United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2001

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.                                     |
+------------------------------------------------------------------------------+