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Event Notification Report for August 29, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/28/2000 - 08/29/2000

                              ** EVENT NUMBERS **

37264  37265  37266  37267  37268  

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|Hospital                                         |Event Number:   37264       |
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| REP ORG:  VA NATIONAL HEALTH PHYSICS PROGRAM   |NOTIFICATION DATE: 08/28/2000|
|LICENSEE:  VA MEDICAL CENTER                    |NOTIFICATION TIME: 13:16[EDT]|
|    CITY:  ALBANY                   REGION:  1  |EVENT DATE:        08/28/2000|
|  COUNTY:                            STATE:  NY |EVENT TIME:        11:00[EDT]|
|LICENSE#:  31-02755-05           AGREEMENT:  Y  |LAST UPDATE DATE:  08/28/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PETE ESELGROTH       R1      |
|                                                |SCOTT MOORE          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOE WISSING                  |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION INVOLVING AN INITIAL UNDERDOSE OF IODINE-131       |
| BECAUSE ONE OF TWO CAPSULES GOT STUCK IN A VIAL AT VA MEDICAL CENTER IN      |
| ALBANY, NEW YORK                                                             |
|                                                                              |
| On 08/09/00, a patient was scheduled to receive a prescribed iodine-131 dose |
| of 5 mCi in order to facilitate a whole body scan.  A nuclear medical        |
| technologist measured the applicable vial at 5 mCi and emptied the contents  |
| of the vial for administration to the patient.  Apparently, only one of two  |
| capsules came out of the vial, and the patient was given only one capsule    |
| which represented 1.1 mCi of the prescribed 5-mCi dose.  The nuclear medical |
| technologist identified the error approximately 1 hour after the initial     |
| administration.  The patient was immediately contacted but was unable to     |
| return to the Medical Center that day.  The patient received the second      |
| capsule (3.68 mCi) on the following morning (08/10/00) approximately 21      |
| hours after administration of the first capsule.  It was reported that there |
| were no negative impacts on the outcome of the scan, no adverse health       |
| affects to the patient, and no health and safety concerns.                   |
|                                                                              |
| The licensee did not believe that this event represented a medical           |
| misadministration but discussed the event with the NRC Region 1 office (Jim  |
| Dwyer).  At approximately 1100 on 08/28/00, the NRC Region 1 office notified |
| the licensee that this issue was considered to be a medical                  |
| misadministration.  Therefore, at 1316 on 08/28/00, the VA's National Health |
| Physics Program reported this event to the NRC Operations Center for the VA  |
| Medical Center in Albany, New York.                                          |
|                                                                              |
| (Call the NRC operations officer for the VA's National Health Physics        |
| Program contact telephone number.)                                           |
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|Power Reactor                                    |Event Number:   37265       |
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| FACILITY: FITZPATRICK              REGION:  1  |NOTIFICATION DATE: 08/28/2000|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 17:31[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        08/28/2000|
+------------------------------------------------+EVENT TIME:        08:51[EDT]|
| NRC NOTIFIED BY:  KERRY ALLEN                  |LAST UPDATE DATE:  08/28/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PETE ESELGROTH       R1      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| UNEXPECTED CLOSURE OF A RESIDUAL HEAT REMOVAL SYSTEM OUTBOARD SUCTION        |
| ISOLATION VALVE                                                              |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "During preparation to place the 'A' side residual heat removal system (RHR) |
| into the shutdown cooling mode, it was discovered that the outboard suction  |
| isolation valve (10MOV-17) had gone closed.  Previous to this evolution,     |
| both the 'A' [and] 'B' recirculation pumps were shut down.  It is suspected  |
| that securing the [recirculation] pumps causes a pressure surge in the       |
| suction piping to the RHR system which causes a pressure switch to actuate.  |
| This pressure switch causes [valve] 10MOV-17 to go closed.  No reactor       |
| pressure instruments indicated a pressure surge.  Initial assessment         |
| determined that this event was not reportable.  Upon subsequent review, it   |
| was determined that a [4]-hour notification should have been made."          |
|                                                                              |
| The licensee stated that no alarms were received.  A panel operator noticed  |
| that the valve had gone closed while verifying the system lineup before      |
| starting a pump.  The 'A' side RHR system was subsequently placed in         |
| shutdown cooling, and everything operated properly.                          |
|                                                                              |
| It was also reported that the event occurred at 0851 on 08/28/00 and that    |
| the event was determined to be reportable at approximately 1630 on the same  |
| day.  In addition, the licensee stated that similar events had previously    |
| occurred.                                                                    |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
|                                                                              |
| (Refer to event #31648 dated 01/24/97, #25534 dated 05/19/93, #25231 dated   |
| 03/11/93, #25134 dated 02/25/93, #24447 dated 10/17/92, #18770 dated         |
| 06/26/90, #18330 dated 04/25/90, #18325 dated 04/24/90, #18183 dated         |
| 04/09/90, #18026 dated 03/20/90, and #17598 dated 01/20/90 for events        |
