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
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|General Information or Other |Event Number: 39426 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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 |
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|Power Reactor |Event Number: 39430 |
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| 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 |
| | |
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EVENT TEXT
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| 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) |
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|Hospital |Event Number: 39432 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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." |
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|Power Reactor |Event Number: 39433 |
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| 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 |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 39434 |
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| 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 |
| | |
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EVENT TEXT
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| 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. |
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|General Information or Other |Event Number: 39435 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Other Nuclear Material |Event Number: 39436 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 39437 |
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| 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 |
| | |
| | |
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EVENT TEXT
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| 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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