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any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.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 September 24, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/21/2001 - 09/24/2001

                              ** EVENT NUMBERS **

38302  38303  38304  38305  38307  38308  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38302       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 09/21/2001|
|LICENSEE:  MEDI-PHYSICS INC., dba NYCOMED AMERSH|NOTIFICATION TIME: 15:30[EDT]|
|    CITY:  San Diego                REGION:  4  |EVENT DATE:        09/21/2001|
|  COUNTY:                            STATE:  CA |EVENT TIME:        11:00[PDT]|
|LICENSE#:  5796-37               AGREEMENT:  Y  |LAST UPDATE DATE:  09/21/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT GREGER                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING RAD CONTAMINATION DURING TRANSPORT          |
|                                                                              |
| "On August 24th at approximately 9:00 a.m. at the Medi-Physics facility      |
| located at 4877 Mercury Street.                                              |
|                                                                              |
| "A courier for Medi-Physics brought back some empty ammo containers from the |
| morning deliveries. The containers were wiped upon receipt and it was        |
| discovered that one of the containers had removable contamination on the top |
| of the container. From our phone conversation it appears that the level of   |
| removable contamination was approximately 300,000 DPM/ 100 cm2. The material |
| was identified as Technetium-99. Medi-Physics will be submitting a letter    |
| with the details to my attention. The RSO at the hospital was contacted and  |
| he completed a survey to check for contamination at their facility. It is    |
| not known at this time the results of that survey. The courier's feet and    |
| the pedals of the vehicle also showed elevated levels of contamination."     |
|                                                                              |
| This information was reported to the San Diego Office on 9/21/01 at          |
| approximately 1100PDT.  CA Event Report Identification XCA 85.               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38303       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  NV DIV OF RAD HEALTH                 |NOTIFICATION DATE: 09/21/2001|
|LICENSEE:  SUNRISE DIAGNOSTIC CENTER            |NOTIFICATION TIME: 17:25[EDT]|
|    CITY:  LAS VEGAS                REGION:  4  |EVENT DATE:        09/21/2001|
|  COUNTY:                            STATE:  NV |EVENT TIME:             [PDT]|
|LICENSE#:  03-12-0395-02         AGREEMENT:  Y  |LAST UPDATE DATE:  09/21/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN PELLET          R4      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STAN MARSHALL                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING POTENTIAL MEDICAL MISADMINISTRATION         |
|                                                                              |
| "Malfunction of Leksell Gamma Knife patient table. Possible                  |
| misadministration to patient. Licensee is preparing a written report with    |
| more detail, corrective action, etc.                                         |
|                                                                              |
| "Patient being treated in a Gamma Knife unit rolled up against the table and |
| table was unable to automatically retract from the Gamma Knife 'cave.'       |
| Licensee personnel were able to enter the room and manually remove the       |
| patient and table from the 'cave.'  Personnel exposure estimated to be       |
| between 3 mr and 20 mr.  Gamma Knife manufacturer (Leksell) has also been    |
| notified."                                                                   |
|                                                                              |
| Event Report ID No. NV-01-004.  Event location Las Vegas, NV.                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38304       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MCGUIRE                  REGION:  2  |NOTIFICATION DATE: 09/22/2001|
|    UNIT:  [1] [2] []                STATE:  NC |NOTIFICATION TIME: 03:48[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/22/2001|
+------------------------------------------------+EVENT TIME:        00:39[EDT]|
| NRC NOTIFIED BY:  ERIC WILKINSON               |LAST UPDATE DATE:  09/22/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES CASTO        R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO THE LOCAL AUTHORITIES DUE TO AN INCIDENT IN FRONT OF |
| THE PLANT                                                                    |
|                                                                              |
| The licensee's security department contacted the local police department     |
| about an incident just outside the plant at the highway entrance about a     |
| quarter mile from the protected area.                                        |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   38305       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 09/22/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 06:21[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        09/22/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        02:25[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  09/22/2001|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |JOHN MADERA          R3      |
|  DOCKET:  0707002                              |ERIC LEEDS           NMSS    |
+------------------------------------------------+RICHARD WESSMAN      IRO     |
| NRC NOTIFIED BY:  ERICK SPAETH                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 4 HOUR REPORT - NRC BULLETIN 91-01                                           |
|                                                                              |
| On 9/22/01 at 0225 hrs., operations personnel in the X-330 process building  |
| discovered that a UO2F2 deposit with "Greater Than Safe Mass" (GSM) was no   |
| longer being buffered with dry air or N2, to greater than or equal to 14     |
| psia. The deposit was located at 31-5, cell 6/8 drop. The buffer pressure    |
| had been monitored from an adjacent cell 31-5-8. Block valves marked as open |
| on a pin chart, were found to be closed, thus isolating the deposit from the |
| monitoring cell. The GSM deposit pressure was verified to be 5.81 psia with  |
| Maintenance and Test Equipment (M&TE).                                       |
