Event Notification Report for April 06, 2000
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/05/2000 - 04/06/2000
EVENT NUMBERS
36870368713687236933
Power Reactor
Event Number: 36870
Facility: HATCH
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/06/2000
Notification Time: 12:38 [ET]
Event Date: 04/06/2000
Event Time: 10:00 [EDT]
Last Update Date: 04/06/2000
Notification Time: 12:38 [ET]
Event Date: 04/06/2000
Event Time: 10:00 [EDT]
Last Update Date: 04/06/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
STEVE CAHILL (R2)
STEVE CAHILL (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
GROUP 1 ISOLATION OCCURRED DURING MAIN TURBINE CONTROL TESTING WHICH CAUSED THE REACTOR COOLANT SAMPLE VALVES TO CLOSE.
During performance of Main Turbine Control testing, a Group 1 isolation occurred which caused Reactor Coolant sample valves 2B31 F019 & F020 (0.75" line; 1.0" valves) to close. One of the jumpers installed during the Main Turbine Control test made the Main Turbine Logic think that the generator was tied to the line. This caused the Main Turbine speed control to go to 1800 RPM because the main turbine speed control was selected to 1800 RPM instead of all valves closed. When the operator reset the Main Turbine, all 4 Main Turbine Stop Valves opened as a result of the speed control being selected to 1800 RPM. A Group 1 isolation occurred due to the Main Turbine stop valves opening coincident with a low Main Condenser Vacuum. Only the Reactor Coolant Sample Valves closed. Main Steam Isolation valves and the Main Steam line drain valves remained closed during the Group 1 isolation. The licensee is continuing the Main Turbine Control Test.
The NRC Resident Inspector was notified of the event by the licensee.
During performance of Main Turbine Control testing, a Group 1 isolation occurred which caused Reactor Coolant sample valves 2B31 F019 & F020 (0.75" line; 1.0" valves) to close. One of the jumpers installed during the Main Turbine Control test made the Main Turbine Logic think that the generator was tied to the line. This caused the Main Turbine speed control to go to 1800 RPM because the main turbine speed control was selected to 1800 RPM instead of all valves closed. When the operator reset the Main Turbine, all 4 Main Turbine Stop Valves opened as a result of the speed control being selected to 1800 RPM. A Group 1 isolation occurred due to the Main Turbine stop valves opening coincident with a low Main Condenser Vacuum. Only the Reactor Coolant Sample Valves closed. Main Steam Isolation valves and the Main Steam line drain valves remained closed during the Group 1 isolation. The licensee is continuing the Main Turbine Control Test.
The NRC Resident Inspector was notified of the event by the licensee.
Power Reactor
Event Number: 36871
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN LAMB
HQ OPS Officer: JOHN MacKINNON
Region: 1 State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN LAMB
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/06/2000
Notification Time: 14:02 [ET]
Event Date: 04/06/2000
Event Time: 12:05 [EDT]
Last Update Date: 04/06/2000
Notification Time: 14:02 [ET]
Event Date: 04/06/2000
Event Time: 12:05 [EDT]
Last Update Date: 04/06/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
Person (Organization):
JACK MCFADDEN (R1)
JACK MCFADDEN (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
SPENT FUEL POOL STORAGE RACKS BORAFLEX DEGRADING.
An evaluation of a preliminary report on the Spent Fuel Pool storage racks Boraflex testing determined that degradation is occurring. Some racks might not be able to receive fuel and ensure the Technical Specification requirement of maintaining Keff <= to 0.95 with un-borated water could be assured. Administrative controls will ensure that Keff is maintained <= to 0.95. The design of the fuel racks was to allow full core off-loads for the term of the license.
The NRC Resident Inspector was notified of this event by the licensee.
An evaluation of a preliminary report on the Spent Fuel Pool storage racks Boraflex testing determined that degradation is occurring. Some racks might not be able to receive fuel and ensure the Technical Specification requirement of maintaining Keff <= to 0.95 with un-borated water could be assured. Administrative controls will ensure that Keff is maintained <= to 0.95. The design of the fuel racks was to allow full core off-loads for the term of the license.
