Event Notification Report for December 3, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/30/2001 - 12/03/2001
** EVENT NUMBERS **
38520 38525 38526 38527 38528 38529 38530 38531 38532
.
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|General Information or Other |Event Number: 38520 |
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| REP ORG: TENNESSEE DIV OF RAD HEALTH |NOTIFICATION DATE: 11/28/2001|
|LICENSEE: TRI-STATE TESTING AND DRILLING, INC. |NOTIFICATION TIME: 11:50[EST]|
| CITY: CHATTANOOGA REGION: 2 |EVENT DATE: 11/28/2001|
| COUNTY: STATE: TN |EVENT TIME: 06:00[EST]|
|LICENSE#: R-33105 AGREEMENT: Y |LAST UPDATE DATE: 11/28/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |EDWARD MCALPINE R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DEBRA SHULTS (fax) | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT REGARDING A TRI-STATE TESTING AND DRILLING, INC.
|
| TROXLER MOISTURE DENSITY GAUGE STOLEN IN CHATTANOOGA, TENNESSEE
|
| |
| The following text is a portion of a facsimile received from the State of |
| Tennessee, Department of Environment and Conservation, Division of |
| Radiological Health: |
| |
| "Event Report ID No.: TN-01-217" |
| |
| "License Number: R-33105" |
| |
| "Licensee: Tri-State Testing and Drilling, Inc." |
| |
| "Event date and time: November 28, 2001, approx. 0600 EST" |
| |
| "Event location: Chattanooga, TN" |
| |
| "Event type: Stolen moisture density gauge" |
| |
| "Notifications: Tennessee Emergency Management Agency, USNRC Region II, |
| Alabama Office of Radiation Control, Georgia Radioactive Materials Program, |
| Chattanooga Police Department" |
| |
| "Media interest: None at this time. A press release is being issued by |
| TDEC." |
| |
| "Event description: Tri-State Testing and Drilling, Inc. reported a Troxler |
| moisture density gauge, Model 3440, SN 17252, containing 8 millicuries of |
| Cesium-137 and 40 millicuries of Americium-241:Beryllium, was stolen from |
| the bed of a pickup truck early this morning. The gauge was chained in the |
| back of the truck parked at an employees residence. Thieves cut the chain |
| and removed the locked container. State DRH inspectors are onsite |
| investigating at this time." |
| |
| (Call the NRC operations officer for contact information.) |
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|Power Reactor |Event Number: 38525 |
+------------------------------------------------------------------------------+
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| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 11/29/2001|
| UNIT: [1] [2] [] STATE: WI |NOTIFICATION TIME: 18:07[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 11/29/2001|
+------------------------------------------------+EVENT TIME: 15:38[CST]|
| NRC NOTIFIED BY: MEYER |LAST UPDATE DATE: 11/30/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
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EVENT TEXT
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| A LOSS OF INSTRUMENT AIR MAY CAUSE A POTENTIAL COMMON MODE FAILURE FOR
ALL |
| AUXILIARY FEEDWATER PUMPS. |
| |
| Instrument Air (IA) can be lost primarily by two failure mechanisms. The |
| first, and most likely, is a loss of off-site power where the IA and Service |
| Air (SA) compressors are stripped from the bus and not automatically |
| re-loaded. The second less likely scenario is a random loss of the |
| instrument air system due to equipment failure without potential for short |
| term recovery. When IA is lost, the minimum flow recirculation valves for |
| AFW fail closed. |
| |
| During these two transients, the AFW pumps will start injecting into the |
| steam generators. Early in the EOP's, the operator is directed to control |
| flow to the steam generators to maintain desired level. This may include |
| shutting off flow to one or both steam generators if level is above the |
| desired band. If flow from any auxiliary feed pump is reduced too low (as |
| would occur if the auxiliary feed regulating valves are closed) without |
| functional recirculation valves, the pump will fail in a very short period |
| of time. This common mode of failure (common loss of instrument air and |
| common response to high steam generator level) could result in simultaneous |
| failure of all AFW pumps. |
| |
| The Auxiliary Feedwater system has passed all required testing and is |
| currently fully operable and capable of performing its safety function. It |
| is only under the specific circumstances outlined above that a failure of |
| Auxiliary Feedwater may occur. The licensee is taking interim corrective |
| actions in the form of Operating Crew briefs to ensure Auxiliary Feedwater |
| is not damaged under Loss of Air conditions and is evaluating procedural and |
| equipment design changes to provide a permanent correction to Aux. |
| Feedwater. |
| |
| The NRC Resident Inspector will be notified. |
| |
| |
| * * * UPDATE ON 11/30/01 @ 1849 BY RAASCH TO GOULD * * * |
| |
| The purpose of this supplement is to clarify the discussion of the potential |
| failure of one or more Auxiliary Feedwater (AFW) pumps as described in Event |
| Notification #38525. The potential failure is limited to only the minimum |
| recirculation flow control valves for the AFW pumps. These recirculation |
| valves function automatically to provide recirculation flow during periods |
| of low Steam Generator (SG) demand from the AFW pumps. This potential |
| failure mode would manifest itself during a loss of offsite power, with an |
| attendant loss of instrument air, if the operator, while reducing AFW flow |
| to a SG after satisfactory initial filling, fails to recognize that the |
| recirculation valves do not open while reducing AFW flow to the steam |
| generators. This action would have to be done individually to each of the |
