United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > March 18

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  



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   39663       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 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."        |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   39666       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 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]."                                                               |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Power Reactor                                    |Event Number:   39673       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| 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      |

|                                                   |                          |

|                                                   |                          |

+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 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.                        |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Hospital                                         |Event Number:   39674       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| 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      |

|                                                |                             |

+------------------------------------------------+                             |

| 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    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 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).                 |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Power Reactor                                    |Event Number:   39675       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| 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|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|                                                   |                          |

|2     N          N       0        Hot Standby      |0        Hot Standby      |

|                                                   |                          |

+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 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.                                     |

+------------------------------------------------------------------------------+