Event Notification Report for May 29, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/25/2001 - 05/29/2001
** EVENT NUMBERS **
38011 38031 38032 38033 38034
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 38011 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/18/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 15:37[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/17/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 16:37[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/25/2001|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |GARY SHEAR R3 |
| DOCKET: 0707001 |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WHITE | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24-HOUR NRC BULLETIN 91-01 RESPONSE |
| |
| At 1640 CDT on 05/17/01, the Plant Shift Superintendent (PSS) was notified |
| that the independent verification required by procedure CP2-CU-CH2137 was |
| not performed. The maintenance segment was not independently verified to be |
| isolated. The same person signed for performance as well as the |
| verification of the segment isolation. NCSA 400.009 requires that fissile |
| operations that credit AQ-NCS function that is disabled due to maintenance |
| must be identified independently and disabled using a tagout prior to |
| disabling the feature and commencing maintenance. This is done to prevent |
| operation of a system while an AQ-NCS component function is disabled. Since |
| the independent verification was not performed, the process condition was |
| not maintained. Therefore, double contingency was not maintained. |
| |
| SAFETY SIGNIFICANCE OF EVENTS: |
| |
| While the NCS control was violated, the fissile operation containing the |
| component(s) undergoing maintenance was tagged out using LOTO both as a |
| standard maintenance practice in C-400 and due to other NCS requirements. |
| In addition, the equipment items removed had no AQ-NCS function which was |
| affected by the maintenance actions. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW |
| CRITICALITY COULD OCCUR): |
| |
| In order for criticality to be possible, the components undergoing |
| maintenance must have an AQ-NCS function that is disabled, and the affected |
| operations must be subsequently performed with fissile solution. |
| Additionally, the maintenance activity must be one of the relatively few |
| maintenance activities that do not require tagout for another NCS reason, |
| such as to prevent fissile solution from leaking from the system. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| |
| Double contingency for this scenario is established by implementing |
| independently verifying the prevention of the affected fissile operation. |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITICAL MASS): |
| |
| Maximum assay of 2.75 wt. % U-235. |
| |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: |
| |
| The first leg of double contingency is based on preventing operation of the |
| Cylinder Wash Facility during maintenance affecting the AQ-NCS component. |
| The components were properly identified as non-AQ-NCS; therefore, this |
| control was not violated. |
| |
| The second leg of double contingency is based on independently preventing |
| operation of the Cylinder Wash Facility during maintenance affecting the |
| AQ-NCS component. The requirement to independently verify the AQ-NCS |
| function of all components affected by maintenance was not performed. The |
| control was violated, and the process condition was not maintained. |
| |
| Since the independent verification was not performed, the process condition |
| was not maintained. Therefore, double contingency was not maintained. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| |
| This condition was identified while reviewing completed maintenance work |
| packages. There is no action that can be performed to resolve this |
| condition and bring the process back into compliance since the maintenance |
| activity has been completed. |
| |
| The NRC Resident Inspector was notified, and the DOE Representative will be |
| informed. |
| |
| * * * UPDATE ON 5/22/01 @ 1235 BY HUDSON TO GOULD * * * |
| |
| As a result of this NCS violation, a review of work packages was initiated |
| to determine if other instances exist where the required second signature |
| was not obtained. On 05/21/01 at 1520 CDT, the PSS was notified that |
| another incident involving the violation of this requirement was discovered |
| pertaining to maintenance on the RF (radio frequency) furnace. |
| |
| The NRC Senior Resident has been notified of this event by Paducah |
| personnel. The Reg 3 RDO (Burgess) and the NMSS EO (Cool) were informed by |
| the NRC Operations Officer. |
| |
| * * * UPDATE 1440 ON 5/25/2001 FROM WALKER TAKEN BY STRANSKY * * * |
| |
| "This report updated on 5-25-01 to document the results of NCS reevaluation |
| of the subject incidents. It has been determined that double contingency was |
| maintained and these incidents are not reportable. |
| |
| "The first leg of double contingency is based on preventing fissile |
| operation of the equipment during maintenance affecting the AQ-NCS |
| component. The components were properly identified as non-AQ-NCS, therefore, |
| this control was not violated. |
| |
| "The second leg of double contingency is based on independently preventing |
| fissile operation of the equipment/system during maintenance affecting the |
| AQ-NCS component. The requirement to independently verify the AQ-NCS |
| function of all components affected by maintenance was not performed so this |
| control was violated. Since the component does not have an AQ-NCS function, |
| there was no process parameter being relied on for double contingency. |
| Therefore, the process condition was maintained. |
| |
| "Although the independent verification was not performed, there was no |
| reliance on NOS parameters since the component had no AQ-NCS function. |
| Therefore there was no parameter to lose and the process condition was |
| maintained. Therefore, double contingency was maintained." |
| |
| The NRC resident inspector has been informed of this update. Notified R3DO |
| (Burgess). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 38031 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TRISTATE INSPECTION AND CONSULTANTS |NOTIFICATION DATE: 05/25/2001|
|LICENSEE: TRISTATE INSPECTION AND CONSULTANTS |NOTIFICATION TIME: 10:15[EDT]|
| CITY: FLINT REGION: 3 |EVENT DATE: 05/24/2001|
| COUNTY: GENESEE STATE: MI |EVENT TIME: 21:10[EDT]|
|LICENSE#: 37-19640-01 AGREEMENT: N |LAST UPDATE DATE: 05/25/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |SONIA BURGESS R3 |
| |JOHN KINNEMAN R1 |
+------------------------------------------------+JOHN HICKEY NMSS |
