Event Notification Report for August 30, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/29/2002 - 08/30/2002
EVENT NUMBERS
39159391603916139263
General Information or Other
Event Number: 39159
Rep Org: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Region: 3
City: EDEN PRAIRIE State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: JEFFREY W. SCHMITT
HQ OPS Officer: STEVE SANDIN
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Region: 3
City: EDEN PRAIRIE State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: JEFFREY W. SCHMITT
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2002
Notification Time: 14:05 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2002
Notification Time: 14:05 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RONALD GARDNER (R3)
JAMES NOGGLE (R1)
STEPHEN CAHILL (R2)
DAVID GRAVES (R4)
VERN HODGE (NRR)
RONALD GARDNER (R3)
JAMES NOGGLE (R1)
STEPHEN CAHILL (R2)
DAVID GRAVES (R4)
VERN HODGE (NRR)
PART 21 INVOLVING NON-CONFORMING ROSEMOUNT PRESSURE TRANSMITTERS AND SPARE PARTS
The following information was received via fax:
"Re: Notification under 10 CFR Part 21 for Model 1153 and 1154 pressure transmitters with optional adjustable damping circuit boards, and spare adjustable damping circuit boards
"Pursuant to 10 CFR Part 21, section 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you that:
(a) certain Model 1153 and 1154 pressure transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 shipped between December 2000 and July 2002, and
(b) certain spare adjustable damping circuit boards with part number 01154-0021-0004 shipped between December 2000 and July 2002, may not meet RNII's published Nuclear Steam Pressure/Temperature specification and/or RNII's published Post DBE Operation specification. Model 1153 and 1154 transmitters which do not contain the special optional adjustable damping circuit board are not affected. The adjustable damping feature establishes the time constant of the transmitter's output. A list of affected Model 1153 and 1154 transmitters and spare adjustable damping circuit boards shipped to the end user's facility is provided in Attachment A.
"1.0 Name and address of the individual providing the information:
Mr. Jeffrey W. Schmitt
Vice President & General Manager
Rosemount Nuclear Instruments, Inc.
12001 Technology Drive
Eden Prairie, MN 55344
"2.0 Identification of items supplied:
Model 1153 and 1154 Pressure Transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 as identified by the appropriate model code. The applicable model codes begin with either '1153' or '1154' and end with the applicable N option number, for example '1154DP5RAN0037.'
and;
Spare adjustable damping circuit boards with part number 01154-0021-0004.
See Attachment A for complete listing of affected equipment shipped to the end user's facility.
"3.0 Identification of firm supplying the item:
Rosemount Nuclear Instruments, Inc.
12001 Technology Drive
Eden Prairie, MN 55344
"4.0 Nature of the failure and potential safety hazard:
This notification impacts:
(a) certain Model 1153 and 1154 pressure transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 shipped between December 2000 and July 2002 and
(b) certain spare adjustable damping circuit boards with part number 01154-0021-0004 shipped between December 2000 and July 2002, which may not meet RNII's published Nuclear Steam Pressure/Temperature specification and/or RNII's published Post DBE Operation specification.
American Capacitor Corporation, the manufacturer of a capacitor used on the adjustable damping circuit board recently informed RNII that capacitors shipped to RNIIs adjustable damping circuit board supplier after June 2000 were inadequately tested for conformance to the required high temperature insulation resistance (IR) as specified by RNII's procurement documents. Subsequent RNII testing confirmed that the capacitors were non-conforming to RNII's IR specifications. These non-conforming capacitors were assembled into certain transmitters and spare circuit boards that were shipped from RNII between December 2000 and July 2002. Further RNII testing demonstrated that model 1153 and 1154 transmitters with the optional adjustable damping circuit boards containing non-conforming capacitors would not meet RNIIs published Nuclear Steam Pressure/Temperature and Post DBE Operation specifications for the published temperature profile. Due to the transmitter performance variation present in the test results, RNII cannot provide an interim specification.
Testing has demonstrated that affected adjustable damping circuit boards do meet product specifications at normal operating temperatures (40-200 degrees F)
RNII does not have sufficient information relative to the end user's specific applications to determine the potential safety-related impact to its plant. The end user must determine the impact on its plant operations and plant safety and take action as deemed necessary.
