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Event Notification Report for February 15, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/14/2001 - 02/15/2001

                              ** EVENT NUMBERS **

37743  37744  37745  37746  37747  37748  37749  37750  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37743       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 02/14/2001|
|    UNIT:  [2] [] []                 STATE:  NY |NOTIFICATION TIME: 02:51[EST]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        02/14/2001|
+------------------------------------------------+EVENT TIME:        01:50[EST]|
| NRC NOTIFIED BY:  MARK LEONE                   |LAST UPDATE DATE:  02/14/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |JOHN ZWOLINSKI       NRR     |
|*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                                   
+------------------------------------------------------------------------------+
| THE LOSS OF A 480-VOLT BUS DUE TO A PERSONNEL ERROR DURING SURVEILLANCE      |
| TESTING RESULTED IN THE AUTOMATIC START OF THREE EMERGENCY DIESEL            |
| GENERATORS.                                                                  |
|                                                                              |
| At 0150 on 02/14/01, 480-volt bus 3A was lost due to incorrect operation of  |
| a switch during performance of a surveillance test.  An individual           |
| performing the test needed to simultaneously hold a switch in the bypass     |
| position while a test button was pressed, and the switch was not held in the |
| correct position.  As a result, an undervoltage signal was inserted on the   |
| bus when the test button was pushed, and all three emergency diesel          |
| generators automatically started as designed.                                |
|                                                                              |
| The licensee stated that the emergency diesel generators do not              |
| automatically load on the loss of an internal bus and that all automatic     |
| functions operated properly.  The licensee also stated that the loss of any  |
| 480-volt bus places the unit in a shutdown action statement in accordance    |
| with Technical Specification 3.0.1.  However, power (via an emergency diesel |
| generator) was restored to the bus in accordance with procedures at 0215,    |
| and restoration of power satisfied the action statement requirements in      |
| Technical Specification 3.0.1 within 25 minutes.  The licensee is currently  |
| in the process of restoring normal bus power supply.                         |
|                                                                              |
| The licensee stated that bus 3A is one of the power supplies for the 22      |
| safety injection pump.  This bus also supplies power to the 21 residual heat |
| removal pump, 22 and 25 service water pumps, 24 fan cooler unit, 21          |
| auxiliary boiler feed pump, 22 charging pump, 21 backup heater for the       |
| pressurizer, and 23 instrument bus (via the 23 battery charger).             |
|                                                                              |
| The licensee plans to notify the NRC resident inspector and applicable       |
| government agencies.  The licensee may also issue a press release.           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   37744       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HONEYWELL INTERNATIONAL, INC.        |NOTIFICATION DATE: 02/14/2001|
|   RXTYPE: URANIUM HEXAFLUORIDE PRODUCTION      |NOTIFICATION TIME: 07:44[EST]|
| COMMENTS: UF6 CONVERSION (DRY PROCESS)         |EVENT DATE:        02/14/2001|
|                                                |EVENT TIME:        02:30[CST]|
|                                                |LAST UPDATE DATE:  02/14/2001|
|    CITY:  METROPOLIS               REGION:  3  +-----------------------------+
|  COUNTY:  MASSAC                    STATE:  IL |PERSON          ORGANIZATION |
|LICENSE#:  SUB-526               AGREEMENT:  Y  |MONTE PHILLIPS       R3      |
|  DOCKET:  04003392                             |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  HUGH ROBERTS                 |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|JBBE 40.60(b)(2)         SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SANITARY WELL WATER FAILURE DUE TO A LINE RUPTURE  (24-Hour Report involving |
| the potential inability to mitigate the circumstances of an accident)        |
|                                                                              |
| Honeywell Metropolis Works is a fuel cycle facility that performs UF6        |
| conversion.                                                                  |
|                                                                              |
| At approximately 0230 CST, a 6-inch diameter sanitary process line ruptured. |
| As a result, the licensee secured (shut down) both the safety showers and    |
| the process.  The ruptured line has been isolated, and process water has     |
| been valved into the safety showers.  However, the licensee has not yet      |
| brought up the process.  Repair planning is underway.                        |
|                                                                              |
| The licensee plans to notify the NRC Region 3 office, an onsite NRC          |
| inspector (Mary Thomas), and the NRC resident inspector at Paducah (Courtney |
| Blanchard).  (The USEC Paducah facility is located across the river.)        |
|                                                                              |
| Call the NRC operations officer for a licensee contact telephone number.     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37745       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MERCY HOSPITAL                       |NOTIFICATION DATE: 02/14/2001|
|LICENSEE:  MERCY HOSPITAL                       |NOTIFICATION TIME: 09:37[EST]|
|    CITY:  PORT HURON               REGION:  3  |EVENT DATE:        02/13/2001|
|  COUNTY:                            STATE:  MI |EVENT TIME:        23:30[EST]|
|LICENSE#:  211563801             AGREEMENT:  N  |LAST UPDATE DATE:  02/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MONTE PHILLIPS       R3      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHUCK SMITH                  |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MISADMINISTRATION AT MERCY HOSPITAL IN PORT HURON, MICHIGAN         |
|                                                                              |
| A patient  was receiving a treatment with a gynecological implant containing |