| NRC NOTIFIED BY: PAT DURKIN | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|IBBE 30.50(b)(2) SAFETY EQUIPMENT FAILUR| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SOURCE HANG-UP AT A TRISTATE INSPECTION AND CONSULTANTS TEMPORARY JOB SITE |
| IN HOMER CITY, PENNSYLVANIA |
| |
| The licensee reported that there was a source hang-up at a temporary job |
| site in Homer City, Pennsylvania. The radiography camera involved was an |
| Amersham-660B which contained a 52-curie iridium-192 source. |
| |
| When the source hang-up occurred, the crew involved (two radiographers) |
| secured the area and notified an AEA Technologies Retrieval Team. Prior to |
| the Retrieval Team's arrival, the Tristate crew (with assistance from other |
| workers) was able to successfully shield the guide tube, straighten it out, |
| and retrieve the source to its shielded position. As a result, the AEA |
| Technologies Retrieval Team was not required. |
| |
| A pocket dosimeter for one of the original two crew members when off scale |
| at some point during the process, but it was also reported that the |
| radiographer had dropped it two exposures prior to this one. He then |
| noticed that the dose had increased by 10 millirem, but it remained on |
| scale. It was later re-zeroed, and it was still approximately 10 millirem |
| high. The second radiographer's total dose was 85 millirem. |
| |
| The licensee plans to send the dosimetry out for analysis today. The |
| licensee also plans to return the camera to Amersham for possible repairs. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38032 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF MED. AND DENT. OF NJ |NOTIFICATION DATE: 05/25/2001|
|LICENSEE: UNIVERSITY OF MED. AND DENT. OF NJ |NOTIFICATION TIME: 16:21[EDT]|
| CITY: NEWARK REGION: 1 |EVENT DATE: 05/23/2001|
| COUNTY: STATE: NJ |EVENT TIME: 16:30[EDT]|
|LICENSE#: 29-02957-13 AGREEMENT: N |LAST UPDATE DATE: 05/25/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN KINNEMAN R1 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: LANKA | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING IR-192 SEEDS |
| |
| On 5/23/01, six ribbons of Ir-192 seeds were implanted into a patient as |
| part of a treatment. When the ribbons were removed from the patient at |
| approximately 1000 on 5/25/01, only five of the six ribbons were recovered. |
| The patient stated that one of the ribbons had come out approximately one |
| hour after implantation and he had discarded it in the trash; however, the |
| doctor had not observed any disturbance to the implantation site during an |
| examination conducted on 5/24/01. The missing ribbon contains nine seeds; |
| each seed contains 0.49 mg Ra equivalent activity. |
| |
| The licensee has conducted an exhaustive search of the facility but has been |
| unable to locate the missing seeds. In addition, interviews were conducted |
| with housekeeping personnel. The licensee has contacted the NRC Region I |
| office regarding this event. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38033 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 05/25/2001|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 18:36[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 05/24/2001|
+------------------------------------------------+EVENT TIME: 20:15[EDT]|
| NRC NOTIFIED BY: MICHAEL CONWAY |LAST UPDATE DATE: 05/25/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN KINNEMAN R1 |
|10 CFR SECTION: | |
|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 |87 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24-HOUR REPORT MADE IN ACCORDANCE WITH FACILITY OPERATING LICENSE |
| |
| "On 5/24/01 at 2015 hrs, Nine Mile Point Unit 2 experienced a sudden failure |
| on the control circuitry of one of two Reactor Recirculation System flow |
| control valves. The failure mechanism of the 'B' flow control valve produced |
| reactor core flow changes in both the increase and decrease directions which |
| had a resultant effect of raising and lowering reactor power. At the time of |
| the failure, Nine Mile Point Unit 2 was operating at 100% power. The core |
| flow changes occurred within a ninety second period and changed neutron flux |
| (APRM) by approximately 30 to 40%. Plant conditions were stabilized by |
| hydraulically locking the malfunctioning flow control valve in a stable |
| position. Reactor Power is now 87% of rated. No Technical Specification |
| Limiting Condition for Operation (LCO) violations are known to have |
| occurred. |
| |
| "This report is being made as required by the Nine Mile Point Unit 2 |
| Facility Operating License #NPF-69 section 2.F. During this event, Reactor |
| Power may have nominally exceeded 102% of rated for several seconds. As |
| such, this event is required to be reported to the NRC Operations Center |
| within 24 hrs as a violation of License section 2.C(1) Maximum Power Level. |
| Event analysis is continuing and may result in retraction of this |
| notification at a later date." |
| |
| The licensee will inform the NRC resident inspector of this notification. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38034 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 05/27/2001|
| UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 08:40[EDT]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 05/27/2001|
+------------------------------------------------+EVENT TIME: 06:18[CDT]|
| NRC NOTIFIED BY: T. GRANLUND |LAST UPDATE DATE: 05/27/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |SONIA BURGESS R3 |
|10 CFR SECTION: | |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 80 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC SCRAM FOLLOWING MAIN TURBINE TRIP DURING SURVEILLANCE TESTING |
| |
| "Unit 2 was operating at 80% Reactor Power, 937 Mwe. LOS-RP-M5, Turbine |
| Control Valve Surveillance was in progress. An Automatic Main Turbine Trip |
| and Reactor Scram occurred at 0618. Initial investigation indicates the |
| cause of the Main Turbine Trip was High Vibration and Electro Hydraulic |
| Controls (EHC) Master Turbine Trip. |
| |
| "All systems operated as designed, there were no ECCS actuations. The lowest |
| Reactor Water Level was minus 10 inches and recovered to the normal band. |
| Reactor Pressure responded normally. No Safety Relief Valves Actuated. All |
| Control Rods fully inserted. |
| |
| "2A and 2C Circulating Water Pumps tripped during the Electrical Bus |
| transfer following the Main Turbine Trip. This is suspected to be caused by |
| electrical perturbation on the system but will be further investigated." |
| |
| The licensee informed the NRC resident inspector. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021