Event Notification Report for January 29, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/26/2001 - 01/29/2001
** EVENT NUMBERS **
37692 37693 37694 37695 37696 37697 37698
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37692 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 01/26/2001|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 09:57[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 01/26/2001|
+------------------------------------------------+EVENT TIME: 08:15[CST]|
| NRC NOTIFIED BY: M RODE |LAST UPDATE DATE: 01/26/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |JAMES CREED R3 |
|10 CFR SECTION: |FRANK CONGEL IRO |
|*AEC 50.72(a) (1) (i) EMERGENCY DECLARED |JOE GIITTER IRO |
| |CALDWELL FEMA |
| |ED GOODWIN, EO NRR |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Decommissioned |0 Decommissioned |
|2 N N 0 Decommissioned |0 Decommissioned |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LOSS OF SPENT FUEL NUCLEAR ISLAND COOLING. |
| |
| Both 12kV feeder lines to the Spent Fuel Nuclear Island deenergized causing |
| a loss of cooling to the Spent Fuel Island. Initial Spent Fuel Nuclear |
| Island temperature was 91 degrees F. In one hour and forty five minutes |
| after a loss of power the water temperature of the Spent Fuel Island |
| increased from 91 degrees F to 92 degrees F. Worst case time to boil is 84 |
| hours. Licensee entered EAL MU3 (Unusual Event for a loss of Spent Fuel |
| Island Cooling) at 0815CT. 12kV power was initially lost at 0715CT. |
| Radiation Monitor in the Spent Fuel Island Area is functioning properly and |
| radiation levels in the area are normal. The licensee expects to have Spent |
| Fuel Island Cooling back in service in less than one hour. Licensee notified |
| State and Local officials. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
| |
| * * * UPDATE BY M. RODE AT 1039 ET TAKEN BY MACKINNON * * * |
| |
| Unusual Event was terminated at 0939 CT after power was restored and the |
| highest Spent Fuel Island water temperature reached was 92 degrees F. R3DO |
| (J Creed), IRO (Congel), NRR EO (Ed Goodwin), and FEMA (Steindurf) |
| notified. |
| |
| The NRC Resident Inspector will be notified by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37693 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 01/26/2001|
| UNIT: [] [4] [] STATE: FL |NOTIFICATION TIME: 11:29[EST]|
| RXTYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 01/26/2001|
+------------------------------------------------+EVENT TIME: 10:00[EST]|
| NRC NOTIFIED BY: P LAFONTAINE |LAST UPDATE DATE: 01/26/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |KERRY LANDIS R2 |
|10 CFR SECTION: |FRANK CONGEL IRO |
|NINF INFORMATION ONLY |ED GOODWIN NRR |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|4 N N 0 Hot Standby |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE REACTOR COOLANT SYSTEM (RCS) LEAKAGE |
| |
| Possible RCS boundary leakage from around a part length CRDM housing. Dry |
| boric acid crystal buildup, less than one cup, was found around a part |
| length CRDM housing. Licensee will have to remove missile shield, etc. to |
| determine which part length CRDM housing has the leak or possibly leaked in |
| the past. Currently the licensee is cooling down the plant and should be in |
| a cold shutdown condition in 6 or 7 hours from 1130 ET. |
| |
| The NRC Resident was notified of this by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 37694 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WAUSAU HOSPITAL |NOTIFICATION DATE: 01/26/2001|
|LICENSEE: WAUSAU HOSPITAL |NOTIFICATION TIME: 11:36[EST]|
| CITY: WAUSAU REGION: 3 |EVENT DATE: 01/24/2001|
| COUNTY: STATE: WI |EVENT TIME: 07:30[CST]|
|LICENSE#: 48-01032-01 AGREEMENT: N |LAST UPDATE DATE: 01/26/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES CREED R3 |
| |BRIAN SMITH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JEFF LIMMER | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| A Cs-137 vaginal cylinder implant was loaded at 9:30 am on 1/23/01. The |
| written directive called for a total implant time of 49 hours. During a |
| check of the patient at 7:30 am on 1/24/01, the authorized user found the |
| loaded vaginal cylinder on the patient's toilet seat. The patient's nurse |
| stated that the source came out at about 6:30 am on 1/24/01 (i.e., after |
| about 42% of the prescribed dose was delivered). The licensee was not sure |
| how the source got to where it was found. The authorized user placed the |
| cylinder in a lead pig and transported it to the secured storage area. The |
| authorized user decided to write another written directive and reload the |
| patient at 10:00 am on 1/24/01 with a prescribed implant time of 7 hours. |
| After the 7 hours, the sources were explanted as intended. The authorized |
| user decided to deliver the remaining radiation dose to the treatment site |
| via teletherapy. |
| |
| At 6:00 am on 1/24/01, the nurse emptied the patient's foley bag and noted |
| that the patient was in bed. Between 6:00 and 6:30 am on 1/24/01, the nurse |
| noticed that the patient was leaving the bathroom to go back to bed. The |
| nurse also noticed that the patient's "T-binder" (used to hold the |
