Event Notification Report for April 2, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/01/2003 - 04/02/2003
** EVENT NUMBERS **
39581 39706 39707 39708 39710 39718 39719 39720
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 39581 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 02/12/2003|
| UNIT: [] [2] [] STATE: AZ |NOTIFICATION TIME: 16:13[EST]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 02/07/2003|
+------------------------------------------------+EVENT TIME: 17:20[MST]|
| NRC NOTIFIED BY: MARKS |LAST UPDATE DATE: 04/01/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHARLES MARSCHALL R4 |
|10 CFR SECTION: | |
|AINC 50.72(b)(3)(v)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 98 Power Operation |98 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LEAKAGE DISCOVERED FROM HIGH PRESSURE SAFETY INJECTION SYSTEM OUTSIDE |
| CONTAINMENT |
| |
| "On February 7, 2003, at approximately 17:20 Mountain Standard Time (MST), |
| Palo Verde Unit 2 discovered leakage from the high pressure safety injection |
| system outside containment that could contain highly radioactive fluids |
| during a serious transient or accident exceeded the safety analysis leakrate |
| limit. The drain valve that was the source of the leakage was promptly |
| tightened to return to within the analysis limit and subsequently repaired |
| to further reduce leakage to a level as low as practicable. There was no |
| release of radioactivity to the environment as a result of this event. |
| There were no adverse safety consequences resulting from the event. |
| |
| The "loss of safety function" reporting requirement would be triggered by |
| the described condition because the post-LOCA dose calculations assume no |
| more than 1500 ml/hour leakage outside of containment in the 10 CFR 100 |
| siting analysis. At the time of discovery, the leakage was 1715 ml/min |
| (102900 ml/hr). Therefore the safety function to control the release of |
| radioactive material such that the dose to a member of the public would not |
| exceed 10 CFR 100 limits during a potential LOCA was not fulfilled. |
| |
| At the time of the discovery the condition was promptly corrected so no ENS |
| report was thought to be required, however on further review it was noted |
| that the reporting requirement states "Any event or condition that at the |
| time of discovery could have prevented.." and therefore remains immediately |
| reportable even if the condition no longer exists." |
| |
| The NRC Resident Inspector was notified. |
| |
| *** RETRACTED ON 4/1/03 AT 1605 EST FROM D. STRAKA TO A. COSTA *** |
| |
| "This notification is a RETRACTION of the February 7, 2003, ENS #39581 which |
| reported a Palo Verde Nuclear Generating Station Unit 2 loss of safety |
| function to control the release of radioactive materials due to leakage from |
| the high pressure safety injection system outside containment that could |
| contain highly radioactive fluids during a serious transient or accident |
| arid exceed the safety analysis Ieakrate limit. |
| |
| "At the time of discovery, the leakage was assumed to exceed the 10 CFR 100 |
| limits for dose to a member of the public during a potential LOCA [Loss of |
| Coolant Accident]. Therefore the safety function to control the release of |
| radioactive material would not be fulfilled. |
| |
| "PVNGS [Palo Verde Nuclear Generating Station] System Engineering |
| re-evaluated the condition and has concluded that the identified leakage was |
| well within the limiting large break loss of coolant accident analysis and |
| that the 10 CFR 100 limits would not have been exceeded. Therefore, the loss |
| of a safety function DID NOT exist and the condition is not reportable. |
| |
| "The NRC Resident Inspector has been notified." |
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|General Information or Other |Event Number: 39706 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 03/27/2003|
|LICENSEE: SOURCE TECH MEDICAL |NOTIFICATION TIME: 16:22[EST]|
| CITY: SCHAUMBERG REGION: 3 |EVENT DATE: 03/26/2003|
| COUNTY: STATE: IL |EVENT TIME: 15:00[CST]|
|LICENSE#: IL-02062-01 AGREEMENT: Y |LAST UPDATE DATE: 03/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MICHAEL PARKER R3 |
| |RUDOLPH BERNHARD R2 |
+------------------------------------------------+E. WILLIAM BRACH NMSS |
| NRC NOTIFIED BY: JOE KLINGER (E-MAIL) | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT - LOST OR STOLEN IODINE SOURCES |
| |
| The following information was received via e-mail from the Illinois |
| Department of Nuclear Safety: |
| |
| "[DELETED], RSO of SourceTech Medical [(DELETED)] in Carol Stream, IL called |
