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Event Notification Report for May 4, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/03/2000 - 05/04/2000

                              ** EVENT NUMBERS **

36861  36959  36960  36961  36962  36963  36964  36965  36966  36967  36968  36969 


+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36861       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  PPG ARCHITECTURAL FINISHES, INC      |NOTIFICATION DATE: 04/03/2000|
|LICENSEE:  PPG ARCHITECTURAL FINISHES, INC      |NOTIFICATION TIME: 13:20[EDT]|
|    CITY:  PITTSBURGH               REGION:  1  |EVENT DATE:        04/03/2000|
|  COUNTY:  ALLEGHENY                 STATE:  PA |EVENT TIME:             [EDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  05/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |VERN HODGE (FAX)     NRR     |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOSEPH KARAS                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 10 CFR PART 21 REPORT                                                        |
|                                                                              |
| "This notification is being made by PPG Architectural Finishes, Inc (PPG)    |
| concerning relatively small quantities of a silicon stainless steel enamel   |
| coating used inside primary containment supplied to a single utility which   |
| is a NRC nuclear power plant licensee. The coating was not appropriately     |
| controlled such that its formulation changed from that which was originally  |
| supplied. The utility has been informed and is working with PPG. Further     |
| investigation is being conducted which may result in the withdrawal or       |
| modification of this notification. Written notification in accordance with   |
| 10 CFR � 21.2 1(d)(3)(ii) will follow."                                      |
|                                                                              |
| * * * UPDATE AT 1640 ON 05/03/00 BY JOSEPH M. KARAS, PPG INDUSTRIES, INC TO  |
| JOLLIFFE * * *                                                               |
|                                                                              |
| Exterior silicone stainless steel enamel coating #8674 qualified for Coating |
| Service Level I Exposure in 1980 by PPG Industries, Inc, Keeler & Long       |
| Division, was supplied as a commercial grade item (not included in the       |
| supplier's Quality Assurance Program) to Duke Energy Company  Nuclear        |
| Facilities, Catawba, McGuire and Oconee.  This coating is being used inside  |
| containment on piping that is contained by mirror insulation which should    |
| minimize the potential for paint chip fouling of sump pumps thereby          |
| interfering with the operation of Emergency Core Cooling Systems in the      |
| event of a DBA incident.                                                     |
|                                                                              |
| The NRC Operations Officer notified the R2DO Bob Haag and NRR Vern Hodge (by |
| fax).                                                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36959       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DRESDEN                  REGION:  3  |NOTIFICATION DATE: 05/03/2000|
|    UNIT:  [] [] [3]                 STATE:  IL |NOTIFICATION TIME: 11:31[EDT]|
|   RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3           |EVENT DATE:        05/03/2000|
+------------------------------------------------+EVENT TIME:        09:46[CDT]|
| NRC NOTIFIED BY:  DAVID GRONEK                 |LAST UPDATE DATE:  05/03/2000|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE BURGESS        R3      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     A/R        Y       100      Power Operation  |0        Hot Shutdown     |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REACTOR SCRAM AND ESF ACTUATION                                              |
|                                                                              |
| Unit 3 auto scrammed from 100 percent power at 0946 CDT on 5/3/00.  Reactor  |
| protection power supplies (120VAC) were being transferred at the time of the |
| reactor scram.  All rods fully inserted into the core. The exact cause of    |
| the scram is unknown at this time.  Licensee investigation into the cause of |
| the scram continues.  All systems responded as expected.   A Group 2 and     |
| Group 3 isolation signal also was received during the scram as expected.     |
| The unit is stable at hot shutdown conditions.                               |
|                                                                              |
| The NRC resident inspector has been notified.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36960       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 05/03/2000|
|    UNIT:  [] [2] [3]                STATE:  CA |NOTIFICATION TIME: 12:20[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        05/03/2000|
+------------------------------------------------+EVENT TIME:        08:25[PDT]|
| NRC NOTIFIED BY:  CLAY WILLIAMS                |LAST UPDATE DATE:  05/03/2000|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |WILLIAM JOHNSON      R4      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|3     N          Y       100      Power Operation  |100      Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OUTSIDE DESIGN BASIS                                                         |
|                                                                              |
| This notification is for San Onofre Units 2 and 3 and is being made in       |
| accordance with 10CFR5072(b)(1)(ii)(B) for the condition of the Salt Water   |
| Cooling (SWC) System and the Shutdown Cooling System potentially being       |
