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Event Notification Report for September 15, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/12/2003 - 09/15/2003

** EVENT NUMBERS **


40144 40151 40152 40153 40156 40157 40158

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General Information or Other Event Number: 40144
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: S.T.A.T.E. TESTING, LLC
Region: 3
City: EAST DUNDEE State: IL
County:
License #: IL-01015-01
Agreement: Y
Docket:
NRC Notified By: JPE KLINGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/10/2003
Notification Time: 17:59 [EST]
Event Date: 09/10/2003
Event Time: 13:15 [CDT]
Last Update Date: 09/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE

"Abstract: The agency received a call at 13:40 on September 10, 2003, from [DELETED] RSO of S.T.A.T.E. Testing, LLC (License Number IL-01015-01). He reported that, at approximately 13:15, this afternoon, a Troxler Model 3440 moisture density gauge, serial number 22737, (containing 8 mCi of Cesium-137 and 40 mCi of Americium-241/Beryllium), was stolen from the back of a locked truck (Ford F-150) parked on the street at 63rd and Racine in Chicago. According to the technician in charge of the gauge, [DELETED], the source rod was locked in the shielded position and the device itself was contained in a locked D.O.T. Type A transport container with Radioactive -Yellow II transport labels on it. The licensee stated that he would notify the police next. We suggested that he provide the police with photographs of such a type A container and the device itself. We also recommended that he consider a press release or other means to get the word out to the public, in case it is abandoned and later found.

"In addition to the written report required by our regs, we instructed [DELETED] to keep us informed of any developments in this case. We also provided him with the number to our Dispatch Center, if it happens to be recovered during off-hours. This event was reported to the NRC Operations Center at 1759 hrs e.s.t. and assigned NRC Event No. 40144."

Illinois Item Number: IL030067

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Fuel Cycle Facility Event Number: 40151
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 3
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: S. SKAGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/12/2003
Notification Time: 02:36 [EST]
Event Date: 09/11/2003
Event Time: 08:45 [CDT]
Last Update Date: 09/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
MONTE PHILLIPS (R3)
PATRICIA HOLAHAN (NMSS)

Event Text

DOUBLE CONTINGENCY WAS NOT MAINTAINED FOR NON-FISSILE NAMs.

NRC BULLETIN 91-01 24 HOUR NOTIFICATION

At 0845 on 9/11/03, it was discovered that non-fissile negative air machines (NAMs) were not verified by two individuals to contain approved and properly installed filters, as specified in NCSA GEN-09, "Operation and Maintenance of Negative Air Machines". Procedure CP4-GP-BG2108, "Negative Air Machine and in-place HEPA System Internal Inspection and Filter Replacement", did not adequately flowdown requirements specified in NCSA GEN-09 was revised to make non-fissile portable negative air machines (NAMs) readily available for fissile use in emergency situations. Contrary to requirements specific in NCSA GEN-09, procedure CP4-GP-BG2108 did not include requirements for two individuals to perform independent verification that approved filters are selected and properly installed. This control prevents mass loadings of fissile material that are outside the scope of that analyzed in NCSE KY/S-249.

SAFETY SIGNIFICANCE OF EVENTS:

Double contingency was not maintained for non-fissile NAMs because the second verification was not performed. However, the non-fissile NAMs were not used for fissile material releases. The non-fissile NAMs have been subsequently verified to contain approved and properly installed filters.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR:

In order for a criticality to be possible, a non-fissile NAM would have to be used in a fissile material release and greater than a safe mass of uranium would have to accumulate within the NAM in a configuration favorable for criticality.

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

Double contingency for the accumulation of an unsafe fissile mass is maintained by implementing two controls on mass.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):

This system has a process limit of (xx) wt% U235.

NUCLEAR CRITICLITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:

The first leg of double contingency is based on one individual verifying and documenting that approved filters are selected and properly installed. This control prevents loadings of fissile material that are outside the scope of that analyzed in NCSE KY/S-249. This verification was performed, therefore, this control was maintained.

