Event Notification Report for February 15, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/14/2000 - 02/15/2000
** EVENT NUMBERS **
36687 36688 36689 36690 36691 36692
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|General Information or Other |Event Number: 36687 |
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| REP ORG: FLORIDA BUREAU OF RADIATION CONTROL |NOTIFICATION DATE: 02/14/2000|
|LICENSEE: HEALTHSOUTH DOCTOR'S HOSPITAL, INC. |NOTIFICATION TIME: 11:15[EST]|
| CITY: CORAL GABLES REGION: 2 |EVENT DATE: 01/28/2000|
| COUNTY: DADE STATE: FL |EVENT TIME: 10:00[EST]|
|LICENSE#: FL 2301-2 AGREEMENT: Y |LAST UPDATE DATE: 02/14/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK LESSER R2 |
| |JOSEPHINE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHARLEY E. ADAMS | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 36688 |
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| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 02/14/2000|
| UNIT: [1] [2] [] STATE: VA |NOTIFICATION TIME: 12:12[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 02/14/2000|
+------------------------------------------------+EVENT TIME: 11:33[EST]|
| NRC NOTIFIED BY: DILLARD |LAST UPDATE DATE: 02/14/2000|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
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EVENT TEXT
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| SPDS DECLARED INOPERABLE |
| |
| THE PLANT NOTICED A FAILURE OF THEIR SPDS PORTION OF THE EMERGENCY RESPONSE |
| FACILITY COMPUTER SYSTEM (ERFCS) AT 1133 EST. HOWEVER ,THE SYSTEM WAS |
| RETURNED TO OPERABLE CONDITION AT 1140 HOURS. THIS CONDITION WAS DUE TO |
| SYSTEM TIME NOT UPDATING. |
| THE ERFCS WAS REBOOTED SATISFACTORILY AND ALL PORTIONS OF THE SYSTEM WERE |
| NOTED TO BE FUNCTIONING CORRECTLY AT 1140 HOURS. INSPECTION OF THE SYSTEM |
| ALARM SUMMARY INDICATED THAT THE LAST TIME A VALID SYSTEM TIME UPDATE |
| OCCURRED WAS 1013 HOURS. |
| |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED. |
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|Power Reactor |Event Number: 36689 |
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| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 02/14/2000|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 12:19[EST]|
| RXTYPE: [1] GE-4 |EVENT DATE: 02/14/2000|
+------------------------------------------------+EVENT TIME: 10:30[CST]|
| NRC NOTIFIED BY: TIM ERGER |LAST UPDATE DATE: 02/14/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| THREE CONTAINMENT NITROGEN MAKEUP FOR TORUS AND DRYWELL VALVES ARE NOT |
| CAPABLE OF CLOSING DURING A DESIGN BASIS ACCIDENT. |
| |
| Control Room was notified by system engineering that design basis review |
| calculations have determined that Air Operated Valves CV4311, CV4312, and |
| CV4313 (containment nitrogen makeup for torus and drywell) are not capable |
| of closing during a design basis accident. The spring closing force is |
| borderline such that the spring force may not be large enough to close the |
| valve when the containment is at its maximum pressure during a design basis |
| accident. |
| |
| CV4311, CV4312, and CV4313 have been declared inoperable. The licensee |
| entered Technical Specification 3.6.1.3 condition B to isolate the affected |
| penetrations within one hour. The valves have been closed and at this time |
| the licensee is de-energizing the power to the valves. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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|Hospital |Event Number: 36690 |
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| REP ORG: LESTER E. COX MEDICAL CENTER |NOTIFICATION DATE: 02/14/2000|
|LICENSEE: LESTER E. COX MEDICAL CENTER |NOTIFICATION TIME: 12:35[EST]|
| CITY: Springfield REGION: 3 |EVENT DATE: 02/03/2000|
| COUNTY: STATE: MO |EVENT TIME: 12:00[CST]|
|LICENSE#: 24-01143-06 AGREEMENT: N |LAST UPDATE DATE: 02/14/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE JORGENSEN R3 |
| |JOSEPHINE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: Dr.TIM LESS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 15 MILLICUIRE NICKEL-63 SOURCE USED IN A HP GAS CHROMATOGRAPHY MISSING |
| |
| Today at 0930 CT the Radiation Safety Officer for Cox Health System was |
