Event Notification Report for April 19, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/18/2000 - 04/19/2000
** EVENT NUMBERS **
36712 36883 36903
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36712 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 02/21/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 12:22[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 02/21/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 10:00[CST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/18/2000|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |BRUCE JORGENSEN R3 |
| DOCKET: 0707001 |ROBERT PIERSON NMSS |
+------------------------------------------------+JOSEPH GIITTER IRO |
| NRC NOTIFIED BY: CALVIN PITTMAN | |
| HQ OPS OFFICER: DICK JOLLIFFE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01, 4 HOUR REPORT - |
| |
| Material storage areas transferred from DOE to USEC contain uncharacterized |
| potentially fissile material that does not comply with USEC NCS program |
| requirements. The stored material also does not meet DOE NCS requirements. |
| Responsibility for the storage areas was transferred to USEC for more rapid |
| remediation of the non-conforming conditions, in part to support the Seismic |
| Upgrade Project in C-331 and C-335, and to improve overall site safety. |
| |
| SAFETY SIGNIFICANCE OF EVENTS: The DOE material storage areas were located |
| within the boundaries of USEC leased space. Transfer to USEC control allows |
| more timely remediation to establish double contingency controls on the |
| material. Timely remediation will improve overall site safety. The |
| material is in a stable condition and double contingency will be established |
| using USEC procedures. These procedures ensure that safety is not degraded |
| during the remediation actions. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED [BRIEF SCEANARIO(S) OF HOW |
| CRITICALITY COULD OCCUR]: In order for a criticality to be possible, more |
| than a critical mass would need to be accumulated in an unsafe geometry. |
| The stored material is primarily equipment items in which the fissile |
| material is deposited in small quantities widely dispersed over large |
| surface areas. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY CONCENTRATION, etc): |
| Since no NCS controls were applied to the equipment, double contingency can |
| not be demonstrated. |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITCAL MASS): Unknown due to DOE previously |
| controlling areas. |
| |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: No NCS controls (other than providing 10 |
| feet buffer zone) where in place. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| Areas are to be remediated in accordance with NCS program requirements. |
| |
| The NRC Resident Inspector has been notified of this event. |
| |
| PGDP Problem Report No. ATRC-OO-1009: PGDP Event Report No. PAD-2000-017. |
| |
| * * * UPDATE 1232 4/18/2000 FROM PITTMAN TAKEN BY STRANSKY * * * |
| |
| An additional area, DMSA 30 in C-337, was transferred from DOE to USEC on |
| 4/18/2000 at 1000 CST. The NRC resident inspector has been informed of this |
| update. Notified R3DO (Ring), NMSS (Sturz). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36883 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 04/12/2000|
| UNIT: [] [2] [] STATE: AL |NOTIFICATION TIME: 17:57[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 04/12/2000|
+------------------------------------------------+EVENT TIME: 14:10[CDT]|
| NRC NOTIFIED BY: RAY SWAFFORD |LAST UPDATE DATE: 04/18/2000|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHRIS CHRISTENSEN R2 |
|10 CFR SECTION: | |
|AINB 50.72(b)(2)(iii)(B) POT RHR INOP | |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LEAK IN THE HPCI TEST RETURN HEADER TO THE CONDENSATE STORAGE TANK |
| |
| On 4/12/2000, at 14:10 while performing 2-SR-3.5.1 .7, HPCI Main and Booster |
| Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure, the |
| Unit Operator (UO)observed unstable HPCI suction pressure, followed by an |
| auto swap of the suction from the Condensate Storage Supply to the |
| Suppression Pool. The UO then observed annunciator, 'HPCI PUMP SUCT |
| CONDENSATE HDR LEVEL LOW'. HPCI was tripped and declared inoperable. |
| Subsequently a leak was discovered on the HPCI Test Return header to the |
| CST. The leak has been isolated. Unit conditions are stable. |
| |
| The licensee notified the NRC resident inspector. |
| |
| * * * RETRACTION 1815 4/18/2000 FROM TIM GOLDEN TAKEN BY BOB STRANSKY * * * |
| |
| "TVA is retracting this report. Subsequent investigation into the cause of |
| this event determined that the source of the leak was a separated weld in a |
| non-safety related portion of the test return flowpath to the condensate |
| storage tank. Testing and engineering analyses performed after the event |
| demonstrated that the conditions which caused the event would not have |
| prevented HPCI from performing it's safety function if required. |
| Specifically, if HPCI had been called upon to mitigate an actual event, |
| automatic closure of the test return control valve would have isolated the |
| leak, thereby establishing a safety injection flow path to the reactor |
| vessel. Therefore, this event is not reportable with respect to |
| 10CFR50.72(b)(2)(iii) and is hereby retracted. The senior NRC resident |
| inspector has been informed." |
| |
| Notified R2DO (Boland). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36903 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. LUKE'S REGIONAL MEDICAL CENTER |NOTIFICATION DATE: 04/18/2000|
|LICENSEE: ST. LUKE'S REGIONAL MEDICAL CENTER |NOTIFICATION TIME: 12:21[EDT]|
| CITY: BOISE REGION: 4 |EVENT DATE: 02/25/2000|
| COUNTY: STATE: ID |EVENT TIME: [MDT]|
|LICENSE#: 11-27312-01 AGREEMENT: N |LAST UPDATE DATE: 04/18/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| |FRITZ STURZ NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ETHAN FAIRBANKS | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| On 2/25/2000, an individual was implanted with 58 I-125 seeds for prostate |
| treatment. However, the activity of the seeds implanted (0.354 mCi/seed) was |
| higher than prescribed (0.27 mCi/seed). The licensee reported that, although |
| the actual dose to the prostate was similar to the planned treatment dose, |
| since the activity of the implanted seeds exceeded the prescribed activity |
| by more than 20%, this occurrence was being treated as a misadministration. |
| |
| The misadministration was discovered during a review performed on 4/17/2000. |
| The licensee reported that an error occurred when the seeds were being |
| ordered, and that additional steps would be added to the procedure to |
| prevent recurrence. The radiation oncologist has been notified, and he will |
| inform the patient of the incident. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021