Event Notification Report for June 18, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/17/2003 - 06/18/2003
** EVENT NUMBERS **
39631 39882 39929 39933 39934 39935 39936 39946 39947
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39631 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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: 06/17/2003|
| 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 |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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. |
| |
| ****UPDATE ON 5/27/03 AT 10:49 FROM HESSLING TO LAURA**** |
| |
| "On 5-27-03, 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 underweight, and missing lower posterior marginals on left side. |
| Turtle's injuries are not causal to plant operation. Per the plant's turtle |
| permit, the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 0850 EDT. This non-emergency notification is being made pursuant |
| to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| Notified R2DO (T. Decker) |
| |
| * * * UPDATE ON 06/17/03 AT 12:45 EDT FROM CALVIN WARD TO ARLON COSTA * * * |
| |
| "At approximately 12:45 p.m. on 6/17/03 a loggerhead turtle was rescued from |
| the St. Lucie Plant intake canal. The turtle was injured and will be |
| transported to the State authorized sea turtle rehabilitation facility. The |
| Florida Dept. of Environmental Protection (FDEP) was notified at 1:09 p.m. |
| as required by the St. Lucie Plant Sea Turtle Permit - see the attached sea |
| turtle stranding report (1 page). |
| |
| "Notification to the state government agency requires a four (4) Hr. |
| Non-Emergency Notification to the NRC per 10 CFR 50.72(b)(2)(xi). There were |
| no unusual plant evolutions in progress which may have contributed to this |
| event." |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (L. Wert). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39882 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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: 06/17/2003|
| 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 |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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 of 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. |
| |
| * * * UPDATE 1614EDT ON 6/17/03 FROM ED McCUTCHEN TO S. SANDIN * * * |
| |
| The licensee is retracting this event based on the following: |
| |
| "Retraction of Event Notification 39882: |
| |
| "On May 27, 2003, Cooper Nuclear Station reported that Reactor Coolant |
| System (RCS) Pressure/Temperature (P/T) Limits for Non-Nuclear Heatup or |
| Cooldown Following Nuclear Shutdown, Figure 3.4.9-1 of Technical |
| Specifications, had been exceeded (Reference Event 39882). This condition |
| occurred when Reactor Recirculation Pumps tripped during the manual scram |
| reported in Event 39881. With the loss of forced circulation, stratification |
| of the reactor coolant occurred and the resultant bottom head (Lower Plenum) |
| temperatures were below the Technical Specification limit. |
| |
| "The condition was reported in accordance with 10 CFR 50.72(b)(3)(ii)(A) as |
| an event or condition that results in the condition of the nuclear power |
| plant, including its principal safety barriers, being seriously degraded. |
| |
| "CNS was in Mode 3 (Hot Shutdown) when the P/T Limits were exceeded. Reactor |
| pressure was lowered and compliance with the curve was reestablished. Per |
| Limiting Condition for Operation (LCO) 3.4.9, Condition B, required Action |
| B.2, the reactor was required to be in Mode 4 (Cold Shutdown) by 1045 on May |
| 28, 2003. The reactor was placed in Mode 4 at 0844 on May 27, 2003. |
| |
| "The Technical Specification required evaluation to determine that the RCS |
| is acceptable for operation prior to entering Mode 2 (Startup) or Mode 3 has |
| been completed. The evaluation determined that pressure and temperature data |
| recorded during the condition demonstrate that the P/T Limits were |
| maintained for the Upper Vessel/Steam Dome and Beltline Regions for the |
| duration of the event. |
| |
| "The recorded data for the Lower Plenum exceeded TS Figure 3.4.9-1 which is |
| a composite curve established by superimposing limits derived from stress |
| analyses of those portions of the reactor vessel and head that are the most |
| restrictive. The analysis developed a bottom head (Lower Plenum) specific |
| P/T curve using bottom head specific stresses and material properties. |
| Considering this bottom head P/T curve, the evaluation results demonstrate |
