Event Notification Report for December 11, 2002
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/10/2002 - 12/11/2002 ** EVENT NUMBERS ** 39426 39430 39432 39433 39434 39435 39436 39437 +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39426 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 12/06/2002| |LICENSEE: NORTHWEST COMMUNITY HOSPITAL |NOTIFICATION TIME: 13:13[EST]| | CITY: ARLINGTON HEIGHTS REGION: 3 |EVENT DATE: 12/05/2002| | COUNTY: STATE: IL |EVENT TIME: [CST]| |LICENSE#: IL-01094-01 AGREEMENT: Y |LAST UPDATE DATE: 12/06/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KENNETH RIEMER R3 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JOE KLINGER | | | HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - MEDICAL EVENT, DOSE GREATER THAN 20% LARGER THAN | | PRESCRIBED | | | | "On December 5, 2002, the RSO at Northwest Community Hospital, Arlington | | Heights IL, notified the department of a 'reportable' (misadministration) | | event that occurred involving Intravascular Brachytherapy. The treatment | | was for a 52 mm lesion using 85 mCi [millicuries] of P-32 (GDT source) in a | | Guidant Corporation Galileo device. The prescribed dose was 20 gray. Using | | a three step automated system, as the 1st step was completed, the | | authorized user intervened and repositioned the markers for the system to | | intentionally deliver an additional dose to this area of the lesion. After | | completing the treatment. The calculated dose to the lesion was determined | | to be 24.6 gray. This is greater than 20% over the prescribed dose for | | this treatment and thus a reportable event. The RSO reported that the | | clinical range for this treatment is 15-26 gray so no adverse health | | effects are anticipated with this event. The RSO stated that a written | | report would be filed with the department within the required 15 day | | period. | | | | "Event Date 12/05/2002 License No: IL-01094-01 Licensee: Northwest | | Community Hospital | | City: Arlington Heights State: IL Event Class: MD2 - MEDICAL EVENT | | Medical Event Information: Patient Number: 1 | | % Overexposed: 23 | | Procedure: BRACHY, REMOTE AFTERLOADER, | | Dose in RAD: 2460 Organ: HEART Study: CARDIOVASCULAR SYSTEM | | Radionuclide: P-32 | | Administered By: PHYSICIAN Keywords: INTRAVASCULAR BRACHYTHERAPY" | | | | Item Number: IL020074 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39430 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 12/09/2002| | UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 12:42[EST]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/09/2002| +------------------------------------------------+EVENT TIME: 10:20[CST]| | NRC NOTIFIED BY: MARK BITTMANN |LAST UPDATE DATE: 12/10/2002| | HQ OPS OFFICER: ERIC THOMAS +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |KENNETH REIMER R3 | |10 CFR SECTION: | | |ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Decommissioned |0 Decommissioned | |2 N N 0 Decommissioned |0 Decommissioned | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF ENS AND COMMERCIAL TELEPHONE LINES | | | | At 10:20 CST on 12/9/2002, experienced a major loss of offsite | | communications ability on the ENS, NARS, and commercial telephone systems. | | Repair personnel have been dispatched to the site by Ameritech. The | | licensee is continually manning a cell phone until the lines are restored. | | | | Internal communications on site are still available, as well as microwave | | communications to the EOF. | | | | A trouble ticket was generated for the FTS lines, ticket number 3612. | | | | The licensee notified the State and stated that the NRC Resident Inspector | | will be notified. | | | | * * * * UPDATE FROM ZION TO MIKE RIPLEY AT 2325 EST 12/9/02 * * * | | | | Repair crews have pinpointed the telephone line problem and anticipate | | completing repairs by mid-day Tuesday, 12/10/02. The licensee continues to | | man a cell phone until the lines are restored. | | | | Notified the R3 DO (P. Hiland) | | | | ***UPDATE FROM ZION TO HOWIE CROUCH AT 0509 EST ON 12/10/02 *** | | | | Licensee reported that all commercial and ENS lines have been repaired and | | returned to service. | | | | Notified the R3 DO (P. Hiland) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 39432 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 12/10/2002| |LICENSEE: LAREDO REGIONAL MEDICAL CENTER |NOTIFICATION TIME: 10:13[EST]| | CITY: LAREDO REGION: 4 |EVENT DATE: 11/26/2002| | COUNTY: STATE: TX |EVENT TIME: [CST]| |LICENSE#: L02192-001 AGREEMENT: Y |LAST UPDATE DATE: 12/10/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KRISS KENNEDY R4 | | |DANIEL GILLEN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JAMES H. OGDEN, JR. | | | HQ OPS OFFICER: JASON FLEMMING | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT ON AN I-131 SPILL AT A TEXAS HOSPITAL | | | | "Patient was administered an I-131 capsule for ablation therapy on November | | 26, 2002. A fragment was dropped on the floor. The fragment was measured to | | contain 