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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
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|General Information or Other |Event Number: 39533 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|General Information or Other |Event Number: 39534 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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." |
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|Power Reactor |Event Number: 39541 |
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| 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 |
| | |
| | |
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EVENT TEXT
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| 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]. |
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|Power Reactor |Event Number: 39542 |
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| 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 |
| | |
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EVENT TEXT
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| 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. |
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|Hospital |Event Number: 39543 |
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| 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| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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." |
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|Fuel Cycle Facility |Event Number: 39544 |
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| 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 | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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." |
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