The second leg of double contingency is based on a different individual verifying and documenting that approved filters are selected and properly installed. This control prevents loadings of fissile material that are outside the scope of the analyzed in NCSE KY/S-249. Because this verification was not performed, this control was lost. No events have occurred to introduce fissile material into any non-fissile NAMs. Therefore, though the control was violated, the parameter was maintained.

Since double contingency is based on two controls on one parameter, and one control was violated, double contingency was not maintained.


CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

1. Non-fissile Nams verified to contain the correct filters and installed in the correct orientation. Completed 9/11/2003.
2. Procedure CP4-GP-BG2108 placed on hold pending revision to include independent verification requirements specific in NCSA GEN-09. Completed 9/11/2003.


The NRC Senior Resident Inspector has been notified of this event.

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Fuel Cycle Facility Event Number: 40152
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: ED STECK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/12/2003
Notification Time: 10:32 [EST]
Event Date: 09/12/2003
Event Time: 10:32 [EDT]
Last Update Date: 09/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
ROBERT HAAG (R2)
LINDA PSYK (NMSS)

Event Text

IMPROPER SCANNING OF LEAD RODS FOR THE PRODUCT ENGINEERING LABORATORY

NRC BULLETIN 91-01 24 HOUR NOTIFICATION

FACILITY:

Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched (<5.0 wt,% U-235) PWR fuel fabricator for commercial light water reactors. License: SNM-1107.

TIME AND DATE OF EVENT:

April 4, 2001 - -- September 5, 2003

REASON FOR NOTIFICATION:

Lead-filled rods in a small number of replica fuel assemblies were scanned using an improper instrument. The rods were to be verified as free of uranium prior to delivery to the Product Engineering Lab. The verification is accomplished by either scanning each individual rod with a hand-held instrument or scanning an assembly with a combination of a thimble tube probe and an external hand-held instrument. A few of the hand-held scans were performed with a marginal instrument.

DOUBLE CONTINGENCY PROTECTION:

Double contingency protection for the VIPER test loop vessel is assured by preventing uranium with greater than 1.0 weight percent uranium-235 from entering the Product Engineering (PE) Lab and preventing that uranium from entering the VIPER test loop vessel. Although lead-filled rods are not tested in the VIPER test loop, the improper scans left less than previously documented double contingency protection for the system. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5), this event satisfies the criteria for a 24-hour notification.

AS FOUND CONDITION:
See "Reason for Notification" above.

NCS detected the absence of a procedure number listing during a normal special routing review. Inquiries led to the discovery that the incorrect instrument was being used to scan lead-filled rods. It was subsequently determined that the response of the instrument used was inadequate to reliably detect a single uranium rod mixed with lead-tilled rods.

The initial investigation revealed a weakness in the procedure structure for scanning lead-filled rods. The procedure steps for scanning lead-filled rods are contained in a procedure for transfer and release of potentially contaminated equipment or materials and not addressed in the instrument procedures.

SUMMARY OF ACTIVITY:

1). An improved procedure is now in place requiring that all lead-filled rods be individually scanned with the appropriate instrument.

2). All health physics personnel have been trained on the new procedure and proper instrument.

CONCLUSIONS:

1). Loss of double contingency protection occurred.

2). At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved.

3). The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures.

4). Notification was the result of a weakness in the procedure structure, not a deficient NCS analysis.

5). A causal analysis will be performed.

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Fuel Cycle Facility Event Number: 40153
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 3
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: KEN O'BRIEN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/12/2003
Notification Time: 07:04 [EST]
Event Date: 09/12/2003
Event Time: 05:31 [CDT]
Last Update Date: 09/12/2003
Emergency Class: ALERT
10 CFR Section:
40.35(f) - EMERGENCY DECLARED
Person (Organization):
MONTE PHILLIPS (R3)
PATRICIA HOLAHAN (NMSS)
DOUG WEAVER (IRO)
JIM DYER (R3RA)
BILL THOMAS (DHS)
BILL SIMES (EPA)

Event Text

ALERT DECLARED DUE TO RELEASE OF ANTIMONY PENTAFLOURIDE

Ken O'Brien, NRC R3 Chief of the Fuels Cycle Branch, called at 0704 EDT to inform us that Honeywell had a chemical release and they had declared an Alert at 0531 CDT. There was no radiological release associated with this event.