| informed by the Chief of Safety for Lester E. Cox Medical Center - North, |
| located in Springfield, Mo., that a 15 millicurie Ni-63 source for a HP Gas |
| Chromatography was missing and is now believed to be buried in a local land |
| fill. The source was initially purchased on July 30. 1982 and it was last |
| used in 1990. Since 1990 the source had been in a storage room located in |
| the toxicology lab at Lester E. Cox Medical Center - North, Springfield, Mo. |
| The items stored in the storage room were moved earlier this year to another |
| location in the Lester E. Cox Medical Center - North. The left over items |
| in the storage room were discarded into a BFI Dumpster at their facility and |
| it is believed that the Ni-63 source was discarded to the BFI Dumpster. On |
| 02/03/00 BFI hauled the contents of the dumpster to a local land fill. At |
| this time the licensee is trying to find out if it is necessary to recover |
| the Ni-63 source. |
| Ni-63 is a pure Beta emitter and the energy of the Beta particles is 17 Kev. |
| HP registry number for the Gas Chromatography is NR-348-D-804-B. |
| |
| Call the Headquarters Operation Officer for address and phone number. |
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|Fuel Cycle Facility |Event Number: 36691 |
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| FACILITY: GLOBAL NUCLEAR FUEL - AMERICAS |NOTIFICATION DATE: 02/14/2000|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 15:40[EST]|
| COMMENTS: LEU CONVERSION (UF6 TO UO2) |EVENT DATE: 02/14/2000|
| LEU FABRICATION |EVENT TIME: 11:30[EST]|
| LWR COMMERICAL FUEL |LAST UPDATE DATE: 02/14/2000|
| CITY: WILMINGTON REGION: 2 +-----------------------------+
| COUNTY: NEW HANOVER STATE: NC |PERSON ORGANIZATION |
|LICENSE#: SNM-1097 AGREEMENT: Y |MARK LESSER R2 |
| DOCKET: 07001113 |BRIAN SMITH NMSS |
+------------------------------------------------+FRANK CONGEL IRO |
| NRC NOTIFIED BY: LON E. PAULSON |CHARLES MILLER IRO |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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| | |
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EVENT TEXT
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| 4-HOUR NRC BULLETIN 91-01 REPORT INVOLVING LOSS OF MASS CONTROL |
| |
| At approximately 1145 on February 14, 2000, nuclear safety confirmed that 55 |
| cans of grinder swarf material (grindings from making fuel pellets) was |
| stored at pad storage in violation of the established mass limit for |
| heterogeneous material. The mass limit used to determine each can's |
| allowable weight was incorrectly assigned. The storage of these cans at |
| this location resulted in a loss of mass control. Geometry control on |
| spacing remained intact, thus no unsafe condition existed. |
| |
| Relocation of affected cans to approved storage locations is in progress and |
| is expected to be completed within 90 minutes of this report. Scrap |
| material movement from the Gadolinium Shop to Fuel Support pad storage has |
| been suspended pending investigation and implementation for corrective |
| actions. |
| |
| SAFETY SIGNICANCE OF EVENTS: |
| |
| Low safety significance - fixed geometry/spacing control on heterogeneous |
| scrap storage remained intact. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED: |
| |
| Multiple failure modes required before a criticality accident could occur. |
| |
| CONTROLLED PARAMETER(S) (MASS, MODERATION, GEOMETRY, CONCENTRATIO, ETC.) |
| |
| Geometry/Spacing: single-planar array of 3-gallon heterogeneous scrap |
| demonstrated safe optimally moderated, 12-inches edge-to-edge spacing |
| provided by treated wooden storage racks. Mass: mass of 3-gallon |
| heterogeneous scrap material limited to 16.5 kgs (gross) weight per can. |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL : |
| |
| Affected 3-gallon gadolinium grinder scrap cans contained approximately 25 |
| kgs of Uranium Dioxide versus limit of 16.5 kgs gross weight. At a 12-inch |
| edge-to-edge spacing, single planar array storage configuration is |
| demonstrated safe for "optimally moderated" heterogeneous Uranium Dioxide |
| plus water mixture. |
| |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTATION |
| OF THE FAILURES OF DEFICIENCIES: |
| |
