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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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIM G. BONZER                |                             |
|  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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| 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                   |                             |
+------------------------------------------------+                             |
|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               |                             |
+------------------------------------------------+                             |
|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     |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES THIGPEN                |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|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    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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