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Event Notification Report for January 29, 2003
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/28/2003 - 01/29/2003 ** EVENT NUMBERS ** 39533 39534 39541 39542 39543 39544 +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39533 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 01/24/2003| |LICENSEE: GILES ENGINEERING ASSOCIATES |NOTIFICATION TIME: 14:50[EST]| | CITY: DALLAS REGION: 4 |EVENT DATE: 01/23/2003| | COUNTY: STATE: TX |EVENT TIME: [CST]| |LICENSE#: L04919 AGREEMENT: Y |LAST UPDATE DATE: 01/24/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |GREG PICK R4 | | |JOHN DAVIDSON IAT | +------------------------------------------------+SUSAN FRANT NMSS | | NRC NOTIFIED BY: HELEN WATKINS | | | HQ OPS OFFICER: MIKE RIPLEY | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE | | | | The following information was received from the Texas Department of Health, | | Bureau of Radiation Control (Texas incident I-7973): | | | | "The nuclear gauge was stolen last night. (January 23-24, 2003). It was | | stolen from an Econoline van parked overnight at an apartment complex. The | | gauge was locked inside its case and was inside a storage compartment in the | | cargo area of the locked van. Access was gained by breaking out the windows | | of the van. | | | | "The gauge operator [DELETED] is uncertain of the exact time of the theft. | | He went out to dinner in his private vehicle and did not notice any problem | | with the van when he returned home at approximately 8 o'clock in the | | evening. However, when he stepped outside at 4:30 am to warm up his wife's | | car, he noticed the Duncanville [Texas] police were on the scene. Three vans | | parked within about 150 feet of each other, including his, had been | | burglarized in a similar fashion. One van belonged to an air conditioning | | company. | | | | "The thief took many other items from the van including concrete testing | | equipment, a coat, measuring tape and a couple of buckets of tools. The | | gauge and its case were taken. The case is clearly labeled with the | | company's name and phone number. Inside the case is a full set of paperwork | | identifying the gauge, a current leak test, and other documents containing | | the company's letterhead. The police report number is 03000589. The RSO | | notified Troxler in Arlington [Texas] of the theft." | | | | The gauge is a Troxler Model # 3430, Serial # 031693, 40 millicuries | | Am-241/Be, 8 millicuries Cs-137. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39534 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 01/24/2003| |LICENSEE: PROFESSIONAL SERVICES INDUSTRIES, INC|NOTIFICATION TIME: 17:53[EST]| | CITY: CLUTE REGION: 4 |EVENT DATE: 11/25/2002| | COUNTY: STATE: TX |EVENT TIME: [CST]| |LICENSE#: L00203-001 AGREEMENT: Y |LAST UPDATE DATE: 01/24/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |GREG PICK R4 | | |JOHN HICKEY NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: HELEN WATKINS | | | HQ OPS OFFICER: MIKE RIPLEY | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - DOSIMETRY LEFT IN RADIOGRAPHY AREA | | | | The following information was received from the Texas Department of Health, | | Bureau of Radiation Control (Texas incident I-7972): | | | | "During the monitoring period 11/25/2002 through 12/24/2002, radiographer | | [deleted] left his badge in an area where it was exposed by a radiography | | crew performing concrete rebar radiography with long exposure times. | | [deleted] phoned the licensee's corporate offices on January 23, 2003 to | | report a badge overexposure. At the current time it is thought that the | | radiographer reported the incident to his supervisor [deleted] RSO in the | | Clute [TX] Office. The date and time of that report is currently unknown. | | His badge exposure was measured at 8.266 Rem. A final report has not been | | received from the badge processor by the Licensee's corporate office, only a | | Fax transmittal. The corporate office indicated the incident was not | | previously reported to the corporate office or they would have had the badge | | submitted for emergency reading." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39541 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 01/28/2003| | UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 10:05[EST]| | RXTYPE: [1] W-4-LP |EVENT DATE: 01/28/2003| +------------------------------------------------+EVENT TIME: 09:20[EST]| | NRC NOTIFIED BY: RON STRICKLAND |LAST UPDATE DATE: 01/28/2003| | HQ OPS OFFICER: ARLON COSTA +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |DANIEL HOLODY 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 | | | | "A fake news article was created on the internet. This fake article appears | | to be a CNN report that claimed Seabrook is under intense FBI investigation | | for dumping several radioactive uranium cores. | | | | "The [NRC] resident inspector was notified at 09:20, and the shift manager | | was notified shortly after. NRC would like to be notified if a press | | release will be [issued by Seabrook]. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39542 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 01/28/2003| | UNIT: [1] [2] [] STATE: PA |NOTIFICATION TIME: 11:39[EST]| | RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 01/28/2003| +------------------------------------------------+EVENT TIME: 09:30[EST]| | NRC NOTIFIED BY: DON ROLAND |LAST UPDATE DATE: 01/28/2003| | HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |DAN HOLODY R1 | |10 CFR SECTION: | | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | PRE-ACCESS CONTRACT SUPERVISOR ACCESS TERMINATED DUE TO A CONFIRMED POSITIVE | | TEST | | FOR A CONTROLLED SUBSTANCE. | | | | At 09:30 on 01/28/03, a contract supervisor for the turbine upgrade project | | had a confirmed positive for a controlled substance during a pre-access | | fitness for duty test. The supervisor's access to the station has been | | suspended in accordance with the station's fitness for duty program. | | | | The NRC Resident Inspector was notified of this event by the licensee. