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Event Notification Report for August 8, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           08/07/2003 - 08/08/2003



                              ** EVENT NUMBERS **



40020  40049  40050  40051  40052  



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|General Information or Other                     |Event Number:   40020       |

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| REP ORG:  NC DIV OF RADIATION PROTECTION       |NOTIFICATION DATE: 07/25/2003|

|LICENSEE:  REX HEALTHCARE                       |NOTIFICATION TIME: 13:09[EDT]|

|    CITY:  RALEIGH                  REGION:  2  |EVENT DATE:        07/14/2003|

|  COUNTY:                            STATE:  NC |EVENT TIME:             [EDT]|

|LICENSE#:  092-0160-1            AGREEMENT:  Y  |LAST UPDATE DATE:  08/07/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |ANNE BOLAND          R2      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  SHARN M. JEFFRIES            |                             |

|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT INVOLVING MISSING IODINE-125 SEEDS                    |

|                                                                              |

| On 7/22/03 Rex Healthcare personnel discovered that five (5) I-125 seeds     |

| (activity 0.384 milliCuries/ea for a total of 1.9 milliCuries) were missing. |

| The licensee conducted a search of the area between 7/22 and 7/24/03 with    |

| negative results.                                                            |

|                                                                              |

| NC Incident No.:  03-32                                                      |

|                                                                              |

| *****UPDATE ON 8/7/03 AT 1405  FROM JEFFRIES TO LAURA*****                   |

|                                                                              |

| At 10:30 EDT on 8/7/03, the licensee found the 5 missing I-125 seeds in the  |

| hospital. The seeds were found contained in a loading apparatus between two  |

| autoclave valves. The licensee is doing an additional review to evaluate any |

| potential radiological exposures.                                            |

|                                                                              |

| Notified NMSS (D. Broaddus) and R2DO (S. Cahill).                            |

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|Power Reactor                                    |Event Number:   40049       |

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| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 08/06/2003|

|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 19:12[EDT]|

|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        08/06/2003|

+------------------------------------------------+EVENT TIME:        16:30[EDT]|

| NRC NOTIFIED BY:  GEORGE STOROLIS              |LAST UPDATE DATE:  08/07/2003|

|  HQ OPS OFFICER:  BILL GOTT                    +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |

|10 CFR SECTION:                                 |                             |

|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|2     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| UNANALYZED CONDITION                                                         |

