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Event Notification Report for July 11, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/10/2001 - 07/11/2001

                              ** EVENT NUMBERS **

38113  38125  38126  38127  38128  

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|Fuel Cycle Facility                              |Event Number:   38113       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 07/02/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 19:31[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        07/02/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        10:00[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/10/2001|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |ANTON VEGEL          R3      |
|  DOCKET:  0707001                              |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  W. F. CAGE                   |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01 RESPONSE - FAILURE TO MAINTAIN THE DOUBLE CONTINGENCY     |
| (24-Hour Report)                                                             |
|                                                                              |
| The following text is a portion of a facsimile received from  Paducah:       |
|                                                                              |
| "At 1000, on 07/02/01, the Plant Shift Superintendent (PSS) was notified     |
| that while approving a cylinder for wash on the C-400 Cylinder Wash stand,   |
| an incorrect cylinder number was both entered and independently verified on  |
| the UF6 Cylinder Wash Facility Data Sheet violating NCSA 400-002.  As a      |
| result of these actions, an unapproved cylinder was washed.  NCSA 400-002    |
| required the cylinder number be independently verified to be correct on the  |
| approval data sheet.  The cylinder number is used to prevent                 |
| misidentification of cylinders.   Since the cylinder washed had an           |
| unverified UF6 heel (mass control) and independent verification of the       |
| cylinder to be washed was incorrectly performed (assay control), double      |
| contingency was not maintained."                                             |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:  Independent verification required to ensure |
| the correct cylinder be washed was not performed correctly."                 |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW           |
| CRITICALITY COULD OCCUR:  In order for a criticality to be possible, a       |
| cylinder containing a critical mass of enriched uranium would need to be     |
| washed.  The cylinder incorrectly washed had an assay <1.0 WT %235U."        |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):    |
| [The] two process conditions relied on for double contingency for this       |
| scenario are assay and mass."                                                |
|                                                                              |
| "ESTIMATED AMOUNT ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):  The cylinder washed was <1.0 WT      |
| %235U."                                                                      |
|                                                                              |
| "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 assay not exceeding 2.0 WT %235U. The cylinder intended for     |
| wash and the cylinder actually washed were both 4BHX cylinders, which are    |
| limited to a maximum enrichment of 1.0%.  While the control was violated,    |
| the process condition was maintained."                                       |
|                                                                              |
| "The second leg of double contingency is based on the heel mass not          |
| exceeding 72 pounds.  The cylinder actually washed has an unverified heel    |
| weight.  Therefore, this control was violated, and this leg of double        |
| contingency was lost."                                                       |
|                                                                              |
| "Since the process parameter for mass was not independently verified prior   |
| to washing the cylinder, double contingency was not maintained."             |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| This condition was identified while reviewing completed cylinder work        |
| records.  There is no action that can be performed to resolve this condition |
| and bring the process back into compliance since the cylinder activity has   |
| been completed."                                                             |
|                                                                              |
| Paducah personnel notified the NRC resident inspector.                       |
|                                                                              |
| * * * UPDATED AT 1535 EDT ON 7/10/01 BY W. F. CAGE TO FANGIE JONES * * *     |
|                                                                              |
| "Nuclear Regulatory Affairs has reviewed the basis for the event report      |
| against the NCS reporting position and determined that the NCS violation     |
| although serious did not cause either of the two NCS process conditions      |
| (assay <2 wt.% or heel mass of 72 pounds) analyzed in NCSA 400-002 to change |
| or to be exceeded. The assay of the material in the cylinder was 0.71 wt. %  |
| and the heel mass was 11 pounds. Under the reporting criteria, reporting     |
| would only be warranted when the double contingency principal has been       |
| violated, but the process conditions cited for double contingency were       |
| maintained, i.e., not exceeded. Thus, the double contingency principal, as   |
| defined in the SAR and ANSI 8.1 was not violated and the incident is not     |
| reportable.                                                                  |
|                                                                              |
| Paducah personnel notified the NRC resident inspector.  The R3DO (David      |
| Hills) and NMSS (Don Cool) were notified.                                    |
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|General Information or Other                     |Event Number:   38125       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/10/2001|
|LICENSEE:  CTC-GEOTECH                          |NOTIFICATION TIME: 12:15[EDT]|
|    CITY:                           REGION:  4  |EVENT DATE:        07/09/2001|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:  CORAM552-01           AGREEMENT:  Y  |LAST UPDATE DATE:  07/10/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHUCK CAIN           R4      |
|                                                |FREDERICK STURZ      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIM BONZER                   |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE                                |
|                                                                              |
| The Colorado Department of Health received a call from CTC-Geotech at        |
| approximately 9:30 (AM) on 7/10/01. The call reported a Troxler gauge model  |
| 3430 serial #32097 stolen late afternoon on 7/9/01.  It was stolen from a    |
| job site in Thorton, CO.  The gauge was chained to the back of pickup truck  |
| and the locks were cut while the user was inside a construction trailer      |
| getting work information.  A police report and a written report will be sent |
| to Colorado Department of Health.                                            |
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|Power Reactor                                    |Event Number:   38126       |
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| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 07/10/2001|
|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 16:47[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        07/10/2001|
+------------------------------------------------+EVENT TIME:        16:11[EDT]|
| NRC NOTIFIED BY:  TERRY ARNETT                 |LAST UPDATE DATE:  07/10/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANTHONY DIMITRIADIS  R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     N          Y       100      Power Operation  |99       Power Operation  |
