The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

Event Notification Report for July 19, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/18/2001 - 07/19/2001

                              ** EVENT NUMBERS **

38148  38149  38150  38151  38152  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38148       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COMANCHE PEAK            REGION:  4  |NOTIFICATION DATE: 07/18/2001|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 10:42[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/18/2001|
+------------------------------------------------+EVENT TIME:        07:59[CDT]|
| NRC NOTIFIED BY:  RAUL MARTINEZ                |LAST UPDATE DATE:  07/18/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |WILLIAM JOHNSON      R4      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|AESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP ON TURBINE TRIP DURING RESTORATION OF AMSAC ALARM     |
|                                                                              |
| "During restoration of AMSAC [Accident Mitigation System Actuation           |
| Circuitry] to restore a trouble alarm, a spurious turbine trip signal was    |
| generated, causing a reactor trip from 100% power.  AFW [Auxiliary           |
| Feedwater] actuation followed the reactor trip and the MSIV's [Main Steam    |
| Isolation Vales] were closed for temperature control."                       |
|                                                                              |
| All control rods fully inserted.  Unit 2 is currently stable at normal       |
| operating pressure and temperature (NOP, NOT) using the Atmospheric Dumps    |
| and both motor-driven AFW pumps for decay heat removal.  There is no known   |
| primary-to-secondary tube leakage and samples confirm less than minimum      |
| detectable activity (less than MDA).  Operators are in the process of        |
| re-opening the MSIV's to place the main condenser back in service.           |
| All electrical buses remained energized throughout the event.                |
|                                                                              |
| The licensee notified the NRC resident inspector and does not plan a press   |
| release.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   38149       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 07/18/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 13:05[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        07/17/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:30[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/18/2001|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |BRUCE JORGENSEN      R3      |
|  DOCKET:  0707002                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SALYERS                      |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)        SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| HIGH PRESSURE FIRE WATER SPRINKLER SYSTEM DECLARED INOPERABLE                |
|                                                                              |
| On 7/17/01 at approximately 1530 hrs, the Plant Shift Superintendent (PSS)   |
| was notified that during a Fire Protection Engineering assessment/inspection |
| that High Pressure Fire Water (HPFW) sprinkler system #165 in the X-333      |
| Building contained five adjacent sprinkler heads with visible corrosion      |
| deposits.  Previous engineering reviews have concluded that the system under |
| this condition would not be capable of meeting the Technical Safety          |
| Requirements (TSR) to maintain operability.                                  |
|                                                                              |
| The PSS declared the affected sprinkler system inoperable and TSR required   |
| actions were implemented.                                                    |
|                                                                              |
| The NRC Resident Inspector was notified along with the DOE Representative.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38150       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MATHY CONSTRUCTION CO                |NOTIFICATION DATE: 07/18/2001|
|LICENSEE:  MATHY CONSTRUCTION CO                |NOTIFICATION TIME: 15:11[EDT]|
|    CITY:  ONALASKA                 REGION:  3  |EVENT DATE:        07/18/2001|
|  COUNTY:                            STATE:  WI |EVENT TIME:        12:00[CDT]|
|LICENSE#:  4818722-01            AGREEMENT:  N  |LAST UPDATE DATE:  07/18/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE JORGENSEN      R3      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DUKATZ                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE LICENSEE REPORTED THEIR TROXLER GAUGE WAS STOLEN                         |
|                                                                              |
| The licensee reported that a Troxler moisture density gauge model 3440       |
| serial #26689 containing 8 millicuries of Cs and 40 millicuries of Am/Be was |
| stolen from the back of a truck in Barabo, WI.  This occurred within 5-10    |
| minutes when the driver entered a store to use the bathroom and buy some     |
| ice.  The licensee will notify the local police and the State.               |
|                                                                              |
| * * * UPDATE ON 7/18/01 @ 1553 FROM DUKATZ TO GOULD * * *                    |
|                                                                              |
| The local police contacted the licensee @ 1550 to inform them the gauge was  |
| located.  There was no damage and the gauge was intact.  Licensee has sent a |
| technician to retrieve the gauge.                                            |
|                                                                              |
| Regon 3 (Darrel Wiedeman) and NMSS (Susan Frant) have been informed.         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38151       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/18/2001|
|LICENSEE:  BOLDER COMMUNITY HOSPITAL            |NOTIFICATION TIME: 15:30[EDT]|
|    CITY:  BOLDER                   REGION:  4  |EVENT DATE:        06/09/2001|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:  262-01                AGREEMENT:  Y  |LAST UPDATE DATE:  07/18/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID GRAVES         R4      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JACOBI (BY FAX)              |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT -  LEAKING SEALED SOURCE                              |
|                                                                              |
| The following is taken from a faxed report:                                  |
|                                                                              |
| "We have recently experienced an incident resulting in the compromising of   |
| the shielding around an Iodine-125 prostate implant seed (sealed source).    |
| This report is filed per the requirements of RH 458                          |