| at 1500 hours on March 26, 2003, to report that he had received a shipment |
| of returned I-125 seeds. The dose rate on the surface of the package was 9 |
| [millirem/hr] instead of the expected dose rate of less than 0.5 |
| [millirem/hr]. Upon opening the box, 2 loose sources were found on top of |
| the packing material. 7 sources were noted in the shipping papers. An |
| additional source was found in a partially loaded Mick applicator but there |
| were no sources in the second Mick applicator. A total of only 3 sources |
| were found after looking through the other two lead containers in the |
| package. |
| |
| "Based on assay of the three seeds, the 4 missing seeds are 425 [microcurie] |
| I-125 each for a total of 1.7 [millicurie]. The contents of the package |
| (Fed Ex tracking no., [DELETED]) were obviously not prepared in accordance |
| with instructions provided by Source Tech in that the lids to the containers |
| were not secured nor were the vials used in the lead containers as the |
| instructions call for. The carrier, Federal Express had been contacted by |
| [DELETED] and the delivery truck surveyed. No sources were located during |
| the survey. According to tracking information, the package had gone from |
| St. Augustine through Jacksonville FL, Atlanta GA, Memphis TN, Chicago, IL |
| and the Schaumburg IL sorting facility prior to delivery in Carol Stream. |
| An inspector was dispatched to the Schaumburg facility at 15:45 to attempt a |
| search of the Schaumburg facility. |
| |
| "The sources were shipped from Slagley Hospital (Florida [DELETED]) in St. |
| Augustine Florida on Monday 3/24/2003. [DELETED] tried contacting the site |
| RSO, [DELETED], this afternoon but was unsuccessful. The department |
| contacted Mr. [DELETED] of the Florida program in their Orlando office and |
| relayed the information available at the time (see above). He indicated |
| that he would attempt a call as well but suspected the hospital staff would |
| be gone given the time of day (16:30) in Fla. On 3/27/03, [DELETED] |
| notified the department that he contacted the Florida licensee and the St. |
| Augustine hospital claimed that they counted twice the seven seeds not used |
| in a patient, placed them in a 'screwed sealed cartridge' then put them in a |
| shipping box for FedEx. The department also informed [DELETED], Ph.D., |
| health physics consultant for FedEx, that there are apparently 4 iodine-125 |
| seeds in FedEx facilities or vehicles somewhere as indicated by the routing |
| in the message below. Jim Lynch of the NRC was also advised of the |
| situation. On 03/26/03, a departmental inspector arrived at the Federal |
| Express Depot located at 1270 Wilkening Road in Schaumburg; [DELETED] and |
| explained the purpose of the visit. The inspector was provided access to |
| the package/truck staging area. Based on the FedEx tracking number, the |
| author was told that the bay used by the vehicle was the same one used in a |
| previous, recent incident involving I-125 seeds. Surveys were performed by |
| the inspector using an Eberline Model PRM-6 ratemeter, serial number 1470, |
| last calibrated on May 16, 2002, with an Eberline Model LEG-1 probe. |
| Background readings were [approximately] 250 - 350 CPM. Areas surveyed |
| included the conveyor belt system, particularly junctions between belts, |
| walkways, and the concrete pad where vehicles park for loading/unloading. |
| Particular attention was paid to the area where the truck was unloaded and |
| the seeds had been found in the previous incident. No seeds were located by |
| the inspector. The department is reviewing the packaging used by |
| SourceTech and the instructions to see if there they can be improved to |
| prevent recurrences. The event was reported to the NRC Operations Center at |
| 1622 hours EST on 3/27/03 and assigned Event No. 39706. A copy of this |
| report was electronically forwarded to the Ops Center as well as the states |
| of FL, GA, TN and NRC Region III." |
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|General Information or Other |Event Number: 39707 |
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| REP ORG: NEW YORK STATE DEPT. OF HEALTH |NOTIFICATION DATE: 03/27/2003|
|LICENSEE: NOT AVAILABLE |NOTIFICATION TIME: 17:40[EST]|
| CITY: REGION: 1 |EVENT DATE: 03/27/2003|
| COUNTY: STATE: NY |EVENT TIME: [EST]|
|LICENSE#: NOT AVAILABLE AGREEMENT: Y |LAST UPDATE DATE: 03/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PAMELA HENDERSON R1 |