| outside their design basis. This condition exists for both Units 2 and 3.    |
|                                                                              |
| The SWC system consists of two separate, 100% capacity safety related        |
| cooling water trains for each unit. Each train consists of two 100% capacity |
| pumps. The pumps aligned to the critical CCW loops are automatically started |
| upon receipt of a safety injection actuation signal and all essential valves |
| are aligned to their post accident positions. Although not specifically      |
| stated, the accident analyses for Unit's 2 and 3 assumes that once these     |
| valves have been placed in their safety-related positions that they would    |
| remain in that position until intentionally realigned by plant personnel.    |
| Recently, the licensee discovered that the air/trip valves for pneumatic     |
| actuators for the saltwater cooling pump discharge valves were leaking a     |
| small amount of air and questioned whether this could cause these valves to  |
| be inoperable under postulated accident conditions.                          |
|                                                                              |
| The pneumatic actuators receive their air supply from the non-safety-related |
| instrument air system, which would not be available following a Loss of      |
| Offsite Power (LOOP) event. The actuator vender indicated that under such    |
| conditions, the accumulators for the actuators would gradually loose         |
| pressure and would not forcibly hold these valves in their safety related    |
| positions. The licensee recognized that hydrodynamic forces inside the pipes |
| could cause these valves to close. Because these valves do not have manual   |
| hand wheels and it may take some time for operators to diagnose this         |
| condition, restore instrument air, and reopen the valves, the licensee       |
| declared the valves inoperable until corrective actions were implemented.    |
| The valves were blocked open to ensure they will remain in their             |
| safety-related positions during postulated accident conditions.              |
|                                                                              |
| A similar condition exists for the pneumatic actuator for the component      |
| cooling water outlet valves for the shutdown cooling heat exchangers. The    |
| licensee restored operability to these valves by engaging manual hand wheels |
| which lock the valves open due to increased closing drag.                    |
|                                                                              |
| The Resident Inspector will be notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36961       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 05/03/2000|
|    UNIT:  [1] [2] []                STATE:  WI |NOTIFICATION TIME: 12:40[EDT]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        05/03/2000|
+------------------------------------------------+EVENT TIME:        10:45[CDT]|
| NRC NOTIFIED BY:  DON POPP                     |LAST UPDATE DATE:  05/03/2000|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE BURGESS        R3      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 1 HOUR SECURITY REPORT                                                       |
|                                                                              |
| Unescorted protected area access granted inappropriately.  Immediate         |
| compensatory measures taken.                                                 |
|                                                                              |
| The licensee will notify the NRC Resident Inspector.                         |
|                                                                              |
| Contact the Headquarters Operations Center for additional details            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36962       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  VETERANS AFFAIRS                     |NOTIFICATION DATE: 05/03/2000|
|LICENSEE:  VA MEDICAL CENTER BIRMINGHAM AL      |NOTIFICATION TIME: 14:06[EDT]|
|    CITY:  BIRMINHAM                REGION:  2  |EVENT DATE:        05/03/2000|
|  COUNTY:                            STATE:  AL |EVENT TIME:        10:00[CDT]|
|LICENSE#:  01-00648-02           AGREEMENT:  Y  |LAST UPDATE DATE:  05/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROBERT HAAG          R2      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GARY WILLIAMS                |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAAA 20.1906(d)           SURFACE CONT/ EXT RAD |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RECEIPT OF A PACKAGE WITH SURFACE CONTAMINATION GREATER THAN LIMIT           |
|                                                                              |
| On May 3, 2000, at approximately 10:00 am, a box of radiopharmaceuticals     |
| containing approximately 68 mCi of Technetium-99m Sestamibi from Birmingham  |
| Central Pharmacy was received.   A nuclear medicine technologist performed   |
| the procedure for incoming packages which included a wipe and survey of the  |
| box. The meter survey did not indicate any contamination, however, the wipe  |
| of the outside of the box indicated contamination of about 178 dpm/cm2.  The |
| package was emptied and surveyed again.  A contaminated spot on the outside  |
| of the box was located by the meter survey.   Rewipe of the area indicated   |
| 606 dpm/cm2 which exceeds the regulatory limit of 22 dpm/cm2.   According to |
| a spectrum made of the contaminated wipe sample, the radionuclide is         |
| Technetium-99m. The contamination was in an area on the side of the box away |
| from the carrier handle. The pharmacy has been contacted.  The Pharmacy wipe |
