Event Notification Report for November 1, 2002
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/31/2002 - 11/01/2002 ** EVENT NUMBERS ** 39235 39323 39325 39327 39328 39329 39333 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39235 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 10/01/2002| | UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 17:44[EDT]| | RXTYPE: [1] W-4-LP |EVENT DATE: 10/01/2002| +------------------------------------------------+EVENT TIME: 08:45[CDT]| | NRC NOTIFIED BY: STEVEN A. HENRY |LAST UPDATE DATE: 10/31/2002| | HQ OPS OFFICER: MIKE NORRIS +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 | |10 CFR SECTION: | | |AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNANALYZED CONDITION RELATING TO CONTROL ROOM EVACUATION | | | | "On October 1 2002, conditions were discovered that if an evacuation of the | | Wolf Creek Generation Station (WCGS) control room were required, due to a | | fire, necessary steps could not be completed within committed time | | requirements. The station is in Mode 1, at 100% power. | | | | "During a timed walk down of procedure OFN RP-017, 'Control Room | | Evacuation,' it was identified that operators did not complete Phase A | | actions of the procedure in the committed five minutes. Phase A provides | | that control of the plant will be established at the Auxiliary Shutdown | | Panel (ASP) and isolation of required instrumentation and other devices on | | the ASP will be accomplished. Phase A was performed in approximately 8 | | minutes. This does not meet our commitment to 10 CFR 50 Appendix R as | | reflected in the WCGS Fire Protection Plan. The effect of additional time to | | complete Phase A of the control room evacuation is being further analyzed to | | determine the safety significance. | | | | "Based on the guidance provided in NUREG 1022 Revision 2, this situation | | meets the criterion of 10CFR50.72(b)(3)(ii)(B) for an 8-hour ENS | | notification, as it relates to being in an unanalyzed condition." | | | | The Licensee has implemented compensatory measures at 1900 CDT, 10/1/02. | | | | The licensee has notified the NRC Resident Inspector | | | | ****RETRACTION JEFF ISCH TO MIKE NORRIS 1429 ET 10/31/02**** | | | | "BASIS FOR RETRACTION: | | | | "A safety significance evaluation was performed for the condition described | | above and it was determined that the circumstances do not constitute a | | significant reduction in plant safety. This conclusion is based on the | | results of simulator exercises that concluded that the 5 minute completion | | time was conservative and that the actions needed to place the plant in a | | safe condition could be performed within 8 minutes. The evaluation provides | | reasonable assurance that operator activities taken to complete Phase A | | actions within a 7 to 8 minute period does not result in consequences of | | safety significance. This conclusion is further validated by comparing the | | results with bounding conditions contained in a Westinghouse WCAP report for | | a similar condition involving a failed open power operated relief valve | | (PORV), as well as an engineering evaluation previously performed for both | | PORVs spuriously opening due to a fire. Therefore, per NUREG 1022, this | | condition is not an unanalyzed condition that significantly degrades plant | | safety and is not required to be reported in accordance with | | 10CFR50.72(b)(3)(ii)(B)." | | | | The Licensee has notified the NRC Resident Inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39323 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 10/28/2002| |LICENSEE: CONSTRUCTION TESTING LAB |NOTIFICATION TIME: 15:23[EST]| | CITY: METAIRIE REGION: 4 |EVENT DATE: 09/20/2002| | COUNTY: STATE: LA |EVENT TIME: [CDT]| |LICENSE#: LA-6427-L01 AGREEMENT: Y |LAST UPDATE DATE: 10/28/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CLAUDE JOHNSON R4 | | |MELVYN LEACH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: SCOTT BLACKWELL | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOUISIANA DEPT OF ENVIRONMENTAL QUALITY AGREEMENT STATE REPORT RE: STOLEN | | MOISTURE/DENSITY GAUGE | | | | "ON SEPTEMBER 20, 2002, A TROXLER 3411-B GAUGE WITH SERIAL NUMBER 4524 WAS | | STOLEN FROM THE BACK SEAT OF A GMC EXTRA CAB TRUCK. THE GAUGE CONTAINED A | | 