and to provide the following updated information. In an effort to check for a common mode problem, the licensee checked the Unit 2 charcoal filters on 01/29/00. They all tested satisfactorily.
The licensee notified the NRC resident inspector. The NRC operations officer notified the R1DO (Rogge).
General Information or Other
Event Number: 36687
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: HEALTHSOUTH DOCTOR'S HOSPITAL, INC.
Region: 2
City: CORAL GABLES State: FL
County: DADE
License #: FL 2301-2
Agreement: Y
Docket:
NRC Notified By: CHARLEY E. ADAMS
HQ OPS Officer: STEVE SANDIN
Licensee: HEALTHSOUTH DOCTOR'S HOSPITAL, INC.
Region: 2
City: CORAL GABLES State: FL
County: DADE
License #: FL 2301-2
Agreement: Y
Docket:
NRC Notified By: CHARLEY E. ADAMS
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/14/2000
Notification Time: 11:15 [ET]
Event Date: 01/28/2000
Event Time: 10:00 [EST]
Last Update Date: 02/14/2000
Notification Time: 11:15 [ET]
Event Date: 01/28/2000
Event Time: 10:00 [EST]
Last Update Date: 02/14/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
MARK LESSER (R2)
JOSEPHINE PICCONE (NMSS)
MARK LESSER (R2)
JOSEPHINE PICCONE (NMSS)
FLORIDA AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION DURING GAMMA KNIFE TREATMENT
"Patient was being treated with Gamma knife for brain lesions. On Tuesday, Jan 25, patient was supposed to have lesions #44-49 treated. A mistake in site location resulted in lesion #16 being retreated instead of lesion #47. This mistake was discovered at approximately 10:00 am on Friday, Jan 28 by Dr. Coy. NRC Region II was notified of this incident on 1-31-00 and agreed that the investigation should be completed before NRC Ops [Center] notification to make sure it was an abnormal occurrence. Investigator found no violations of the license or regulations. The licensee's quality assurance program found the error. The licensee had the wrong site set in the computer when the procedure was performed. The additional dose to this site has not caused any harmful effects in the patient."
The maximum dose received was 12 gray from a Gamma knife loading of 201 rods each containing 36 Curies Co-60 activity/rod.
"Patient was being treated with Gamma knife for brain lesions. On Tuesday, Jan 25, patient was supposed to have lesions #44-49 treated. A mistake in site location resulted in lesion #16 being retreated instead of lesion #47. This mistake was discovered at approximately 10:00 am on Friday, Jan 28 by Dr. Coy. NRC Region II was notified of this incident on 1-31-00 and agreed that the investigation should be completed before NRC Ops [Center] notification to make sure it was an abnormal occurrence. Investigator found no violations of the license or regulations. The licensee's quality assurance program found the error. The licensee had the wrong site set in the computer when the procedure was performed. The additional dose to this site has not caused any harmful effects in the patient."
The maximum dose received was 12 gray from a Gamma knife loading of 201 rods each containing 36 Curies Co-60 activity/rod.