13 millicuries of I-131. A contamination survey of the room | | determined that an area by the sink and an area by the imaging table | | revealed contamination. The room was sealed off, contamination by the sink | | was determined to have contamination in the amount of 2 millirem/hour near | | the sink and 1.6 millirem /hour near the imaging table. After | | decontamination the room was re-surveyed with the result of 1.6 | | millirem/hour near the sink and 0.8 millirem/hour. Wipe tests were sent to | | the nuclear pharmacy for analysis. Results of the analysis indicated 87,313 | | dpm near the sink and 1,229 dpm near the imaging table. With readings still | | above the action limits for contamination the facility closed the room for | | four (4) weeks. At that time additional wipe tests will be conducted and | | submitted to the nuclear pharmacy for analysis. Bioassay of personnel | | performing decontamination were conducted 24-hours after the clean-up with | | no action required for the clean-up crew. The fragment of the capsule was | | packaged in a lead container and returned to the nuclear pharmacy for | | disposal." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39433 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 12/10/2002| | UNIT: [1] [] [] STATE: AL |NOTIFICATION TIME: 10:39[EST]| | RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 12/10/2002| +------------------------------------------------+EVENT TIME: 08:25[CST]| | NRC NOTIFIED BY: HUNTER |LAST UPDATE DATE: 12/10/2002| | HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |BRIAN BONSER R2 | |10 CFR SECTION: | | |ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| | |AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 M/R Y 100 Power Operation |0 Hot Standby | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL TRIP FROM 100% POWER DUE TO STEAM GENERATOR LEVELS APPROACHING LOW | | LEVEL TRIP POINT | | | | The unit was manually tripped from 100% power due to steam generator levels | | approaching the low level trip setpoint. The motor driven auxiliary | | feedwater pumps auto started as a result of a trip of both main feedwater | | pumps and the turbine driven auxiliary feedwater pump autostarted due to low | | steam generator levels. The main feed pumps trip was a result of loss of | | power to the control systems. An unintentional impact to the power supply | | for the control systems by plant facilities personnel resulted in the loss | | of power. All rods fully inserted, no ECCS actuation occurred and no relief | | valves lifted. The unit is currently in mode 3 and all plant systems | | responded as designed. | | | | The NRC Resident inspector was notified. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39434 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: BRAIDWOOD REGION: 3 |NOTIFICATION DATE: 12/10/2002| | UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 12:20[EST]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/10/2002| +------------------------------------------------+EVENT TIME: 11:20[CST]| | NRC NOTIFIED BY: CARL MOORE |LAST UPDATE DATE: 12/10/2002| | HQ OPS OFFICER: ARLON COSTA +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |PATRICK HILAND R3 | |10 CFR SECTION: |CHRISTOPHER GRIMES NRR | |APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION |NADER MAMISH IRO | | |ELIZABETH HAYDEN OPA | | |SCOTT MORRIS EDO | | |JAN STRASMA R3 | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 100 Power Operation |100 Power Operation | |2 N Y 100 Power Operation |100 Power Operation | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION DUE TO SUSPICIOUS INDIVIDUAL | | | | The licensee is issuing the following press release: | | | | "BRACEVILLE, IL - About 11:30 p.m. Monday, a man driving a compact vehicle | | failed to stop at the Braidwood Nuclear Station's initial security | | checkpoint in violation of station security policies. The unidentified male, | | who was in the plant's parking lot briefly, refused to obey the security | | officers' instructions, drove through the station parking lot and left the | | site. He did not threaten the safety of the plant. At no time was the health | | and safety of the public threatened. The man left the site after a few | | minutes and was detained in a short period of time by officers from the | | Wilmington Police Department, who had been notified by the Braidwood Police | | Department. | | | | "After the man entered the station property, Braidwood security officers | | used a direct communications link to immediately contact local authorities, | | who subsequently notified the FBI. Exelon is working with the FBI's Chicago | | office and local authorities and has notified the Nuclear Regulatory | | Commission. | | | | "Plant security forces acted promptly and effectively in handling the | | incident and received outstanding support from local law enforcement. The | | FBI is handling the investigation." | | | | The Licensee notified the NRC Resident Inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39435 