| two cesium-137 sources (with 13.74 milligrams radium equivalent each).  The  |
| patient was reportedly restless and moving around quite a bit, and the       |
| applicator was in its proper position at 2100.  However, when nurses checked |
| on positioning of applicator  at 2330 on 02/13/01, it was discovered that    |
| the applicator had gotten past the sutures and come out completely.  The     |
| implant treatment procedure was terminated at that time.                     |
|                                                                              |
| Based on the minimum and maximum amount of time that the applicator may have |
| been in the proper position, the patient received between 66% and 71% of the |
| intended dose.  Conservative calculations (assuming that the applicator came |
| out at 2100) revealed doses to unintended areas were not anticipated to      |
| cause adverse health complications as a result of this exposure.  The        |
| patient has been informed.                                                   |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37746       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 02/14/2001|
|LICENSEE:  RONE ENGINEERS                       |NOTIFICATION TIME: 10:00[EST]|
|    CITY:  DALLAS                   REGION:  4  |EVENT DATE:        02/03/2001|
|  COUNTY:                            STATE:  TX |EVENT TIME:             [CST]|
|LICENSE#:  L02356                AGREEMENT:  Y  |LAST UPDATE DATE:  02/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES H. OGDEN, JR. (fax)    |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER NUCLEAR DENSITY GAUGE      |
|                                                                              |
| The following text is a portion of a facsimile received from the Texas       |
| Department of Health, Bureau of Radiation Control:                           |
|                                                                              |
| "This is an initial notification of a stolen nuclear gauge.  The gauge was   |
| stolen on Saturday February 3, 2001, from the parking lot of the Midway      |
| Point Restaurant, [...], Dallas, Texas, while the [driver] ate lunch between |
| jobs.  The Licensee's initial report indicates that the gauge was secured in |
| it's transport case and chained to the company pickup with chain and lock.   |
| The driver noted that the gauge, the lock, and chain were all missing.  The  |
| stolen gauge was a Troxler Model 3430, Serial Number 31580.  The gauge       |
| contained two sources:  8 millicuries of Cs-137, Source Serial No. 750-6419, |
| and 40 millicuries of Am-241:Be, Source Serial No. 47-28229.  A Police       |
| Report was filed with the Dallas Police Department (Report Service           |
| #0083748-K - [...]).  The operator reported the loss to his supervisor and a |
| report was telephoned to this Agency on February 5, 2001.  Two written       |
| reports were faxed to the Agency [...].  The gauge has not been recovered to |
| date.  An Agency investigation is ongoing.  The Texas Licensee (L02356) is   |
| Rone Engineers [located in] Dallas, Texas [...]."                            |
|                                                                              |
| (Call the NRC operations officer for contact information.)                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37747       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 02/14/2001|
|    UNIT:  [2] [] []                 STATE:  NY |NOTIFICATION TIME: 10:49[EST]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        02/14/2001|
+------------------------------------------------+EVENT TIME:        04:08[EST]|
| NRC NOTIFIED BY:  PHIL SANTINI                 |LAST UPDATE DATE:  02/14/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |TAD MARSH            NRR     |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| HIGH PRESSURE FIRE HEADER IMPAIRMENT AND SURVEILLANCE PER STATION            |
| ADMINISTRATIVE ORDER (SAO) 703  (24-Hour Report in accordance with the       |
| license)                                                                     |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "The high pressure Fire Water Protection System is degraded due to planned   |
| maintenance work.  The inner and outer high-pressure fire headers are split  |
| to provide protection for work on the valves for [the] 12 Fire Main Booster  |
| Pump.  [The] 12 Fire Main Booster Pump is inoperable during this tag-out.    |
| The diesel fire pump is in service as the alternate fire protection for the  |
| outside fire header.  [The] 11 Fire Main Booster Pump is in service for the  |
| inside header.  SAO-703 states [that] one fire main booster pump out of      |
| service is a 7-day action statement to return it to operable status.  The    |
| headers being separated or any part of the fire protection piping or valves  |
| not being able to perform [their] function other than the specific instances |
| described in SAO-703 [require] an alternate fire protection system shall be  |
| established.  This was established within 24 hours to ensure compliance with |
| SAO-703 as described above.  A special report shall be submitted to the NRC  |
| Regional Administrator of the Region 1 Office outlining this issue within 14 |
| days."                                                                       |
|                                                                              |
| The licensee notified the NRC resident inspector and plans to notify the NRC |
| Region 1 office (Pete Eselgroth).                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37748       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 02/14/2001|
|LICENSEE:  DRASH CONSULTING ENGINEERS, INC.     |NOTIFICATION TIME: 12:33[EST]|
|    CITY:  HARLINGEN                REGION:  4  |EVENT DATE:        01/01/2001|
|  COUNTY:                            STATE:  TX |EVENT TIME:             [CST]|
|LICENSE#:  TX L04724             AGREEMENT:  Y  |LAST UPDATE DATE:  02/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  HELEN WATKINS                |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF STOLEN HUMBOLDT GAUGE                              |
|                                                                              |
| The following text is a portion of a facsimile received from the Texas       |
| Department of Health, Bureau of Radiation Control:                           |
|                                                                              |
| "On Monday January 1, 2001, a moisture/density gauge was stolen from the     |
