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Event Notification Report for May 13, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           05/12/2003 - 05/13/2003



                              ** EVENT NUMBERS **



39838  39840  39841  39842  



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|Power Reactor                                    |Event Number:   39838       |

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| FACILITY: SUMMER                   REGION:  2  |NOTIFICATION DATE: 05/12/2003|

|    UNIT:  [1] [] []                 STATE:  SC |NOTIFICATION TIME: 03:28[EDT]|

|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        05/12/2003|

+------------------------------------------------+EVENT TIME:        01:02[EDT]|

| NRC NOTIFIED BY:  EDDIE BYARS                  |LAST UPDATE DATE:  05/12/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |PAUL FREDRICKSON     R2      |

|10 CFR SECTION:                                 |                             |

|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     A/R        Y       100      Power Operation  |0        Hot Standby      |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO MAIN GENERATOR OUTPUT BREAKER     |

| OPENING                                                                      |

|                                                                              |

| Main Generator output breaker opened after receiving Main Generator voltage  |

| regulator # 1 (core 1)  & # 2 (core 2) alarms causing an automatic turbine   |

| trip followed by an automatic reactor trip  (first out annunciator was over  |

| temperature differential temperature).  All rods fully inserted into the     |

| core.  Both motor driven auxiliary feedwater pumps were manually started to  |

| maintain reactor coolant temperature and proper steam generator water        |

| levels.  Steam is being dumped to the main condenser.  Emergency Operating   |

| procedure 1.0 entered and then Emergency Operating procedure 1.1, Reactor    |

| Recovery Procedure was entered.   All emergency core cooling systems and the |

| emergency diesel generators are fully operable if needed.  The licensee      |

| believes that the main generator exciter breaker opened before the main      |

| generator output breaker opened. No work was going on in the area of the     |

| main generator when the output breaker opened.                               |

|                                                                              |

| The NRC Resident Inspector was notified of this event by the licensee.       |

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|Other Nuclear Material                           |Event Number:   39840       |

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| REP ORG:  STATE OF MISSOURI                    |NOTIFICATION DATE: 05/12/2003|

|LICENSEE:  MISSOURI  DEPT. OF TRANSPORTATION    |NOTIFICATION TIME: 14:57[EDT]|

|    CITY:  JEFFERSON CITY           REGION:  3  |EVENT DATE:        05/10/2003|

|  COUNTY:  COLE                      STATE:  MO |EVENT TIME:        18:00[CDT]|

|LICENSE#:  24-20415-01           AGREEMENT:  N  |LAST UPDATE DATE:  05/12/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |SONIA BURGESS        R3      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  BETH BROWN                   |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| LOST AND THEN RECOVERED TROXLER ASPHALT CONTENT GAUGE                        |

|                                                                              |

| The following information was obtained from the licensee via facsimile:      |

|                                                                              |

| "On Saturday evening, May 10, 2003, at approximately 6:00 pm [CDT], a        |

| tornado wiped out a trailer at an asphalt plant that contained an asphalt    |

| nuclear gauge 3241 [Troxler]. The gauge was in its gray shipping container   |

| that was locked inside a metal case, which was bolted to the floor. The      |

| gauge was found about 100 feet from the trailer site out of the metal box,   |

| but the gray shipping case was still intact. It did not appear to be         |

| damaged. The contractor, Chester Bross Construction Company, found the gauge |

| and stored it in their plant shack with their gauge. Their Safety Director,  |

| [DELETED], also came up on Sunday morning and took readings. Neither gauge   |

| appeared to be leaking."                                                     |

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|Hospital                                         |Event Number:   39841       |

