Event Notification Report for June 1, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/31/2001 - 06/01/2001
** EVENT NUMBERS **
38026 38039 38040 38041 38042
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 38026 |
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 05/23/2001|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 16:19[EDT]|
| RXTYPE: [1] CE |EVENT DATE: 05/23/2001|
+------------------------------------------------+EVENT TIME: 14:45[CDT]|
| NRC NOTIFIED BY: MATZKE |LAST UPDATE DATE: 05/31/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK SHAFFER R4 |
|10 CFR SECTION: | |
|DDDD 73.71 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| DISCOVERY OF CRIMINAL ACT INVOLVING INDIVIDUAL GRANTED ACCESS TO THE SITE. |
| |
| COMPENSATORY MEASURES NOT FULLY IMPLEMENTED |
| |
| THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED |
| |
| CONTACT NRC HEADQUARTERS OPERATIONS OFFICER FOR ADDITIONAL INFORMATION |
| |
| * * * RETRACTED AT 1600 EDT ON 5/31/01 BY ERICK MATZKE TO FANGIE JONES * * |
| * |
| |
| Further investigation of the issue determined that the event notification |
| was not reportable and retracts the notification of event #38026. |
| |
| The licensee notified the NRC Resident Inspector. R4DO (Dale Powers) was |
| notified. |
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|Fuel Cycle Facility |Event Number: 38039 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/31/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 10:17[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/30/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 11:00[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/31/2001|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |MARK RING R3 |
| DOCKET: 0707001 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: M. C. PITTMAN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| FIRE PROOF COVER OVER A PROCESS OPENING COULD NOT PERFORM ITS INTENDED |
| FUNCTION. |
| |
| |
| NRC BULLETIN 91-01 24 HOUR NOTIFICATION |
| |
| |
| At 1400, 05/30/01 the Plant Shift Superintendent (PSS) was notified that the |
| Zetex material used as a fire proof cover on the # 3 low speed purge and |
| evacuation pump has deteriorated to the point of failure such that it could |
| not perform its intended function. The material was being used according to |
| CP2-CO-CN2030, as a fire proof cover over a process opening. The material |
| has become brittle and failed to the point of leaving openings to the |
| process system. NCSA GEN-10, Removal and Handling of Contaminated Equipment |
| from the Cascade at PGDP, requires fire proof covers to be installed on |
| cascade system openings to prevent the introduction of moderation from a |
| sprinkler activation, lube oil leak, or RCW leak. Double contingency for |
| this scenario is established by implementing two controls on moderation. |
| One leg of double contingency is based on the fire proof cover preventing a |
| moderator release from entering the open process system. Since the fire |
| proof cover deteriorated to the point of leaving openings to the process |
| system, the ability to prevent introduction of moderator was lost. This |
| control was violated and double contingency was not maintained. |
| |
| SAFETY SIGNIFICANCE OF EVENTS: |
| A material credited to perform a criticality safety related function was not |
| able to perform its function. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED [BRIEF SCENARIO(S) OF HOW |
| CRITICALITY COULD OCCUR]: |
| |
| In order for criticality to be possible, greater than 10 kg of a moderator |
| would have to enter the open process system and interact with a uranium |
| deposit greater than the minimum critical mass in a geometry favorable for a |
| criticality. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| |
| Double contingency for this scenario is established by implementing two |
| controls on moderation. |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITICAL MASS): |
| |
| Maximum assay of 1.08 wt.% U235. |
| |
| 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 the unlikelihood of a |
| moderator release (Sprinkler, RCW, oil) into the open process system during |
| the time the system is open. Since there was no moderator release into the |
| system, this leg of double contingency was maintained. |
| |
| The second leg of double contingency is based on the fire proof cover |
| preventing a moderator release from entering the open process system. Since |
| the fire proof cover deteriorated to the point of leaving openings in the |
| process system, the ability to prevent introduction of moderator was lost. |
| The control was violated and double contingency was not maintained. |
| |
| Since double contingency is based on two controls on moderation, double |
| contingency was not maintained. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| |
| The degraded Zetex fire proof material was replaced with an approved AQ-NCS |
| aluminum cover. Other cascade openings using Zetex material are being |
| inspected for signs of degradation and will be replaced as necessary. The |
| use of Zetex material as a fire proof cover will be re-evaluated. |
| |
| The NRC Resident Inspector was notified of this event by the certificate |
| holder. |
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|Hospital |Event Number: 38040 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF PITTSBURGH MED. CENT. |NOTIFICATION DATE: 05/31/2001|