"5.0 The corrective action which is taken, the name of the individual or organization responsible for that action, and the length of time taken to complete that action:
(a) Upon notification from the capacitor manufacturer of this issue, RNII placed holds on all shipments containing potentially affected equipment (model 1153 and 1154 transmitters with the special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 and spare adjustable damping circuit boards with part number 01154-0021-0004).
(b) The capacitor manufacturer identified the specific capacitor lots that were inadequately tested. Only adjustable damping circuit boards built with capacitors from these lots are affected.
(c) RNII performed subsequent testing and established that Model 1153 and 1154 transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 having adjustable damping circuit boards containing capacitors that do not meet RNII IR specifications would not meet the published Nuclear Steam Pressure/Temperature specification and/or Post DBE Operation specification for the published temperature profile. Testing has demonstrated that affected adjustable damping circuit boards do meet product specifications at normal operating temperatures (40-200 degrees F),
(d) RNII has initiated actions with the adjustable damping circuit board supplier to ensure that all capacitors received from sub-suppliers are tested to demonstrate compliance with the IR specifications prior to installation on adjustable damping circuit boards.
(e) Replacement capacitors have been identified and tested which conform to RNII's procurement specifications. RNII will audit the quality system of the new supplier to assure its quality system meets the requirements of 10CFR Part 50 Appendix B and all requirements of a qualified supplier to RNII. Completion: 6 September 2002.
(f) RNII will repair or replace any affected adjustable damping circuit board at the end user's request. Completion: As required.
"6.0 Any advice related to the potential failure of the item:
"The end user must determine the impact of this deviation upon its plant's operation and safety and take action as deemed necessary. If the end user determines that replacement of the affected special adjustable damping circuit boards is required, please contact Rosemount Nuclear Instruments, Inc. to obtain a replacement adjustable damping circuit board."
The following information was received via fax:
"Re: Notification under 10 CFR Part 21 for Model 1153 and 1154 pressure transmitters with optional adjustable damping circuit boards, and spare adjustable damping circuit boards
"Pursuant to 10 CFR Part 21, section 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you that:
(a) certain Model 1153 and 1154 pressure transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 shipped between December 2000 and July 2002, and
(b) certain spare adjustable damping circuit boards with part number 01154-0021-0004 shipped between December 2000 and July 2002, may not meet RNII's published Nuclear Steam Pressure/Temperature specification and/or RNII's published Post DBE Operation specification. Model 1153 and 1154 transmitters which do not contain the special optional adjustable damping circuit board are not affected. The adjustable damping feature establishes the time constant of the transmitter's output. A list of affected Model 1153 and 1154 transmitters and spare adjustable damping circuit boards shipped to the end user's facility is provided in Attachment A.
"1.0 Name and address of the individual providing the information:
Mr. Jeffrey W. Schmitt
Vice President & General Manager
Rosemount Nuclear Instruments, Inc.
12001 Technology Drive
Eden Prairie, MN 55344
"2.0 Identification of items supplied:
Model 1153 and 1154 Pressure Transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 as identified by the appropriate model code. The applicable model codes begin with either '1153' or '1154' and end with the applicable N option number, for example '1154DP5RAN0037.'
and;
Spare adjustable damping circuit boards with part number 01154-0021-0004.
See Attachment A for complete listing of affected equipment shipped to the end user's facility.
"3.0 Identification of firm supplying the item:
Rosemount Nuclear Instruments, Inc.
12001 Technology Drive
Eden Prairie, MN 55344
"4.0 Nature of the failure and potential safety hazard:
This notification impacts:
(a) certain Model 1153 and 1154 pressure transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 shipped between December 2000 and July 2002 and
(b) certain spare adjustable damping circuit boards with part number 01154-0021-0004 shipped between December 2000 and July 2002, which may not meet RNII's published Nuclear Steam Pressure/Temperature specification and/or RNII's published Post DBE Operation specification.