|                                                                              |
| NCSA-0330_004.A06 requirement #8a states in part, "If there is a deposit     |
| greater than a safe mass for systems conditions in the equipment, the        |
| pressure in the equipment shall monitored each shift and if the pressure is  |
| less than 14 psia it shall be adjusted with dry air or N2 to greater than 14 |
| psia within 12 hours."                                                       |
|                                                                              |
| Buffer pressure was increased to greater than 14 psia at 0425 hours.         |
| Remaining areas of the plant with similar conditions were checked and        |
| verified to be compliant with the 14 psia Buffer pressure requirement.       |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
| MODERATE, in this event the equipment was potentially without a buffer for 5 |
| months which is insufficient time to allow enough water to enter the pipe    |
| and moderate the deposit to the level required to support a criticality.     |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR): Sufficient moderation must be added to a deposit   |
| at > safe mass to potentially create a critical configuration. This is       |
| highly dependent on geometry and reflection conditions.                      |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, FTC.):     |
| In this event, moderation is the only available control, and it was not      |
| maintained. Other parameters, like geometry and reflection, are assumed to   |
| be optimum.                                                                  |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF CRITICAL MASS):                                    |
| Worst case 1549 pounds U02F2 +/- 50% (max. 2323 pounds) at 2.26% based on    |
| available Non-Destructive analysis Measurements.  This mass is above the     |
| minimum critical mass (690 pounds U02F2 at optimum conditions) for this      |
| enrichment level.                                                            |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
| Moderation Control was not maintained for up to 5 months, change in system   |
| configuration unknowingly isolated the deposit from pressure monitoring      |
| point.                                                                       |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
| 0425 hours required buffer re-established, the valves involved were opened   |
| and tagged to remain open, verified remaining 4 like conditions were         |
| buffered as required. Investigation in progress.                             |
|                                                                              |
| The licensee notified the NRC Resident Inspector and the on-site DOE         |
| representative.                                                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38307       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATTS BAR                REGION:  2  |NOTIFICATION DATE: 09/23/2001|
|    UNIT:  [1] [] []                 STATE:  TN |NOTIFICATION TIME: 18:45[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/23/2001|
+------------------------------------------------+EVENT TIME:        18:34[EDT]|
| NRC NOTIFIED BY:  BEN HUNT                     |LAST UPDATE DATE:  09/23/2001|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRIAN BONSER         R2      |
|10 CFR SECTION:                                 |JOHN ZWOLINSKI       NRR     |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| CONDITION FOR AN UNUSUAL EVENT REPORTED BUT NOT DECLARED.                    |
|                                                                              |
|                                                                              |
| At 1755ET the sensing line to the "B" Centrifugal Charging Pump (CCP) local  |
| discharge pressure gage broke.  The operator noticed that the Volume Control |
| Tank level was decreasing, Reactor Coolant System Pressurizer level did not  |
| change, but the VCT low level alarm was never reached.  The leak was from    |
| the sensing line for "B" CCP local discharge pressure gage which is located  |
| in the Auxiliary Building.  The leak rate was determined to be approximately |
| 25 gpm by using the plant computer monitor to determine the rate of change   |
| of the  Volume Control Tank level.    All the water issuing from the sensing |
| line drained into the Auxiliary Building drain system which drained into the |
| radwaste system.  No release offsite.                                        |
|                                                                              |
| The licensee is not in any Limiting Condition of Operation at this time.     |
| "B" CCP  is fully operable because it's discharge pressure can be read from  |
| several locations, "A" CCP is fully operable.  All other emergency core      |
| cooling systems, emergency diesel generators are fully operable if needed.   |
| State and Local officials were notified of this event.                       |
|                                                                              |
| The time between 1801 hours and 1834 hours were used to determine the size   |
| of the leak from the Volume Control Tank.                                    |
|                                                                              |
| The NRC Resident Inspector will be notified of this event by the licensee.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38308       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 09/24/2001|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 05:55[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        09/24/2001|
+------------------------------------------------+EVENT TIME:        04:55[EDT]|
| NRC NOTIFIED BY:  LAURIE RAYLE                 |LAST UPDATE DATE:  09/24/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES LINVILLE       R1      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| LOSS OF PROMPT NOTIFICATION TONE ALERT RADIO FOR GREATER THAN 1 HOUR         |
|                                                                              |
| The licensee received a call at 0504 EDT from the Oswego County Warning      |
| Point that the Oswego County Prompt Notification Tone Alert Radio had been   |
| out-of-service for greater than 1 hour as of 0455 EDT.  The cause of the     |
| outage is unknown and is being investigated.                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+


Page Last Reviewed/Updated Thursday, March 25, 2021