|LICENSEE: UNIVERSITY OF PITTSBURGH |NOTIFICATION TIME: 11:24[EDT]|
| CITY: PITTSBURGH REGION: 1 |EVENT DATE: 09/03/1996|
| COUNTY: STATE: PA |EVENT TIME: 18:00[EDT]|
|LICENSE#: 37-00245-02 AGREEMENT: N |LAST UPDATE DATE: 05/31/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ERIC REBER R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JERRY ROSEN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| The following is taken from a faxed report: |
| |
| The following event is being reported as a medical misadministration in |
| accordance with the May 22, 2001, directive of NRC Region I |
| representatives. |
| |
| At 6:00 PM on September 3,1996, a patient was implanted with six ribbons, |
| each containing four Iridium-192 seeds. The seeds each contained 1.01 |
| millicuries (total activity of 24.2 millicuries). The ribbons were placed in |
| catheters implanted into the patient's right jaw and secured by crimping a |
| metal button around the catheter. The corresponding written directive |
| prescribed a treatment time of 47 hours. At 4:45 PM on September 5, 1996, |
| the radiation oncologist arrived to remove the sources and determined that |
| one ribbon was missing from the treatment site. The Radiation Safety Office |
| (RSO) was notified. The five remaining ribbons were removed from the patient |
| and a survey was done of the patient, the patient's room and surroundings. |
| The missing ribbon was located on the floor in front of a laundry bin. The |
| ribbon was secured and returned to storage. |
| |
| The RSO investigated this event and determined that all six ribbons were in |
| place at 8:00 AM on September 5th when the day nurse checked the patient and |
| documented the status of the brachytherapy implant in the patient's record. |
| (Note: Prior to this event nurses were required to evaluate and document the |
| status of brachytherapy implants at the beginning of each work shift.) At |
| approximately 9:30 AM the patient complained of discomfort and experienced |
| significant vomiting. This condition persisted through the remainder of the |
| day. A Patient Service Technician (PST) reported that she changed the |
| patient's gown and bed linens at approximately 2:30 PM. Staff physicians, |
| nurses and residents evaluated the patient throughout that day as documented |
| in the patient's record. However, such documentation does not include an |
| indication or the status of the implant. |
| |
| The licensee concluded that the brachytherapy ribbon likely became dislodged |
| from the treatment site due to the patient's vomiting and/or |
| self-intervention sometime between 9:30 AM and 2:30 PM on September 5th. The |
| ribbon was apparently entangled in the patient's bed linens until the linens |
| were changed by the PST at 2:30 PM; whereupon the ribbon dropped from the |
| soiled linens when they were placed in the linen storage bin. It is also |
| possible that the ribbon may have become dislodged at the time (2:30 PM) the |
| patient's gown was being changed. |
| |
| Assuming the worst case that the brachytherapy ribbon became dislodged at |
| 9:30 AM, the deviation from the total prescribed treatment dose due to the |
| single ribbon missing for 7.5 hours is 2.7 percent, The possible localized |
| radiation dose outside the treatment Site was also evaluated. If it is |
| assumed that with patient movement the average location of the ribbon would |
| be 10 cm from the patient's body. then the closest area of the body exposed |
| would receive a radiation dose of less than one rad. This radiation dose is |
| no more than the lower extremities would receive from the prescribed |
| brachytherapy implant procedure and substantially less than that which would |
| be received by the upper torso and head in areas near the implant site. If |
| the ribbon became dislodged when the patient's gown was being changed, there |
| would be no significant radiation dose to any portion of the patient's body |
| since the source had been removed from the bed at that time. |
| |
| Based on its review of the circumstances surrounding this event and the |
| possible associated radiation exposures, the licensee concluded that the |
| event did not constitute a misadministration or recordable event. However, |
| in consideration of the possible ramifications of a future such event, the |
| licensee implemented a policy requiring that documented checks of the |
| implant site be performed at four hour intervals by nursing personnel. |
| (Note: The NRC's regulations and guidance are silent on the issue of |
| frequency of monitoring implants.) |
| |
| Elmer Cano, M.D., the Radiation Oncologist, did not feel that this event |
| would impact on the well being of the patient. The patient's referring |
| physician was verbally notified of this event at the time of its |
| occurrence. |
| |
| Full details of the event were documented and placed in the incident file to |
| be reviewed during the next NRC inspection. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 38041 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/31/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 16:52[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/31/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:30[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/31/2001|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |MARK RING R3 |
| DOCKET: 0707002 |LARRY CAMPER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RICK LARSON | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| BULLETIN 91-01 - 24 HOUR REPORT |
