Event Notification Report for May 6, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/03/2002 - 05/06/2002
** EVENT NUMBERS **
38883 38884 38895 38896 38897 38898 38899 38900
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|General Information or Other |Event Number: 38883 |
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| REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: TULANE UNIVERSITY |NOTIFICATION TIME: 11:03[EDT]|
| CITY: NEW ORLEANS REGION: 4 |EVENT DATE: 04/22/2002|
| COUNTY: STATE: LA |EVENT TIME: 10:25[CDT]|
|LICENSE#: LA-0004-L01 AGREEMENT: Y |LAST UPDATE DATE: 04/30/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SCOTT BLACKWELL | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| The following event description is taken from a facsimile: |
| |
| "On April 22, 2002, the technologist injected a patient with a syringe |
| labeled Tc-99m MAG 3 in order to image the kidneys. The gamma camera showed |
| uptake in the liver-kidney indicating a sulfur colloid dose. The patient was |
| prescribed a 4.5 mCi dose of Tc-99m MAG 3, but received a 4.5 mCi dose of |
| Tc-99m Sulfur Colloid. The patient and the pharmacy were notified of the |
| error. The dose for a patient receiving 5 mCi of Tc-99m Sulfur Colloid is |
| estimated as the following: Liver - 12.15 Rad, Spleen - 7.65 Rad, Bone |
| Marrow - 0.05 Rad, Testes - 0.02 Rad, Ovaries - 0.2 Rad, and Total Body - |
| 0.675 Rad." |
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|General Information or Other |Event Number: 38884 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: LONGVIEW INSPECTION |NOTIFICATION TIME: 15:05[EDT]|
| CITY: CHANNAHON REGION: 3 |EVENT DATE: 06/01/2000|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 04/30/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+PAUL LOHAUS STP |
| NRC NOTIFIED BY: JOSEPH KLINGER |TIM MCGINTY IRO |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|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 OF RADIOGRAPHER OVEREXPOSURE FROM TWO
YEARS AGO |
| |
| "On April 29, 2002, the department completed its investigation into a |
| reported radiography incident that may have occurred in June 2000. After a |
| review of all available information, the department cannot definitively |
| eliminate the possibility that an industrial radiographer received a |
| radiation burn while performing industrial radiography at a temporary |
| jobsite near Channahon, Illinois. The radiographer was using an 81.2 Ci |
| lr-192 source while performing radiographs on 8-inch pipe welds. The |
| radiographer alleges that after cranking the source back in, he approached |
| the area without looking at his survey meter. He set the meter behind the |
| camera and knelt down in front of the camera, He changed out the film and |
| then changed out the band and numbers for the next shot. He then |
| disconnected the guide tube and saw 4-6 inches of the drive cable. He looked |
| over at the survey meter and saw that it was pegged. He then immediately |
| went to the controls and cranked the source fully into the camera. He |
| performed a survey of the area and saw that the source was shielded |
| properly. He looked at his alarming rate meter and saw that the battery |
| indicator showed low battery. His self-reading pocket dosimeter showed |
| off-scale. What happened after that is even more unclear but the |
| radiographer continued working for the rest of the day. The radiographer did |
| not report the incident to the RSO nor did the other radiographer on the two |
| certified radiographer team. In fact, the other radiographer denies knowing |
| anything about the reported incident. The allegedly overexposed radiographer |
| states that after one or two weeks, he noticed a red area, about the size of |
| a nickel, on his leg. He stated that it was a red area with what appeared to |
| be white scar tissue in the center. It was not until May or June of 2001 |
| that he realized that it may have been a radiation burn. During August or |
| September 2001 his condition apparently worsened and the area would not |
| heal. In early January 2002 the Radiation Safety Officer finally became |
| aware of this matter, and notified the department on January 15, 2002. In |
| early January 2002 the radiographer was apparently examined by a physician. |
| The radiographer stated that the physician took a biopsy and the diagnosis |
| was either sarcoma or radiodermatitis. A preliminary report was provided to |
| the department by the licensee on January 16, 2002. The department |
| recommended the licensee seek assistance from the REAC/TS Center in Oak |
| Ridge, which they did. The information pertaining to this incident was |
| provided to REAC/TS by the licensee and REAC/TS concluded that the medical |
| condition could be attributed to the event in June 2000. After thoroughly |
| reviewing all the information available and scheduling interviews for |
| involved out of state personnel, the department conducted interviews and |
