Event Notification Report for February 28, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/27/2002 - 02/28/2002
** EVENT NUMBERS **
38727 38728 38729 38730 38731 38732 38733
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|General Information or Other |Event Number: 38727 |
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| REP ORG: RI DEPT OF RADIOLOGICAL HEALTH |NOTIFICATION DATE: 02/27/2002|
|LICENSEE: RHODE ISLAND HOSPITAL |NOTIFICATION TIME: 09:47[EST]|
| CITY: PROVIDENCE REGION: 1 |EVENT DATE: 01/28/2002|
| COUNTY: PROVIDENCE STATE: RI |EVENT TIME: 15:00[EST]|
|LICENSE#: 7D-051-01 AGREEMENT: Y |LAST UPDATE DATE: 02/27/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES LINVILLE R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JACK FERRUOLO | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING POSSIBLE MISADMINISTRATION |
| |
| "Event description: Cordis Checkmate IVBT system was used to treat a |
| coronary artery on 1/28/02. On 1/31/02 dosimetry and physicist records were |
| being reviewed by licensee physics staff and it was discovered that the |
| 'diameter' of the vessel was used in the calculation instead of the |
| 'radius'. Agency was contacted by phone on 14 February 2002 to inform |
| Agency of possible misadministration. At this time the actual increase in |
| dose had not been determined. On 14 February 2002 the Agency was notified |
| by FAX that, in fact, a misadministration had occurred. Estimated dose |
| received by the outer portion of the coronary artery was 14.6 Gy rather than |
| the intended 8 Gy. Patient and physician were notified." |
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|Fuel Cycle Facility |Event Number: 38728 |
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| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION |NOTIFICATION DATE:
02/27/2002|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 11:59[EST]|
| COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 02/26/2002|
| COMMERCIAL LWR FUEL |EVENT TIME: 15:00[EST]|
| |LAST UPDATE DATE: 02/27/2002|
| CITY: COLUMBIA REGION: 2 +-----------------------------+
| COUNTY: RICHLAND STATE: SC |PERSON ORGANIZATION |
|LICENSE#: SNM-1107 AGREEMENT: Y |CAUDLE JULIAN R2 |
| DOCKET: 07001151 |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID WILLIAMS | |
| 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 INVOLVING A C4 DISSOLVER ACID WASH PUMPOUT
|
| (24-Hour Report) |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "Facility -- Westinghouse Electric Company, Commercial Fuel Fabrication |
| Facility, Columbia SC, low enriched (<=5.0 wt. % U-235) PWR fuel fabricator |
| for commercial light water reactors. License: SNM-1107." |
| |
| "Time and Date of Event -- Approx. 15:00 hours, Tuesday, February 26, |
| 2002." |
| |
| "Reason for Notification -- During an internal procedure review by |
| Operations, it was discovered that a current Process Information Form (PIF) |
| for flushing and pumping out the lines of the C4 dissolvers did not contain |
| all the required criticality controls. The operating procedure for pumpout |
| of UN product to non-favorable geometry bulk storage requires sampling for |
| grams U-235 per liter, pH, and % free acid. The PIF required only % free |
| acid." |
| |
| "Summary of Process -- During normal processing, uranium is recovered from |
| scrap materials in the favorable geometry C4 dissolvers system. The |
| resulting uranyl nitrate (UN) is sampled and released. It is then pumped |
| through gamma monitors, an active engineered control, to the non-favorable |
| geometry UN bulk storage tanks." |
| |
| "When needed for uranium accountability purposes, the C4 dissolver system |
| tanks are filled with water to the 40% level and then with water and acid to |
| the 43% level (approximately 102.3 gallons total) to flush the system." |
| |
| "As-Found Condition -- A summary of the as found conditions is as follows: |
| * The condition was found during an internal procedure review - not during |
| acid wash pumpout. |
| * The PIF was approved for use on February 14, 2002. |
| * The PIF required only sampling for free acid. |
| * The gamma monitors were functioning properly." |