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| REP ORG:  TRIPLER ARMY MEDICAL CENTER          |NOTIFICATION DATE: 05/12/2003|

|LICENSEE:  TRIPLER ARMY MEDICAL CENTER          |NOTIFICATION TIME: 17:32[EDT]|

|    CITY:  HONOLULU                 REGION:  4  |EVENT DATE:        05/12/2003|

|  COUNTY:                            STATE:  HI |EVENT TIME:        11:00[HST]|

|LICENSE#:  53-00458-04           AGREEMENT:  N  |LAST UPDATE DATE:  05/12/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |LINDA SMITH          R4      |

|                                                |SONIA BURGESS        R3      |

+------------------------------------------------+MELVYN LEACH         NMSS    |

| NRC NOTIFIED BY:  MAJ. ARTHUR MORTON, USA      |MATT HAHN            IAT     |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| NUCLEAR MATERIAL MISSING DURING SHIPMENT                                     |

|                                                                              |

|                                                                              |

| The following information was received from the licensee via facsimile:      |

|                                                                              |

| "An order for 150 milli-curies (mCi) of iodine-131 was placed with           |

| Mallinckrodt on May 9, 2003. The package was received by the Nuclear         |

| Pharmacist,[DELETED], on May 12, 2003 and indicated that the package had     |

| 154.10 mCi of iodine-131 but was measured to contain only 54.0 mCi of        |

| iodine-131.                                                                  |

|                                                                              |

| "At 11:00 [HST] the Nuclear Pharmacist paged me and I immediately went to    |

| the Nuclear Pharmacy laboratory.  I verified that the dose calibrator was    |

| set on I-131and inquired about the package receipt procedures. The Nuclear   |

| Pharmacist indicated that the package was in excellent condition with no     |

| sign of physical damage.  The package was received in a timely manner,       |

| metered and swiped without incident.  The package contained two vials        |

| supposedly containing 140.00 mCi and 14.10 mCi of iodine-131 for a total of  |

| 154.10 mCi.  The contents of the package appeared to be intact.  The Nuclear |

| Pharmacist combined the two vials and assayed the dose in the dose           |

| calibrator for an iodine ablation therapy but measured only 54.0 mCi of      |

| I-131.                                                                       |

|                                                                              |

| "At 11:20 I notified Mallinckrodt of the discrepancy, and then at 11:30 I    |

| notified the NRC Operations Center to report the missing licensed material   |

| in accordance with 10 CFR Part 20.2201(a)(1)(i).  I will also contact the    |

| shipper, MMS Courier, and the Army Medical Command as well as any local or   |

| state notifications that are required."                                      |

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|Fuel Cycle Facility                              |Event Number:   39842       |

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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 05/12/2003|

|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 23:08[EDT]|

| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/12/2003|

|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:00[CDT]|

|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/12/2003|

|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+

|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |

|LICENSE#:  GDP-1                 AGREEMENT:  Y  |SONIA BURGESS        R3      |

|  DOCKET:  0707001                              |MELVYN LEACH         NMSS    |

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

| NRC NOTIFIED BY:  THOMAS WHITE                 |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NBNL                     RESPONSE-BULLETIN      |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| LOSS OF ONE OF TWO CONTROLS ON MODERATION                                    |