| |E. WILLIAM BRACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT DANSEREAU (FAX) | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION |
| |
| The following information was received from the New York State Department of |
| Health, Bureau of Environmental Radiation Protection: |
| |
| "This notice is in regard to a medical misadministration involving a Novoste |
| Beta-Cath IVB 3.5F system, Model A1767 with AEAT Model SIC W.2 source train. |
| The event occurred on March 25, 2003. |
| |
| "Two attempts to advance the source train into the delivery catheter were |
| unsuccessful. A third (and final) attempt resulted in the source train |
| becoming stuck in the patient's femoral artery, somewhere in the lower groin |
| area. The sources could not be returned to the base unit. The treatment team |
| then removed the catheter, with the source extended, and placed these items |
| into the emergency bailout box. |
| |
| "The licensee estimated that the patient received an exposure of 250 Rads to |
| an area of the femoral artery in the lower groin area. The oncologist and |
| cardiologist decided not to proceed with IVB treatment of this patient. |
| Hospital staff concluded that the misdirected radiation exposure would not |
| have a significant health effect on the patient. |
| |
| "This event meets the reporting requirements in 10 NYCRR 16. The facility |
| will investigate the circumstances, procedures, training, history of use, |
| etc., and will submit a written report within 7 days. The device, including |
| catheter and hydraulic attachment (syringe) will be sent to the vendor for |
| evaluation." |
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|General Information or Other |Event Number: 39708 |
+------------------------------------------------------------------------------+
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 03/27/2003|
|LICENSEE: THOMPSON ENGINEERING AND TESTING, INC|NOTIFICATION TIME: 15:18[EST]|
| CITY: REGION: 2 |EVENT DATE: 03/27/2003|
| COUNTY: STATE: AL |EVENT TIME: [CST]|
|LICENSE#: 694 AGREEMENT: Y |LAST UPDATE DATE: 03/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RUDOLPH BERNHARD R2 |
| |E. WILLIAM BRACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID WALTER (FAX) | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT - LOST TROXLER MOISTURE/DENSITY GAUGE |
| |
| The following information was received from Alabama Office of Radiation |
| Control via facsimile: |
| |
| "The Agency has been notified by Thompson Engineering and Testing, Inc. that |
| a Troxler Model 3440 Gauge (serial #32128) containing a maximum of 9 |
| millicuries of cesium 137 and 44 millicuries of americium 241/beryllium is |
| missing. They have conducted a search of many of their Alabama offices, and |
| have been unable to locate it. Since their records do not show this device |
| being used in some time, it had been in storage, and was not detected as |
| lost until the six month leak test was due. They are continuing to search |
| for the gauge, and will notify this office of their findings." |
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|General Information or Other |Event Number: 39710 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 03/28/2003|
|LICENSEE: BAKER ATLAS |NOTIFICATION TIME: 12:15[EST]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 03/26/2003|
| COUNTY: STATE: TX |EVENT TIME: 07:30[CST]|
|LICENSE#: L05104 AGREEMENT: Y |LAST UPDATE DATE: 03/28/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |TRISH HOLAHAN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GLENN CORBIN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT - INJURED AND CONTAMINATED EMPLOYEE TRANSFERRED |
| OFFSITE |
| |
| The following information was obtained from Texas Department of Health, |
| Bureau of Radiation Control via facsimile: |
| |
| "The Agency was notified that at 7:30 AM [CST] [on] 3/26/03, a neutron tube |
| blew apart inside the pulse neutron facility located at 2001 Rankin Road, |
| Houston, TX 77073-5114. The employee that was involved received superficial |
| lacerations. EMT's were notified at this time. Immediately after the |
| accident H-3 [tritium] contamination was found around the wound area. The |
| contamination was found in a swipe that was analyzed by the licensee using |
| their laboratory located on the premises. The swipe was found to have 19 |
| [nanocuries] of H-3 contamination. The employee was transferred by |
| ambulance to a local hospital. We believe at this time it was Memorial |
| Hospital. The EMT's and the hospital were made aware of the radiological |
| contamination and all precautions were taken. The licensee requested that |
