Event Notification Report for March 18, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/17/2003 - 03/18/2003
** EVENT NUMBERS **
39663 39666 39673 39674 39675
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|General Information or Other |Event Number: 39663 |
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| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE: 03/12/2003|
|LICENSEE: PM TESTING LABORATORY |NOTIFICATION TIME: 11:11[EST]|
| CITY: Tacoma REGION: 4 |EVENT DATE: 03/05/2003|
| COUNTY: STATE: WA |EVENT TIME: 20:00[PST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ARDEN SCROGGS | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| WA AGREEMENT STATE REPORT ON POSSIBLE OVEREXPOSURE INCIDENT |
| |
| |
| "Licensee: PM TESTING LABORATORY |
| "Licensee number: WN-11R047-1 |
| "Type of licensee: Industrial Radiography |
| |
| "Date of event: March 5, 2003 |
| "Location of event: Port of Tacoma, WA. German cargo ship 'Big Lift' |
| |
| "ABSTRACT: (as reported by licensee's representative) A radiographer and |
| Assistant Radiographer were performing radiography at the Port of Tacoma, on |
| a German cargo ship 'Big Lift' on March 5, 2003, at approximately 10 PM |
| [PST]. The work required the radiographers to use a cherry-picker type |
| lifting vehicle to access the work area since the area was about 100 feet |
| above deck level. The Radiographer and Assistant were both in the lift |
| bucket, 2 feet apart, at the time of the incident. The industrial |
| radiographic device (Amersham Corporation Model 660B, containing |
| approximately 70 curies of iridium 192) with connected guide tube, |
| collimator and control cables had been lifted into position and secured in |
| the area of the intended exposure. The exposure device had been made ready |
| for the exposure. The operation required the Radiographer and Assistant to |
| move the lift as far from the exposure area as possible while extending the |
| control cable. |
| |
| "As the lift was being positioned away from the work area it swayed, this |
| startled the radiographer who dropped the control cable. The sway also |
| caused the lift's engine to stall. The action of dropping the control cable |
| to the extent of its length and resulting sudden stop at the end of the drop |
| caused the source to become unshielded. Their survey meter immediately went |
| off scale on the highest scale and their alarm-rate meters were alarming. |
| |
| "It took the radiographers, by their estimate, about 30 seconds to restart |
| the [lift] vehicle, move the bucket so they could recapture the control |
| cable and secure the source. When they were able to check their pocket |
| ion-chambers, they found them off scale. Work was stopped for the day and |
| both film badges were sent for processing. |
| |
| "Results from film badge processing and analysis indicated the Radiographer |
| received a whole body exposure of 1600 millirem. This coincided with the |
| calculations made by the Radiographer after the incident. The film badge for |
| the Assistant indicated an exposure of 1,423,000 millirem. When the badge |
| processor was contacted and asked to reanalyze the film they stated they got |
| the same exposure. |
| |
| "Since both radiographers were within 2 feet of each other in the lift |
| basket and calculations confirmed that the Radiographer's exposure was 1600 |
| milliRem, it appears the exposure to the Assistant was incorrectly |
| determined. In addition, the Assistant is not exhibiting any signs of an |
| excessive exposure. The company is submitting a report of the incident. The |
| Division is performing an investigation. Media, at present, are not |
| involved. |
| |
| "What is the notification or reporting criteria involved? WAC 246-221-260, |
| Reports of overexposures and excessive levels and concentrations. |
| |
| "Activity and Isotope(s) involved? 70 curies of Iridium 192. |
| |
| "Overexposure? Until the investigation indicates otherwise, the process |
| report of the Assistant's film badge indicates a whole body exposure of |
| about 1,423,000 milliRem. The over exposure is apparently not real since |
| calculations using exposure time, distance and source activity and a second |
| film badge, worn by another individual closely associated with the first all |
| indicate exposure is unusual but much lower. Staff will investigate." |
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|General Information or Other |Event Number: 39666 |
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| REP ORG: NEW MEXICO RAD CONTROL PROGRAM |NOTIFICATION DATE: 03/13/2003|
|LICENSEE: CARDINAL HEALTH |NOTIFICATION TIME: 15:00[EST]|
| CITY: ALBUQUERQUE REGION: 4 |EVENT DATE: 03/03/2003|
| COUNTY: STATE: NM |EVENT TIME: [MST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BILL FLOYD | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| NEW MEXICO AGREEMENT STATE REPORT ON LOST SOURCE |
| |
| "On March 3, 2003, Cardinal Health in Albuquerque shipped out an ammo-can, |
| via Federal Express Overnight, containing 1.251 Giga-Becquerel of I-131 in |
| an inorganic salt, solid state to the Cardinal Health facility in Amarillo, |
| TX. for delivery on 03/04/03. The Amarillo facility called on Tuesday, |
| 03/04/03, to state they never received it. [DELETED ] placed a call with |
| Federal Express immediately to trace the package. She continued to place |
| calls with Federal Express on 03/05/03 and 03/06/03 to check on the status |
| of the package. On each occasion, Federal Express stated they had yet to |
| locate the package. On Friday 03/07/03 I called [DELETED ] at our Quality |
| and Regulatory Dept. to notify them of the missing package. He, in turn, |
| placed a call with the New Mexico Environment Dept. On Monday, 03/10/03, I |
| called Federal Express and spoke with [DELETED ] of the Amarillo office. She |
| stated that they had done a thorough search of the Amarillo office and could |
| not find the package. She also stated that there was to be a search of the |
| Memphis location and that they would hopefully know something by Tuesday |
| 03/11/03. I notified [DELETED ] of my conversation with Federal Express. We |
| did not hear anything from FedEx on Tuesday. On Wednesday 03/12/03, I called |