| Administrative mass control on gadolinium grinder swarf. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| |
| 1. All gadolinium scrap movement to fuel support suspended. |
| 2. Relocated affected cans to approved storage locations under NSE |
| direction. |
| 3. Investigation and implementation of corrective actions pending. |
| |
| The Licensee will inform NRC Region 2, State and Local officials of this |
| event notification. |
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|Fuel Cycle Facility |Event Number: 36692 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 02/15/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 00:30[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 02/14/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 17:00[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 02/15/2000|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |BRUCE JORGENSEN R3 |
| DOCKET: 0707002 | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JIM McCLEERY | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| 24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING LOSS OF GEOMETRY/VOLVUME |
| CRITICALITY CONTROL IN THE X-705 DECONTAMINATION FACILITY |
| |
| "On 2/14/00 the Plant Shift Superintendent (PSS) was notified of the loss of |
| one control parameter, geometry/volume in the X-705 decontamination |
| facility. A vinyl covered foam padded chair was found in the high bay area |
| with the vinyl covering worn open. This is a violation of NSCA-0705_076 |
| inadvertent containers. The foam padding thickness was greater than the |
| requirement for absorbent material described in NCSA-0705_076. |
| |
| "The system integrity of nearby uranium-bearing pipes was maintained. |
| Therefore, no solution was actually present to accumulate on/in the padding |
| of the chair. |
| |
| "The chair was moved to an area in the high bay not covered by the above |
| described NCSA. Compliance with NCSA--0705_076 is restored |
| |
| "THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR |
| RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT. |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: |
| |
| "A padded chair (seat dimensions approximately 17.5" x 21" x 3.5") was used |
| near a uranium solution transfer line. The vinyl on the seat was damaged to |
| the point that any solution if splashed in to the chair could have |
| accumulated in the padding. The padding is an unsafe height > 1 .5") and has |
| a total volume >20 liters, which is well above the allowed limit of 4.8 |
| liters. The transfer line near this seat can contain high concentrations of |
| HEU solution. |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): |
| |
| "If the solution line had failed, uranium-bearing solution could have |
| splashed/sprayed onto the seat padding and accumulated. Since the total |
| volume of the padding was greater than the allowed 4.8 liters and the height |
| (excluding and swelling of the material) was greater than the allowed 1.5" |
| an unsafe condition would have resulted and a criticality could have |
| resulted. |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION. GEOMETRY, CONCENTRATION, ETC.): |
| |
| The parameter lost was the geometry/volume of the absorbent material on the |
| chair. The physical integrity of the transfer line was maintained. |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST |
| |
| "No material accumulated on/in the chair padding. The transfer line near the |
| chair can contain HEU solutions with high uranium concentrations. |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES |
| |
| "Requirement #4 requires that absorbent material be covered or modified to |
| prevent an unfavorable accumulation in the event of a solution leak in a |
| nearby system. The chair padding was absorbent and the vinyl covering had |
| degraded to the point that solution hitting the chair could accumulate in |
| the padding. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: |
| |
| "Compliance was regained when the chair was moved to an area not covered by |
| NCSA-0705_076. Crew briefing are being conducted shiftily and the chair in |
| question is caution boundaried." |
| |
| Operations personnel notified both the DOE Site Representative and the NRC |
| Resident Inspector. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021