| all materials removed or used at the hospital, and in the ambulance be |
| returned to the licensee. [Urinalysis] was [performed] on the employee and |
| found to be at baseline levels. Contamination was contained in the building |
| where the accident happened and contamination on the floor was |
| decontaminated to background levels. The licensee is following up with the |
| hospital concerning the contaminated clothing, and debris associated with |
| the incident. The licensee will submit a report within thirty days." |
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|Power Reactor |Event Number: 39718 |
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| FACILITY: COLUMBIA GENERATING STATIREGION: 4 |NOTIFICATION DATE: 04/01/2003|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 13:53[EST]|
| RXTYPE: [2] GE-5 |EVENT DATE: 04/01/2003|
+------------------------------------------------+EVENT TIME: 10:50[PST]|
| NRC NOTIFIED BY: FRED SCHILL |LAST UPDATE DATE: 04/01/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANTHONY GODY R4 |
|10 CFR SECTION: |JOHN DAVIDSON IAT |
|DDDD 73.71(b)(1) SAFEGUARDS REPORTS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 97 Power Operation |97 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| VULNERABILITY DISCOVERED IN A SAFEGUARD SYSTEM AT COLUMBIA GENERATING |
| STATION |
| |
| Immediate compensatory measures taken upon discovery. |
| |
| Licensee will notify the NRC Resident Inspector. |
| |
| Contact the Headquarters Operations Officer for additional details. |
+------------------------------------------------------------------------------+
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|Hospital |Event Number: 39719 |
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| REP ORG: YORK HOSPITAL |NOTIFICATION DATE: 04/01/2003|
|LICENSEE: YORK HOSPITAL |NOTIFICATION TIME: 16:45[EST]|
| CITY: YORK REGION: 1 |EVENT DATE: 03/30/2001|
| COUNTY: STATE: PA |EVENT TIME: [EST]|
|LICENSE#: 37-07161-01 AGREEMENT: N |LAST UPDATE DATE: 04/01/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RONALD BELLAMY R1 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DEBRA SWAIM | |
| HQ OPS OFFICER: ARLON COSTA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| LICENSEE TRANSFERRED RADIOACTIVE MATERIAL TO NON-LICENSED ENTITY |
| |
| On March 30, 2001, the Licensee transferred a Varian 6/100 linear |
| accelerator containing depleted uranium source for disposal to a recipient |
| who was not authorized to possess depleted uranium. The linear accelerator |
| was eventually sold and transferred to a clinic in Reynosa, Mexico. On |
| October 14, 2002 the Licensee submitted a written report on this incident to |
| Region 1. The NRC has issued Office of Investigation Report No. 1-2002-036, |
| Inspection Report No. 03003085/2002001 and the Licensee has responded to |
| these two reports via correspondence with Region 1, dated March 27, 2003. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 39720 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 04/01/2003|
| UNIT: [] [2] [] STATE: FL |NOTIFICATION TIME: 19:46[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 04/01/2003|
+------------------------------------------------+EVENT TIME: 16:03[EST]|
| NRC NOTIFIED BY: CALVIN WARD |LAST UPDATE DATE: 04/01/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MIKE ERNSTES 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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 100 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSER VACUUM |
| |
| "At 1603 EST, PSL [Plant Saint Lucie] Unit 2 was manually tripped due to |
| increasing condenser backpressure (loss of vacuum). The manual trip is |
| considered an RPS [Reactor Protection System] actuation. The plant was |
| stabilized in Mode 3. Auxiliary Feedwater actuation occurred due to reduced |
| steam generator level, as expected. The 2A and 2B AFW [Auxiliary Feedwater] |
| pumps started and supplied feedwater to the 2A and 2B S/Gs [steam |
| generators]. The 2C (steam driven AFW pump tripped. This was not expected. |
| The 2C AFW pump has been reset for operation, but was not tested." |
| |
| The reactor was shutdown with all control rods fully inserted, the unit is |
| currently stable in mode 3 with the main feedwater pumps supplying cooling |
| to the steam generators. With the exception of the 2C steam driven AFW |
| pump, all other electrical power sources and decay heat removal systems |
| functioned as required. This incident had no impact on Unit 1 which remains |
| at full power. |
| |
| The Licensee notified the NRC Resident Inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021