| test data arriving with the package did not indicate contamination.          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36963       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WA DEPT OF RADIATION PROTECTION      |NOTIFICATION DATE: 05/03/2000|
|LICENSEE:  NEORX CORP                           |NOTIFICATION TIME: 14:40[EDT]|
|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        05/02/2000|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:  WN-L0114-1            AGREEMENT:  Y  |LAST UPDATE DATE:  05/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY C. FRAZEE              |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - POTENTIAL SKIN OVEREXPOSURE                         |
|                                                                              |
| A worker was extracting a small amount of Holmium 166 from a vial containing |
| 400 millicuries per milliliter of solution. As the syringe needle was        |
| extracted from the vial septum, small droplets were sprayed into the         |
| worker's face. Initial estimate was 0.5 microcuries of contamination on      |
| forehead, cheeks and lips. The worker was wearing safetyglasses. The worker  |
| was decontaminated on site and residual contamination was noted on forehead  |
| and right cheek (0.6 millirem per hour), lips (0.3 millirem per hour), and   |
| left cheek (0.08 millirem per hour) .   Possible internal contamination was  |
| indicated by nasal and saliva samples.   Worker was sent to the University   |
| of Washington Nuclear Medicine department for further assessment.   An       |
| on-site investigation by the state Department of Health, Division of         |
| Radiation Protection will be conducted. Washington State incident number     |
| WA-00-016.                                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36964       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GEOTECH                              |NOTIFICATION DATE: 05/03/2000|
|LICENSEE:  GEOTECH                              |NOTIFICATION TIME: 15:24[EDT]|
|    CITY:  MAPLE SHADE              REGION:  1  |EVENT DATE:        05/03/2000|
|  COUNTY:                            STATE:  PA |EVENT TIME:        08:00[EDT]|
|LICENSE#:  29-28286-02           AGREEMENT:  N  |LAST UPDATE DATE:  05/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |NIEL DELLA GRECA     R1      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CARL DINICOLANTONIO          |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STOLEN TROXLER MOISTURE DENSITY GAUGE                                        |
|                                                                              |
| On April 27, 2000 a technician was involved in an automobile accident in     |
| Philadelphia, Penn.   At that time the gauge was stored in the trunk of the  |
| vehicle.   When police arrived on the scene the technician was arrested.     |
| The technician informed the police that the gauge was in the trunk and       |
| showed the gauge to the police officers.   After the technician was arrested |
| the vehicle was stolen.   The vehicle was recovered on April 29, 2000.  The  |
| gauge was not in the trunk when the vehicle was recovered.  The device       |
| contained 8 mCi of Cs-137 and 40 mCi of Am-241.                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36965       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 05/03/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 16:50[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/03/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        12:38[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/03/2000|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |BRUCE BURGESS        R3      |
|  DOCKET:  0707001                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  JIM UNDERWOOD                |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 4 HOUR NRC BULLETIN 91-01 REPORT - LOSS OF 1 OF 2 CONTINGENCY CONTROLS -     |
|                                                                              |
| Annual visual inspections of the cylinder wall, valve, and plug which are    |
| credited for double contingency in Nuclear Criticality Safety Evaluation     |
| (NCSE) 1493-03 have not been performed for fissile 12A (MD-type) UF6         |
| cylinders stored in Room 144 of Building C-710.  Scenario 8 of NCSE 1493-03  |
| takes credit for the annual visual inspections required by Nuclear           |
| Criticality Safety Approval (NCSA) GEN-03 to ensure cylinder integrity is    |
| maintained.  However, NCSA GEN-03 states that the inspections are required   |
| for cylinders in "cylinder storage yards".  Because the cylinders are not    |
| located In the cylinder storage yards, the annual inspections were not       |
| performed for the fissile 12A MD cylinders.                                  |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENT:                                                |
| One of the controls relied upon for double contingency was not implemented.  |
| However, based on followup visual inspections, the process parameter.        |
| moderation, was not lost,                                                    |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED [BRIEF SCENARIO(S) OF HOW            |
| CRITICALITY COULD OCCUR]:                                                    |
| In order for a criticality to be possible, the cylinder would have to be     |
| breached and large quantities of water would have to be introduced.  Upon    |
| discovery of the problem, the cylinder was inspected and determined to be    |
| acceptable.  Because the cylinder was not breached, a criticality resulting  |
| from this event is not possible.                                             |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC):      |