|                                                                              |

| NRC BULLETIN 91-01 24 HOUR NOTIFICATION                                      |

|                                                                              |

| The following information was received from the licensee via facsimile:      |

|                                                                              |

| "At 0900 on 5/12/03, the Plant Shift Superintendent (PSS) was notified that  |

| differential pressure transmitter inputs for three Freezer/Sublimers,        |

| U/2(Unit # 2) C/B (Cell B), U3 C/B and U/4 C/B located in C-337, were        |

| installed incorrectly. The transmitter (PDT-338) measures the differential   |

| pressure between the R-114 (freon) and the Recirculating Cooling Water       |

| (RCW). NCSA CAS-001 requires that the pressure differential between the      |

| R-114 and RCW pressures be such that the R-114 pressure is at least 2.0 psia |

| above the RCW pressure. This would preclude the introduction of a moderator  |

| (RCW) into the process side of the system. The correct configuration of      |

| these inputs has the pressure tap on the inlet line to the                   |

| condenser/reboiler. For Freezer/Sublimers U/2 C/B, U/3 C/B and U/4 C/B the   |

| pressure tap is located on the outlet line from the condenser/reboiler.  As  |

| installed, the low differential pressure-alarm may not come in until after   |

| the R-114 pressure and RCW pressure at the inlet of the Condenser/Reboiler   |

| have exceeded the NCS limit.  At 1040 on 5/12/03, the PSS was notified by    |

| Nuclear Criticality Safety that one of the two controls on moderation had    |

| been lost.                                                                   |

|                                                                              |

| The System Engineer identified four additional Freezer/Sublimers, two in     |

| C-331 and two in C-335, with the same problem. These Freezer/Sublimer units  |

| were out-of-service and the RCW had been drained prior to the walk-down. ,   |

|                                                                              |

|                                                                              |

| SAFETY SIGNIFICANCS OF EVENTS:                                               |

|                                                                              |

| Although high side Condenser/Reboiler pressure readings could not be taken   |

| due to incorrect installation of an AQ-NCS pressure instrument, the          |

| integrity of the F/S tubes has been maintained. All of the                   |

| Condenser/Reboilers had the RCW drained by 1345 hours on 5-12-03. thus       |

| re-establishing double contingency.                                          |

|                                                                              |

| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(s) OF HOW            |

| CRITICALITY COULD OCCUR)                                                     |

|                                                                              |

| In order for a criticality to be possible, an unsafe mass of uranium would   |

| have to be present within the Freezer/Sublimer unit and a moderator would    |

| have to enter through the Freezer/Sublimer and Condenser/Reboiler tubes.     |

|                                                                              |

| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,ETC.)       |

|                                                                              |

| Double contingency is maintained by implementing two controls on             |

| moderation.                                                                  |

|                                                                              |

|                                                                              |

| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |

| LIMIT AND  % WORST CASE CRITICAL MASS):                                      |

|                                                                              |

| For the 20 MW Freezer/Sublimers, less than a safe mass of uranium, at less   |

| than or equal to (LEU) U235.                                                 |

| For the 10 MW Freezer/Sublimers, less than a safe mass of uranium, at less   |

| than or equal to (LEU) U235                                                  |

|                                                                              |

|                                                                              |

| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |

| OF THE FAILURES OR DEFICIFNCIES                                              |

|                                                                              |

| The first leg of double contingency relies on Freezer/Sublimer and           |

| Condenser/Reboiler tube integrity. Since high UF6 pressure alarms or other   |

| operational indicators, caused by leaking R-114 into the Freezer/Sublimer,   |

| have not been received on the Freezer/Sublimer units, the integrity of the   |

| Freezer/Sublimer tubes has been maintained. Therefore, this leg of double    |

| contingency was maintained.                                                  |

|                                                                              |

| The second leg of double contingency relies on the differential pressure     |

| between the R-114 and RCW, controlling the differential pressure such that   |

| the R-114 is maintained at least 2.0 psi above the RCW precludes the         |

| introduction of RCW to the process side of the unit. Monitoring the RCW      |

| pressure on the outlet to the Condenser/Reboiler, instead of the inlet, does |

| not give correct differential pressure readings. Therefore. This leg of      |

| double contingency was not maintained.                                       |

|                                                                              |

| Even though the moderation parameter was maintained through integrity of the |

| Freezer/Sublimer and Condenser/Reboiler tubes, double contingency Is based   |

| on two controls on moderation. Thus, double contingency was not maintained.  |

|                                                                              |

| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLFMENTED:  |

|                                                                              |

| 1. Drain Condenser/Reboiler RCW for the affected Freezer/Sublimer units.     |

| Completed at 1345 on 5-12-03.                                                |

| 2. Correct the installation of the pressure taps In accordance with the      |

| approved Engineering drawings. Complete prior to returning Freezer/Sublimors |

| to service                                                                   |

|                                                                              |

| The NRC Resident Inspector was notified of this event by the licensee.       |

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