American Capacitor Corporation, the manufacturer of a capacitor used on the adjustable damping circuit board recently informed RNII that capacitors shipped to RNIIs adjustable damping circuit board supplier after June 2000 were inadequately tested for conformance to the required high temperature insulation resistance (IR) as specified by RNII's procurement documents. Subsequent RNII testing confirmed that the capacitors were non-conforming to RNII's IR specifications. These non-conforming capacitors were assembled into certain transmitters and spare circuit boards that were shipped from RNII between December 2000 and July 2002. Further RNII testing demonstrated that model 1153 and 1154 transmitters with the optional adjustable damping circuit boards containing non-conforming capacitors would not meet RNIIs published Nuclear Steam Pressure/Temperature and Post DBE Operation specifications for the published temperature profile. Due to the transmitter performance variation present in the test results, RNII cannot provide an interim specification.
Testing has demonstrated that affected adjustable damping circuit boards do meet product specifications at normal operating temperatures (40-200 degrees F)
RNII does not have sufficient information relative to the end user's specific applications to determine the potential safety-related impact to its plant. The end user must determine the impact on its plant operations and plant safety and take action as deemed necessary.
"5.0 The corrective action which is taken, the name of the individual or organization responsible for that action, and the length of time taken to complete that action:
(a) Upon notification from the capacitor manufacturer of this issue, RNII placed holds on all shipments containing potentially affected equipment (model 1153 and 1154 transmitters with the special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 and spare adjustable damping circuit boards with part number 01154-0021-0004).
(b) The capacitor manufacturer identified the specific capacitor lots that were inadequately tested. Only adjustable damping circuit boards built with capacitors from these lots are affected.
(c) RNII performed subsequent testing and established that Model 1153 and 1154 transmitters with special adjustable damping options N0037, N0039, N0058, N0085, N0102, N0108, N0120 having adjustable damping circuit boards containing capacitors that do not meet RNII IR specifications would not meet the published Nuclear Steam Pressure/Temperature specification and/or Post DBE Operation specification for the published temperature profile. Testing has demonstrated that affected adjustable damping circuit boards do meet product specifications at normal operating temperatures (40-200 degrees F),
(d) RNII has initiated actions with the adjustable damping circuit board supplier to ensure that all capacitors received from sub-suppliers are tested to demonstrate compliance with the IR specifications prior to installation on adjustable damping circuit boards.
(e) Replacement capacitors have been identified and tested which conform to RNII's procurement specifications. RNII will audit the quality system of the new supplier to assure its quality system meets the requirements of 10CFR Part 50 Appendix B and all requirements of a qualified supplier to RNII. Completion: 6 September 2002.
(f) RNII will repair or replace any affected adjustable damping circuit board at the end user's request. Completion: As required.
"6.0 Any advice related to the potential failure of the item:
"The end user must determine the impact of this deviation upon its plant's operation and safety and take action as deemed necessary. If the end user determines that replacement of the affected special adjustable damping circuit boards is required, please contact Rosemount Nuclear Instruments, Inc. to obtain a replacement adjustable damping circuit board."
General Information or Other
Event Number: 39160
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TOSCO CORPORATION
Region: 4
City: TORRANCE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: STEVE SANDIN
Licensee: TOSCO CORPORATION
Region: 4
City: TORRANCE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2002
Notification Time: 15:30 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [PDT]
Last Update Date: 08/30/2002
Notification Time: 15:30 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [PDT]
Last Update Date: 08/30/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID GRAVES (R4)
E. WILLIAM BRACH (NMSS)
DAVID GRAVES (R4)
E. WILLIAM BRACH (NMSS)
AGREEMENT STATE REPORT INVOLVING LOSS/RECOVERY OF GENERAL LICENSED MATERIAL
"Hugo Neu-Proler Company received a load of scrap material today from BHL Industries that set off our gate radiation detectors. We processed the load and found a piece of equipment with the following information on it: Manufacturer: Texas Nuclear Products, Cs-137, 200 mCi [millicuries] measured January '93. Series: SG, Model: 5202, Serial No. B1865.
"The piece of equipment was segregated and is currently being temporarily stored at Hugo Neu-Proler, pending [...issuance of shipping approval]."
