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. |
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|Fuel Cycle Facility |Event Number: 37268 |
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| 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
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| 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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