| Double contingency for this scenario Is established by Implementing two      |
| Independent controls on moderation.                                          |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):                                       |
| 419 pounds in the form of UF6 at an enrichment of 4.46 wt % U-235.           |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
| The first leg of double contingency relies on moderation control by          |
| prohibiting the use of water or steam to heat the fissile 12A MD cylinders.  |
| This control prevents the entry of large quantities of water into the        |
| cylinders.  This control was not violated and the first leg of double        |
| contingency was maintained,                                                  |
|                                                                              |
| The second leg of double contingency relies on a second control on           |
| moderation by crediting an annual cylinder inspection to identify corrosion  |
| and cylinder damage in order to maintain the integrity of the cylinders and  |
| prevent the introduction of moderating material.  The annual cylinder        |
| inspections were credited but not performed.  Therefore, double contingency  |
| was not maintained.                                                          |
|                                                                              |
| One of the two controls on moderation credited for double contingency was    |
| not implemented, therefore double contingency was not maintained.            |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:  |
| The NCSE/A will be revised to include annual visual inspection of fissile    |
| 12A MD cylinders.                                                            |
|                                                                              |
| The NRC resident inspector has been notified of this event.                  |
|                                                                              |
| PGDP Problem Report No. ATRC-00-2499; PGDP Event Report No. PAD-2000-037     |
| Responsible Division: Production Support                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36966       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 05/03/2000|
|LICENSEE:  MAYO CLINIC/MEDICAL CENTER           |NOTIFICATION TIME: 16:59[EDT]|
|    CITY:  SCOTTSDALE               REGION:  4  |EVENT DATE:        05/03/2000|
|  COUNTY:                            STATE:  AZ |EVENT TIME:        11:00[MST]|
|LICENSE#:  AZ 07-448             AGREEMENT:  Y  |LAST UPDATE DATE:  05/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DANIEL H. KUHL               |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT- Missing Indium-111 capsules at Mayo Clinic/Medical   |
| Center, Scottsdale, AZ                                                       |
|                                                                              |
| On 05/01/00, a standing order of three capsules, each capsule containing 100 |
| microcuries of Indium-111, was misplaced at the Mayo Clinic/Medical Center,  |
| Scottsdale, AZ (AZ License #07-448).  The missing capsules have not been     |
| located as of 1100 MST on 05/03/00, as reported to the Arizona Radiation     |
| Regulatory Agency (ARRA) by the AZ licensee's Radiation Safety Officer       |
| (RSO).  The RSO is planning an investigation into the events leading to the  |
| loss and will file a report with the ARRA within 30 days.  This isotope has  |
| a half-life of 67 hours.                                                     |
|                                                                              |
| The ARRA has notified NRC Region 4, Mexico, and the states of Colorado,      |
| Nevada, Utah, New Mexico and California of this event (ARRA First Notice     |
| #00-4).                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36967       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 05/03/2000|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 22:27[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        05/03/2000|
+------------------------------------------------+EVENT TIME:        22:15[EDT]|
| NRC NOTIFIED BY:  TONY PETRELLI                |LAST UPDATE DATE:  05/04/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |NIEL DELLA GRECA     R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |96       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 2 TECH SPEC REQD SHUTDOWN DUE TO 2 CONTAINMENT PURGE VALVES FAILING     |
| THEIR LLRT-                                                                  |
|                                                                              |
| The licensee is shutting Unit 2 down from 100% power in accordance with Tech |
| Spec 3.6.3.A, 12 Hour Shutdown LCO, due to containment purge valves          |
| #CPS*AOV-104 & 106 failing their local leak rate test #N2-ISP-CPS-Q001.      |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| * * *UPDATE ON 05/04/00 AT 0002 ET BY M. ERON TAKEN BY MACKINNON * * *       |
|                                                                              |
| Licensee exited Technical Specification 3.6.3.A at 2350 ET after manual      |
| Containment Purge Supply valve, 2CPS-V6, an upstream valve to #CPS*AOV-104 & |
| 106 was leak tested and verified closed. Lowest reactor power level reached  |
| was 92%.  R1DO (Della Greca) notified.                                       |
|                                                                              |
