Event Notification Report for May 27, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/23/2003 - 05/27/2003
** EVENT NUMBERS **
39631 39868 39877 39878 39880 39881 39882
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|Power Reactor |Event Number: 39631 |
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| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 03/02/2003|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 16:00[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 03/02/2003|
+------------------------------------------------+EVENT TIME: 14:30[EST]|
| NRC NOTIFIED BY: CHARLES PIKE |LAST UPDATE DATE: 05/24/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WALTER RODGERS R2 |
|10 CFR SECTION: |DAVID AYRES R2 |
|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 |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| OFFSITE NOTIFICATION TO STATE AGENCY OF EXPIRED GREEN SEA TURTLE FOUND AT |
| BARRIER NET |
| |
| "NRC notification [is] being made due to state notification to [the] Florida |
| Wildlife Commission regarding a Green Sea Turtle found dead at barrier net |
| pursuant to 10 CFR 50.72(b)(2)(xi)." |
| |
| The turtle was found on the surface at the barrier net with no injuries or |
| abnormalities except for fresh cuts common for turtles coming through pipes. |
| The cause of death is unknown at this time. A necropsy is planned. |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/15/03 @ 1033 EST FROM TEREZAKIS TO CROUCH * * * |
| |
| "On 3-15-03, a green sea turtle was retrieved from the plant's intake canal. |
| The turtle was determined to be in need of rehabilitation. The injuries to |
| the turtle are not causal to plant operation. Per the plant's turtle permit, |
| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified at |
| 0920 EST. This non-emergency notification is being made pursuant to 10 CFR |
| 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/19/03 AT 1222 EST FROM E. SUMNER TO RIPLEY * * * |
| |
| "On 03/19/03 @ 1105 hrs., one loggerhead turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injury to the turtle is not causal to plant operation. |
| Per the plant's turtle permit, the Florida Fish and Wildlife Conservation |
| Commission (FWCC) was notified at 1115 EST." |
| |
| The NRC Resident Inspector was notified. |
| |
| * * * UPDATED ON 3/31/03 AT 1159 EST FROM W.L. PARK TO A. COSTA * * * |
| |
| "On 3-31-03 [1105 EST], a loggerhead sea turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injuries to the turtle are not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission (FWCC) was notified at 1105 EST. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to the |
| notification of FWCC." |
| |
| The NRC Resident Inspector will be notified. |
| |
| * * * UPDATE 1235EST ON 4/9/03 FROM ANDY TEREZAKIS TO S.SANDIN * * * |
| |
| "On 4-9-03, a loggerhead sea turtle was retrieved from the plant's Intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC) |
| was notified at 1100 EST. This non-emergency notification is being made |
| pursuant to 10CFR50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The licensee informed the NRC resident inspector. Notified R2DO(Landis). |
| |
| *** UPDATE ON 5/2/03 AT 1826 FROM S. OEHRLE TO A. COSTA *** |
| |
| "On 5/2/03, a green sea turtle was retrieved from the intake canal. The |
| turtle required rehabilitation. The injuries were not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission was notified at 1445 EDT. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to |
| offsite notification." |
| |
| The Licensee will notify the NRC Resident Inspector. Notified R2DO |
| (Munday). |
| |
| **** update on 05/24/03 at 1417 EDT FROM JOE HESSLING TO JOHN MACKINNON |
| **** |
| |
| "On 5-24-03, a loggerhead sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| turtle was very underweight and lethargic, no injuries or anomalies noted. |
| Turtle's condition is not causal to plant operation. Per the plant's turtle |
| permit the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 1345 EDT. This non-emergency notification is being made |
| pursuant to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC. NRC R2DO |
| (TOM DECKER) notified. |
| |
| The NRC Resident Inspector was by notified of this event by the licensee. |
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|General Information or Other |Event Number: 39868 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 05/20/2003|
|LICENSEE: OKLAHOMA UNIVERSITY MEDICAL CENTER |NOTIFICATION TIME: 19:13[EDT]|
| CITY: OKLAHOMA CITY REGION: 4 |EVENT DATE: 05/05/2003|
| COUNTY: STATE: OK |EVENT TIME: [CDT]|