| that region specific P/T Limits for the Lower Plenum region of the vessel |
| were maintained for the duration of the event. |
| |
| "This event is bounded by the existing fatigue analysis for a loss of |
| Feedwater Pumps. The transient has been captured in the fatigue monitoring |
| program. The vessel usage factor of 1.0 has not been exceeded. Consequently, |
| the reactor vessel maintains adequate structural integrity for continued |
| operation. |
| |
| "CNS is retracting this event based on the evaluation which demonstrates |
| that the plant safety barrier (RCS) was not degraded." |
| |
| The licensee informed the NRC resident inspector. Notified R4DO(Powers). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39929 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/12/2003|
|LICENSEE: ST JOSEPH'S HOSPITAL |NOTIFICATION TIME: 15:59[EDT]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 06/11/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02279-000 AGREEMENT: Y |LAST UPDATE DATE: 06/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: OGDEN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| INCORRECT TREATMENT AREA DISCOVERED DURING A BREAST CANCER TREATMENT |
| |
| At the beginning of the 6th treatment the physicist discovered a geographic |
| location error on the placement of a 3 curie +/- Iridium-192 source in the |
| patient for treatment of breast cancer. Discovered an input error on the |
| five previous treatments. Measurements should have been input to the Gamma |
| Med Plus (HDR device) in millimeters were mistakenly entered in centimeters. |
| Steps for the 20 millimeter source should have been in 1 millimeter |
| increments. Therefore, the source was actually never in the patient's body. |
| The physicist has estimated 70 Gray superficial dose to the skin at a depth |
| of up to 1 centimeter. Deep dose (beyond 1 centimeter) is estimated at 30 |
| Gray. The patient has developed a small red spot which is being monitored |
| by the hospital for potential blistering. The patient and the hospital have |
| agreed to re-start this patient's treatments. Corrective actions to prevent |
| a re-occurrence of this event will follow with the Licensee's 15 day written |
| report of the incident. Dose to original treatment site is in excess of 20% |
| of the intended dose. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39933 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: QUALITY TESTING |NOTIFICATION TIME: 13:00[EDT]|
| CITY: TEMPE REGION: 4 |EVENT DATE: 06/10/2003|
| COUNTY: STATE: AZ |EVENT TIME: 08:00[MST]|
|LICENSE#: AZ07-491 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GODWIN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| ARIZONA LICENSEE, QUALITY TESTING, REPORTED A MISSING TROXLER MOISTURE |
| DENSITY GAUGE |
| |
| "At approximately 8:00 AM MST June 10, 2003, Arizona was informed by the |
| Licensee Radiation Safety Officer that they believe a Troxler Model 3411 B |
| SN 4647 moisture-density gauge was missing and had been since 5:00 AM. At |
| approximately 8;30 MST the Agency was informed that gauge fell off of the |
| truck and had been recovered by JSW Concrete Contractor. The gauge was |
| recovered from Price Road under the Fry Road Overpass. The Department of |
| Public Safety and the Chandler Police were notified prior to recovery. The |
| Licensee took possession of the gauge at approximately 9:00AM. There were no |
| indications the gauge had been opened. Inspection by the State Agency |
| revealed several possible violations." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39934 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: CHRISTUS SANTA ROSA |NOTIFICATION TIME: 14:47[EDT]|
| CITY: SAN ANTONIO REGION: 4 |EVENT DATE: 06/13/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02237-001 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WATKINS | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| WRONG DOSAGE ADMINISTERED TO A PATIENT DUE TO HUMAN ERROR |
| |
| Discovery of right patient/ right radiopharmaceutical but wrong dosage. |
| Patient returned after 48 hours for a scan. Doctor asked the tech for the |
| prescription that was issued. The tech had ordered the wrong dose for the |
| prescribed procedure. A thyroid scan was conducted with 2.3 millicuries of |
| Iodine -131 vs. the required 300 microcuries of I-131. As corrective action |
| any I-131 dose will require concurrence of the physician prior to ordering |
| the dose. The cause was due to human error since the radiopharmacy sent the |
