Event Notification Report for May 25, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/24/2001 - 05/25/2001
** EVENT NUMBERS **
38028 38029 38030
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38028 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WA DIVISION OF RADIATION CONTROL |NOTIFICATION DATE: 05/23/2001|
|LICENSEE: SWEDISH MEDICAL CENTER |NOTIFICATION TIME: 18:22[EDT]|
| CITY: SEATTLE REGION: 4 |EVENT DATE: 05/17/2001|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: WN-M008-1 AGREEMENT: Y |LAST UPDATE DATE: 05/24/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TERRY FRAZEE (EMAIL) | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT |
| |
| "ABSTRACT: A 0.326-millicurie I-125 seed was damaged and leakage occurred. |
| Five Medi-Physics OncoSeed model 6711 brachytherapy seeds were loaded in a |
| hollow needle for insertion into a prostate implant patient. During the |
| insertion attempt, the needle tip struck bone. The radiation oncologist |
| withdrew the needle and determined there was a slight bend in the needle. |
| In attempting to straighten the needle, the radiation oncologist broke the |
| needle into two pieces. The most distal seed was crimped and broken into |
| two pieces as well. All items potentially in contact with the broken seed |
| were immediately isolated. Contamination on the exterior of the broken seed |
| was 0.012 microcuries. The patient was not contaminated. The broken seed |
| will be held for decay. Implant personnel were instructed not to bend |
| loaded needles to prevent this from recurring. |
| |
| "What is the notification or reporting criteria involved? WAC 246-221-265 |
| Leaking source |
| |
| "Activity and Isotope(s) involved: 0.326 millicuries of I-125" |
| |
| HOO NOTE: Event entered late - updated for dispatch in 5/25/01 events |
| package. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38029 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 05/24/2001|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 21:50[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/24/2001|
+------------------------------------------------+EVENT TIME: 18:09[CDT]|
| NRC NOTIFIED BY: MIKE HAUNER |LAST UPDATE DATE: 05/24/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |SONIA BURGESS R3 |
|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 1 Startup |1 Startup |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| HPCI DECLARED INOPERABLE |
| |
| "During a reactor startup following a refueling outage, HPCI was declared |
| inoperable and is reportable under 50.72(b)(3)(v)(D) and 50.72(b)(3)(vi) as |
| a single failure. |
| |
| "Upon completion of HPCI system operability testing, it was discovered that |
| the HPCI system flow controller indicated approximately 500 GPM verses an |
| expected 0 GPM. Since the plant is in MODE 2 and reactor pressure is greater |
| than 150 PSIG, HPCI was declared inoperable and a 14-day LCO was entered per |
| TS 3.5.1, condition F. |
| |
| "The preliminary investigation results are that air in the HPCI system flow |
| transmitter sensing lines is causing the erroneous flow indication. |
| Troubleshooting efforts are in progress." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38030 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: CA RADIATION CONTROL PRGM |NOTIFICATION DATE: 05/24/2001|
|LICENSEE: IBA/STERIGENICS INTERNATIONAL |NOTIFICATION TIME: 23:05[EDT]|
| CITY: CORONA REGION: 4 |EVENT DATE: 04/24/2001|
| COUNTY: STATE: CA |EVENT TIME: [PDT]|
|LICENSE#: 5956-33 AGREEMENT: Y |LAST UPDATE DATE: 05/24/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT GREGER | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT |
| |
| On 4/24/2001, an irradiator facility experienced a loss of electrical power |
| to a programmable logic controller (PLC) which resulted in the inability to |
| automatically lower the source racks. The source racks were manually lowered |
| to a safe condition upon discovery of the failure. |
| |
| The following information was provided by the licensee to the California |
| Radiation Control Program on 5/15/2001: |
| |
| "Description of Events: |
| |
| "The first indication that there was a problem came at 9:00 p.m. 4/24/01, |
| when the in-line water monitor signaled a failure. The Shift Leader took |
| appropriate action per the Emergency Procedures and determined that there |
| was no radiation present in the water system. He notified the QA Technician, |
| who had performed a calibration of the monitor that afternoon. |
| |
| "After reviewing the procedure followed for calibration routine and |
| determining that no problems occurred with the calibration that would trip |
| the alarm, the QA Technician, notified the facility Radiation Protection |
| Office (RPO). She determined that this was a false alarm, probably caused by |
| air bubbles in the system, as has previously occurred with the water |
| monitor. [... Permission was given] to allow the system to continue running |
| with the water alarm disarmed until more investigation could be performed in |
| the morning. |
| |
