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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  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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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                                   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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