United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2002

Event Notification Report for November 4, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/01/2002 - 11/04/2002

                              ** EVENT NUMBERS **

39327  39328  39329  39337  39338  39339  39340  

+------------------------------------------------------------------------------+
|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  REPORT INVOLVING A  MEDICAL EVENT                           |
|                                                                              |
| "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[CST]|
|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[CST]|
|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:   39337       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 11/01/2002|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 17:52[EST]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        11/01/2002|
+------------------------------------------------+EVENT TIME:        15:08[EST]|
| NRC NOTIFIED BY:  QUENTIN HICKS                |LAST UPDATE DATE:  11/01/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID SILK           R1      |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(3)(ii)(A)  DEGRADED 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                                   
+------------------------------------------------------------------------------+
| DEGRADED PLANT CONDITION DUE TO LOSS OF SAFETY RELATED OFFSITE POWER         |
|                                                                              |
| "This report is being filed per 10CFR50.72.b.3. This is an eight hour        |
| notification of a degraded plant condition based on a loss of safety related |
| offsite power.                                                               |
|                                                                              |
| "At 1508 hours, Central New York Power Control notified Nine Mile Point Unit |
| 1 control room staff that a Low Contingency Voltage alarm had been received. |
| Per plant procedures NMP1 entered a 24-hour shutdown Limiting Condition of   |
| Operation per Technical Specification 3.6.3. Power Control's Load Flow       |
| Computer program that monitors the 115 kV grid for NMP1, determined that     |
| there is insufficient voltage (based on the grid loading) to supply NMP1     |
| ECCS loads during a LOCA.                                                    |
|                                                                              |
| "NMP1 has started its DIV 1 emergency diesel generator (EDG). DIV 1 ECCS bus |
| is currently being supplied by the DIV 1 EDG. Plant operators are currently  |
| starting the DIV 2 EDG; it will supply DIV 2 ECCS bus.                       |
|                                                                              |
| "Power is still available for other non-safety related buses from offsite,   |
| however for safety related buses it is considered degraded."                 |
|                                                                              |
| The Licensee has notified the NRC Resident Inspector.                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39338       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FT CALHOUN               REGION:  4  |NOTIFICATION DATE: 11/01/2002|
|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 18:26[EST]|
|   RXTYPE: [1] CE                               |EVENT DATE:        11/01/2002|
+------------------------------------------------+EVENT TIME:        11:58[CST]|
| NRC NOTIFIED BY:  RANDY CADE                   |LAST UPDATE DATE:  11/01/2002|
|  HQ OPS OFFICER:  ARLON COSTA                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLAUDE JOHNSON       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  FOR PRESSURIZER LEVEL TRANSMITTER CABLE SEPARATION     |
|                                                                              |
| "During an internal (Self Assessment) Fire Protection Program Review,        |
| documentation discrepancies were found related to Pressurizer Level          |
| Transmitters LT-101Y and LT-101X (Normal Operating Level Indications) and    |
| LT-106 (Cold Calibrated Shutdown Indication). The information did not        |
| provide adequate documentation to ensure Appendix R cable separation was met |
| in Containment. A field verification was performed and confirmed that        |
| Appendix R cable separation for the above mentioned Pressurizer Level        |
| transmitters may not exist. The Plant engineering Department is continuing   |
| to evaluate the situation and a Plant Review Committee (PRC) meeting is      |
| planned for later this evening to review Engineering's conclusions."         |
|                                                                              |
| "Currently the affected transmitters are operable and this issue relates to  |
| Appendix R Licensing Documentation only."                                    |
|                                                                              |
| The Licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39339       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BRUNSWICK                REGION:  2  |NOTIFICATION DATE: 11/01/2002|
|    UNIT:  [] [2] []                 STATE:  NC |NOTIFICATION TIME: 22:12[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        11/01/2002|
+------------------------------------------------+EVENT TIME:        16:41[EST]|
| NRC NOTIFIED BY:  DON BAIN                     |LAST UPDATE DATE:  11/01/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |KERRY LANDIS         R2      |
|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       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| HPCI INOPERABLE DUE TO INDICATED HIGH DIFFERENTIAL PRESSURE ALARM            |
|                                                                              |
| "On November 1, 2002 at 16:41 hours, a High Pressure Coolant Injection       |
| (HPCI) Steam Line Break high differential pressure alarm was received, which |
| caused a HPCI Steam Isolation System 'A' signal, closure of the 2-E41-F003,  |
| HPCI Steam Supply Outboard Isolation Valve, and a closure signal to the      |
| normally closed 2-E41-F041, Torus Suction Valve. Temperature indications,    |
| inspection of associated trip instrumentation, and local inspection          |
| confirmed that all  temperatures for the HPCI system were normal and no      |
| steam or line break was present. The high differential pressure alarm        |
| cleared at 16:49 hours.                                                      |
|                                                                              |
| "Investigation is currently in progress and drifting of a differential       |
| pressure transmitter is suspected.                                           |
|                                                                              |
| "This event is reportable in accordance with 10CFR50.72(b)(3)(v)(D) since    |
| the HPCI system is needed to mitigate the consequences of an accident.       |
|                                                                              |
| "INITIAL SAFETY SIGNIFICANCE EVALUATION                                      |
| "The Reactor Core Isolation Cooling (RCIC) system is operable and Unit 2 has |
| entered the Technical Specification action statement to restore the HPCI     |
| system in 14 days. Therefore, this event poses minimal safety significance.  |
|                                                                              |
| "CORRECTIVE ACTIONS                                                          |
| "Initial actions were taken to verify no evidence of a steam leak using      |
| available indications and an inspection of HPCI steam lines, Further         |
| investigation is in progress on the associated differential pressure         |
| transmitter."                                                                |
|                                                                              |
| The Licensee has notified the NRC Resident Inspector.                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39340       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 11/02/2002|
|    UNIT:  [] [2] []                 STATE:  CA |NOTIFICATION TIME: 08:38[EST]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        11/02/2002|
+------------------------------------------------+EVENT TIME:        03:16[PST]|
| NRC NOTIFIED BY:  BOB CONOSCENTI               |LAST UPDATE DATE:  11/02/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLAUDE JOHNSON       R4      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 2 REACTOR  TRIP ON LOW STEAM GENERATOR WATER LEVEL                      |
|                                                                              |
| The San Onofre Unit 2 reactor tripped from full power on reactor protection  |
| system (RPS) actuation due to low steam generator (SG) 2E089 water level.    |
| The low SG water level was caused by the momentary closure of main feedwater |
| regulator valve 2-FV-1111. The momentary valve closure caused the #1 SG      |
| water level to drop to the ESFAS/reactor trip setpoint of 21% (NR) resulting |
| in RPS actuation, automatic auxiliary feedwater system initiation, and the   |
| trip of both main feedwater pumps. The auxiliary feedwater system was used   |
| to restore and maintain SG water levels after the reactor trip. All control  |
| rods fully inserted into the reactor and all plant systems responded to the  |
| event as expected. The plant is currently stable in hot standby conditions.  |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+