| involving closure of shutdown cooling suction/isolation valves for various   |
| [possibly similar] reasons.)                                                 |
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|Power Reactor                                    |Event Number:   37266       |
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| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 08/28/2000|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 20:17[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        08/28/2000|
+------------------------------------------------+EVENT TIME:        16:30[EDT]|
| NRC NOTIFIED BY:  RICHARD LANGE                |LAST UPDATE DATE:  08/28/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PETE ESELGROTH       R1      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| INOPERABILITY OF THE PASS AND BOTH DIVISION I/II H2O2 MONITORING SYSTEMS     |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On 8/28/2000, at 1630, [the Division] I and [II] Hydrogen/Oxygen (H2O2)     |
| Containment Monitoring Systems were declared inoperable.  The Division I     |
| system was declared inoperable on 8/28/2000, at 0818, for planned            |
| maintenance.  Subsequently, the Division II system was declared inoperable   |
| due to a failed channel check."                                              |
|                                                                              |
| "In addition, the Post Accident Sampling System (PASS) was previously        |
| declared inoperable.  With the PASS and both Division I/II H2O2 Monitoring   |
| Systems inoperable, this event is reportable in accordance with 10 CFR       |
| 50.72(b)(2)(iii)(D)."                                                        |
|                                                                              |
| "Also, on 8/28/2000, at 1905, the Division I H2O2 Monitor was restored to    |
| operable [status] following completion of planned maintenance."              |
|                                                                              |
| The licensee stated that the unit remained in a 30-day limiting condition    |
| for operation (LCO) and that a 7-day shutdown LCO was exited when the        |
| Division I H2O2 Monitor was restored to operable status.                     |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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|Fuel Cycle Facility                              |Event Number:   37267       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 08/28/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 22:22[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        08/28/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        13:10[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  08/28/2000|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MELVYN LEACH         R3      |
|  DOCKET:  0707002                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01 RESPONSE (24-HOUR REPORT) - LOSS OF ONE CRITICALITY       |
| CONTROL                                                                      |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth      |
| personnel:                                                                   |
|                                                                              |
| "At 1310 on 08/28/00, during a self assessment in the X-710 room 229, it was |
| discovered that the U-235 mass log was not verified as required by NCSA      |
| 710-022.  NCSA 710-022 control #4 states in part, 'A log entry shall consist |
| of the measured U-235 mass values plus analytical uncertainty and shall be   |
| verified by a second knowledgeable person or supervisor.'  This is           |
| [considered] a loss of one control."                                         |
|                                                                              |
| "The PSS (Plant Shift Superintendent) directed the facility owner to enter   |
| an anomalous condition and directed NCS to oversee the recovery of the loss  |
| of one control."                                                             |
|                                                                              |
| "The log in question was verified as required by NCSA 710-022.  Control      |
| [was] regained[,] and [the] anomalous condition [was] exited within 4        |
| hours."                                                                      |
|                                                                              |
| "[The] safety significance is low.  The inventory log for the room showed    |
| 138 [grams] U-235.  The allowable limit is 350 grams U-235."                 |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:  The safety significance is low.  The        |
| inventory log for the room showed 138 grams U-235 with an enrichment of <5%  |
| present in the room.  The total allowable mass for the room is 350 grams     |
| U-235."                                                                      |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR):  If the U-235 for the room was at the maximum      |
| allowable value, there would need to be an additional 456 grams U-235        |
| present [in] the room before the critical mass for full reflection, optimum  |
| moderation, and spherical geometry was exceeded.  For this amount of U-235   |
| to be present, multiple errors in the log book would need to occur."         |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):    |
| The control parameter for this operation is mass.  NCSA-0710-022 places two  |
| controls on this parameter.  The combined mass of all fissile material is    |
| limited to 350 grams U-235.  The [NCSA] requires [that] a log of U-235 mass  |
| inventory be maintained to demonstrate that the mass limit is not exceeded.  |
| Each log entry consists of the [mass] value plus analytical uncertainty.  A  |
| log entry is made by the person responsible [for] the movement of U-235 into |
| the room and is verified by a second knowledgeable person."                  |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS):  Approximately 138 grams [was] in  |