| running AFW pumps for multiple failures to occur. |
| |
| The air operated valves for controlling AFW pump output flowrate are |
| safety-related and are not susceptible to this condition since the |
| instrument air supply to these valves is backed up by a safety-related |
| Nitrogen backup system. These valves would continue to be capable of |
| supplying and controlling the required AFW flow to the steamgenerators. |
| |
| As an interim corrective action, operating personnel were provided a |
| briefing on this potential failure mechanism to ensure the AFW pumps are not |
| damaged under a Loss of Instrument Air condition. Additionally, temporary |
| information tags have been hung to ensure continued awareness until an |
| evaluation of potential procedural and equipment design changes can be |
| completed. |
| |
| The NRC Resident Inspector was notified. |
| |
| The Reg 3 RDO(Jorgensen) was informed. |
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.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38526 |
+------------------------------------------------------------------------------+
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 11/30/2001|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 10:37[EST]|
| RXTYPE: [1] CE |EVENT DATE: 11/29/2001|
+------------------------------------------------+EVENT TIME: 13:00[CST]|
| NRC NOTIFIED BY: ERICK MATZKE |LAST UPDATE DATE: 11/30/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WILLIAM JOHNSON R4 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
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| FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED EMPLOYEE'S USE OF A
|
| CONTROLLED SUBSTANCE |
| |
| A non-licensed employee (supervisor) was determined to be under the |
| influence of a controlled substance. The employee's access to the plant has |
| been terminated. Contact the Headquarters Operations Officer for additional |
| details. The licensee will inform the NRC resident inspector. |
+------------------------------------------------------------------------------+
.
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|Hospital |Event Number: 38527 |
+------------------------------------------------------------------------------+
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| REP ORG: GENESYS REGIONAL MEDICAL CENTER |NOTIFICATION DATE:
11/30/2001|
|LICENSEE: GENESYS REGIONAL MEDICAL CENTER |NOTIFICATION TIME:
12:03[EST]|
| CITY: GRAND BLANC REGION: 3 |EVENT DATE: 11/30/2001|
| COUNTY: STATE: MI |EVENT TIME: 09:30[EST]|
|LICENSE#: 21-26740-01 AGREEMENT: N |LAST UPDATE DATE: 11/30/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE JORGENSEN R3 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: FREDERICK | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAA2 20.1906(d)(2) EXTERNAL RAD LEVELS > | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INCORRECT SHIPPING PACKAGE USED FOR SHIPPING I-133 TO THE MEDICAL
FACILITY |
| |
| The Genesys Regional Medical Center received a shipment of 156 millicuries |
| of I-133 from Syncor International in Flint, Mi. that was packaged in a |
| Yellow - 2 package. Yellow - 2 packages have a 50 mr/hr limit for |
| transporting radiological materials. Syncor had monitored the shipment as |
| 80 mr/hr and the medical facility monitored it at 100 mr/hr. Therefore, it |
| should have been shipped in another type of package(possibly a Yellow - 3). |
| There was no contamination measured. Syncor was notified of this error by |
| the medical center. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38528 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE:
11/30/2001|
|LICENSEE: UNIVERSITY OF CALIFORNIA AT SAN DIEGO|NOTIFICATION TIME:
12:48[EST]|
| CITY: SAN DIEGO REGION: 4 |EVENT DATE: 11/28/2001|
| COUNTY: STATE: CA |EVENT TIME: 11:00[PST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 11/30/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT GREGER | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - LOST SOURCE |
| |
| A patient receiving palliative treatment for lung cancer had six seeds |
| implanted in the lungs. Each seed contained 0.4 mCi of I-125. After about |
| 2 hours, an x-ray of the lungs was performed to verify positioning of the |
| seeds and 3 of the seeds were missing. A search/survey of the area did not |
| find the missing seeds. It is unknown where the seeds are, it is possible |
| the patient coughed up the seeds and swallowed them. The patient was |
| released later that day. There is minimal threat to any member of the |
| public. |
| |
| California Radiation Control Program office contacted NRC State Programs |
| (Pat Larkin). |
+------------------------------------------------------------------------------+
.+-----------------------------------------------------------------------------+
|Hospital |Event Number: 38529 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
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| REP ORG: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION DATE: 11/30/2001|
|LICENSEE: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION TIME: 14:28[EST]|
| CITY: ROYAL OAKS REGION: 3 |EVENT DATE: 11/29/2001|
| COUNTY: STATE: MI |EVENT TIME: 17:00[EST]|
|LICENSE#: 210133301 AGREEMENT: N |LAST UPDATE DATE: 11/30/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE JORGENSEN R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SCHULTZ | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION AT THE WILLIAM BEAUMONT HOSPITAL |
| |
| A patient was prescribed a total dose of 2,800 centigrays of Ir - 192 given |
| in seven fractions for treatment of recurring cancer. However, the standard |
| fraction dose for 7 fractions @ 500 centigrays/fractions was administered |
| resulting in a total dose of 3,500 centigrays. This misadministration |