| The NRC Resident Inspector was notified of this update by the licensee.      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36968       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 05/03/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 23:39[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/03/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:00[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/03/2000|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |BRUCE BURGESS        R3      |
|  DOCKET:  0707002                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SISLER                       |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MODERATION CONTROL LOST (NO FREE LIQUIDS) WHILE MASS CONTROL WAS             |
| MAINTAINED.                                                                  |
|                                                                              |
|                                                                              |
| NRC BULLETIN 91-01 24 HOUR NOTIFICATION                                      |
|                                                                              |
| On 05/03/2000 at 0954 hours a violation of a contingency control designated  |
| in NCSA-PLANT018.A02 was identified.  During dry active waste (DAW) sorting  |
| operations a Chemical Operator discovered two plastic bags containing 3M     |
| cloth saturated and dripping with oil.  This is in violation of              |
| NCSA-PLANT018.A02 requirement #1a, which states the following in regards to  |
| placing items in a DAW drum: "The items shall contain no free liquid (ie.,   |
| not dripping or saturated with liquid)."                                     |
|                                                                              |
| This constituted the loss of one control of the double contingency           |
| principle.  Moderation control was lost (no free liquids) while mass control |
| (no visible uranium) was maintained.                                         |
|                                                                              |
| This condition was corrected under Nuclear Criticality Safety Engineering    |
| guidance when the material was removed from the DAW drum and handled per the |
| applicable NCSA.                                                             |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
|                                                                              |
| The safety significance of this event is low.  Two bags of 3M cloth          |
| contaminated with lube oil were found DAW drum during sorting operation.     |
| The NCSE evaluates a DAW material saturated with liquid.  The drum of DAW    |
| material did not have any items in it that had visible amounts of uranium    |
| beyond fixed stains/films.  Also NCSA-PLANT054.A03 has controls on lube oil  |
| and data used in the NCSE for this NCSA shows that the uranium concentration |
| in lube oil (even lube oil spills) is less than 50ppm uranium-235.           |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR):                                                    |
|                                                                              |
| For criticality to occur with DAW material there would have to be visible    |
| uranium on the items placed in the DAW drum.                                 |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| The controlled parameters in this NCSA are moderation (no free liquids) and  |
| mass (no visible uranium).                                                   |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):                                       |
|                                                                              |
| The highest enrichment for DAW material in the X-326 building is 100%.  The  |
| form of the material in DAW is uranyl fluoride and uranyl tetrafluoride      |
| contamination.  The amount of mass involved is less than 350 grams which is  |
| the safe mass value of 100% enriched uranyl tetrafluoride solution.          |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES                                              |
|                                                                              |
| The failure in this case is moderation.  The NCSA requires that material     |
| that is saturated or dripping is to be disposed of in favorable geometry     |
| containers or under other specific NCSAs.                                    |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
|                                                                              |
| The oil saturated 3M cloth was transferred to an NCSA-PLANT054.A03 approved  |
| storage container, at which time compliance with NCSA-PLANT018.A02 was       |
| restored.                                                                    |
|                                                                              |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36969       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 05/04/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 05:46[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/03/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        08:00[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/04/2000|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |BRUCE BURGESS        R3      |
|  DOCKET:  0707002                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SISLER                       |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ACCUMULATION OF SLUDGE CONTAINING HEAVY METALS CONTAINS AN ACCUMULATION      |
| POINT ON/IN THE LID.                                                         |
|                                                                              |
| NRC BULLETIN 91-01 24 hour notification                                      |
|                                                                              |
