Event Notification Report for March 18, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/15/2002 - 03/18/2002
** EVENT NUMBERS **
38770 38771 38772 38773 38774 38775
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|Hospital |Event Number: 38770 |
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| REP ORG: FOX CHASE CANCER CENTER |NOTIFICATION DATE: 03/15/2002|
|LICENSEE: FOX CHASE CANCER CENTER |NOTIFICATION TIME: 10:23[EST]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 03/15/2002|
| COUNTY: STATE: PA |EVENT TIME: [EST]|
|LICENSE#: 37-02766-01 AGREEMENT: N |LAST UPDATE DATE: 03/15/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID LEW R1 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KAREN SHEEHAN | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|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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| P-32 SOURCE USED IN RESEARCH DISCOVERED MISSING |
| |
| The following preliminary information was provided by the licensee: |
| |
| "This is to inform you of an incident that occurred at our facility |
| involving a recent shipment of 250 microcuries of phosphorous-32 [P-32] |
| deoxyguanosine 5 triphosphate. The shipment was delivered to our facility |
| (License # 37-02766-01) on March 8, 2002 as an excepted package, limited |
| quantity [49 CFR173.421]. The package was delivered to the recipient lab and |
| the blue plastic container was placed in a freezer that was locked for |
| storage of the material. On March 11, 2002 when the freezer was unlocked and |
| the blue container was removed for use there was no vial of P-32 inside. The |
| lab worker immediately reported the situation to her Principal Investigator. |
| Initially the assumption was simply that the facility was shortchanged a |
| vial and indeed that is our conclusion after investigation of the incident. |
| The Radiation Safety Officer [RSO] was notified via e-mail at or about the |
| time the purchasing department was notified. |
| |
| "The RSO immediately began an investigation of the incident. It was |
| determined that the initial recipient did not follow the facilities |
| procedure for opening packages of radioactive material and failed to monitor |
| the surface of the package or look inside and verify the contents. The |
| shipper, Perkin Elmer, was notified and asked to investigate the matter. The |
| distribution coordinator at Perkin Elmer indicated that there might have |
| been other incidents where primary vials have been omitted from a shipment. |
| She declined to give further details until they finish their investigation. |
| The RSO was informed that each package is not routinely surveyed by Parker |
| Elmer even though an exposure rate was indicated on the packing slip. |
| |
| "Physical inventories of the laboratory concerned and an adjacent laboratory |
| were conducted and there were no discrepancies. Hospital security has been |
| notified and they are conducting an investigation. A radiation survey using |
| a Ludlum Model 3 survey meter with a 44-9 probe was performed of the lab in |
| question, as well as the tissue culture room where the material was stored, |
| and the Principal Investigator's Office. The shelves, drawers, cabinets, |
| sinks, trashcans were surveyed in these areas with no positive results. A |
| water cooler in the vicinity was swipe tested on the advice of our |
| consultant. The water cooler showed no evidence of P-32 contamination. All |
| the bottles next to the water cooler were also surveyed via a meter and no |
| levels were found. |
| |
| "The Principal Investigator [ ] was interviewed by the RSO. She indicated |
| that she was not aware of any personal conflicts within her lab nor any |
| other labs at the facility. She indicated that not only is their |
| radioactive material kept locked within a freezer dedicated to radioactive |
| materials storage, but that the tissue culture room is kept locked when not |
| in use. |
| |
| "Access to the building requires an access card and there is a record of all |
| personnel who entered the building during the period March 8-11. They are in |
| the process of interviewing those personnel on the list. |
| |
| "Shipping and Receiving was checked for other shipments from Perkin Elmer |
| but none were received on March 8. |
| |
| "We have completed the following corrective actions. A review of package |
| receipt procedures including survey of the package and inspection of the |
| primary vial was done with the personnel in the lab that received the |
| shipment. The lab in question also developed a procedure checklist that |
| includes not only the above but also the step of matching the lot number on |
| the vial with that on the shipping papers. A memo has been sent to all of |
| the other research labs reminding them of the procedures for receiving |
| packages include a survey of the surface of the package even though |
| regulations do not require that for an exempt quantity package and an email |
| send as urgent went to all research areas, Nuclear Medicine and Radiation |
| Oncology. A review of the incident and package receipt procedures will be |
| included in annual inservices and information conveyed during routine |
| inspections of radioactive materials laboratories. |
| |
| "We have concluded that the primary vial was probably not shipped, because |
| the material was secured within the building, the tissue culture room, and |
| within the freezer from the time delivered until the attempt to use it. No |
| evidence of any irregularity resulted from the investigations conducted by |
| the RSO and Security. But since we cannot rule out that the vial was shipped |
| we are notifying the Nuclear Regulatory Commission. Security has always been |
| a priority at Fox Chase Cancer Center and we are aware of the heightened |