8.0 mCi (MILLICURIE) SOURCE OF CS-137 AND A 40 mCi SOURCE OF AM241:BE. THE | | GAUGE WAS STOLEN BY BREAKING THE LOCK ON THE SIDE REAR WINDOW OF THE TRUCK. | | THE GAUGE WAS NOT CHAINED TO THE TRUCK. THE FACILITY HAS CHANGE ITS | | PROCEDURES TO PREVENT THIS TYPE OF EVENT FROM OCCURRING AGAIN." | | | | "CONSTRUCTION TESTING LAB, 3008 5TH STREET, METAIRIE, LA" | | | | "STOLEN FROM 1995 GMC EXTRA CAB TRUCK" | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39325 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 10/28/2002| |LICENSEE: LITTLE COMPANY OF MARY HOSPITAL |NOTIFICATION TIME: 23:33[EST]| | CITY: TORRANCE REGION: 4 |EVENT DATE: 10/25/2002| | COUNTY: LOS ANGELES STATE: CA |EVENT TIME: 14:30[PDT]| |LICENSE#: 1258-19 AGREEMENT: Y |LAST UPDATE DATE: 10/28/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CLAUDE JOHNSON R4 | | |MELVYN LEACH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: ROBERT GREGER | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - MISSING IODINE- 125 SEEDS | | | | The Medical Physicist from Little Company of Mary Hospital called to report | | the loss of 5 Iodine-125 seeds of approximately 0.4 millicuries each. The | | facility was doing an implant for the treatment of prostate cancer and had | | cut the strips in half (5 seeds each). After having implanted 9 strips they | | were unable to locate the tenth piece. They surveyed the room and trash and | | did not find the missing seeds. The patient was fluoroscoped and x-rayed, | | the implanted seeds were counted and verified with what had been implanted. | | A representative from Amersham was present during the procedure and it was | | not determined if the tube shipped was half empty. | | | | The seeds came in steel tubes of 10. It is possible that one steel tube | | only had 5 when sent. Implant performed at 11:00 on 10/24/02. The tubes | | were counted, but not opened until the procedure (sterile) was initiated. | | | | The licensee kept looking for the missing Iodine-125 seeds and today, | | October 28, 2002, concluded that the event was reportable and notified the | | State of CA today at 1458 hours PST. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39327 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: FLORIDA BUREAU OF RADIATION CONTROL |NOTIFICATION DATE: 10/29/2002| |LICENSEE: ROBERT BOISSONEAULT ONCOLOGY INSTITUT|NOTIFICATION TIME: 13:04[EST]| | CITY: LACANTO REGION: 2 |EVENT DATE: 10/22/2002| | COUNTY: STATE: FL |EVENT TIME: [EDT]| |LICENSE#: 2155-1 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KERRY LANDIS R2 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: CHARLES ADAMS | | | HQ OPS OFFICER: MIKE RIPLEY | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE - MEDICAL MISADMINISTRATION | | | | "On 10-22-02 the patient was undergoing the first of six fraction therapy | | using a HDR source in the cervix. The source was misplaced by approximately | | 2 centimeters. The dose received was 800 Rem instead of the prescribed dose | | of 500 Rem. On 10-28-02 the error was discovered during planning for the | | second fraction, and it was reported the same day. The patient and physician | | have been notified. No long term health effect is expected and the | | prescribed treatment is continuing. Licensee will submit a letter of | | explanation within 15 days. Florida is continuing it's investigation." | | | | Florida Incident No. FL02-161 | | Isotope used was 9.961 Curies Ir-192. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39328 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 10/29/2002| |LICENSEE: ALPHA TESTING, INC. |NOTIFICATION TIME: 13:44[EST]| | CITY: DALLAS REGION: 4 |EVENT DATE: 10/28/2002| | COUNTY: STATE: TX |EVENT TIME: 06:30[CDT]| |LICENSE#: L03411 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CLAUDE JOHNSON R4 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JAMES H. OGDEN Jr. | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - STOLEN NUCLEAR DENSITY GAUGE | | | | | | "A company technician returned to the office at 6:30 a.m. after an extended | | job in Brundidge, Alabama. He was in the office to return to operations at | | the Dallas, office and was beginning to unload his truck and return his | | equipment to the office. He unlocked his gauge (Troxler Model 3411B, Serial | | # 6819) and