|                                                                              |

| "On 8/06/2003 at 1630 hours, the Beaver Valley Power Station (BVPS) Unit 2   |

| control room was notified by Engineering that the manual operator actions    |

| specified in Unit 2 post-fire procedures are not adequate for defeating a    |

| potential fire-induced spurious operation of the Power Operated Relief       |

| Valves (PORVs).  The procedure step de-energizes the PORVs by opening        |

| breakers at the d-c distribution panel.  This action alone would not be      |

| sufficient to prevent a cable-to-cable hot short from re-energizing the      |

| circuit since the de-energized circuit is routed in cable trays with other   |

| energized circuits in the affected fire areas.  Preliminary reviews have     |

| identified the following potentially affected fire areas:                    |

|                                                                              |

| CB-1 Control Building Instrumentation and Relay Area                         |

| CB-2 Control Building Cable Spreading Room                                   |

| CB-3 Control Building Main Control Room                                      |

| CB-6 Control Building West Communication Room                                |

| CT-1 Cable Tunnel                                                            |

| CV-1 Cable Vault and Rod Control Area                                        |

| SB-1 Emergency Switchgear Room (Orange)                                      |

| RC-1 Reactor Containment                                                     |

|                                                                              |

| "An hourly roving fire watch patrol has been established for the affected    |

| fire areas as compensatory measures, with the exception of the Main Control  |

| Room and the Reactor Containment area, until the condition is fully          |

| evaluated and resolved.  The Main Control Room is continuously manned and    |

| does not require an hourly fire watch patrol.  The Reactor Containment area  |

| is not accessible during normal power operations and, as such, compensatory  |

| measures for this area will include a once-per-shift verification of remote  |

| instrumentation by operations personnel to confirm that there are no         |

| abnormal conditions or indications for this area.                            |

|                                                                              |

| "This condition was discovered during the review of manual operator actions  |

| for fire-induced spurious operations to confirm the safe shutdown circuit    |

| analysis is consistent with the manual actions identified in the             |

| procedures.                                                                  |

|                                                                              |

| "This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii) as an   |

| unanalyzed condition that significantly degraded plant safety since the      |

| failure to assure the PORVs remain in the closed position could result in    |

| the failure to meet the fire protection safe shutdown criteria.  BVPS Unit 2 |

| was licensed to the NUREG 0800 Standard Review Plan 9.5.1 "Fire Protection   |

| Program", and License Condition 2.F requires compliance to the provisions of |

| the approved fire protection program as described in the Final Safety        |

| Analysis Report.  UFSAR Section 9.5A.1.2.1.6 states that the safe shutdown   |

| capability should not be adversely affected by a fire in any plant area      |

| which results in spurious actuation of the redundant valves in any one       |

| high-low pressure interface line.  Even though there is a very low           |

| likelihood of multiple shorts causing a spurious PORV actuation in an        |

| ungrounded DC circuit, the existing actions to prevent re-energizing the     |

| circuit and causing a spurious actuation of the PORVs is not consistent with |

| the NRC guidance for high-low pressure interface valves.                     |

|                                                                              |

| "The NRC resident inspector has been notified."                              |

|                                                                              |

| * * * UPDATE ON 8/7/03 AT 1726 EDT FROM D. SOMMERS TO E. THOMAS * * *        |

|                                                                              |

| "On 8/07/03 at 1515, the following additional areas were identified as being |

| potentially affected by this condition:                                      |

|                                                                              |

| CV-2 Cable vault and Rod Control Area (East)                                 |

| CV-3 Cable vault and Rod Control Area (Elev 755'6")                          |

| SB-2 Emergency Switchgear Room (Purple)                                      |

| SB-3 Service Bldg. Cable Tray Area                                           |

| ASP Alternative Shutdown Panel Room                                          |

|                                                                              |

| "Interim compensatory measures in the form of hourly roving watch patrols    |

| have been expanded to include the above noted areas until the condition is   |

| fully evaluated and resolved.                                                |

|                                                                              |

| "The NRC Resident Inspector has been notified."                              |

|                                                                              |

| Notified the Region 1 Duty Officer (C. Anderson)                             |

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|Power Reactor                                    |Event Number:   40050       |

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| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 08/07/2003|

|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 13:07[EDT]|

|   RXTYPE: [1] GE-3                             |EVENT DATE:        08/07/2003|

+------------------------------------------------+EVENT TIME:        11:31[EDT]|

| NRC NOTIFIED BY:  DAVID NOYES                  |LAST UPDATE DATE:  08/07/2003|

|  HQ OPS OFFICER:  ERIC THOMAS                  +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |

|10 CFR SECTION:                                 |DAVID SKEEN          NRR     |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |TIM MCGINTY          IRO     |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|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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                                   EVENT TEXT                                   

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| OFFSITE NOTIFICATION                                                         |

|                                                                              |

| "At approximately 1131 [EDT] on August 7, 2003, an error during prompt alert |

| notification system testing resulted in all sirens in the town of Duxbury,   |

| Massachusetts to wail for 15 to 20 seconds.  Appropriate state and local     |

| authorities have been notified.  Investigation into the cause is             |

| continuing."                                                                 |

|                                                                              |

| The NRC Resident Inspector has been notified.                                |

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|Other Nuclear Material                           |Event Number:   40051       |

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| REP ORG:  DEPARTMENT OF THE NAVY               |NOTIFICATION DATE: 08/07/2003|

|LICENSEE:  DEPARTMENT OF THE NAVY               |NOTIFICATION TIME: 13:35[EDT]|

|    CITY:  ARLINGTON                REGION:  2  |EVENT DATE:        06/03/2003|

|  COUNTY:                            STATE:  VA |EVENT TIME:             [EDT]|

|LICENSE#:  45-23645-01NA         AGREEMENT:  N  |LAST UPDATE DATE:  08/07/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |STEPHEN CAHILL       R2      |

|                                                |JACK WHITTEN         R4      |

+------------------------------------------------+DOUG BROADDUS        NMSS    |

| NRC NOTIFIED BY:  CAPT DAVE FARRAND            |                             |

|  HQ OPS OFFICER:  BILL GOTT                    |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|ISAF 30.50(b)(2)         SAFETY EQUIPMENT FAILUR|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| RADIOGRAPHIC EXPOSURE DEVICE FAILURE                                         |