| applicator in place), was loose, so she tightened it. The authorized user |
| visited the patient at 7:30 am and noticed that the T-binder was on the |
| bathroom floor and the loaded vaginal cylinder was on the toilet seat. |
| Based on nurse interviews, all nurses caring for the patient were badged, |
| and none of them handled the applicator. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 37695 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: NEW MEXICO RAD CONTROL PROGRAM |NOTIFICATION DATE: 01/26/2001|
|LICENSEE: SCHLUMBERGER |NOTIFICATION TIME: 16:00[EST]|
| CITY: ARTESIA REGION: 4 |EVENT DATE: 01/03/2001|
| COUNTY: STATE: NM |EVENT TIME: [MST]|
|LICENSE#: WL197 AGREEMENT: Y |LAST UPDATE DATE: 01/26/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| |C.W. (BILL) REAMER NMSS |
+------------------------------------------------+FRANK CONGEL IRO |
| NRC NOTIFIED BY: PAT LARKINS (NRC OSP FAX) | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT REGARDING THE LOSS OF A 9-MICROCURIE Cs-137 |
| STABILIZATION SOURCE DURING A BLOW-OUT AND FIRE AT A WELLHEAD |
| |
| The following text is a portion of a facsimile that was sent from the State |
| of New Mexico: |
| |
| "AGREEMENT STATE EVENT REPORT ID NO. NM-01-01" |
| |
| " ... " |
| |
| "NEW MEXICO" |
| |
| " ... " |
| |
| "LICENSEE - Schlumberger" |
| "NUMBER - WL197" |
| "LOCATION - Artesia, NM" |
| |
| "OTHER PARTIES - Yates Petroleum Corp." |
| |
| "DISCOVERY DATE / REPORT DATE - 12/29/[00] / 01/03/01" |
| |
| "EVENT TYPE - Loss of RAM" |
| |
| "EVENT DESCRIPTION -" |
| |
| "While logging a well[,] the tool was expelled from the hole by a blow-out |
| and fire at the wellhead. The down hole instruments were violently ejected |
| from the hole striking the rig and breaking into pieces. ... After the |
| resulting fire was under control, the intact sources were located in the |
| equipment debris and shipped to the company's source storage facility in |
| Houston. This was accomplished using survey meters, source handling |
| tools[,] and shielding. Dose calculations for all employees involved in the |
| retrieval indicate a 16-microrem dose to all but one, who was estimated to |
| have received 0.4 millirem." |
| |
| "The tool being used contained 5 sources: one Cs-137 source of 1.7 |
| [curies], one Am-241[/]Be source of 16 [curies], two (2) Cs-137 |
| stabilization sources of 9 microcuries[,] and one (1) Cs-137 stabilization |
| source of 0.6 microcuries." |
| |
| "The analysis of the equipment in Houston confirmed the integrity of the |
| sources and the fact that one of three stabilization sources was missing. |
| The instrument that impacted the top of the rig is where this source was |
| contained. The remaining rig and surrounding area [were] surveyed[,] but |
| the source could not be found. After extensive surveys[,] the search was |
| terminated. The lost source was one of the [9-microcurie] sources and is an |
| exempt quantity." |
| |
| "CORRECTIVE ACTIONS - Blow-outs will occur during normal drilling |
| operations. The response of Schlumberger was appropriate and complete." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 37696 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: CITIZENS GENERAL HOSPITAL |NOTIFICATION DATE: 01/26/2001|
|LICENSEE: CITIZENS GENERAL HOSPITAL |NOTIFICATION TIME: 17:58[EST]|
| CITY: NEW KENSINGTON REGION: 1 |EVENT DATE: 01/25/2001|
| COUNTY: ALLEGHENY STATE: PA |EVENT TIME: 16:00[EST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 01/26/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |STEVEN DENNIS R1 |
| |C.W. (BILL) REAMER NMSS |
+------------------------------------------------+DALE POWERS R4 |
| NRC NOTIFIED BY: ANDREW BUKOVITZ |FRANK CONGEL IRO |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DISCOVERY OF THE POSSIBLE LOSS OF TWO GADOLINIUM-153 SOURCES AT CITIZENS |
| GENERAL HOSPITAL IN NEW KENSINGTON, PENNSYLVANIA |
| |
| Due to an ongoing merger with Allegheny Valley Hospital, Citizens General |
| Hospital ceased nuclear medical activities and properly transferred all |
| sources (except for two gadolinium-153 sources) to Allegheny Valley Hospital |
| (located within approximately 2 miles). The gadolinium sources were not |
| included because Allegheny Valley Hospital was not licensed for |
| gadolinium-153. (A license amendment has been requested.) Accordingly, the |
| gadolinium-153 sources were being kept in Hot Lab at Citizens General |
| Hospital in the mean time. |
| |
| Approximately 3 weeks ago, a closeout survey was preformed of the Nuclear |
| Medicine Department at Citizens General Hospital (where the gamma camera was |
| located and recorded were done). The results indicated that there were no |
| activities. There was also documentation in place to prohibit use of the |
| Hot Lab because it had not yet been closed out. |
| |
| It was reported that an unknown individual made arrangements to de-install |
| and sell the gamma camera and other equipment. Two individuals (middlemen |
| for other companies) arrived yesterday (01/25/01) with a crew. The |
| individuals were told that they could take the gamma camera and other items |
| but not to touch the gadolinium sources, which were located in the Hot Lab. |