placed it on the tailgate of the truck. He walked into the | | office to get a chain and lock to secure the gauge in the company storage | | cabinet. He walked back to the truck to get the gauge and discovered that | | the gauge and the concrete air meter were missing from the truck. He | | contacted the dispatcher, who had not yet arrived at the office, to notify | | the company RSO. Notifications were made to the Bureau of Radiation | | Control, the Dallas Police Department (Police Report # 823204L - a copy has | | not been received yet), and three local nuclear gauge repair centers | | (Richardson & Associated, Component Sales - Houston, and Troxler Labs, | | Arlington). The gauge has not been located. Source Serial #'s are: Cs-137, | | 10 millicuries, S/N CC3975, and AmBE-241, 40 millicuries, S/N CCA3132. The | | BRC is still investigating the incident." | | | | "Company truck with Logo, Texas Licensee # 5ND G59" | | | | "Texas Incident No.: I-7945" | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39329 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 10/29/2002| |LICENSEE: WOODWARD REGIONAL HOSPITAL |NOTIFICATION TIME: 15:19[EST]| | CITY: woodward REGION: 4 |EVENT DATE: 10/28/2002| | COUNTY: STATE: OK |EVENT TIME: 15:00[CDT]| |LICENSE#: OK-21269-01 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CLAUDE JOHNSON R4 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: M. BRODERICK | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FOLLOW-UP PATIENT GIVEN INCORRECT PREP DRUG | | | | | | Woodward Regional Hospital was doing an Iodine-131 follow-up scan for | | residual Thyroid on cancer patient. A nurse injected the patient with the | | incorrect prep drug, non radioactive drug, prior to the patient being | | administered 4 millicuries of Iodine-131. The caller believes that the | | patient was given the incorrect prep drug on October 28, 2002 and today, | | October 29, 2002, was administered the 4 millicuries of Iodine-131 before | | given the scan. After the scan was performed it was discovered that the | | patient was given the incorrect prep drug for the scan. The State of | | Oklahoma is investigating this event. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39333 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 10/31/2002| | UNIT: [1] [] [] STATE: AZ |NOTIFICATION TIME: 11:04[EST]| | RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 10/31/2002| +------------------------------------------------+EVENT TIME: 05:45[MST]| | NRC NOTIFIED BY: DONALD STRAKA |LAST UPDATE DATE: 10/31/2002| | HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |CLAUDE JOHNSON R4 | |10 CFR SECTION: |TERRY REIS NRR | |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 M/R Y 19 Power Operation |0 Hot Standby | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 1 MANUALLY TRIPPED DUE TO HIGH SULFATE CONCENTRATIONS IN THE STEAM | | GENERATORS | | | | "On October 31 2002, at approximately 05:45 MST Palo Verde Unit 1 | | experienced a manual reactor trip from approximately 19% rated thermal power | | due to high sulfate concentrations in the steam generators. Unit 1 was at | | normal temperature and pressure prior to the trip. All CEAs inserted fully | | into the reactor core. This was an uncomplicated reactor trip. No ESF | | actuations occurred and none were required. Safety related buses remained | | energized during and following the reactor trip. The offsite power grid is | | stable. No significant LCOs have been entered as a result of this event. No | | major equipment was inoperable prior to the event that contributed to the | | event. | | | | "Unit 1 is stable at normal operating temperature and pressure in Mode 3. | | The event did not result in any challenges to fission product barriers and | | there were no adverse safety consequences as a result of this event. The | | event did not adversely affect the safe operation of the plant or the health | | and safety of the public." | | | | The licensee stated that the trip was initiated at the recommendation of the | | Chemistry Manager. The licensee continues to investigate the reason for the | | high sulfate concentration and an estimated restart date was not given. | | | | The licensee notified the NRC Resident Inspector. | +------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021