| dose as ordered by the Tech. |
| |
| Both the referring physician and the patient have been informed of the |
| error. The physician has stated that the dose error has caused no injury to |
| the patient. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39935 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: COLLEGE STATION HOSPITAL |NOTIFICATION TIME: 15:14[EDT]|
| CITY: COLLEGE STATION REGION: 4 |EVENT DATE: 06/11/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02559 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WATKINS | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SIX VIOLATIONS FOUND DURING RECENT INSPECTION AT A TEXAS LICENSED FACILITY |
| |
| On June 11, 2003 the Texas Department of Health, Bureau of Radiation Control |
| conducted a follow up inspection of licensed activities at the Humana |
| Hospital Day Surgery Center DBA The Surgical Center (TSC), Bryan, Texas. The |
| inspection findings were discussed with Dr. Alikhan, Radiation Safety |
| Officer and his staff In a preliminary exit briefing at close of |
| inspection. |
| |
| Based on the results of his inspection., the Inspector has determined that |
| at least 6 violations of the Agency requirements occurred. In addition, the |
| violations were identified by this Agency rather than through the Licensee |
| conducting Radiation Protection Program (RPP) audits. |
| |
| The Inspector reviewed five (5) total patients affected, since the last |
| inspection by this Agency conducted on January 18, 2001. Utilization logs |
| indicate that this number could increase given a review of the patients |
| treated prior to January 18, 2001, with the use of the stroutium-90 eye |
| applicator. Therefore, as discussed with the RSO during the exit briefing, |
| additional information may be required of TSC before the Agency can make a |
| determination to conclude this issue. The Inspector informed the Licensee |
| that the number and characterization of apparent violations could change as |
| a review Is conducted. |
| |
| Inspection Findings: Items of Noncompliance |
| |
| 1. Violation of 25 TAC �289.256(ee)(1)(a)(i): |
| The Licensee failed to report and notify this Agency of a dose that differs |
| from the prescribed dose by more than 5 rem (0.05 Sv) effective dose |
| equivalent, 50 rem (0.5 Sv) to an organ or tissue, or 50 rem (0.5 Sv) |
| shallow dose equivalent to the skin and either: |
| |
| a. the total dose delivered differs from the prescribed dose by 20% or |
| more. |
| |
| 2. Violation of 25 TAC �289.202(e)(1): |
| |
| The Licensee failed to conduct a Radiation Protection Program (RPP), |
| sufficient to ensure compliance with the provisions of �289.202. The RPP was |
| not developed, documented, and implemented. |
| |
| 3. Violation of 25 TAC �289.201(g)(1)(b): |
| |
| The Licensee exceeded the six-month leak test interval for a sealed source |
| of radioactive material for a 100mCi Sr-90 source, S/N 0214, during the time |
| period from January 18, 2001 until June 4, 2003. |
| |
| 4. Violation of 25 TAC �289.256(p)(1)&(2): |
| |
| At the time of the inspection, the Licensee had failed to generate written |
| directives signed and dated by an authorized user prior to administration of |
| Sr-90 Brachytherapy. |
| |
| (i) prior to implantation: the treatment site, the radionuclide, number of |
| sealed sources and dose; and |
| (ii) after implantation but prior to completion of the procedure: the |
| radionuclide, treatment site, number of sealed sources, total sealed source |
| strength and exposure time or, equivalently, the total dose. |
| |
| 5. Violation of 25 TAC�289.256(bb)(6)(A)(B)(C)&(D): |
| |
| The Licensee failed to determine the calibration measurements of |
| Brachytherapy sealed sources. |
| |
| 6. Violation of 25 T,AC �289.256(i)(2)(A)&(B): |
| |
| The Licensee's Radiation Safety Committee has not been composed of the |
| required personnel. By evidence of the January 30, 2003 Radiation Safety |
| Committee minutes that identifies representatives to attendance, the |
| Radiation Safety Officer and an authorized user of type of use permitted |
| (surgery) by the license, were not present. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39936 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: UNITED DAIRYMAN OF AZ |NOTIFICATION TIME: 15:55[EDT]|
| CITY: TEMPE REGION: 4 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: AZ |EVENT TIME: 16:20[MST]|