| the room [with] less than 5% U-235 solution."                                |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES:  One of the controls on the mass parameter  |
| was not performed.  A second knowledgeable person did not perform the log    |
| verification as required by [the] NCSA.  The safety significance of the      |
| event is low due to the small amount of U-235 involved."                     |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:  |
| "A second knowledgeable person verified the current mass log.  A [second]    |
| person verified today's log to ensure administrative correctness."           |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector and the Department  |
| of Energy site representative.                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   37268       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 08/29/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 01:36[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        08/28/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:29[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  08/29/2000|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MELVYN LEACH         R3      |
|  DOCKET:  0707002                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 24-HOUR NRC BULLETIN 91-01 REPORT                                            |
|                                                                              |
| "On 8/28/00 at 1529, during implementation of NCSA 0705_076 (Inadvertent     |
| Containers) a concern was raised about the maximum distance of spray from a  |
| leak from a pressurized pipe. Calculations were reevaluated and the          |
| corrected spray distance for the system in question resulted in a distance   |
| of 106 feet. This new distance for the system in question is greater than    |
| the original implementation distance of 15 feet which the NCSA had           |
| previously predicted for the entire X-705. This is considered a loss of one  |
| control. The control considered lost is control #2 which states in part,     |
| 'When unattended all potential inadvertent containers shall be:              |
| "-modified to prevent unsafe accumulation                                    |
| "-covered to prevent the in-leakage of spilled materials                     |
| "-oriented to prevent an unsafe accumulation'                                |
|                                                                              |
| "The PSS(Plant Shift Superintendent) directed the facility custodian to      |
| enter an anomalous condition. The system in question was previously shut     |
| down prior to recalculation of the spray distance. The same equipment        |
| remains shutdown until compliance with NCSA 0705_076 can be determined.      |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:                                              |
|                                                                              |
| "Safety significance is low. The resulting situation is conservatively being |
| identified as a violation of one control contained in NCSA 0705_076 which    |
| requires that all potential inadvertent containers utilized in the X-705 be  |
| modified, covered, or oriented to prevent an unsafe accumulation. However,   |
| since the system in question maintained its physical integrity and thus no   |
| uranium bearing material was involved the safety significance of this event  |
| is low.                                                                      |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR):                                                    |
|                                                                              |
| "If a sufficient amount of uranium bearing material had leaked, spilled,     |
| splashed from the micro filtration system and the resuming material          |
| accumulated on/in an inadvertent container, an unsafe geometry 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 optimally moderated  |
| solution which contains uranium enriched to l00wt% U235.                     |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC):     |
|                                                                              |
| "The parameter which was violated during this upset was maintaining          |
| geometry/volume controls regarding potential accumulation points available   |
| on/in nearby inadvertent containers.                                         |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS):                                    |
|                                                                              |
| "No uranium-bearing material was actually involved in the upset.             |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| "NCSA 0705_076 takes credit for the physical integrity of systems which      |
| contain uranium bearing materials. NCSA 0705_076 also takes Credit that      |
| unsafe volume/geometry containers are either modified, covered or oriented   |
| while in areas where uranium bearing material can leak, spill or spray to    |
| prevent an unsafe configuration from resulting in the event of a leak. The   |
| administrative control #2 was not being followed for the new area identified |
| where uranium bearing materials can leak, spill or spray. The resulting      |
| situation is conservatively being identified as a violation of the           |
| administrative control in NCSA 0705_076.                                     |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:  |
|                                                                              |
| "The PSS (Plant Shift Superintendent) directed the facility custodian to     |
| enter an anomalous condition. The system in question was previously shut     |
| down prior to recalculation of the spray distance. The same equipment will   |
| remain shutdown until NCS (Nuclear Criticality Safety) can assist in         |
| determination of operability of that system and compliance with NCSA         |
| 0705_076."                                                                   |
|                                                                              |
| The NRC resident inspector has been informed of this event.                  |
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