The State of California contacted the source owner who is arranging for return shipment.
"Hugo Neu-Proler Company received a load of scrap material today from BHL Industries that set off our gate radiation detectors. We processed the load and found a piece of equipment with the following information on it: Manufacturer: Texas Nuclear Products, Cs-137, 200 mCi [millicuries] measured January '93. Series: SG, Model: 5202, Serial No. B1865.
"The piece of equipment was segregated and is currently being temporarily stored at Hugo Neu-Proler, pending [...issuance of shipping approval]."
The State of California contacted the source owner who is arranging for return shipment.
Fuel Cycle Facility
Event Number: 39161
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: STEVE SANDIN
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2002
Notification Time: 17:02 [ET]
Event Date: 08/30/2002
Event Time: 01:05 [EDT]
Last Update Date: 08/30/2002
Notification Time: 17:02 [ET]
Event Date: 08/30/2002
Event Time: 01:05 [EDT]
Last Update Date: 08/30/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD GARDNER (R3)
E. WILLIAM BRACH (NMSS)
RONALD GARDNER (R3)
E. WILLIAM BRACH (NMSS)
REPORT INVOLVING A VALID ACTUATION OF A "Q" SAFETY SYSTEM
"At 0105 hrs, Autoclave (AC) #4 in the X-344 facility experienced a steam shutdown due to condensate level alarms A and B actuating. AC #4 was in an applicable TSR mode II (heating) when the alarms actuated. This is considered a valid actuation of a 'Q' safety system. The AC was placed in mode 7 (shutdown). An investigation is underway to determine the cause of the actuation."
Operations informed both the DOE Site Representative and the NRC Resident Inspector.
"At 0105 hrs, Autoclave (AC) #4 in the X-344 facility experienced a steam shutdown due to condensate level alarms A and B actuating. AC #4 was in an applicable TSR mode II (heating) when the alarms actuated. This is considered a valid actuation of a 'Q' safety system. The AC was placed in mode 7 (shutdown). An investigation is underway to determine the cause of the actuation."
Operations informed both the DOE Site Representative and the NRC Resident Inspector.
Hospital
Event Number: 39263
Rep Org: ST PATRICK HOSPITAL
Licensee: ST PATRICK HOSPITAL
Region: 4
City: MISSOULA State: MT
County:
License #: 121677302
Agreement: N
Docket:
NRC Notified By: BREWER
HQ OPS Officer: CHAUNCEY GOULD
Licensee: ST PATRICK HOSPITAL
Region: 4
City: MISSOULA State: MT
County:
License #: 121677302
Agreement: N
Docket:
NRC Notified By: BREWER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/09/2002
Notification Time: 16:38 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [MDT]
Last Update Date: 10/09/2002
Notification Time: 16:38 [ET]
Event Date: 08/30/2002
Event Time: 00:00 [MDT]
Last Update Date: 10/09/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
WILLIAM JONES (R4)
ERIC LEEDS (NMSS)
WILLIAM JONES (R4)
ERIC LEEDS (NMSS)
MEDICAL MISADMINISTRATION
A patient was receiving a gynecological implant of Cs-137 which had the incorrect activity entered into the computer. The calibrated activity was inadvertently entered instead of the current activity. The patient was also receiving external beam therapy from a linear accelerator along with the Cs-137 implant. With the incorrect data being entered into the computer, the patient received a total dose(external and implant) which deviated below the prescribed dose by approximately 16%. The implant dosage, however had greater than a 20% deviation less than the prescribed dose. This medical misadministration was discovered on 10/09/02 @ 1620 MT.
A patient was receiving a gynecological implant of Cs-137 which had the incorrect activity entered into the computer. The calibrated activity was inadvertently entered instead of the current activity. The patient was also receiving external beam therapy from a linear accelerator along with the Cs-137 implant. With the incorrect data being entered into the computer, the patient received a total dose(external and implant) which deviated below the prescribed dose by approximately 16%. The implant dosage, however had greater than a 20% deviation less than the prescribed dose. This medical misadministration was discovered on 10/09/02 @ 1620 MT.