| back of a pickup truck that was parked at an apartment complex in Harlingen, |
| Texas. The technician who had used the gauge went to his apartment from      |
| 10:00 am to 1:00 pm after completing work at one job site. When the          |
| technician was getting into his truck, he noticed the lid on the gauge       |
| transport case was cracked open and the gauge was missing.                   |
|                                                                              |
| "The stolen gauge is a Humboldt Model 5001-C, serial number 1467. The gauge  |
| contained two sources:                                                       |
| 10 millicuries of Cs-137, source serial No. 692GH, and 40 millicuries of     |
| Am-241:Be, source serial No.                                                 |
| NJO1429.                                                                     |
|                                                                              |
| "The Licensee notified the Harlingen Police Department, this Agency, and the |
| manufacturer. The Licensee placed an ad in a local newspaper offering a $500 |
| reward for the return of the gauge."                                         |
|                                                                              |
| Call the NRC operations officer for contact information.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37749       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 02/14/2001|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 17:05[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        02/14/2001|
+------------------------------------------------+EVENT TIME:        08:51[CST]|
| NRC NOTIFIED BY:  BRUCE SCHOENBACH             |LAST UPDATE DATE:  02/14/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GREG PICK            R4      |
|10 CFR SECTION:                                 |                             |
|*IND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BOTH TRAINS OF CONTAINMENT COOLERS AND ONE TRAIN OF CONTAINMENT SPRAY        |
| INOPERABLE                                                                   |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On 2/14/01, the 'A' train containment cooling train was removed from        |
| service at 0507 CST for associated circuit breaker work. At 0851 CST the 'B' |
| Train Essential Service Water pump was started to support performance of the |
| 'A' Train SIS/CIS Slave Relay Test.                                          |
|                                                                              |
| "The 'B' Essential Service Water pump failed to achieve rated flow and       |
| pressure and was declared inoperable at 0851 CST. This resulted in entry     |
| into Technical Specification LCO 3.6.6, Required Action F.1 for both trains  |
| of containment coolers inoperable and one train ('B') of Containment Spray   |
| inoperable. LCO 3.6.6 Required Action F.1 also requires entry into LCO       |
| 3.0.3. Technical Specification 3.0.3 was entered at 0851 CST and exited at   |
| 1123 CST when the 'A' train of Containment Cooling was returned to service.  |
| The plant remains in Technical Specification LCO 3.7.8 Required Action A.1   |
| (72-Hour Action Statement) for one train ('B') of Essential Service Water    |
| inoperable.                                                                  |
|                                                                              |
| "This condition at the time of discovery could have prevented the            |
| fulfillment of the safety function of structures or systems that are needed  |
| to control the release of radioactive material or mitigate the consequences  |
| for an accident. It was concluded that this event was reportable per         |
| 10CFR50.72(b) (3) (v) since:                                                 |
|                                                                              |
| (1) Both trains of containment cooling were lost as a result of the          |
| unanticipated failure of the 'B' train Essential Service Water pump in       |
| conjunction with the 'A' train containment coolers being removed from        |
| service.                                                                     |
| (2) Cascading through technical specification resulted in the loss of 'B'    |
| train containment spray system.                                              |
|                                                                              |
| "The failure of the 'B' train Essential Service Water pump is under          |
| evaluation."                                                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37750       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 02/14/2001|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 20:00[EST]|
|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        02/14/2001|
+------------------------------------------------+EVENT TIME:        16:00[CST]|
| NRC NOTIFIED BY:  GARY HARRINGTON              |LAST UPDATE DATE:  02/14/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MONTE PHILLIPS       R3      |
|10 CFR SECTION:                                 |                             |
|*UNA 50.72(b)(3)(ii)(B)  UNANALYZED COND OP     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       96       Power Operation  |96       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ANALYSES OF AN ELECTRICAL BOX DOES NOT MEET THE FIRE RESISTANCE OF APPENDIX  |
| R                                                                            |
|                                                                              |
| The Kewaunee Engineering staff, while conducting a review, recognized that   |
| they could provide no analyses to support compliance to 10CFR50, Appendix R, |
| for an electrical wiring pull box.  The box provides an enclosure for        |
| dedicated safe shutdown equipment wiring, 'A' train equipment.  The box is   |
| located in an alternate safe shutdown equipment room, 'B' train, where the   |
| box provides protection against fire.  However, though the analyses of the   |
| box provides assurance that the design will protect the 'A' train equipment  |
| wiring from a fire, it does not provide a three hour barrier consistent with |
| Appendix R requirements.  Therefore, this places the plant in an unanalyzed  |
| condition.  The box was designed and installed in the early to mid 1980s.    |
| Compensatory measures have been taken to ensure continued safe plant         |
| operation.                                                                   |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+