| On 5/3/00 at 0800 hours it was discovered that a NCSA-0705_027.A003 control  |
| was not in place. The sludge tub used for accumulating heavy metal           |
| (including uranium) sludge had an unsafe/unfavorable geometry molded into    |
| the design. The unfavorable dimensions created by the raised lip is 7.75" by |
| 37" by 2". This could have resulted in the potential accumulation, of an     |
| unsafe volume on the sludge tub lid had a leak developed In a nearby system  |
| containing uranium-bearing solution.                                         |
| NCSA-705_027.A003 requirement #17 states "Geometrically unfavorable          |
| containers shall not be left uncovered while unattended in the heavy metals  |
| precipitation process area or on the mezzanine in the area of the heavy      |
| metals precipitation raffinate storage (HMPRS)". This was a loss of one      |
| control (geometry/volume) in the double contingency principle for the afore  |
| mentioned NCSA. The second control (physical integrity of nearby             |
| uranium-bearing systems) was maintained throughout the event.                |
| At the direction of the Plant Shift Superintendent (PSS), the requirements   |
| for the NCS anomalous condition were initiated. At 1015 hours compliance was |
| regained by covering the molded design                                       |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
|                                                                              |
| On May 3, 2000, it was discovered that the sludge tub used for accumulating  |
| sludge containing heavy metals (including uranium) contains an accumulation  |
| point on/in the lid. That accumulation point is created by a raised lip and  |
| has unfavorable geometric dimensions (7.75" by 37" by 2"). This is a         |
| violation of NCSA-0705_027 and NCSA-0705_076. This could have resulted in    |
| the potential accumulation of an unsafe volume of solution on/in the sludge  |
| tub lid had a leak developed in a nearby system which contain                |
| uranium-bearing solution. No uranium-bearing material was involved in the    |
| violation, since the remaining barrier to criticality (i.e., the physical    |
| integrity of nearby uranium-bearing systems) was maintained. Therefore, the  |
| safety significance of this event is low.                                    |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR):                                                    |
|                                                                              |
| If a leak had developed in a nearby uranium-bearing system such that the     |
| solution could have accumulated on/in the sludge tub lid, an unsafe geometry |
| of solution could have resulted. If the leaking solution had contained a     |
| sufficient amount of uranium, the resulting configuration could have been    |
| sufficient for a criticality to occur. It should be noted that the allowed   |
| safe geometry and volume limits established In NCSA-0705_076 are based on    |
| potentially moderated, UO2F2 and water solution which contains uranium       |
| enriched to 100 wt%.                                                         |
|                                                                              |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| The parameter which was violated during this upset was the geometry of       |
| potential accumulation present in the sludge tub Iid (i.e., the volume in    |
| which uranium-bearing solution could have accumulated in the event of a      |
| leak). The physical integrity of the nearby systems containing               |
| uranium-bearing material was maintained.                                     |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF CRITICAL MASS):                                    |
|                                                                              |
| No uranium bearing material was actually introduced into the lid of the      |
| sludge tub.                                                                  |
|                                                                              |
|                                                                              |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES                                              |
|                                                                              |
| NCSA-0705_076.A00 and NCSA-0705_027 take credit for the physical integrity   |
| of Systems which contain uranium-bearing material and that unsafe            |
| volume/geometry containers are either modified, covered, or oriented to      |
| prevent an unsafe configuration from resulting In the event of a leak. The   |
| lid of the sludge tub observed was not protected from a potential            |
| accumulation and it had been left unattended.                                |
|                                                                              |
|                                                                              |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
|                                                                              |
| At 0800 hours, a NCS anomalous condition was initiated.                      |
|                                                                              |
| At 1015 hours compliance was re-established                                  |
|                                                                              |
|                                                                              |
| The NRC Resident Inspector was notified of this event.                       |
+------------------------------------------------------------------------------+


Page Last Reviewed/Updated Wednesday, March 24, 2021