Event Notification Report for November 9, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/08/2001 - 11/09/2001
** EVENT NUMBERS **
38479 38480 38482 38483 38484 38485 38486
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38479 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/08/2001|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 10:39[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 11/08/2001|
+------------------------------------------------+EVENT TIME: 10:39[EST]|
| NRC NOTIFIED BY: KORTH |LAST UPDATE DATE: 11/08/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |R2 IRC TEAM MANAGER 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
+------------------------------------------------------------------------------+
| THE LICENSEE NOTIFIED THE STATE THAT TWO DEAD SEA TURTLES WERE
DISCOVERED IN |
| THE INTAKE CANAL |
| |
| At approximately 0800 on 11/8/01 two dead sea turtles(one green and one |
| loggerhead) were recovered from the licensee's intake canal. Pursuant to |
| the sea turtle permit, the Florida Department of Environmental |
| Protection(FDEP) was notified at approximately 0845. Both turtles |
| apparently drowned below the surface of the 5" mesh barrier net. The |
| carcasses will be turned over to the FWCC. |
| |
| The NRC Resident Inspector and the FDEP were notified. |
+------------------------------------------------------------------------------+
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38480 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/08/2001|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 14:00[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 11/08/2001|
+------------------------------------------------+EVENT TIME: 13:05[EST]|
| NRC NOTIFIED BY: JACK BREEN |LAST UPDATE DATE: 11/08/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |R2 IRC TEAM MANAGER 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 N 0 Hot Standby |0 Hot Standby |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE LICENSEE NOTIFIED THE STATE OF A DEAD SEA TURTLE DISCOVERED IN THE
|
| INTAKE CANAL |
| |
| "At approximately 1230, one dead sea turtle was recovered from the St. Lucie |
| Intake Canal. Pursuant to the sea turtle permit the Florida Department of |
| Environmental Protection (FDEP) was notified at 1305. The notification of |
| FDEP necessitates a four (4) hour non-emergency notification of [the] NRC |
| per 10CFR50.72(b)(2)(xi)." |
| |
| The licensee informed the State of Florida and will inform the NRC Resident |
| Inspector. |
| |
| HOO Note: See previous event #38479. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38482 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION DATE: 11/08/2001|
|LICENSEE: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION TIME: 16:05[EST]|
| CITY: PHILADELPHA REGION: 1 |EVENT DATE: 11/08/2001|
| COUNTY: STATE: PA |EVENT TIME: 15:15[EST]|
|LICENSE#: 37-00118-07 AGREEMENT: N |LAST UPDATE DATE: 11/08/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |R1 IRC TEAM MANAGER R1 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: FORREST | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE LICENSEE REPORTED A MEDICAL MISADMINISTRATION OCCURRED DURING
|
| THERAPEUTIC TREATMENT |
| |
| At approximately 2:45 pm on November 7, 2001, a physician, an authorized |
| user in Nuclear Medicine, began administration of a Y-90 therapeutic |
| radiopharmaceutical dose in accordance with the written directive for the |
| treatment. |
| |
| The administration system used a saline flush followed by an air flush to |
| administer the radiopharmaceutical. During the air flush at approximately |
| 3:15 pm, fluid was observed on the top of the second dose vial. To avoid |
| infusing a potentially non-sterile dose, the doctor stopped the dose |
| administration before the entire dose was infused. Based on post infusion |
| measurements of the dose vials, the patient received approximately 80 mCi |
| instead of the prescribed 120 mCi. |
| |
| The administrating physician informed the patient on November 7, 2001 that |
| because of the administration problem, the total prescribed dose was not |
| administered. The referring physician will be notified. |
| |
| There are no expected harmful effects as a result of this treatment. The |
| treatment protocol requires the subject to receive three separate 120 mCi |
| doses of the Y-90 radiopharmaceutical. This was the patient's second |
| treatment. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38483 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/08/2001|
| UNIT: [1] [] [] STATE: FL |NOTIFICATION TIME: 16:30[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 11/08/2001|
+------------------------------------------------+EVENT TIME: 12:40[EST]|
| NRC NOTIFIED BY: JIM TOTTON |LAST UPDATE DATE: 11/08/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |R2 IRC TEAM MANAGER R2 |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| INFORMATION REPORT INVOLVING A CONTROLLED PLANT SHUTDOWN FOR REPAIRS