|LICENSE#: AZ-GL AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GODWIN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| ARIZONA LICENSEE, UNITED DAIRYMEN OF AZ, DISCOVERED A DAMAGED HYDROGEN 3 |
| EXIT SIGN |
| |
| At approximately 4:20 PM MST June 12, 2003, the Agency was informed by the |
| General Licensee that they had discovered an EXIT sign containing Tritium |
| was damaged. The sign contained 11.5 Curies of Tritium when installed. The |
| General Licensee had no idea when the sign was damaged, in fact, he was |
| surprised to learn that it contained radioactive material. The sign was a |
| Safety Light Model XT. When the Agency arrived on scene, it was determined |
| that the light tubes were all missing for this sign. One individual had |
| used a ladder to attempt to replace the "light" bulbs since they were |
| "burned" out. Wet wipes taken of the remains of the sign did not detect |
| hydrogen 3. No one could tell the Agency of the condition of the glow |
| tubes or where they are now located. The sign was located in a 30,000 |
| square foot warehouse storing powdered milk. Evaporative coolers circulate |
| cool air into the warehouse. |
| |
| The Agency continues to investigate this incident. |
| |
| The NRC and FBI will be notified of this event |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39946 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 06/17/2003|
| UNIT: [2] [3] [] STATE: NY |NOTIFICATION TIME: 18:47[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 06/17/2003|
+------------------------------------------------+EVENT TIME: 15:57[EDT]|
| NRC NOTIFIED BY: SEAN EAGLETON |LAST UPDATE DATE: 06/17/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RAYMOND LORSON R1 |
|10 CFR SECTION: |HERB BERKOW NRR |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LOSS OF EMERGENCY SIREN CAPABILITY DUE TO EQUIPMENT FAILURE |
| |
| "At 15:57 on 6/17/03, the network link used to activate all Emergency Sirens |
| was inoperable. As a result of the failed link, a total of 154 sirens in |
| Westchester, Orange, Putnam and Rockland Counties in New York were |
| inoperable. The network link was restored at 16:44 on 6/17/03; all Emergency |
| Sirens are currently operable. |
| |
| "Parties Notified: Westchester, Orange, Putnam and Rockland Counties, New |
| York State and the IPEC NRC Resident Inspector were notified." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39947 |
+------------------------------------------------------------------------------+
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| FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 06/17/2003|
| UNIT: [1] [] [] STATE: LA |NOTIFICATION TIME: 23:35[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 06/17/2003|
+------------------------------------------------+EVENT TIME: 16:20[CDT]|
| NRC NOTIFIED BY: SAM BELCHER |LAST UPDATE DATE: 06/17/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DALE POWERS R4 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
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| | |
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EVENT TEXT
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| HPCS SYSTEM RENDERED INOPERABLE DUE TO PERSONNEL ERROR |
| |
| Text to follow from fax |
| |
| "While performing scheduled maintenance activities on SWP-P2C, Standby |
| Service Water Pump P2C, operators inadvertently removed an adjacent 4160 |
| volt switchgear breaker, E22-ACB002, which supplies the High Pressure Core |
| Spray Pump, at 16:20 Central Daylight Time (CDT) on June 17, 2003 while |
| operating at 100% power. The HPSC pump breaker is adjacent to the SWP-P2C |
| breaker on the same switchgear. This action rendered the High Pressure Core |
| Spray system (HPCS) inoperable and unable to fulfill the HPCS safety |
| function to mitigate the consequences of an accident. This inadvertent |
| action was immediately recognized by the control room operating team and |
| immediate actions were taken to restore the system to operable. The pump |
| breaker was promptly restored and functional testing of the HPCS pump was |
| completed at 16:36 CDT on June 17, 2003. The High Pressure Core Spray |
| system was restored to full operable status within 16 minutes. All other |
| divisional Emergency Core Cooling Systems (ECCS) were operable. The Reactor |
| Core Isolation Cooling System (RCIC) was also operable during this time |
| period. Investigation into the removal of the HPCS pump breaker is in |
| progress." |
| |
| |
| The licensee informed the NRC resident inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021