| |
| This morning (01/26/01), it was discovered that the gadolinium sources were |
| missing. Apparently, the de-installation crew left a mess and took more |
| than they were authorized to take including a refrigerator, survey meters, |
| signs off the walls, etc. The Director of Materials Management did not have |
| a list. It is currently believed that the sources were removed at |
| approximately 1600 EST on 01/25/01 by an individual who worked for BC |
| Technical, and it was reported that the sources may currently be in Salt |
| Lake City, Utah. |
| |
| The other individual worked as an independent for Jet Services and was |
| believed to be involved with removal of the gamma camera. The licensee was |
| able to contact this individual, who in turn informed the licensee that the |
| other individual's company (BC Technical in Salt Lake City) had a license to |
| transfer radioactive materials. Therefore, there was an impression that |
| they were doing the hospital a favor by getting rid of sources for the |
| hospital. |
| |
| The licensee also contacted the company based in Salt Lake City, Utah. The |
| individual who actually removed the sources was not available because he was |
| performing a de-installation at another hospital. |
| |
| The missing gadolinium sources had an activity of 200 millicuries each |
| approximately 2 years ago. The current activity level was conservatively |
| estimated to be approximately 50 millicuries each. |
| |
| The licensee has notified the NRC Region 1 office (Michelle Beardsley). |
| |
| (Call the NRC operations officer for licensee contact information and |
| contact information regarding the individuals involved in the |
| de-installation and removal of equipment.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37697 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 01/28/2001|
| UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 23:38[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 01/28/2001|
+------------------------------------------------+EVENT TIME: 22:28[EST]|
| NRC NOTIFIED BY: SANTINI |LAST UPDATE DATE: 01/28/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |STEVEN DENNIS R1 |
|10 CFR SECTION: | |
|*ESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| STEAM GENERATOR BLOWDOWN ISOLATED FOLLOWING ALARM RECEIVED ON RAD MONITOR |
| R-49 |
| |
| An alarm was received for rad monitor R-49, Steam Generator radiation |
| monitor, due to a spike. This resulted in automatic closure of the Steam |
| Generator Blowdown isolation valves which is an ESF actuation. All other |
| primary to secondary leakage parameters were normal. At the time of the |
| spike, the Nuclear NPO was adjusting 24 S/G sample flow to obtain the |
| required flow (as found: 35gph, required: 38-40gph). AOI 1.2(Steam |
| Generator Tube Leak Procedure) was entered and supplemental monitoring was |
| initiated. There are no indications of primary to secondary steam generator |
| tube leakage. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37698 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 01/29/2001|
| UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 05:36[EST]|
| RXTYPE: [3] CE |EVENT DATE: 01/28/2001|
+------------------------------------------------+EVENT TIME: 22:45[CST]|
| NRC NOTIFIED BY: PELLEGRIN |LAST UPDATE DATE: 01/29/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |DALE POWERS R4 |
|10 CFR SECTION: | |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PRESSURIZER STEAM SPACE SAMPLE ISOLATION VALVES FAILED TO CLOSE |
| |
| At 2245 on 1/28/01 it was discovered that PSL-303 and PSL-304, Pressurizer |
| Steam Space Sample Inside and Outside Containment Isolation Valves would not |
| close when their respective control switches at OP-8 in the Control Room |
| were taken to the "Close" position. The valves had been open since 1455 |
| that same day to perform degas of the Pressurizer. The Nuclear Plant |
| Operator first took the switch for PSL-304 to the "Close" position and |
| observed that the valve continued to indicate "Open". He then took the |
| Switch for PSL-303 to the "Close" position, and observed that valve continue |
| to indicate "Open". Technical Specification 3.6.3 was entered and a Nuclear |
| Auxiliary Operator was dispatched to verify the position of PSL-304 locally. |
| PSL-304 was found to be in the open position and the on-shift chemistry |
| technician confirmed that there were still indications of flow through the |
| sample line. Another attempt to close PSL-304 was made using the switch on |
| CP-8 in the control room. The Nuclear Auxiliary Operator observed that the |
| valve moved approximately one quarter-inch in the closed direction. At |
| 2257 PSL-304 was closed using the manual gagging device. At 2310 PSL-304 |
| was de-energized to comply with the action requirements of Technical |
| Specification 3.6.3.b. At 0007 on 1/29/01, another attempt was made to |
| close PSL-303 using the control switch at OP-8. This attempt was successful. |
| The affected containment penetration is a one-half-inch line and is |
| currently isolated. They are investigating the cause. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021