| time in motion studies on February 25, 2002. Subsequent to the interviews |
| and time in motion studies, careful review was performed as well as |
| additional clarifying information was requested and reviewed. Finally on |
| April 29, 2002, the department concluded that it could not definitively |
| eliminate the possibility that this industrial radiographer received a |
| radiation burn while performing industrial radiography at a temporary job |
| site near Channahon, Illinois in June 2000. The radiographer underwent skin |
| grafting on February 26, 2002, and was released after several days. The |
| radiographer currently remains under medical surveillance and reports that |
| the graft was less than successful. The licensee has been issued a Notice of |
| Violation and will take appropriate actions to prevent a recurrence. The |
| radiographer may be subject to additional department enforcement action |
| related to his industrial radiographer certification resulting from this |
| event." |
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|Power Reactor |Event Number: 38895 |
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| FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 05/03/2002|
| UNIT: [1] [] [] STATE: AL |NOTIFICATION TIME: 14:42[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/03/2002|
+------------------------------------------------+EVENT TIME: 13:21[CDT]|
| NRC NOTIFIED BY: DANA WHITE |LAST UPDATE DATE: 05/03/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RUDOLPH BERNHARD R2 |
|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
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| AUTOMATIC REACTOR TRIP DUE TO INDICATED LOSS OF RCS FLOW |
| |
| RPS indicated that there was a loss of RCS flow to 1 loop, which resulted in |
| an automatic reactor trip. All three loops of RCS flow were in operation |
| throughout the event. All rods fully inserted, no ECCS systems actuated, |
| and decay heat is being removed by the Auxiliary Feedwater system. The |
| Licensee indicated that the electrical grid was stable and that a post trip |
| investigation is ongoing. |
| |
| The NRC Resident Inspector will be notified. |
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|General Information or Other |Event Number: 38896 |
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| REP ORG: BOSTON SCIENTIFIC |NOTIFICATION DATE: 05/03/2002|
|LICENSEE: BOSTON SCIENTIFIC |NOTIFICATION TIME: 15:25[EDT]|
| CITY: SPENCER REGION: 3 |EVENT DATE: 04/03/2002|
| COUNTY: OWEN STATE: IN |EVENT TIME: [CST]|
|LICENSE#: GENERAL AGREEMENT: N |LAST UPDATE DATE: 05/03/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DIMITRI KONEAS | |
| HQ OPS OFFICER: MIKE NORRIS | |
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|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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| 5 LOST AIR NOZZLE SOURCES |
| |
| Licensee reports that 5 static eliminator Po-210 sources are missing. All |
| of the sources are 10 micro-curie, with the following serial numbers and |
| dates: #119686 19 Apr 00, #104160 28 Jul 98, #108071 18 Jan 99, |
| #108072 Jan 18 99, and #111277 10 May 99. The Licensee is still looking |
| for the missing sources and has contacted the vendor which has indicated |
| that the sources were never shipped back to the vendor. |
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|General Information or Other |Event Number: 38897 |
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 05/03/2002|
|LICENSEE: UNIVERSITY OF ALABAMA AT BIRMINHAM |NOTIFICATION TIME:
17:07[EDT]|
| CITY: BIRMINGHAM REGION: 2 |EVENT DATE: 05/03/2002|
| COUNTY: STATE: AL |EVENT TIME: 11:30[CDT]|
|LICENSE#: 266 AGREEMENT: Y |LAST UPDATE DATE: 05/03/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RUDOLPH BERNHARD R2 |
| |ERIC LEEDS NMSS |
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| NRC NOTIFIED BY: DAVID TURGERVILLE | |
| HQ OPS OFFICER: MIKE NORRIS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT-SHIPMENT WITH LOOSE SURFACE CONTAMINATION
LEVELS > |
| LIMITS |
| |
| "At 11:30 am on May 3, 2002, the writer was advised by [the], Assistant |
| Radiation Safety Officer at the University of Alabama at Birmingham (UAB) in |
| Birmingham, Alabama that their nuclear medicine department had received a |
| radiopharmaceutical package that was found to have removable radioactive |
| contamination on the external surface of the package that exceeded 22,200 |
| disintegration's per minute (dpm) per 100 square centimeters. The package |
| was received on the afternoon of May 2, 2002 from Central Pharmacy Services, |
| Inc., d/b/a as Birmingham Central Pharmacy in Birmingham, Alabama. Central |
| Pharmacy Services, Inc. is authorized to prepare and distribute |
| radiopharmaceuticals under Alabama Radioactive Material License No. 1168 and |
| the University of Alabama at Birmingham is authorized to receive radioactive |
| material under Alabama Radioactive Material License No. 266. The package as |