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: FRAMATOME |NOTIFICATION DATE: 12/10/2002| |LICENSEE: FRAMATOME |NOTIFICATION TIME: 14:41[EST]| | CITY: REGION: |EVENT DATE: 12/10/2002| | COUNTY: STATE: |EVENT TIME: [EST]| |LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 12/10/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KRISS KENNEDY R4 | | |CHRISTOPHER GRIMES NRR | +------------------------------------------------+ | | NRC NOTIFIED BY: JERALD S. HOLM | | | HQ OPS OFFICER: ERIC THOMAS | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POWERPLEX INCORE MONITORING SYSTEM | | | | Location of fuel assemblies in BWR/6 reactors with the POWERPLEX incore | | monitoring system may affect their orifice pressure loss coefficients by as | | much as 40%. The GE core monitoring system uses average orifice loss | | coefficient values for all assemblies in the core, and a recent evaluation | | by GE for current fuel designs indicates that the assumption may be | | non-conservative by up to .01 in predicted MCPR. | | | | Analyses have been performed at Grand Gulf and River Bend, the two BWR/6 | | reactors in the U.S. which use the POWERPLEX incore monitoring system, to | | assess the impact of using position dependent orifice loss coefficients. | | The analyses indicate that for Grand Gulf, MCPR is non-conservatively over | | predicted by not more that 2%, and that LHGR and MAPLHGR are | | non-conservatively under predicted by not more than 2%. For River Bend, the | | analyses indicate that MCPR is non-conservatively over predicted by up to | | 1.2%, LHGR is non-conservatively under predicted by up to 0.7%, and MAPLHGR | | is non-conservatively under predicted by up to 0.6%. | | | | The affected plants, Grand Gulf and River Bend, have been notified by | | Framatome. Compensatory measures were recommended to apply an | | administrative penalty on the allowed values of MCPR, LHGR, and MAPLHGR. | | The POWERPLEX incore monitoring input decks have been modified to include | | the correct orifice loss coefficients. The plants are currently operating | | with correct orifice loss coefficients in the POWERPLEX incore monitoring | | system. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Other Nuclear Material |Event Number: 39436 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: R. M. WESTER ASSOCIATES CONSULTING |NOTIFICATION DATE: 12/10/2002| |LICENSEE: TSI ENGINEERING |NOTIFICATION TIME: 18:18[EST]| | CITY: ST LOUIS REGION: 3 |EVENT DATE: 12/10/2002| | COUNTY: STATE: MO |EVENT TIME: 14:30[CST]| |LICENSE#: 24-32205-01 AGREEMENT: N |LAST UPDATE DATE: 12/10/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |PATRICK HILAND R3 | | |NADER MAMISH IRO | +------------------------------------------------+LARRY CAMPER NMSS | | NRC NOTIFIED BY: ROBERT WESTER | | | HQ OPS OFFICER: ERIC THOMAS | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | HUMBOLT MOISTURE DENSITY GAUGE DAMAGED | | | | At a construction site in Downtown St. Louis, a moisture density gauge was | | run over by a high lift. The gauge was in the uncovered position, and is | | currently buried in the soil. Local fire department was notified, and came | | to the site to measure radiation levels. Levels were 112 mr/hr at a | | distance of 3 feet. The area has been secured, awaiting arrival of a | | hazardous material removal team from R.M. Wester Associates (license | | #24-20091-01). The hazmat team will remove the gauge and any contaminated | | soil that they find. Humbolt is also dispatching an environmental response | | team to the site. The moisture density gauge contains 10 mCi of Cs-137 and | | 40 mCi of Am-241. | | | | The R3 PAO was notified. The R3DO (P. Hiland) contacted the state of | | Missouri. | | | | **** UPDATE AT 2030 EST FROM R3DO AND DARREL WIEDEMAN TO MIKE RIPLEY **** | | | | Gauge has been recovered. Actual readings were 1.25 mr/hr at 3 feet. Gauge | | was slightly damaged, but the source was intact. No contamination was found | | in the area. Humbolt representative was on the scene. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39437 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 12/11/2002| | UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 02:41[EST]| | RXTYPE: [1] GE-2 |EVENT DATE: 12/11/2002| +------------------------------------------------+EVENT TIME: 02:30[EST]| | NRC NOTIFIED BY: STEVE FULLER |LAST UPDATE DATE: 12/11/2002| | HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |MICHELE EVANS R1 | |10 CFR SECTION: | | |APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION TO FAA | | | | Licensee made an offsite notification to FAA due to loss of power to plant | | stack lighting. FAA assigned notification number MIV-212/061-RG. FAA was | | again notified at 0230 EST that the stack lights were returned to service, | | | | Licensee notified NRC resident. | +------------------------------------------------------------------------------+
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Page Last Reviewed/Updated Thursday, March 25, 2021