| FedEx again and spoke with a representative by the name of [DELETED]. She |
| confirmed that the package had still not been located. I then contacted |
| [DELETED ] again to report the information. I also left a message with the |
| New Mexico Environment Dept. regarding the current state of the matter. We |
| will continue to monitor the situation. The tracking number for the package |
| is [DELETED]." |
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|Power Reactor |Event Number: 39673 |
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| FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 03/17/2003|
| UNIT: [1] [] [] STATE: TX |NOTIFICATION TIME: 01:25[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/16/2003|
+------------------------------------------------+EVENT TIME: 21:49[CST]|
| NRC NOTIFIED BY: STEVEN SEWELL |LAST UPDATE DATE: 03/17/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK SHAFFER R4 |
|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 REACTOR TRIP AND AUXILIARY FEEDWATER ACTUATION DUE TO CONDENSATE PUMP |
| TRIP |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| "Unit 1 manual reactor trip (RPS actuation) was initiated at 2149 [CST] due |
| to a loss of main feedwater. The event was initiated by a trip of |
| Condensate Pump 1-01 which resulted in a trip of Main Feedwater Pump 'B' and |
| Main Feedwater Pump 'A' due to inadequate suction pressure. |
| |
| "An automatic initiation of Auxiliary Feedwater (ESF actuation) occurred |
| when both Main Feedwater Pumps tripped. |
| |
| "Unit 1 is currently in Hot Standby (Mode 3) with decay heat removal via |
| Auxiliary Feedwater and Steam Dump to the Main Condenser. All safety |
| systems responded appropriately. The cause of the Condensate Pump 1-01 trip |
| is currently under investigation." |
| |
| All control rods fully inserted. There are no indications of any |
| primary-to-secondary leakage. There were no primary or secondary power |
| operated relief or manual relief valves lifted. The electrical grid is |
| stable. The licensee did receive low steam generator level alarms (as |
| expected) but levels were recovered and are being maintained via the |
| Auxiliary Feedwater system. Unit 2 is stable and was not affected by the |
| Unit 1 trip. |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Hospital |Event Number: 39674 |
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| REP ORG: ELMBROOK MEMORIAL HOSPITAL |NOTIFICATION DATE: 03/17/2003|
|LICENSEE: ELMBROOK MEMORIAL HOSPITAL |NOTIFICATION TIME: 14:29[EST]|
| CITY: BROOKFIELD REGION: 3 |EVENT DATE: 03/07/2003|
| COUNTY: STATE: WI |EVENT TIME: 13:00[CST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 03/17/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KENNETH O'BRIEN R3 |
| | |
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| NRC NOTIFIED BY: BILL ARTNER | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
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EVENT TEXT
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| MISSING IODINE-125 SEED |
| |
| On March 3, 2003 120 Iodine-125 seeds, each with an activity of |
| 0.31millicuries, were implanted in a patient. Four of the seeds were |
| recovered from the bladder and placed in a lead pig. On March 7, 2003 an |
| inventory was taken of the lead pig before shipping the seeds back to the |
| manufacturer. During the inventory check it was discovered that the lead |
| pig only contained 3 Iodine-125 seeds instead of 4. A radiation surveys |
| were taken of the areas where the seeds had been removed and the missing |
| seed was not found. |
| |
| Notified NMSS EO (F. Brown) and R3DO (K. O'Brien, J. Creed). |
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|Power Reactor |Event Number: 39675 |
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| FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 03/17/2003|
| UNIT: [] [2] [] STATE: CA |NOTIFICATION TIME: 16:48[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/17/2003|
+------------------------------------------------+EVENT TIME: 08:18[PST]|
| NRC NOTIFIED BY: DYE |LAST UPDATE DATE: 03/17/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLAUDE JOHNSON R4 |
|10 CFR SECTION: | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
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| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
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|2 N N 0 Hot Standby |0 Hot Standby |
| | |
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EVENT TEXT
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| REACTOR WAS MANUALLY TRIPPED WHILE IN MODE 3 DUE TO ONE ROD REMAINING AT 0 |
| STEPS WHILE THE BANK OF RODS WAS BEING WITHDRAWN |
| |
| "On 3/17/2003 at 0818, Unit 2 was in its 11th refueling outage in MODE 3 |
| (hot standby). Post-maintenance testing of digital rod position indication |
| (DRPI) was in progress in accordance with Surveillance Test Procedure (STP) |
| R-1C. Rod control bank B was being withdrawn. As the bank of rods was |
| withdrawn, rod F2 DRPI indication remained at 0 steps. When the bank |
| demand position indication exceeded rod F2's DRPI indication by greater than |
| 12 steps, the reactor trip breakers were opened by manual reactor trip |
| initiation. This action was taken to comply with the STP precautions to |
| positively place the control rods in a known position, i.e. fully inserted. |
| All systems actuated as required rods fully inserted, the main turbine |
| automatically tripped. |
| |
| "Manual initiation of a reactor trip where the actuation is not part of a |
| pre-planned evolution is reportable under 10CFR50.72. (b) (3) (iv) (A) and |
| 50.72(b) (3) (iv) (B) (1). While the reactor trip was initiated in |
| accordance with the STPs precautions, the manual actuation was not an |
| expected outcome of the STP. |
| |
| "Subsequently, it was determined that rod F2 was indeed on the bottom as |
| indicated by DRPI. A moveable gripper fuse was blown preventing that rod |
| from being withdrawn. The blown fuse was replaced and testing continued in |
| accordance with the outage schedule." |
| |
| The NRC Resident Inspector was notified. |
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