Event Notification Report for May 10, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/09/2002 - 05/10/2002
** EVENT NUMBERS **
38901 38907 38908 38909 38911
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|General Information or Other |Event Number: 38901 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 05/06/2002|
|LICENSEE: |NOTIFICATION TIME: 13:58[EDT]|
| CITY: DENVER REGION: 4 |EVENT DATE: 04/03/2002|
| COUNTY: ARAPAHOE STATE: CO |EVENT TIME: [MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 05/06/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: TIM G. BONZER | |
| HQ OPS OFFICER: GERRY WAIG | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| OCCUPATIONAL RADIATION EXPOSURE EXCEEDED ANNUAL LIMIT |
| |
| On April 3, 2002, it was identified that a radiographer had received a total |
| occupational exposure of 5.227 Rem Total Effective Dose Equivalent for the |
| monitoring period of January 1, 2001 through December 31, 2001. |
| |
| While compiling Occupational Exposure Reports it was determined that the |
| dose received by a radiographer was in excess of the limits allowed by RH |
| 4.6.1.1.1. The Corporate Radiation Safety Department then notified the |
| Denver Lab Manager of the findings. Exposure records have been reviewed to |
| verify the accuracy of the reported exposure. It has been determined that |
| the reported total is accurate as stated. |
| |
| The radiographer received an exposure of 5.227 Rem Deep Dose Equivalent, and |
| 5.157 Rem Shallow Dose Equivalent for the period of January 1, 2001 through |
| December 31, 2001. |
| |
| Throughout the monitoring period the radiographer worked at various |
| jobsites. The isotope utilized to perform the radiography was Iridium 192. |
| Varying curie strengths from 10 curies to 100 curies were used throughout |
| the year. |
| |
| The root cause of the excessive exposure was due to a lack of attention paid |
| to the cumulative exposure total by the Radiation Safety personnel and by |
| the Radiographer. On August 1, 2001 CONAM Inspection switched to a new |
| dosimetry processor. The result was two dosimetry reports, neither having a |
| cumulative total for the year. The radiographer failed to notify his |
| Radiation Safety Officer of the amount of his total exposure and his |
| proximity to the annual limit. Additionally, the Radiation Safety Officer |
| and the Corporate Radiation Safety Department failed to identify the |
| radiographers proximity to the annual limit and remove him from radiographic |
| activities. |
| |
| The following corrective actions and program enhancements have been made. |
| The Corporate Radiation Safety Department has added a staff member to assist |
| with the oversight of the radiation safety program All monthly exposures in |
| excess of 420 mR now require an ALARA review. All monthly dosimetry reports |
| are reviewed by the lab and by the corporate radiation safety departments to |
| prevent this type of incident. CONAM Inspection intends to utilize our |
| current dosimetry company for the remainder of the monitoring period |
| eliminating the dual reports. The entire radiography staff has been informed |
| of this incident. They have also been instructed of their responsibility to |
| prevent this type of incident. The Radiation Safety Officer has been |
| retrained on his responsibility to ensure that all employees are maintaining |
| their exposure ALARA. When the results from the June monitoring period |
| become available, any employee in excess of 2.5 Rem TEDE will be removed |
| from radiographic activities. Additionally, an employee receiving in excess |
| of 4 Rem will be removed from radiographic activities for the remainder of |
| the monitoring year. The corrective actions are in place as of the date of |
| this letter. |
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|Fuel Cycle Facility |Event Number: 38907 |
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| FACILITY: GLOBAL NUCLEAR FUEL - AMERICAS |NOTIFICATION DATE: 05/09/2002|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 13:20[EDT]|
| COMMENTS: LEU CONVERSION (UF6 TO UO2) |EVENT DATE: 05/08/2002|
| LEU FABRICATION |EVENT TIME: [EDT]|
| LWR COMMERICAL FUEL |LAST UPDATE DATE: 05/09/2002|
| CITY: WILMINGTON REGION: 2 +-----------------------------+
| COUNTY: NEW HANOVER STATE: NC |PERSON ORGANIZATION |
|LICENSE#: SNM-1097 AGREEMENT: Y |ROBERT HAAG R2 |
| DOCKET: 07001113 |JOHN HICKEY NMSS |
+------------------------------------------------+JOSEPH HOLONICH IRO |
| NRC NOTIFIED BY: ALLEN MABRY | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| LOSS OF CRITICALITY CONTROLS AT FUEL FACILITY |
| |
| NRC BULLETIN 91-01 24 HOUR NOTIFICATION |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: Low safety significance - less than 1% of |
| the worst base critical mass involved." |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW |
| CRITICALITY COULD OCCUR): |
| Multiple failure modes required before a criticality accident could occur. |
| |
| "CONTROLLED PARAMETERS: Mass and geometry |
| |
| "ESTIMATED AMOUNT, ENRICHMENT FORM OF LICENSED MATERIAL (INCLUDE
PROCESS |
| LIMIT AND % WORST BASE CRITICAL MASS): Approximately 0.5 Kg of uranium |
| solids enriched to less than 5% U235. Process limit is 25 Kg (gross) at 5% |
| U235. (Approximately 1% of worst base critical mass) |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND
DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: Procedural requirements specify the bags, |
| when removed from associated filter housings, should be placed in 3 gallon |
| cans. The filters were hung to dry rather than placed in cans. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS
IMPLEMENTED: |
| Process was immediately shut down. Geometry control was restored by placing |
| the bag filters in approved 3 gallon cans. This activity was completed at |
| 4:00 p.m. on 5/8/02. Investigation of event and evaluation of additional |
| corrective actions pending." |
| |
| EVENT DESCRIPTION |