|                                                                              |
| "On June 5, 2001, during the course of an I-125 seed implant of a patient's  |
| prostate gland an Iodine-125 seed which was thought to have been implanted   |
| was instead withdrawn with the implant plunger back into a position partly   |
| in the implant applicator and partly in the seed cartridge. This seed        |
| position will not allow the cartridge to be removed normally from the        |
| implant applicator.  A GM counter (thin end window) survey was performed     |
| over that section of the implant applicator but the presence of the seed was |
| not detected. The cartridge was then forcefully removed from the applicator. |
| The applicator was rinsed into a stainless steel basin to remove blood clots |
| that were present.  The routine survey at the end of the procedure indicated |
| that a seed was present in this washbasin.   A bent seed was found in a      |
| blood clot.  When the seed was removed from the basin, a survey of the basin |
| indicated that the water was also contaminated.   It was concluded that the  |
| shielding around the seed had been compromised.                              |
|                                                                              |
| "The contents of the rinse basin were poured into a plastic container that   |
| could be sealed.  All equipment, which had come in contact with the seeds,   |
| was surveyed and cleaned until wipe tests demonstrated that removable        |
| contamination had been reduced to less than 200 dpm.  The sealed plastic     |
| container containing the contaminated liquid, and all of the cleaning        |
| materials were placed in our long-term waste storage facility for decay.     |
| Absorbent material was added to this container on July 11th to soak up any   |
| remaining liquid and eliminate any potential spill hazard over the two years |
| (10 half-lives) this container will be in storage.                           |
|                                                                              |
| "The two individuals most closely involved in extracting the seed cartridge  |
| and performing the cleanup were given thyroid bioassay exams in the week     |
| immediately following the incident.  Those exams were negative. The patient  |
| was given the same exam approximately one month following the procedure that |
| indicated an uptake of 0.2 � 0.09 �Ci corrected to the day of the implant.   |
| If this uptake is real and not the result of radiation scatter from his      |
| active prostate seed implant (87 seeds, 22.3 mCi on the day of the thyroid   |
| scan), this would result in a radiation dose to the thyroid of not more that |
| 0.8 cGy. This radiation dose has no clinical significance.                   |
|                                                                              |
| "Corrective Actions: This incident occurred because the applicator plunger,  |
| which most likely had a blood clot adhering at the point normally in contact |
| with the iodine-125 seed, extracted the seed previously pushed into the      |
| prostate gland.  The seed, believed to have been implanted, instead came to  |
| rest across the space between the applicator body and the seed cartridge. A  |
| GM survey of the applicator body and cartridge combination failed to detect  |
| the presence of the seed. The seed was damaged when the cartridge was        |
| forcefully withdrawn.                                                        |
|                                                                              |
| "This incident could have been averted using the following procedure:        |
|                                                                              |
| 1. Assume that any cartridge jam is caused by an unaccounted for I-125       |
| seed.                                                                        |
| 2. Remove the implant needle from the applicator body. (If there is believed |
| to be only one seed involved in the jam, the applicator body may be surveyed |
| by directing the sensitive portion of the GM detector down the barrel of the |
| applicator previously occupied by the implant needle.  The GM detector may   |
| not be sensitive enough to detect radiation though the sides of the          |
| applicator body.)                                                            |
| 3. Place the body of the applicator with the cartridge still in place, into  |
| the rinse pan.                                                               |
| 4. Advance the plunger slowly through the seed cartridge until the seed is   |
| visible and can be rinsed away from the body of the applicator. (This may    |
| requite lifting the cartridge plunger to allow the applicator plunger past   |
| such that it can traverse the full extent of the cartridge.)  If the         |
| cartridge is not empty the seed causing the jam will be pushed out by        |
| another seed so two seeds will deposit in the rinse basin.                   |
| 5. Withdraw the applicator plunger completely and remove the seed cartridge  |
| normally.                                                                    |
| 6. NEVER forcefully remove a seed cartridge!                                 |
|                                                                              |
| "All individuals involved In this incident have reviewed this procedure."    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38152       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 07/19/2001|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 05:16[EDT]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        07/19/2001|
+------------------------------------------------+EVENT TIME:        03:00[CDT]|
| NRC NOTIFIED BY:  RYAN RODE                    |LAST UPDATE DATE:  07/19/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRUCE JORGENSEN      R3      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |90       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                  
+------------------------------------------------------------------------------+
| TECH SPEC REQUIRED SHUTDOWN DUE TO TIME LIMIT ON NON-SAFETY POWER TO         |
| INSTRUMENT BUS                                                               |
|                                                                              |
| The licensee entered Technical Specification 15.3.7(b)(1)(j) at 1900 CDT on  |
| 7/18/2001, which allowed 8 hours to restore electrical power from a safety   |
| powered bus to the Unit 1 instrument bus.  Non-safety power was provided     |
| when a problem caused an automatic transfer.  At 0300 CDT on 7/19/2001 a     |
| Technical Specification required shutdown was commenced.  The plant has 6    |
| hours to reach Hot Shutdown and another 44 hours to reach Cold Shutdown.     |
| The licensee has been and continues to research the problem and does not     |
| know when safety power will be restored to the instrument bus.               |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

Page Last Reviewed/Updated Thursday, March 25, 2021