| |
| "Double Contingency Protection -- Double contingency protection for this |
| situation is based on concentration control, that is (1) preventing |
| solutions with >10 grams U-235 per liter from being transferred into the UN |
| bulk storage tanks, and (2) detecting any increasing concentration of U-235 |
| in the tanks and taking corrective actions. It was determined, however, |
| that documented double contingency protection was lost because sampling for |
| pH was not required on the PIF. Double contingency protection was |
| immediately restored by withdrawing the PIF. Therefore, the incident |
| requires notification in accordance with Westinghouse Operating License |
| (SNM-1107), paragraph 3.7.3(c.5), in which less than previously documented |
| double contingency protection remains in an analyzed system, but less than |
| safe mass is involved." |
| |
| "Summary of Activity -- |
| * The PIF was immediately withdrawn. |
| * Immediate instructions were given to Operations to ensure that all |
| required sampling was performed. |
| * A causal analysis will be performed to determine corrective actions |
| needed to prevent recurrence." |
| |
| "Conclusions -- |
| * Loss of documented double contingency protection did occur, but was |
| immediately restored. |
| * At no time was criticality possible because the gamma monitors ensure |
| that the concentration remains <5 grams U-235 per liter. |
| * At no time was there any risk to the health or safety of any employee or |
| member of the public. No exposure to hazardous material was involved. |
| * It has been determined that this is a safety significant incident in |
| accordance with governing procedures. A root cause analysis will be |
| performed." |
| |
| The licensee notified the NRC Region 2 office (David Ayres) and NMSS (Dennis |
| Morey). |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
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|Other Nuclear Material |Event Number: 38729 |
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| REP ORG: UNIV OF MICHIGAN |NOTIFICATION DATE: 02/27/2002|
|LICENSEE: UNIV OF MICHIGAN |NOTIFICATION TIME: 12:00[EST]|
| CITY: ANN ARBOR REGION: 3 |EVENT DATE: 02/27/2002|
| COUNTY: WASHTENAW STATE: MI |EVENT TIME: 08:30[EST]|
|LICENSE#: 21-00215-04 AGREEMENT: N |LAST UPDATE DATE: 02/27/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHRISTINE LIPA R3 |
| |ALEXANDER ADAMS/PM NRR |
+------------------------------------------------+DON COOL NMSS |
| NRC NOTIFIED BY: MARK DRISCOLL |JOSEPH HOLONICH IRO |
| HQ OPS OFFICER: LEIGH TROCINE |IMOB Office via fax NMSS |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
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EVENT TEXT
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| 10 CFR PART 21 NOTIFICATION REGARDING FAILURE OF A J.L. SHEPHERD & |
| ASSOCIATES, MARK-1, MODEL-25, IRRADIATOR, DOOR INTERLOCK |
| |
| During the performance of a pre-operations inspection, an operator |
| discovered that an irradiator door interlock could be defeated and that the |
| door could be raised and expose the source. The irradiator involved is a |
| J.L. Shepherd & Associates, Mark 1, Model 25, irradiator which contains 780 |
| curies of cesium-137, and it is used for irradiating biological specimens. |
| |
| The university has been contacted. The licensee notified the NRC Region 3 |
| office (Darryl Weideman), and the licensee plans to notify the vendor. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
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|Power Reactor |Event Number: 38730 |
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| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 02/27/2002|
| UNIT: [] [] [3] STATE: CA |NOTIFICATION TIME: 14:54[EST]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 02/27/2002|
+------------------------------------------------+EVENT TIME: 10:43[PST]|
| NRC NOTIFIED BY: DOUG KNUDSON |LAST UPDATE DATE: 02/27/2002|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID GRAVES R4 |
|10 CFR SECTION: |TOM KOSHY NRR |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|JOSEPH HOLONICH IRO |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