|LICENSE#: OK-21035-01 AGREEMENT: Y |LAST UPDATE DATE: 05/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TROY PRUETT R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PAM BISHOP | |
| 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 - MEDICAL MISADMINISTRATION |
| |
| The licensee reported a medical misadministration involving High Dose Rate |
| brachytherapy MammoSite treatment to a 70-year old female. Upon |
| administering the first of ten planned fractions it was noticed that the |
| Ir-192 source did not reach the center of the balloon but was near the |
| periphery 30 millimeters from the center. The patient dose was reassessed |
| and it was determined that the dose to the target area was less than planned |
| (56% of the planned dose). The patient and the patient's physician were |
| notified. It has been determined that there were no adverse effects to the |
| patient. Corrective actions will address four factors contributing to the |
| misadministration: wrong orientation of the patient during a CT scan; delays |
| in issuing the treatment plan due to a computer network failure; |
| mis-communications regarding the specified treatment plan; and similarities |
| between CT-based and radiographic-based printouts. |
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|General Information or Other |Event Number: 39877 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 05/22/2003|
|LICENSEE: UNIVERSITY HOPSITALS OF CLEVELAND |NOTIFICATION TIME: 14:10[EDT]|
| CITY: Cleveland REGION: 3 |EVENT DATE: 05/13/2003|
| COUNTY: STATE: OH |EVENT TIME: 12:00[EDT]|
|LICENSE#: OH-0211018007 AGREEMENT: Y |LAST UPDATE DATE: 05/22/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARK LIGHT | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| RADIATION TREATMENT TO WRONG AREA |
| |
| The Ohio Department of Health Bureau of Radiation Protection received a |
| report of misadministration from University Hospitals of Cleveland on May |
| 20, 2003. The report involved a Brachytherapy prostrate therapy with |
| Iodine-125 seeds. The total amount of activity administered was 20.0 |
| millicuries. Preliminary indications is a treatment to the wrong target |
| area. A written report will be sent to the Ohio Department of Health within |
| 15 days. |
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|General Information or Other |Event Number: 39878 |
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 05/22/2003|
|LICENSEE: TWITCHELL CORP. |NOTIFICATION TIME: 15:45[EDT]|
| CITY: Dothan REGION: 2 |EVENT DATE: 05/22/2003|
| COUNTY: STATE: AL |EVENT TIME: 12:00[CDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 05/22/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |THOMAS DECKER R2 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+TOM ESSIG NMSS |
| NRC NOTIFIED BY: DAVID WALTER | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| LOST NDC GAUGE |
| |
| "During an inspection of a general licensee in Dothan, AL, the Agency has |
| discovered that an NDC Model 103 gauge (S/N 2112), containing one 150 |
| millicurie Americium 241 source is unaccounted for. The device was |
| purchased by Ludlow Coated Products in Dothan, AL. That plant closed and the |
| three GL gauges were supposedly transferred to another Ludlow plant in |
| Mississippi in 2000. The plant was then acquired by Twitchell Corporation |
| (another GL licensee of this Agency's). During our inspection of Twitchell, |
| questions arose regarding the whereabouts of the 3 GL gauges from the site |
| once registered to Ludlow. Investigations by Twitchell representatives |
| resulted in documentation of the transfer of 2 of the devices, but no |
| information regarding the NDC device. The investigation and search for the |
| lost device is continuing." |
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|Power Reactor |Event Number: 39880 |
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| FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 05/25/2003|
| UNIT: [1] [2] [] STATE: MD |NOTIFICATION TIME: 23:12[EDT]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 05/25/2003|
+------------------------------------------------+EVENT TIME: 21:45[EDT]|
| NRC NOTIFIED BY: DAVID FRYE |LAST UPDATE DATE: 05/25/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANTHONY DIMITRIADIS 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 |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| INADVERTENT ACTUATION OF EMERGENCY SIREN # 38 IN DORCHESTER COUNTY, |
| MARYLAND |
| |
| |
| Emergency Siren # 38 inadvertently actuated in Dorchester County, Maryland |
| at 1610 EDT. Dorchester County Emergency Response Center drove out to the |
| Emergency Siren and verified that the Emergency Siren had actuated. |