|
| |
| "A controlled plant shutdown was performed due to a small (1 inch or less) |
| steam leak on 'B' main steam header. The leak originated from a 1 inch |
| drain line located upstream of the 'B' MSIV. The Unit was shutdown in |
| accordance with plant procedures. A plant cooldown to mode 5 is in progress |
| to affect repairs." |
| |
| The licensee informed the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38484 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: CONAM |NOTIFICATION DATE: 11/08/2001|
|LICENSEE: CONAM |NOTIFICATION TIME: 16:52[EST]|
| CITY: GLEN DALE HTS. REGION: 3 |EVENT DATE: 11/08/2001|
| COUNTY: STATE: IL |EVENT TIME: 09:35[CST]|
|LICENSE#: 12-16559-02 AGREEMENT: Y |LAST UPDATE DATE: 11/08/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |R3 IRC TEAM MANAGER R3 |
| |R1 IRC TEAM MANAGER R1 |
+------------------------------------------------+PATRICIA HOLAHAN NMSS |
| NRC NOTIFIED BY: SLACK | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
| | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE CONAM COMPANY REPORTED THAT ONE OF THEIR RADIOGRAPH CAMERAS HAD
A SOURCE |
| THAT BECAME STUCK |
| |
| An Iridium - 192 AEA model 660B radiography camera in use at the Sunoco |
| refinery at Gerard Pt. Philadelphia, Pa. had the source get stuck while the |
| licensee was retracting it into the camera. The source was moved in and out |
| of the camera a few times before it finally was fully retracted into the |
| camera. No one was overexposed and the camera will be returned to the |
| manufacturer for inspection and repair. They believe the cause was due to a |
| locking problem in the camera. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 38485 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE:
11/08/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 22:35[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 11/08/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 10:45[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 11/08/2001|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |R3 IRC TEAM MANAGER R3 |
| DOCKET: 0707002 | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KEITH VANDERPOOL | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|OCBA 76.120(c)(2) SAFETY EQUIPMENT FAILUR| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SAFETY SYSTEM DISCOVERED INOPERABLE DURING SURVEILLANCE TEST |
| |
| "At 1045 hours maintenance personnel identified the failure of the safety |
| system component in the X-760 building. During the scheduled TSR |
| surveillance, maintenance on the X-760 Criticality Accident Alarm System |
| (CAAS), maintenance personnel identified that the associated nitrogen horns |
| would not have functioned as designed. Post maintenance testing of the |
| associated nitrogen horn identified that the horns would not sound as |
| required due to a gross leak at the block manifold. Repairs and a |
| successful post maintenance test were completed under the direction of the |
| System Engineer. The Plant Shift Superintendent (PSS) has directed a random |
| check of the site CAAS facilities be conducted to ensure this condition does |
| not exist elsewhere. The X-760 CAAS remains inoperable pending the |
| completion of the requested engineering evaluation to address the gross leak |
| condition causing the safety system failure." |
| |
| Operations informed both the NRC Resident Inspector and the DOE Site |
| Representative. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38486 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 11/09/2001|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 01:08[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 11/08/2001|
+------------------------------------------------+EVENT TIME: 20:57[EST]|
| NRC NOTIFIED BY: RONALD GREEN |LAST UPDATE DATE: 11/09/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |R1 IRC TEAM MANAGER R1 |
|10 CFR SECTION: | |
|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
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R N 0 Startup |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP DURING UNIT STARTUP |
| |
| "During a reactor start up, BVPS Unit One Reactor tripped prior to reaching |
| criticality. The apparent cause of the trip is a blown control power fuse |
| on Intermediate Range Nuclear Instrument channel N36. The blown fuse caused |
| actuation of the Intermediate Range high level trip. All control rods fully |
| inserted. All equipment properly functioned. Unit One is presently in mode |
| three at normal temperature and pressure. Decay heat removal is through the |
| steam bypass valves to the main condenser as it was throughout the event. A |
| main feed pump is supplying feedwater through the bypass feedwater |
| regulating valves." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
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