Event Notification Report for May 22, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/21/2002 - 05/22/2002
** EVENT NUMBERS **
38922 38923 38933 38934
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|General Information or Other |Event Number: 38922 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE:
05/16/2002|
|LICENSEE: HUNTINGTON MEMORIAL HOSPITAL |NOTIFICATION TIME: 17:25[EDT]|
| CITY: PASADENA REGION: 4 |EVENT DATE: 05/15/2002|
| COUNTY: STATE: CA |EVENT TIME: 11:00[PDT]|
|LICENSE#: 0239-19 AGREEMENT: Y |LAST UPDATE DATE: 05/16/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GREG PICK R4 |
| |C.W. (BILL) REAMER NMSS |
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| NRC NOTIFIED BY: BARBARA HAMRICK | |
| HQ OPS OFFICER: MIKE NORRIS | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING THEFT OF LICENSED MATERIAL >1000 TIMES
|
| |
| "At 11:00 am PDT on May 15, 2002, four packages were stolen from an |
| unsecured Airborne Express truck parked at 39 Congress Avenue, Pasadena, Ca. |
| Due to a mix-up by the driver, it was not known that one of the packages |
| contained radioactive material until the next day, when Huntington Memorial |
| Hospital's Radiation Safety Officer[ ], realized that they had not received |
| one of the packages of Palladium-103 seeds that they were expecting. [The |
| RSO] reported the loss to the California Radiologic Health Branch at 12:15 |
| PM PDT on May 16, 2002. |
| |
| "The package was supposed to have contained 72 seeds at 1.54 mCi/seed, or a |
| total of 110 mCi of Pd-103, which would produce a field of about 230 mR/hr |
| at one foot from the unshielded material. |
| |
| "Los Angeles County personnel took the initial call from the hospital, and |
| is following up on this incident. Los Angeles County is a Contract County in |
| California's Agreement State Program. The L.A. County inspector talked to |
| the hospital about issuing a press release, and they are currently preparing |
| one. The inspector will also obtain information on the package dose-rates, |
| when it was shipped by Imagyn in TX, and the calibration dates for the |
| seeds.. The seeds were purchased from Theragenics, shipped to Imagyn for |
| some preparation, then shipped to the California licensee in two packages. |
| The first package was received in tact. The second was stolen from the |
| Airborne Express truck. There has been no indication by any of the parties |
| that the other three packages stolen contained any radioactive material." |
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|General Information or Other |Event Number: 38923 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 05/16/2002|
|LICENSEE: LUTHERAN MEDICAL CENTER |NOTIFICATION TIME: 18:29[EDT]|
| CITY: REGION: 4 |EVENT DATE: 05/16/2002|
| COUNTY: STATE: CO |EVENT TIME: [MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 05/16/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GREG PICK R4 |
| |C.W. (BILL) REAMER NMSS |
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| NRC NOTIFIED BY: TIM G. BONZER (fax) | |
| HQ OPS OFFICER: MIKE NORRIS | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT ON MEDICAL MISADMINISTRATION |
| |
| "[ ]Med. Physicist called on the date of this memo. It was regarding the |
| placing of 111 seeds [of I-125] when the prescribed dose was 110 seeds. Per |
| the physicist he could not see the additional seed because of the blood. |
| After doing a source count he believes the additional seed was implanted |
| into the patient. The additional seeds activity was 0.33 mCi. Additional |
| information will follow." |
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|Power Reactor |Event Number: 38933 |
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| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 05/21/2002|
| UNIT: [] [2] [] STATE: NJ |NOTIFICATION TIME: 15:52[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/20/2002|
+------------------------------------------------+EVENT TIME: 15:30[EDT]|
| NRC NOTIFIED BY: BRAIN BONNER |LAST UPDATE DATE: 05/21/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
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|EMERGENCY CLASS: NON EMERGENCY |FRANK COSTELLO R1 |
|10 CFR SECTION: | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 98 Power Operation |98 Power Operation |
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EVENT TEXT
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| FIRE PROTECTION CARBON DIOXIDE IN SAFETY RELATED AREAS |
| |
| REPORTED UNDER FIRE PROTECTION LICENSE CONDITION 2.C.X |
| |
| |
| |
| Tracer gas testing was being performed for the following fire areas at Salem |
| Unit 1 and Unit 2: |
| |
| (1) Unit 1 EL. 78 Lower Electrical Penetration Area |
| (2) Unit 1 EL. 64 4160V Switchgear Room |
| (3) Unit 2 EL. 78 Lower Electrical Penetration Area |
| |
| |
| The tracer gas test, along with a door fan test were being performed to |
| determine actual field conditions for inclusion in a re-analysis of the |
| carbon dioxide fire suppression system for these areas. At 1730 hours on |
