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 |
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| NRC NOTIFIED BY: W. F. CAGE | |
| HQ OPS OFFICER: LEIGH TROCINE | |
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|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 | |
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| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
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|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 |
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| NRC NOTIFIED BY: DOUGLAS SIMPKIN | |
| HQ OPS OFFICER: FANGIE JONES | |
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|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 |
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| 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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