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                                   EVENT TEXT                                   
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| PLANT SHUTDOWN REQUIRED DUE TO FAILED CONTAINMENT LEAK RATE TEST             |
|                                                                              |
| The licensee was conducting normal technical specification surveillance of   |
| containment leak rate and determined that the personnel access airlock has   |
| failed the surveillance.  The plant commenced a technical specification      |
| required reactor shutdown to Mode 3 at 1611 EDT on 7/10/01.  The licensee    |
| will remain in Mode 3 until the airlock is repaired.                         |
|                                                                              |
| The licensee has notified the NRC Resident Inspector and the State of        |
| Connecticut.                                                                 |
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|Hospital                                         |Event Number:   38127       |
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| REP ORG:  ST. LUKES MEDICAL CENTER             |NOTIFICATION DATE: 07/10/2001|
|LICENSEE:  ST. LUKES MEDICAL CENTER             |NOTIFICATION TIME: 17:33[EDT]|
|    CITY:  MILWAUKEE                REGION:  3  |EVENT DATE:        07/10/2001|
|  COUNTY:                            STATE:  WI |EVENT TIME:        14:30[CDT]|
|LICENSE#:  48-01338-01           AGREEMENT:  N  |LAST UPDATE DATE:  07/10/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID HILLS          R3      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DOUGLAS SIMPKIN              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION INVOLVING TREATMENT TO WRONG SITE                  |
|                                                                              |
| There were 2 patients prepared for treatment with a gamma knife.  The wrong  |
| treatment package was used for the first patient.  There were 4 of 8 shots   |
| administered to the wrong site before it was discovered that the wrong       |
| package was being used.  The patient received approximately 13 gray over a   |
| short period to a small area.  The consequences of the exposure are not      |
| known at this time and are being investigated and the patient's progress     |
| will be followed for some time.  The patient received the correct treatment  |
| subsequently.  The attending physician has been notified and the patient     |
| will be informed tomorrow.                                                   |
|                                                                              |
| There is a review and evaluation of procedures on going to determine how to  |
| insure this event is not repeated.                                           |
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|Fuel Cycle Facility                              |Event Number:   38128       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 07/10/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 20:56[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        07/10/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:10[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/10/2001|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |DAVID HILLS          R3      |
|  DOCKET:  0707002                              |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC SPAETH                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 24 HOUR REPORT - NRC BULLETIN 91-01                                          |
|                                                                              |
| The following text is a portion of a facsimile received from  PORTSMOUTH:    |
|                                                                              |
| At 0910 on 07/10/2001 it was identified that control #5 of NCSA-0705_076.A03 |
| was not being maintained for two filter press plates covered in plastic.     |
| NCSA-0705_076.A03 requires that no inadvertent containers that could contain |
| greater than 2.5 liters of solution be permitted in any areas in which       |
| uranium bearing solution could be accumulated in the inadvertent container.  |
| The loose plastic wrapped on the filter press plates had the potential to    |
| deform into a container that would exceed the maximum criteria identified in |
| the NCSA. This constitutes a loss of one control (geometry) of the double    |
| contingency control principle identified in NCSA-0705_076.A03. No fissile    |
| material leaked in the area while the plastic wrap was present.              |
|                                                                              |
| NCSA-0705_076.A03 compliance was reported restored at 1010 hours.            |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
|                                                                              |
| The safety significance is low because at the time of the event there was no |
| uranium bearing material present that could leak into the inadvertent        |
| container. The area in question is designated an 'Inadvertent Container      |
| Area' due to the presence of the Complexing Hand table. However. the Hand    |
| table is not currently in operation. The next nearest fissile material       |
| operation is Microfiltration which is currently in operation, but is more    |
| than 15 feet from the location of the plastic wrap in question.              |
| Nevertheless, the presence of an inadvertent container at that location is a |
| violation of NCS controls and one leg of the double contingency principle    |
| described in NCSE-0705_076.E03.                                              |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR):                                                    |
|                                                                              |
| For a criticality to occur, the following events would be required: The      |
| complexing Hand table would have to be in operation and be processing        |
| uranium bearing liquid with an unknown or high concentration of uranium.     |
| Then a leak in this system must occur such that an unsafe amount of liquid   |
| sprays (presumably under pressure) from the Hand table system onto the       |
| plastic wrap in question. The liquid would then have to collect and deform   |
| the plastic wrap such that more than 2.5 liters collects to a depth greater  |
| than 1.5 inches forming an unsafe geometry.                                  |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| Inadvertent containers are controlled based upon volume (2.5 liters maximum) |
| or geometry (1.5 inches in depth or 4 inches in diameter. Flexible material  |
| (e.g., plastic wrap) is specifically controlled such that solution cannot    |
| pool to a depth grater than 1.5 inches,                                      |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF CRITICAL MASS):                                    |
|                                                                              |
| No uranium bearing material was involved in this event. There were no leaks  |
| of uranium bearing material in the area while the inadvertent container was  |
| present. The event involves the presence of an unsafe geometry container     |
| that could collect solution in the event of a spill.                         |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| Loose plastic wrap placed over filter press plates in an inadvertent         |
| Container Area was not configured or secured such that it cannot be deformed |
| into an inadvertent container with an unsafe accumulation potential. This is |
| a violation of control #5 of NCSA-0705_076.A03.  Use of Inadvertent          |
| Containers                                                                   |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
|                                                                              |
| Requirements of an NCS Anomalous condition entered. At the direction of an   |
| NCS engineer, the condition was corrected.                                   |
|                                                                              |
| Portsmouth personnel notified the NRC Resident Inspector.                    |
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