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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  

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|Fuel Cycle Facility                              |Event Number:   38011       |
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| 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      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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).                                                                   |
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|Other Nuclear Material                           |Event Number:   38031       |
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| 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|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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.)   |
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|Hospital                                         |Event Number:   38032       |
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| 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  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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.                                                 |
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|Power Reactor                                    |Event Number:   38033       |
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| 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  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 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.    |
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|Power Reactor                                    |Event Number:   38034       |
+------------------------------------------------------------------------------+
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| 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     |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 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.                            |
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