| 05/20/02, preliminary results were obtained for tests 1 and 2 above that |
| indicated a significant amount of leakage through the ventilation control |
| dampers in these areas that would prevent the carbon dioxide system from |
| achieving the required concentration of 50% and a hold time of 20 minutes as |
| required by NFPA-12. The results for Test 3 have not been completed but |
| identify a similar condition for the Unit 2 Lower Electrical Penetration |
| Area. |
| |
| The problem with leakage from these fires areas appears to be from a high |
| differential pressure across the ventilation dampers that close on a carbon |
| dioxide discharge, however, the ventilation fans continue to operate. Based |
| on this information, the Unit 2 4160 VAC Switchgear Room, the Unit 1 460 VAC |
| Switchgear Room and the Unit 2 460 VAC Switchgear Room have a similar |
| configuration on carbon dioxide actuation and will most likely not meet the |
| 50% concentration requirement. As a result, the carbon dioxide system for |
| all six areas above were impaired and continuous fire watches were |
| established. |
| |
| Although air leakage from the ventilation supply and exhaust dampers affects |
| the ability to achieve or maintain the carbon dioxide design concentration |
| in accordance with NFPA-12, the carbon dioxide discharge into the room still |
| provides a fire suppression function. Automatic early warning (ionization) |
| fire detection will alert the dedicated onsite fire brigade, who will |
| respond and extinguish any fire using manual fire suppression methods. The |
| fire brigade can manually activate an additional carbon dioxide system |
| discharge. Based on the above, there is reasonable assurance that the plant |
| can achieve and maintain safe shutdown. |
| |
| Failure to meet the carbon dioxide concentration in all six of these areas |
| is a violation of the Fire Protection Program License Condition 2.C.5 (Unit |
| 1) and 2.C.10 (Unit 2). Failure to meet Unit 2 License condition 2.C.10 |
| requires a 24-hour report accordance with Unit 2 License Condition 2I and a |
| follow-up 14 day special report. |
| |
| The NRC Resident inspector will be notified of this event by the licensee. |
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|Power Reactor |Event Number: 38934 |
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| FACILITY: COLUMBIA GENERATING STATIREGION: 4 |NOTIFICATION DATE: 05/21/2002|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 18:59[EDT]|
| RXTYPE: [2] GE-5 |EVENT DATE: 05/03/2002|
+------------------------------------------------+EVENT TIME: 15:40[PDT]|
| NRC NOTIFIED BY: BOB BROWNLEE |LAST UPDATE DATE: 05/21/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
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|EMERGENCY CLASS: NON EMERGENCY |LINDA SMITH R4 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
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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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| UNANALYZED CONDITION THAT SIGNIFICANTLY DEGRADED PLANT SAFETY |
| |
| On May 3, 2002, approximately 20 gallons of water was spilled on the floor |
| of the cable spreading room (CSR). Some of the water leaked down into rooms |
| below the CSR floor, resulting in an electrical ground on the on the 125-VAC |
| Division 2 battery bus S1-2. The S1-2 bus remained operable. It has since |
| been determined that the pathway for leakage through the floor of the CSR |
| was cracks in the concrete due to abandoned concrete anchors, and through |
| shrinkage cracks in the reinforced concrete floor slab. Shrinkage cracks |
| are also located in the 525' elevation floor above the Control Room. These |
| two floors are considered essential fire rated assemblies and are required |
| to be "leak tight". These floors have not had a qualified paint/sealant |
| applied that would render them "leaktight". Other floors that are fire |
| rated assemblies are believed to have had the appropriate paint/sealant |
| applied, but this is being verified. Should a fire system actuate, or |
| develop a leak in either the CSR or the room above the Control Room, there |
| is the potential for leakage through the floors to impact Division 1 or 2 |
| safety-related equipment in the rooms below. A barrier impairment has been |
| initiated for the CSR on May 6, 2002 and for the 525' elevation above the |
| Control Room on May 7, 2002 with compensatory action to include these areas |
| on an hourly fire/flood tour. With the hourly fire/flood tours in place, the |
| floors of the CSR and the room above the Control Room have been declared |
| "operable but degraded" per formal assessment of operability, and no longer |
| represent an unanalyzed condition that significantly degrades plant safety. |
| The cracks associated with the abandoned anchor bolts have been sealed. |
| Hourly fire/flood tours remain in effect until both floors have been |
| properly sealed. |
| |
| The NRC Resident Inspector has been notified of this event. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021