| |
| "At approximately 2:00 p.m on May 8, 2002, eight used filter bags from the |
| radioactive waste system were determined by Nuclear Safety Engineering to be |
| stored outside of approved storage locations. The filters are cloth bags |
| used to reduce solids in the low level liquid waste system and contain |
| solids with low ppm U (approximately 60,000 ppm U). Nuclear safety |
| requirements specify the bags, when removed from associated filter housings, |
| should be placed in 3 gallon cans in approved storage locations. The filters |
| were hung to dry, rather than placed in approved storage. This condition led |
| to a loss of geometry control. |
| |
| "The bags have a maximum diameter of 8 inches when fully extended. The as |
| found condition exceeded the analyzed geometry limit of 8 inches. The mass |
| limit (25 kg) was not exceeded. The measured gross weight of the bags and |
| contents was 12.83 kg. The mass control was not violated thus no unsafe |
| condition existed, and the situation was corrected in less than four hours. |
| This condition was reported pursuant to NRC Bulletin 91-01 due to a |
| degradation of criticality controls. Activities in the affected area have |
| been suspended pending an investigation to determine the root cause and |
| establishment of corrective actions." |
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|Hospital |Event Number: 38908 |
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| REP ORG: GEORGE WASHINGTON UNIV. HOSPITAL |NOTIFICATION DATE:
05/09/2002|
|LICENSEE: G.W. UNIV. HOSPITAL |NOTIFICATION TIME: 16:25[EDT]|
| CITY: WASHINGTON DC REGION: 1 |EVENT DATE: 05/09/2002|
| COUNTY: STATE: DC |EVENT TIME: 10:30[EDT]|
|LICENSE#: 08-30607-01 AGREEMENT: N |LAST UPDATE DATE: 05/09/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MICHELE EVANS R1 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+JOE HOLONICH IRO |
| NRC NOTIFIED BY: ANIS CHOWDHURG | |
| HQ OPS OFFICER: JOHN MacKINNON | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAE1 20.2202(b)(1) PERS OVEREXPOSURE/TEDE | |
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EVENT TEXT
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| PRELIMINARY ESTIMATED EXPOSURE OF 63 ROENTGEN TO THE HANDS OF A
MEDICAL |
| PHYSICIST |
| |
| |
| While using a Cordis delivery system to insert a ribbon containing Ir-192 |
| seeds into a patient, the ribbon came out into the hands of the Medical |
| Physicist. The screw and cap of the Cordis delivery system had been loosened |
| and the ribbon containing the Ir-192 seeds was supposed to be pushed into |
| patient via a catheter but somehow the ribbon containing the Ir-192 seeds |
| ended up in the hand of the Medical Physicist. George Washington Hospital |
| Radiation Safety Officer preliminarily estimated the minimum exposure to the |
| Medical Physicist hand was 63 roentgens. The Medical Physicist walked 5 or |
| 6 feet into another room where the Radiation Oncologist was located and |
| dropped the ribbon to the floor. The Radiation Oncologist, wearing gloves, |
| picked the ribbon up and placed it in a safe location. The Radiation Safety |
| Officer for George Washington Hospital said that the Radiation Oncologist |
| received a dose to his hand while carrying the ribbon. An estimated dose |
| calculation to Radiation Oncologist hands, etc., had not been made at the |
| time of the notification. |
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|General Information or Other |Event Number: 38909 |
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| REP ORG: ROCKWELL AUTOMATION |NOTIFICATION DATE: 05/09/2002|
|LICENSEE: ROCKWELL AUTOMATION |NOTIFICATION TIME: 16:30[EDT]|
| CITY: FLOWERY BRANCH REGION: 2 |EVENT DATE: 05/09/2002|
| COUNTY: STATE: GA |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 05/09/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |VERN HODGE NRR |
| | |
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| NRC NOTIFIED BY: JAMES THIGPEN | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
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EVENT TEXT
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| PART 21 ISSUE ON ELECTRIC MOTORS |
| |
| Rockwell Automations report a potential defect involving insufficient slot |
| fill in electric motor windings used to drive fan assemblies. They have |
| contacted Hayden Company located in New Philadelphia, Ohio who was supplied |
| with these motors. The motors may be in use at commercial nuclear power |
| plants. |
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|Power Reactor |Event Number: 38911 |
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| FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 05/09/2002|
| UNIT: [] [2] [3] STATE: IL |NOTIFICATION TIME: 21:02[EDT]|
| RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 05/09/2002|
+------------------------------------------------+EVENT TIME: 17:50[CDT]|
| NRC NOTIFIED BY: JESSE COLVIN |LAST UPDATE DATE: 05/09/2002|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANTON VEGEL R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 96 Power Operation |96 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| LOSS OF CONTROL ROOM HVAC AT DRESDEN |
| |
| "At 1750 hours on May 9, 2002 the B Control Room HVAC Refrigeration and |
| Condensing Unit (RCU) would not stay running during surveillance testing. |
| The B RCU is a single train system and therefore is reportable per SAF 1.8 & |
| LS-AA-1400, Event Reporting Guidelines Section 3.2.7. The B RCU is required |
| to operate during a design basis accident to remove the heat from the Main |
| Control Room. The Air Filtration Unit (AFU) of CREVS remains operable. This |
| places both units in a 30 day LCORA per Tech Spec 3.7.5. Required Action A. |
| 1." |
| |
| Train "A" is not fully qualified but is available to maintain proper control |
| room temperatures. |
| |
| The NRC Resident Inspector was notified. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021