|                                                                              |

| "Description of the equipment problem.  On June 3, 2003, gamma radiography   |

| operations using an AEA Technology/QSA Model 660A exposure device in a       |

| permanent radiography facility at Shore Intermediate Maintenance Activity    |

| were being performed under the authority of Naval Radioactive Materials      |

| Permit (NRMP) No. 0465918--A1NP.  On the tenth exposure of the day the       |

| radiographer attempted to retract the radiographic source into the           |

| radiographic exposure device.  The radiographer placed the drive cable brake |

| in the "off" position and rapidly cranked the source in the retract          |

| direction.  The number of turns coming in matched the number of turns going  |

| out.  The permanent facility gamma alarm shut off, however the radiographer  |

| did not hear the locking slide mechanism engage which is normally heard      |

| clearly when retracting the source.  When attempting to re-expose the source |

| as required by the operating procedure, the source did expose again.  The    |

| Radiation Safety Officer was present and directed the radiographer to        |

| retract the source again.  As with the first attempt to retract the source,  |

| the slide bar did not click in the safe position.  Again and the gamma alarm |

| shut off.  The Radiation Safety Officer entered the permanent facility with, |

| an operating survey meter.  The locking slide bar indicated green (safe) but |

| it was not locked in that position.  The Radiation Safety Officer approached |

| the device and observed a reading of approximately 8 millirem/hour on the    |

| front of the device and 10 millirem/hour on the back of the device.  She     |

| exited the permanent facility and discussed the situation with the           |

| radiographer.  The Radiation Safety Officer then directed the radiographer   |

| to maintain control of the crank assembly handle and she entered the         |

| permanent facility with a survey meter and pushed the slide bar to the red   |

| (expose) position.  The Radiation Safety officer exited the permanent        |

| facility and instructed the radiographer to retract the source to the fully  |

| locked position.  The retraction was successful and the slide bar was heard  |

| to click to the fully green (safe) position. The Radiation Safety Officer    |

| checked her self-indicating pocket dosimeters which both indicated zero      |

| exposure.                                                                    |

|                                                                              |

| "The source was transferred to an AEA 650L source changer on June 4, 2003.   |

| A "dummy" source was installed in the exposure device and the locking slide  |

| bar was placed in various positions to experiment and recreate the scenario. |

| Frequently during these tests, the radiographers were not able to lock the   |

| slide into place without unlocking the drive cable crank assembly and        |

| applying minimal pressure towards the expose position.  This is considered a |

| neutral position and not an exposed position.  With minimal pressure the     |

| slide bar mechanism easily locked into the exposed position.                 |

|                                                                              |

| "Cause of each incident.  The cause of the incident appears to be twofold.   |

| Primarily the compression springs for the posi-lock may have been            |

| excessively worn.  Secondarily, the Shore Intermediate Maintenance Activity, |

| San Diego operating procedure did not call for them to unlock the crank      |

| assembly cable lock prior to rotating the selector ring to the operate       |

| position and pushing the posi-lock slide bar from the green (retracted)      |

| position to the red (operate) position as stated in the most recent AEA      |

| exposure device manual.  We believe that the faulty springs were the main    |

| factor as the posi-lock slide bar can be pushed to the red position with the |

| crank assembly cable lock in the "on" position but that procedure may have   |

| contributed to the excessive wear on the compression springs.                |

|                                                                              |

| "Name of the manufacturer and model number of equipment involved in the      |

| incident. The equipment involved in the incident was manufactured by AEA     |

| Technology/QSA and consisted of a Model 660A exposure device, serial number  |

| A4450 with a 13.6 curie Ir-192 source.                                       |

|                                                                              |

| "Place, date and time of the incident.  The incident occurred at Shore       |

| Intermediate Maintenance Activity, San Diego, California in a permanent      |

| facility on June 3, 2003.                                                    |

|                                                                              |

| "Actions taken to establish normal operations.  The Radiation Safety Officer |

| entered the permanent facility and manually pushed the locking slide bar to  |

| the unlocked (red) position.  The Radiation Safety Officer exited the        |

| permanent facility and instructed the radiographer to attempt to retract the |

| source.  The source was successfully retracted to the fully locked position  |

| and the locking slide bar was heard to lock.                                 |

|                                                                              |

| "Corrective actions taken or planned to prevent recurrence.  Shore           |

| Intermediate Maintenance Facility, San Diego replaced the compression        |

| springs for the posi-lock assembly on the exposure device.  Additionally,    |

| they have changed their operating procedure to unlock the crank assembly     |

| cable lock prior to rotating the selector ring to the operate position and   |

| pushing the posi-lock slide bar from the green (retracted) position to the   |

| red (operate) position."                                                     |

|                                                                              |

| The licensee notified R2 (Diaz).                                             |

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|Power Reactor                                    |Event Number:   40052       |

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| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 08/07/2003|

|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 16:49[EDT]|

|   RXTYPE: [1] GE-3                             |EVENT DATE:        08/07/2003|

+------------------------------------------------+EVENT TIME:        09:15[EDT]|

| NRC NOTIFIED BY:  DAVID NOYES                  |LAST UPDATE DATE:  08/07/2003|

|  HQ OPS OFFICER:  ERIC THOMAS                  +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |

|10 CFR SECTION:                                 |                             |

|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   |

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

|1     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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

| LOSS COMM/ASMT/RESPONSE                                                      |

|                                                                              |

| At 0915 EDT on 8/7/03, during testing of the Prompt Alert Notification       |

| Sirens, 44 of 112 (39 percent) of the sirens were found to be inoperable due |

| to a failed radio repeater.  The repeater was repaired, and all sirens       |

| declared fully operable at 1010 EDT on 8/7/03.                               |

|                                                                              |

| The NRC Resident Inspector was informed of this event.                       |

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