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| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
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|3 A/R Y 100 Power Operation |0 Hot Standby |
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EVENT TEXT
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| AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO A LOSS OF OFFSITE POWER ON
UNIT 3 |
| DURING THE PERFORMANCE OF SWITCHYARD MAINTENANCE |
| |
| |
| Prior to this transient, the 220-kV, switchyard, section-B, west bus was |
| de-energized to facilitate the performance of maintenance activities. |
| During the performance of local breaker failure backup testing on the |
| switchyard, section-B, west bus; the switchyard section-B east bus tripped |
| at 1043 PST resulting in a loss of offsite power on Unit 3. The loss of |
| offsite power in turn caused a turbine trip/reactor trip signal to be |
| generated. All rods fully inserted. An emergency feedwater actuation |
| signal (EFAS) initiated as expected on steam generator shrinkage, and a |
| containment cooling actuation signal (CCAS) was manually initiated. The |
| loss of offsite power also resulted in a loss of all non-1E power. The |
| reactor coolant pumps remained running because their power supply |
| automatically transferred to Unit 2, and the Unit 3, 1E, 4-kV buses remained |
| energized from Unit 2. The emergency diesel generators automatically |
| started but did not load due to the automatic power supply transfers to Unit |
| 2. Preliminary indications revealed that the primary safety valves remained |
| closed. The licensee stated that all systems functioned as required and |
| that there was no impact on Unit 2. |
| |
| Unit 3 is currently stable in Hot Standby with emergency feedwater supplying |
| water to the steam generators and secondary steam being dumped to atmosphere |
| via the atmospheric dump valves (due to a loss of condenser vacuum). The |
| licensee reported that there was no steam generator tube leakage. |
| Containment parameters remain normal. |
| |
| The Unit 3 east and west switchyard buses have been re-energized, and all |
| non-1E power was restored to the 4-kV buses at 1120 PST. The emergency |
| diesel generators have been secured. The licensee currently plans to |
| perform secondary equipment inspections, and the event evaluation is |
| ongoing. |
| |
| The licensee notified the NRC resident inspector and may make a press |
| release. |
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|Other Nuclear Material |Event Number: 38731 |
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| REP ORG: CANBERRA INDUSTRIES, INC. |NOTIFICATION DATE: 02/27/2002|
|LICENSEE: CANBERRA INDUSTRIES, INC. |NOTIFICATION TIME: 15:13[EST]|
| CITY: WARRINGTON REGION: 1 |EVENT DATE: 01/28/2002|
| COUNTY: STATE: PA |EVENT TIME: 13:00[EST]|
|LICENSE#: 37-02401-01 AGREEMENT: N |LAST UPDATE DATE: 02/27/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES LINVILLE R1 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TERRY SCHWAGER | |
| HQ OPS OFFICER: MIKE NORRIS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
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EVENT TEXT
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| LOSS OF LICENSED NUCLEAR MATERIAL |
| |
| On 1/28/02 at 1300, it was discovered that 13 Cl-36 sources were missing. |
| The sources were 10 microcuries each and were manufactured on Nov 1995. The |
| sources were 1 inch diameter, flat disc with mylar window, and assembled |
| with an ion chamber instrument. Each source was individually packaged in a |
| 2ft x 1ft x 1ft cardboard box. The assemblies were packaged for shipment on |
| 1/28/02 and stored on a shelf prior to shipment. A clean up had been |
| performed recently and it is believed by the Licensee, that these materials |
| had been thrown into a waste dumpster for disposal. |
| |
| There was no detectable radiation levels on the shipping container, and it |
| is believed by the Licensee that there is no threat to the general |
| population. |
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|Power Reactor |Event Number: 38732 |