| delivered contained unit doses of Tc-99m and a vial of I-131. These inside |
| containers were found not to be contaminated. The actual contamination was |
| found to be on a magnetic Department of Transportation transport label. The |
| maximum amount of removable contamination was 150,000 dpm on a wipe sample |
| of the magnetic label. Spectrum analysis indicate that the isotope was |
| Tc-99m. The package was isolated. |
| |
| "Central Pharmacy Services, Inc. was notified of the incident. The cause of |
| the incident is currently being investigated by this office." |
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|Power Reactor |Event Number: 38898 |
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| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 05/03/2002|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 17:33[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 05/02/2002|
+------------------------------------------------+EVENT TIME: 18:34[EDT]|
| NRC NOTIFIED BY: KEVIN DAHM |LAST UPDATE DATE: 05/03/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| ABILITY TO MEET 10 CFR 50 APPENDIX R III.G.3 NOT ANALYZED |
| |
| "Operating License Condition 2.C(9) - Modification for Fire Protection ( |
| Section 9.5.1 SSER #5 and SSER #6) |
| |
| "On May 2, 2002 at 1834 hours, during a Fire Protection Self-Assessment |
| field walk down of procedure 20.000.18, 'Shutdown From Outside The Control |
| Room', a procedure step was identified that could not be performed as |
| written. Valve N2000F636, 'Condenser Hotwell Emergency Makeup Bypass Valve' |
| could not be manually operated without the use of a ladder. No ladders were |
| staged for this purpose, and the requirement for a ladder was not specified |
| in the procedure. The time required to procure a ladder and perform the |
| required operation has not been analyzed for impact on the ability to meet |
| safe shutdown requirements of 10CFR50 Appendix R III.G.3. |
| |
| "The condition was documented in the corrective action program and a ladder |
| has been staged at the valve. This condition is being reported as a |
| potential non conformance with Operating License Condition 2.C(9)." |
| |
| The NRC Resident Inspector has been notified. |
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|General Information or Other |Event Number: 38899 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 05/03/2002|
|LICENSEE: SOILS AND MATERIALS CONSULTANTS, INC |NOTIFICATION TIME:
18:51[EDT]|
| CITY: REGION: 4 |EVENT DATE: 05/03/2002|
| COUNTY: STATE: CO |EVENT TIME: [MDT]|
|LICENSE#: 595-01 AGREEMENT: Y |LAST UPDATE DATE: 05/03/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |ERIC LEEDS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TIM BONZER (fax) | |
| HQ OPS OFFICER: MIKE NORRIS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT-DAMAGED DENSITY GAUGE |
| |
| "RSO for the above licensee called on the date of this memo to report a CPN |
| (model MC-1) was run over. The gauge was run over with the Cs-137 source in |
| the ground, the user turned to get something out of his truck, which was |
| near by and a roller ran over the gauge and then since people were waving at |
| him, backed over the gauge. Per the RSO, the CPN representative in Denver |
| will take possession of the gauge and return [it]." |
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|Power Reactor |Event Number: 38900 |
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| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 05/05/2002|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 13:53[EDT]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 05/05/2002|
+------------------------------------------------+EVENT TIME: 11:43[CDT]|
| NRC NOTIFIED BY: JERRY RISTE |LAST UPDATE DATE: 05/05/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
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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 Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| TECHNICAL SPECIFICATION REQUIRED SHUTDOWN |
| |
| "At 1143 CDT, the Kewaunee Nuclear Power Plant commenced a plant shutdown. |
| The plant shutdown was initiated due to an expected inability to restore the |
| Component Cooling (CC) heat exchanger 'A' to an operable status prior to |
| exceeding it's 72 hour LCO action time. The 72 LCO action time expires at |
| 0934, Monday, May 6, 2002. The CC heat exchanger was declared inoperable |
| when it was removed from service to investigate CC system leakage of |
| approximately 0.37 gpm. With only one CC heat exchanger operable, Kewaunee |
| T.S. require that after 72 hours, with one CC heat exchanger inoperable, a |
| plant shutdown commences to < 350 F. Current plans are to shut the plant |
| down <350 F and repair the CC heat exchanger. CC heat exchanger 'B' has no |
| detectable leakage." |
| |
| The NRC Resident Inspector has been notified. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021