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 39543 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION DATE: 01/28/2003| |LICENSEE: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION TIME: 17:27[EST]| | CITY: ROYAL OAKS REGION: 3 |EVENT DATE: 01/28/2003| | COUNTY: STATE: MI |EVENT TIME: 10:30[EST]| |LICENSE#: 21-01333-01 AGREEMENT: N |LAST UPDATE DATE: 01/28/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |MARK RING R3 | | |M. WAYNE HODGES NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: CHERYL SCHULTZ | | | HQ OPS OFFICER: GERRY WAIG | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION - RADIATION DOSE EXCEEDED PLANNED DOSE | | | | The following is taken from a facsimile sent from the licensee: | | | | A patient with and injury in the right coronary artery was to be treated | | with Novoste Sr-90 40 mm [millimeter] 3.5 Fr [French] device for 4 minutes | | 31 seconds each for a pullback procedure. The radiation oncologist had | | difficulty with the device and had to perform an emergency bail-out. We | | later confirmed that the sources were stuck either inside or just slightly | | outside the device, so there was no dose to the patient. The decision was | | made to proceed with the treatment with the Novoste Sr-90 40 mm 5 Fr device. | | The radiation oncologist scrubbed and primed the catheter with the dummy | | device. The change in the treatment device and new treatment time of 3 | | minutes 41 seconds was noted on the QM form. The revised treatment time, | | however, was not entered into the stopwatch. Only the physicist verified the | | time on the stopwatch and because of the similarities in the timing units (4 | | m 31 s versus 3 m 41 s),did not catch the error in time on the stopwatch. | | At the end of the treatment the physicist noted that the timer had not been | | reset for the 5 Fr device. During the 50 extra seconds of treatment time the | | patient received a dose of 28.2 Gy [Gray] rather than the prescribed dose of | | 23 Gy (22.6% more than the prescribed dose). The patient was informed of the | | error by the radiation oncologist and cardiologist later the same day. No | | adverse effect is expected for the patient | | | | "Some of the corrective actions under review include: | | 1. Improve the double-checking process prior to the start of the treatment. | | Usually the radiation oncologist double checks the treatment time, but in | | this case he was scrubbed and could not fully confirm the change in the | | treatment time on the QM form. Also the clinical coordinator who double | | checks the time programmed into the stopwatch and handles the back-up timer, | | was not available during this case, | | 2. The emergency bail out procedure disrupted the normal flow of the | | treatment. The team needs to be very aware of the greater vulnerability to | | error whenever emergency procedures are involved. | | 3. Scheduling issues may need to be addressed. | | 4. Additional training issues may need to be addressed." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Fuel Cycle Facility |Event Number: 39544 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 01/28/2003| | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 22:57[EST]| | COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 01/28/2003| | 6903 ROCKLEDGE DRIVE |EVENT TIME: 15:30[CST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 01/28/2003| | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION | |LICENSE#: GDP-1 AGREEMENT: Y |MARK RING R3 | | DOCKET: 0707001 |FRED BROWN NMSS | +------------------------------------------------+KEN RIEMER R3 | | NRC NOTIFIED BY: TOM WHITE | | | HQ OPS OFFICER: GERRY WAIG | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION - PADUCAH GDP | | | | | | "At 1530 On 1-28-03, the Plant Shift Superintendent (PSS) was notified that | | the condenser pressure on Unit 4 Cell 9 in C-335 was not monitored at the | | require[d] frequency. When the condenser return valve will be closed and the | | supply spool piece will remain in place, the condenser supply pressure must | | be maintained at 20 psig or less to ensure that less than 10Kg of water can | | enter the process gas system. In order to ensure the pressure Is maintained | | below the maximum allowable pressures a gauge is installed arid monitored at | | a frequency of once every 8 hours for Unit 4 Cell 9 in C-335. The gauge was | | installed and first read at 2245 on 1-27-03. The next reading was taken at | | 0950 on 1-28-03. This period exceeded the 8 hours allowed. The NRC Resident | | Inspector has been notified of this event. | | | | "SAFETY SIGNIFICANCE OF EVENTS: | | | | "The pressure reading frequency was violate, however, the RCW [Recirc | | Cooling Water] pressure limit was not exceeded. Although a control relied | | upon for double contingency was violated. | | | | "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW | | CRITICALITY COULD OCCUR | | | | "In order for criticality to be possible, there must be a large condenser | | leak at the same time as a high RCW pressure. In addition, the high RCW | | pressure condition would have to go unnoticed and uncorrected beyond the | | specified time limits. | | | | "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC | | | | "Double contingency is maintained by implementation of two controls on | | moderation. | | | | "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS | | LIMIT AND WORST CASE CRITICAL MASS): | | | | "No known mass of licensed material exists in the condenser. System NCS | | limit is [deleted] wt.% U235. | | | | "NUCLEAR CRITICALITY SAFETY CONTROLS) OR CONTROL SYSTEMS(S) AND DESCRIPTION | | OF THE FAILURES OR DEFICITS | | | | "The first leg of double contingency is based on the ability to identify a | | pressure exceedance of the RCW condenser pressure limit within 8 hours. RCW | | pressure readings are monitored at a frequency at 1/2 the time it would take | | for an unsafe mass of moderator to leak into the process gas side. The RCW | | condenser pressure reading was obtained after the 8 hour time limit. | | Therefore, this leg of double contingency was lost. | | | | "The second leg of double contingency is based on the ability to check the | | pressure reading within 16 hours and to take corrective actions within 23 | | hours. The pressure was checked within 16 hours and was not In excess of the | | limit. Since the pressure limit was not exceeded, this leg of double | | contingency was maintained. | | | | "Since the first leg was lost, the double contingency principle was | | violated. | | | | "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS | | IMPLEMENTED: | | | | "At the time of discovery, the appropriate frequency of monitoring was | | identified and initiated." | +------------------------------------------------------------------------------+