| concerns due to the terrorist attacks of September 11". |
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|Fuel Cycle Facility |Event Number: 38771 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE:
03/15/2002|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 12:55[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 03/14/2002|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 15:00[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 03/15/2002|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |MONTE PHILLIPS R3 |
| DOCKET: 0707002 |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ERIC SPAETH | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
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EVENT TEXT
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| 24-HOUR NRC BULLETIN 91-01 REPORT |
| |
| "During Field-testing of the west annex floor, the floor failed to maintain |
| the solution in a safe slab by allowing water to seep in cracks along the |
| wall. This is a violation of NCSA- 0705_076 (inadvertent containers) |
| administrative controls on potential inadvertent containers. While an unsafe |
| amount of solution was NOT lost in this event, the cracks represent a loss |
| of one leg of double contingency control as defined in NCSE- 0705_076. |
| |
| "Background information: On March 6, a low level probe for the storage |
| columns in the West Annex developed a leak and allowed uranium-bearing |
| solution to accumulate on the floor. The amount of spilled solution on the |
| floor was estimated at that time to be no more than 18.4 liters. The spill |
| amount did not meet the definition of an unsafe amount of uranium bearing |
| material, the process conditions credited for meeting double contingency in |
| the NCSE's were maintained. |
| |
| "On March 14, after completing repairs to the low level probe, the solution |
| level in the West Annex storage columns was remeasured. The solution volume |
| lost, calculated from the system sight glasses was calculated to be |
| approximately 97.5 liters. Given the known assay and concentration of |
| uranium, the spilled solution still did not represent an unsafe amount of |
| uranium bearing material even when the volume was increased from 18.4 liters |
| to 97.5 liters. |
| |
| "On March 14, an NCS engineer and Operations personnel investigated the |
| difference between the amount of solution observed on the floor and the |
| amount estimated by the level of the sight glass. A field test was conducted |
| where as water was observed to seep into cracks between the floor and the |
| wall. |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: Low. The solution in question could not |
| support a criticality in any geometry. Less than a safe mass amount of |
| solution was involved. |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): |
| For a criticality to occur, the following events are required. The West |
| Annex blending system would have to be operating and processing solution |
| with a high concentration of uranium and assay. Then a leak would have to |
| occur such that an unsafe amount of solution would collect on the floor. The |
| solution would then flow into the cracks on the floor into an unsafe |
| geometry. Depending on the amount of solution collected some reflection |
| would be required to maintain a critical chain reaction. |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,
ETC.): |
| N/A. Volume or Geometry |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE
PROCESS |
| LIMIT AND % WORST CASE OF CRITICAL MASS): Based upon the amount of solution |
| that leaked on the floor, 51 grams U235. This represents 3% of the required |
| amount of solution |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND
DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: Cracks between the floor and the wall could |
| allow solution to enter an unknown unfavorable geometry in the event of a |
| spill. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS
IMPLEMENTED: |
| The PSS directed remaining in an anomalous condition until the repairs to |
| the cracks can be made." |
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|General Information or Other |Event Number: 38772 |
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| REP ORG: WV RADIOLOGICAL HEALTH PROGRAM |NOTIFICATION DATE:
03/15/2002|
|LICENSEE: WEIRTON MEDICAL CENTER |NOTIFICATION TIME: 17:37[EST]|
| CITY: WEIRTON REGION: 2 |EVENT DATE: 03/02/2002|
| COUNTY: STATE: WV |EVENT TIME: [EST]|
|LICENSE#: 47-17567-01 AGREEMENT: N |LAST UPDATE DATE: 03/15/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK LESSER R2 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAN HILL | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
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EVENT TEXT
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| COURTESY NOTIFICATION |
| |
| The West Virginia Radiological Health Program was notified by the Ohio |
| Bureau of Radiation Protection that a shipment of medical waste from the |
| Weirton Medical Center activated a radiation detector at the Stericycle |
| medical waste incineration facility in Ohio. The dose rate at the surface of |
| the package was greater than 500 microR/hr (as of 3/15/02, it was 200 |
| microR/hr). The incinerator facility is holding the package in a secure |
| location until the Weirton Medical Center is able to retrieve it. |
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|Power Reactor |Event Number: 38773 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 03/16/2002|
| UNIT: [1] [2] [] STATE: PA |NOTIFICATION TIME: 06:59[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/16/2002|
+------------------------------------------------+EVENT TIME: 02:40[EST]|
| NRC NOTIFIED BY: ROBERT BOESCH |LAST UPDATE DATE: 03/16/2002|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID LEW R1 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