| "Starting at about 7:00 a.m., additional water counts, using the monitor, |
| were taken and resulted in normal background readings. Since the routine |
| counts showed expected background levels and the alarm did not activate |
| again, the concluded that a pocket of water bubbles from a filter change had |
| worked its way through the system and caused spurious readings on the |
| monitor, which had occurred on previous occasions. All of the events to this |
| point were consistent with this determination. |
| |
| "At 8:20 am., the Operator notified the RPO that the in-line alarm was |
| sounding again. On reviewing the PLC control panel, she noted that none of |
| the indicators on the panel were lit, as they should have been, even though |
| the computer monitor (PLC user interface) was operating. In concert with the |
| Plant Manager, they determined that the audible alarm that the Operator |
| heard was not the in-line monitor, but was an alarm indicating that the PLC |
| was off-line. |
| |
| "Further investigation revealed that the system conveyor had stopped moving |
| (i.e., product was stationary within the cell), but that the source racks |
| bad not automatically returned to the shielded position, as they should |
| have, the source racks were manually lowered from the roof by 8:40 a.m. |
| During this time, the door interlock continued to function properly, |
| prohibiting access to the cell through the personnel access door. |
| |
| "In determining the probable cause of the event, the first evaluation was |
| that the power supply had malfunctioned. However, upon further |
| investigation, it was determined that the most probable cause was an |
| electrical short in the system. After extensive trouble-shooting and |
| investigation, the electrical short was finally located in the line going to |
| one of the emergency pull cords in the cell. The cable had actually melted |
| at the point of the failure. |
| |
| "That part of the systems was rewired and the system restarted at |
| approximately 4:00 p.m. The safety system was checked for proper operation |
| and routine processing resumed at 4:45 p.m. |
| |
| "Evaluation of Event and Root Cause: |
| |
| "Upon Engineering review of the electrical drawings, it was determined that |
| a short circuit on the pull cords or other devices could have tripped one of |
| the circuit breakers, power from which feeds the PLC and other modules in |
| the PLC rack. The audible alarm was the PLC Off Line Sonalert, which, as |
| intended, served as a warning the PLC was not operating. With the PLC off, |
| there was no power control to lower the source racks. In normal |
| circumstances of power failure, the uninterruptible power supply (UPS) |
| provides adequate emergency power to lower the source racks by releasing the |
| hoist brakes in a pulsed mode. However, with the PLC not operating, this |
| power was not supplied to the brakes, which then had to be released |
| manually. |
| |
| "The water monitor alarm activation was probably caused by shorting line |
| voltage to the grounding circuit. This momentary surge in current, |
| particularly on the ground path, could cause an erroneous indication at the |
| monitor. Other facilities have had spurious water monitor alarms resulting |
| from ground fault conditions. |
| |
| "Corrective Actions and Additional Considerations: |
| |
| "Corrective actions to the event are: |
| |
| "1. The circuit will be modified to ensure the PLC does not lose power |
| if a device or device wiring causes a short circuit. |
| |
| "2. Additional training will be provided to operators to be more |
| cognizant of the system response to a PLC off-line fault. While the PLC |
| off-line alarm is a local alarm, meaning that it sounds at the control |
| console and does not active general alarms throughout the warehouse, all |
| system operations are stopped, including overhead conveyors and the 4-shelf |
| elevator (i.e., device that shifts totes among positions in the carrier). |
| The absence of movement in these systems should have alerted the operator to |
| a systemic failure of the controls. In this instance, the tune period |
| between the equipment failure and initial resolution (manually lowering the |
| source racks) was only a few minutes. Because the door interlock continues |
| to function under these circumstances, the situation did not pose a |
| radiation safety hazard to the operator or other personnel. Although, |
| operator training currently includes instructions for determining console |
| power status and the proper procedure for lowering the source racks under |
| circumstances such as occurred here, the training will be reinforced and |
| repeated |
| |
| "3. To avoid further problems with the in-line water monitor alarm, an |
| evaluation is being conducted to determine whether the water monitor can be |
| connected to an isolated-ground receptacle and circuit. This would have the |
| effect of making the monitor less affected by stray currents, and other |
| sources of 'noise' on the power line." |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021