| |
| The licensee, during a review of the plant surveillance program, discovered |
| a surveillance that was suppose to be done every 6 months was missed the |
| last time and is about 6 months overdue. |
| |
| The following is taken from a faxed report: |
| |
| At 1330 hrs. the Plant Shift Superintendent was notified that a required |
| surveillance for NCSA 705_040 was not performed in the required periodicity. |
| This surveillance is necessary to ensure that uranium bearing material is |
| not accumulating in the piping due to either precipitating out or through |
| bonding with oil-bearing material which then layers out in the piping. By |
| not performing this surveillance one of the barriers for maintaining double |
| contingency was lost for this operation thus making this a reportable |
| event. |
| |
| SAFETY SIGNIFICANCE OF EVENTS: |
| |
| The surveillance required to perform non-destructive analysis (NDA) on |
| piping of the 705 geometrically safe overhead storage (GSS) was not |
| performed. However, based on the historic evidence as discussed in sections |
| 4.3 and 4.5 of analysis performed for this system it is highly unlikely that |
| material is accumulating in the piping and thus the safety significance of |
| this event is low. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): |
| |
| Without measuring a significant amount of material could accumulate in GSS |
| piping and result in an unsafe condition. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| |
| The parameter which was violated during this upset was maintaining the |
| concentration of material in the GSS piping to a safe level through periodic |
| NDA surveillance of various piping in the GSS. It should be noted that the |
| physical integrity of the piping in question (i.e., that containing the |
| uranium-bearing material) was maintained. |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE OF: |
| |
| Based on the most recent sampling of solution contained in the GSS the |
| amount of uranium involved is small (approximately 0.0002 grams |
| uranium/liter) |
| |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: |
| |
| Did not perform the required surveillance within the allotted time period. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: |
| |
| Isolated the GSS from other influents at 1335 hrs. Will commence NDA |
| measurements 06/01/01. |
| |
| The licensee notified the NRC Resident Inspector and the local DOE |
| representative. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38042 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 05/31/2001|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 17:03[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 00:05[EDT]|
| NRC NOTIFIED BY: BRIAN THOMAS |LAST UPDATE DATE: 05/31/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ERIC REBER R1 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
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| INADVERTENT LOSS OF 'A' RPS BUS |
| |
| The following is taken from a faxed report: |
| |
| This 60-day optional report in accordance with 10CFR50.73(a)(1), is being |
| made under the reporting requirement of 10CFR50.73(a)(2)(iv)(A) to describe |
| an invalid actuation of the Containment Isolation System. |
| |
| On April 11, 2001, at 0005 hours, the control room received an alarm for |
| loss of the 'A' Reactor Protection System (RPS) bus. As a result of the loss |
| of the 'A' RPS bus the following actuations occurred: an A1 & A2 RPS half |
| scram, a Nuclear Steam Supply System Shutoff (NSSSS) logic A & C trip, |
| tripping of the 'A' and 'B' Reactor Water Clean Up (RWCU) pumps due to |
| closure of the inboard isolation valve BG-HV-F001, recirculation sampling |
| isolation, and closure of the inboard Main Steam Line Drain valve |
| AB-HV-F016 |
| |
| The 'A' RPS bus was shifted to the alternate feed at 0023 and the RPS A1 & |
| A2, the NSSSS, and the primary containment isolation signals (PCIS) were |
| reset. At 0036, recirculation sampling was restored. Valve, BG-HV-F001 and |
| AB-HV-F016 were reopened at 0039 hours. |
| |
| The above actuations and isolations were expected as a result of the loss of |
| the 'A' RPS bus. These actions and isolations were due to an invalid signal |
| resulting from the inadvertent de-energization of the 'A' RPS bus. |
| |
| Fire Protection Operators were performing testing of the smoke detectors in |
| the RPS motor-generator (MG) set room using a test pole. When the Fire |
| Protection Operator in the overhead was handing the test pole to the Fire |
| Protection Operator on the floor, the pole slipped and struck breaker switch |
| for H1SB-1AN410 (A RPS EPA breaker), causing the breaker to open. Opening of |
| the breaker lead to the loss of the 'A' RPS bus. |
| |
| After determining that no damage occurred to breaker H1SB-1AN410, the 'A' |
| RPS was restored to the normal power source. |
| |
| The impact on the plant safety from this event was minimal. The isolations |
| and equipment losses during the event caused only a minor plant transient |
| and the equipment performed as expected. After the plant was stabilized and |
| the cause of the loss of the 'A' RPS was identified, the half scram was |
| reset. |
| |
| This event has been entered into the corrective action program. |
| |
| |
| The licensee intends to notify the NRC Resident Inspector. |
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