| Dorchester County Emergency Response Center notified Calvert Cliffs Nuclear |
| Power Plant at 2145 EDT that Emergency Siren # 38 had actuated. Some kind |
| of atmospheric anomaly caused the Emergency Siren to actuate. |
| |
| The NRC Resident Inspector will be notified of this event by the licensee. |
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|Power Reactor |Event Number: 39881 |
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| FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 05/26/2003|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 21:47[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/26/2003|
+------------------------------------------------+EVENT TIME: 17:27[CDT]|
| NRC NOTIFIED BY: WILLIAM B. GREEN |LAST UPDATE DATE: 05/26/2003|
| HQ OPS OFFICER: ERIC THOMAS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |TROY PRUETT R4 |
|10 CFR SECTION: |CYNTHIA CARPENTER NRR |
|ACCS 50.72(b)(2)(iv)(A) ECCS INJECTION | |
|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 92 Power Operation |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| MANUAL REACTOR SCRAM |
| |
| This report is being made in accordance with 10CFR50.72 section |
| (b)(2)(iv)(A), (b)(2)(iv)(B), and (b)(3)(iv)(A). |
| |
| At 1727 on 5/26/03 a manual Reactor Scram was inserted from approximately 90 |
| percent power due to high vibration on the main turbine. This action was |
| taken in accordance with station procedures. The subsequent shrink caused |
| reactor water level to lower to approximately -42 inches below instrument |
| zero on the wide range level instruments. This level was low enough to cause |
| the actuation of: Primary Containment Group Isolations 2, 3, and 6, High |
| Pressure Coolant Injection (HPCI) system, Reactor Core Isolation Cooling |
| (RCIC) system, and the Alternate Rod Insertion (ARI) system. The HPCI and |
| RCIC systems injected for less than one minute. After Reactor water level |
| recovered HPCI and Reactor Feed Pumps (RFP) were tripped prior to receiving |
| the high water level trip of these pumps. The RCIC turbine tripped |
| automatically on high reactor water level. A single RFP has been restarted |
| and is currently providing feed water to the Reactor. |
| |
| On the Scram all rods inserted and all systems appear to have functioned as |
| designed. The Nebraska Public Power Load Dispatcher reports that the |
| electrical grid is stable. The plant is currently in Mode 3 and is being |
| cooled down to Mode 4. |
| |
| When operators first noted the high turbine vibration, reactor power was |
| lowered from 100 percent to 90 percent. The maximum specification for |
| turbine vibration is 14 mils, and the operators noted a maximum indication |
| of 12.5 mils prior to the scram. The cause of the excessive vibration is |
| believed to be the number 5 bearing on the low pressure turbine. All |
| Emergency Core Cooling Systems and Emergency Diesel Generators are |
| operable. |
| |
| The licensee notified the NRC Resident Inspector |
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|Power Reactor |Event Number: 39882 |
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| FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 05/27/2003|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 05:32[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/26/2003|
+------------------------------------------------+EVENT TIME: 22:15[CDT]|
| NRC NOTIFIED BY: WILLIAM GREEN |LAST UPDATE DATE: 05/27/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |TROY PRUETT R4 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Hot Shutdown |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| REACTOR COOLANT SYSTEM PRESSURE/TEMPERATURE TS LIMITS WERE EXCEEDED |
| |
| At 2215 on 5/26/03 it was noted that Reactor Coolant System (RCS) |
| Pressure/Temperature Limits for Non-Nuclear Heatup or Cooldown Following |
| Nuclear Shutdown, Figure 3.4.9-1 of Technical Specifications, had been |
| exceeded. This condition occurred due to Bottom Head Temperature being low |
| due to a loss forced circulation when Reactor Recirculation Pumps tripped |
| during the manual scram reported in notification 39881. Reactor pressure |
| was lowered and compliance with the curves has been reestablished. An |
| analysis of this condition is required to be conducted in accordance with |
| Technical Specification Required Action 3.4.9 A.2 to determine RCS |
| acceptability for continued operation. The Reactor is required, as per LCO |
| action statement, to be placed in Mode 4 by 1045 on 5/28/03, |
| |
| |
| The NRC Resident Inspector was notified. |
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