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| | |
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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 |
|2 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| UNIT 2 ENTERED TS 3.0.3 AFTER DECLARING ESS BUSES INOPERABLE DUE TO
ERROR IN |
| CLEARANCE |
| |
| "On 3/16/02 at 0240 hours, a field operator was directed to remove a |
| clearance and rack in 4 Kv breakers for the Unit 1 A & B Control Rod Drive |
| system. The system had been out of service for maintenance during the refuel |
| outage. Upon arrival at the load center, the operator found both breakers |
| racked out but not secured with the required seismic restraints. According |
| to plant procedures, this renders the associated bus inoperable. Shift |
| supervision was notified and the Unit 1 'A' and 'D' ESS Busses were declared |
| inoperable. The immediate effects were for Unit 2 to enter TS 3.0.3 which |
| was exited 30 minutes later, once the breakers were returned to their |
| racked-in position. In review of the Loss of Safety Function, it was |
| discovered that, with the 'A' and 'D' ESS Busses inoperable, the Control |
| Structure chillers were inoperable resulting in an event or condition that |
| could have prevented fulfillment of a Safety Function required to Mitigate |
| the consequences of an accident. In accordance with 10CFR50.72(b)(3)(,v)(D) |
| this loss of safety function requires an 8 hour ENS Notification." |
| |
| The 4 Kv breakers were racked out 8 days ago. Due to an oversight in |
| preparation of the clearance, the procedure requiring installation of the |
| seismic restraints was not referenced. The licensee informed the NRC |
| Resident Inspector. |
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|Power Reactor |Event Number: 38774 |
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| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 03/16/2002|
| UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 13:55[EST]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 03/16/2002|
+------------------------------------------------+EVENT TIME: 12:15[CST]|
| NRC NOTIFIED BY: MICHAEL FITZPATRICK |LAST UPDATE DATE: 03/16/2002|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MONTE PHILLIPS 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
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| PLANT SHUTDOWN IN ACCORDANCE WITH TECHNICAL SPECIFICATIONS |
| |
| "This notification is being made pursuant to 10CFR50.72(b)(2)(i), and Exelon |
| Reportability Manual section SAF 1.2. At 1215 CST on 03/16/02, during Unit 2 |
| steady state operation at 100% power, a unit shutdown was initiated due to |
| an increase in Reactor Coolant System Unidentified Leakage in excess of |
| Technical Specification limits. RCS unidentified leakage has increased by |
| 2.1 gallons per minute over a 24 hour period, from 0.9 gpm to 3.0 gpm, which |
| is above the Tech Spec limit of less than or equal to 2 gpm. On 3/16/02 at |
| 0555 CST, a 12 hour timeclock was entered to be in Hot Shutdown by 1755 CST, |
| followed by Cold Shutdown on 3/17/02 at 1755 CST. Current plans are to enter |
| Cold Shutdown in order to enter the Primary Containment, and determine and |
| correct the cause of the unidentified leakage." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
| |
| * * * UPDATE 2214 EST 3/16/2002 FROM DANIEL COVEYOU TAKEN BY BOB STRANSKY *
|
| * * |
| |
| "This notification provides an update of EN #38774 and is being made |
| pursuant to 10CFR50.72(c)(2) and Exelon Reportability Manual section SAF |
| 1.2. |
| |
| "As of 1540 CST, the indicated increase in the Unit 2 unidentified leakage |
| rate over the previous 24 hr period has decreased to 1.7 gpm. As this value |
| meets the LCO requirements of LaSalle Technical Specification 3.4.5 (<2 gpm |
| increase within previous 24 hours), the plant shutdown initiated at 1215 CST |
| is no longer required. |
| |
| "The increase (and subsequent decrease) in the indicated unidentified |
| leakage rate is consistent with previously observed behaviors following |
| primary containment cooling equipment lineup changes that induce containment |
| air temperature changes. Initial chemistry analyses of the primary |
| containment environment (air and sump samples) indicate that there has been |
| no increase in reactor coolant system leakage. |
| |
| "The shutdown was terminated with the reactor operating at 69% power. |
| Current plans are to return the unit to full power operation." |
| |
| The NRC resident inspector has been informed of this update by the licensee. |
| Notified R3DO (Phillips). |
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|Power Reactor |Event Number: 38775 |
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 03/17/2002|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 17:03[EST]|
| RXTYPE: [1] CE |EVENT DATE: 03/17/2002|
+------------------------------------------------+EVENT TIME: 15:25[CST]|
| NRC NOTIFIED BY: ANTHONY CHRISTIANSON |LAST UPDATE DATE: 03/17/2002|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GAIL GOOD R4 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 98 Power Operation |98 Power Operation |
| | |
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EVENT TEXT
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| OFFSITE NOTIFICATION DUE TO BRUSH FIRE NEAR SITE |
| |
| The licensee contacted the local volunteer fire department to respond to two |
| small brush fires burning under the plant access road bridge. The fire |
| department responded at 1537 CST and both fires were extinguished by 1556 |
| CST. The licensee believes that the fires were caused by a passing train. |
| The NRC resident inspector has been informed of this event by the licensee. |
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