| resulted when the authorizing physician initially prescribed seven standard |
| fraction doses(500 centigrays/fraction), but then changed his mind and |
| prescribed seven fractions @ 400 centigrays/fraction which would have |
| resulted in the total prescribed dose of 2,800 centigrays. These treatments |
| took place between 09/27/01 and 11/02/09, but the mistake was not discovered |
| until 11/20/01 @ 1700 during an audit. The error was made when the |
| authorizing physicist did not transcribe from the treatment plan onto the |
| worksheet the correct information used to program the HDR device and put in |
| the 500 centigrays instead of the 400 centigrays. The patient and the |
| referring physician were notified. No adverse affects to the patient are |
| expected. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38530 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE:
11/30/2001|
|LICENSEE: WEYERHAEUSER TECHNOLOGY CENTER |NOTIFICATION TIME:
14:32[EST]|
| CITY: FEDERAL WAY REGION: 4 |EVENT DATE: 11/29/2001|
| COUNTY: STATE: WA |EVENT TIME: [PST]|
|LICENSE#: WN-L083-1 AGREEMENT: Y |LAST UPDATE DATE: 11/30/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: FRAZEE (FAX) | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LEAKING PROMETHIUM SOURCE AT WEYERHAEUSER TECH CENTER |
| |
| The licensee provided notification to the State of Washington that leakage |
| was discovered when a 3 millicurie Promethium-147 source was about to be |
| re-installed in an AMBERTEC Oy model BET- 1 formation tester. At this time |
| it appears that the radioactive source was removed from the formation tester |
| by licensee personnel in mid 1999. The source was placed into a storage |
| container kept under the licensee's control. The un-sourced device was |
| subsequently shipped to the manufacturer in Finland for repair. The device |
| was recently returned to the licensee facility. A Finnish technician |
| accompanying the device tested the source prior to installation and |
| discovered contamination on the source and in the storage container. No |
| contamination was detected on the outside of the container, in the storage |
| location or at the work bench where the device is presumed to have been |
| disassembled two years ago. Other details are unclear at this time and a |
| Division of Radiation Protection staff will be on-site today to investigate. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38531 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 12/02/2001|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 18:17[EST]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 12/02/2001|
+------------------------------------------------+EVENT TIME: 14:48[EST]|
| NRC NOTIFIED BY: RESTUCCIO |LAST UPDATE DATE: 12/02/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WILLIAM RULAND R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 75 Power Operation |0 HotShutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MANUAL REACTOR SCRAM FROM 75% POWER |
| |
| On December 2, 2001 at 1448, Unit 2 manually scrammed from approximately |
| 75% reactor power due to a low water level trip (159.3" - Level 3). |
| Preliminary indications are an electrical fault/trip on feedwater Pump "A" |
| was the cause of the reactor low level condition. The "A" Recirculation |
| Flow Control Valve (FCV) ran back to minimum position as required on the low |
| level alarm at 178.3" - Level 4. The "B" FCV failed to fully run back as |
| required due to the electrical transient and the subsequent loss of |
| hydraulic control units. The "B" FCV stabilized at 50% open. The |
| Operators were inserting cram rods in an attempt to lower power further when |
| the low water level trip alarm came in for Division 1. The Control Room |
| Supervisor (CRS) ordered the mode switch to shutdown. All Control Rods |
| inserted as required. Reactor water level is being controlled in the normal |
| level band with Condensate Booster pumps. Reactor pressure is being reduced |
| to place the shutdown cooling system in service by the use of the turbine |
| bypass valves. |
| |
| Additionally, indications show that the Neutron Monitoring System (NMS) |
| scram setpoints were exceeded for the Average Power Range Monitoring (APRM) |
| thermal power trip. This trip signal was in close sequence to the mode |
| switch being placed in the shutdown position. |
| |
| The NRC Resident Inspector was notified. |
| |
| |
| HOO NOTE: see event # 38532 |
+------------------------------------------------------------------------------+
.+-----------------------------------------------------------------------------+
|Power Reactor |Event Number: 38532 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 12/02/2001|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 20:40[EST]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 12/02/2001|
+------------------------------------------------+EVENT TIME: 17:21[EST]|
| NRC NOTIFIED BY: PETRELLI |LAST UPDATE DATE: 12/02/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WILLIAM RULAND 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
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A N 0 Hot Shutdown |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT RECEIVED A SECOND SCRAM WHILE IN MODE 3 |
| |
| Following the manual scram at 1448 the plant had a second scram at 1721 |
| which was an automatic scram on low water level (Level 3 - 159.3") when |
| lowering reactor pressure to inject with the booster pumps at 1721. The |
| scram was reset and plant shutdown and cooldown is continuing. |
| |
| The NRC Resident Inspector was notified. |
| |
| HOO NOTE: see event #38531 |
+------------------------------------------------------------------------------+
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