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| FACILITY: DAVIS BESSE REGION: 3 |NOTIFICATION DATE: 02/27/2002|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 15:42[EST]|
| RXTYPE: [1] B&W-R-LP |EVENT DATE: 02/27/2002|
+------------------------------------------------+EVENT TIME: 13:30[EST]|
| NRC NOTIFIED BY: DALE MILLER |LAST UPDATE DATE: 02/27/2002|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHRISTINE LIPA R3 |
|10 CFR SECTION: |TOM KOSHY NRR |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION |JOSEPH HOLONICH IRO |
|NBNL RESPONSE-BULLETIN | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
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EVENT TEXT
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| IDENTIFICATION OF AXIAL THROUGH-WELD INDICATIONS (REACTOR COOLANT
SYSTEM |
| PRESSURE BOUNDARY LEAKAGE) ON ONE CONTROL ROD DRIVE MECHANISM
NOZZLE |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "On February 26, 2002, following shutdown for a scheduled refueling outage, |
| the Davis-Besse Nuclear Power Station performed a qualified visual |
| examination of the Reactor Vessel head per NRC Bulletin 2001-01. This |
| examination revealed evidence of boric acid build up around Control Rod |
| Drive Mechanism (CRDM) nozzles but was inconclusive due to the previous |
| known boric acid deposits. At approximately 1330 hours on February 27, |
| 2002, Ultrasonic Testing (UT) data identified axial through weld indications |
| on one CRDM. Engineering evaluation of this data confirmed Reactor Coolant |
| System pressure boundary leakage exists. Technical Specification 3.4.6.2.a |
| states that Reactor Coolant System leakage shall be limited to no pressure |
| boundary leakage. As a result this is being reported as a non-emergency, |
| 8-hour report in accordance with 10CFR50.72(b)(3)(ii)(a), a condition that |
| resulted in the nuclear power plant, including its principal safety barriers |
| being seriously degraded." |
| |
| The licensee stated that UT inspections are continuing on other nozzles. |
| |
| The licensee plans to notify the NRC resident inspector. |
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|General Information or Other |Event Number: 38733 |
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| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE:
02/27/2002|
|LICENSEE: ACS ENGINEERING GROUP, CONSTRUCTION |NOTIFICATION TIME:
16:01[EST]|
| CITY: TEMPE REGION: 4 |EVENT DATE: 02/26/2002|
| COUNTY: STATE: AZ |EVENT TIME: [MST]|
|LICENSE#: 07-422 AGREEMENT: Y |LAST UPDATE DATE: 02/27/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: NRC REGION 4 | |
| 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 THE LOSS OF CONTROL AND RECOVERY
OF AN ACS |
| ENGINEERING GROUP, CONSTRUCTION, MOISTURE/DENSITY GAUGE IN TEMPE,
ARIZONA |
| |
| The following text is a portion of Preliminary Notification PNO-IV-02-013 |
| received from NRC Region 4: |
| |
| "On February 26, 2002, the Arizona Radiation Regulatory Agency (ARRA) |
| notified NRC Region IV by facsimile of the loss of control and recovery of a |
| portable gauge. The ARRA was informed by the Gilbert, Arizona fire |
| department on February 26, 2002, that a Troxler moisture/density gauge, |
| Model 2401 (Serial No. MD91 005368) containing a 370 megabecquerel (10 |
| millicurie) source of americium-241/beryllium and a 1.48 gigabecquerel (40 |
| millicurie) cesium-137 source had been recovered by a motorist that saw the |
| device fall off of a truck. The motorist picked up the gauge and turned it |
| into the local police department. ARRA determined that the truck was |
| operated by two employees of ACS Engineering Group, Construction, an Arizona |
| licensee. The gauge was not damaged. The licensee reclaimed the device on |
| February 26, 2002. ARRA will be investigating the event. Media interest |
| included reports by three local television stations." |
| |
| "Region IV received notification of this occurrence by facsimile from ARRA |
| at 2:35 p.m. (CT) on February 26, 2002. Region IV has informed OEDO, NMSS, |
| STP, and OPA." |
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Page Last Reviewed/Updated Wednesday, March 24, 2021