The NRC Resident Inspector was notified of this event by the licensee.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 36872
Rep Org: ST LOUIS UNIVERSITY HOSPITAL
Licensee: ST LOUIS UNIVERSITY HOSPITAL
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-00196-07
Agreement: N
Docket:
NRC Notified By: MARK HAENCHEN
HQ OPS Officer: JOHN MacKINNON
Licensee: ST LOUIS UNIVERSITY HOSPITAL
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-00196-07
Agreement: N
Docket:
NRC Notified By: MARK HAENCHEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/07/2000
Notification Time: 16:42 [ET]
Event Date: 04/06/2000
Event Time: 17:36 [CDT]
Last Update Date: 04/10/2000
Notification Time: 16:42 [ET]
Event Date: 04/06/2000
Event Time: 17:36 [CDT]
Last Update Date: 04/10/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
THOMAS KOZAK (R3)
JOHN HICKEY (NMSS)
THOMAS KOZAK (R3)
JOHN HICKEY (NMSS)
MEDICAL MISADMINISTRATION
A patient on a ventilator was being treated with a High Dose Radiation Remote Afterloader when the patient intervened causing a jarring motion which caused the patient's catheter to come part way out. The catheter came part way out after 13 of 14 dwell positions had been completed. Just before the commencement of the 14th dwell position the catheter was pulled out and the physicist immediately intervened and retracted the source such that the 14th dwell position was underdosed between 10 and 60%. The worst case is that the 14th dwell position, which was outside of the tumor volume, would have received as little as 40% of the original planned dose at that location.
NRC Region 3 (Kevin Null) was notified of this event by the licensee.
* * * UPDATE AT 1215 ON 04/10/00 BY DAWSON RECEIVED BY WEAVER * * *
The licensee has requested that this event be retracted after discussions with NRC Region III. The dose did not deviate by greater than 20% from the intended dose and no dose was delivered to unintended sites.
The NRC Operations Officer notified the R3DO (Hiland) and NMSS (Hickey).
A patient on a ventilator was being treated with a High Dose Radiation Remote Afterloader when the patient intervened causing a jarring motion which caused the patient's catheter to come part way out. The catheter came part way out after 13 of 14 dwell positions had been completed. Just before the commencement of the 14th dwell position the catheter was pulled out and the physicist immediately intervened and retracted the source such that the 14th dwell position was underdosed between 10 and 60%. The worst case is that the 14th dwell position, which was outside of the tumor volume, would have received as little as 40% of the original planned dose at that location.
NRC Region 3 (Kevin Null) was notified of this event by the licensee.
* * * UPDATE AT 1215 ON 04/10/00 BY DAWSON RECEIVED BY WEAVER * * *
The licensee has requested that this event be retracted after discussions with NRC Region III. The dose did not deviate by greater than 20% from the intended dose and no dose was delivered to unintended sites.
The NRC Operations Officer notified the R3DO (Hiland) and NMSS (Hickey).
Other Nuclear Material
Event Number: 36933
Rep Org: OFFICE OF EMERGENCY PREPAREDNESS
Licensee: U.S. PUBLIC HEALTH SERVICE
Region: 2
City: WINSTON-SALEM State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT CORNISH
HQ OPS Officer: JOHN MacKINNON
Licensee: U.S. PUBLIC HEALTH SERVICE
Region: 2
City: WINSTON-SALEM State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT CORNISH
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/26/2000
Notification Time: 16:16 [ET]
Event Date: 04/06/2000
Event Time: 12:00 [EDT]
Last Update Date: 04/26/2000
Notification Time: 16:16 [ET]
Event Date: 04/06/2000
Event Time: 12:00 [EDT]
Last Update Date: 04/26/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAUL FREDRICKSON (R2)
JAMES NOGGLE (R1)
JOE HOLONICH (NMSS)
PAUL FREDRICKSON (R2)
JAMES NOGGLE (R1)
JOE HOLONICH (NMSS)
TWO CHEMICAL AGENT MONITORS EACH CONTAINING 15 MILLICURIES OF NICKEL-63 MISSING DURING SHIPMENT FROM WINSTON-SALEM, NC TO BALTIMORE, MD VIA FEDEX
On March 29, 2000, two Chemical Agent Monitors, APD-2000, each containing 15 mCi of Nickel-63 were shipped by FEDEX from Winston-Salem, North Carolina to Environmental Technology Group, Baltimore, Maryland to be wiped tested. On April 06, 2000, U.S. Public Health Service was notified that the two Chemical Agent Monitors were missing. The U.S. Public Health Service and FEDEX are unable to located the missing monitors using the FEDEX tracking number. FEDEX is still trying to locate the missing monitors.
On March 29, 2000, two Chemical Agent Monitors, APD-2000, each containing 15 mCi of Nickel-63 were shipped by FEDEX from Winston-Salem, North Carolina to Environmental Technology Group, Baltimore, Maryland to be wiped tested. On April 06, 2000, U.S. Public Health Service was notified that the two Chemical Agent Monitors were missing. The U.S. Public Health Service and FEDEX are unable to located the missing monitors using the FEDEX tracking number. FEDEX is still trying to locate the missing monitors.