The event occurred when a plant employee attempted to obtain a sample from a tank of antimony pentaflouride. During the sampling process, the tank was inadvertently over pressurized and was vented outside of the building to atmosphere. The winds in the area during the release directed the chemical away from town. The building was isolated and the tank reduced to sub-atmospheric pressure by the plant response personnel. Their were no injuries as a result of the incident.

An all-clear was given at 0655 CDT and the Alert was terminated at 1114 CDT.

The Paducah Gaseous Diffusion Plant NRC Resident Inspector was notified by Honeywell.

Notified the following federal agencies: FEMA(Caldwell), HHS-CDC(Davidson), DHS-DOE Desk(Yates), DOE(Turner), USDA(Thomas), NRC-EPA(Baumgarner).

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Power Reactor Event Number: 40156
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: CHRIS VERDONI
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/13/2003
Notification Time: 01:10 [EST]
Event Date: 09/12/2003
Event Time: 20:55 [CDT]
Last Update Date: 09/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
LINDA HOWELL (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 16 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO UNANTICIPATED NEGATIVE AXIAL SHAPE INDEX (ASI).


"This report is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) due to manual initiation of the RPS, although briefed, was not part of any written pre-planned sequence. The unanticipated negative ASI response that began to approach RPS APD trip settings drove the decision to manually initiate an RPS trip.

"Fort Calhoun Station Unit 1 was being shutdown for a planned refueling outage. During scheduled power shutdown at 3% per hour, ASI was trending more negative (power shifting to top of core) than expected. Reactor Engineering was contacted about the trend at 67% reactor power on September 11, 2003. New guidance was issued, however negative ASI trend continued. RPS Axial Power Distribution (APD) pretrip/trip setpoints were -0.55/-0.58 ASI Units. Below 15% power APD trips are bypassed. Operations briefed the continued power descension with manual trip criteria being the receipt of any 1 of 4 APD pretrip setpoints.


"At 15.8% delta T power it became apparent that with ASI approaching APD pretrips (-0.5305 ASIU recorded), an Automatic Trip could be initiated if the downpower continued. At 2055 on September 12, 2003, with power at 15.8% delta T, a briefing was conducted and an manual reactor trip was initiated by tripping the Primary RPS Trip pushbutton on Control Board-4.

"Operations entered EOP-00, "Standard Post Trip Actions" and transitioned to EOP-01, "Reactor Trip Recovery" with all safety functions verified. EOP-01 was exited at 2200 hours and the plant entered OP-3A, "Plant Trip". The plant is currently stable in Mode 3 with RCS Tave at 535 degrees F.

"The only abnormal plant response noted was a feedwater side relief valve lifted and failed to fully reseat on FW-16A, High Pressure Feedwater Heater. The relief valve was cycled by maintenance and was reseated approximately 10 minutes after opening."


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

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Power Reactor Event Number: 40157
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: MATZKE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/14/2003
Notification Time: 09:04 [EST]
Event Date: 09/14/2003
Event Time: 05:49 [CDT]
Last Update Date: 09/14/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
LINDA HOWELL (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

SLIGHTLY CONTAMINATED WORKER TRANSFERRED TO THE HOSPITAL FOR HEAT STRESS

At about 0549, Sunday, September 14, 2003 a slightly contaminated worker who was exhibiting heat stress symptoms was transported to an off-site medical facility for treatment. The worker was very slightly contaminated on both the forearms and elbows. The worker has been treated and is being observed prior to being released. No contamination was spread off-site.

Licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40158
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BRIAN OVERMILLER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/15/2003
Notification Time: 03:06 [EST]
Event Date: 09/15/2003
Event Time: 02:39 [EDT]
Last Update Date: 09/15/2003
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MOHAMED SHANBAKY (R1)
PATRICIA HOLAHAN (NMSS)
DOUG WEAVER (IRO)
RANDY BLOUGH (R1)
HUB MILLER (R1RA)
DORA HEYMAN (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Shutdown
3 A/R Y 91 Power Operation 0 Hot Shutdown

Event Text

DUAL UNIT REACTOR SCRAM. DISCRETIONAY UNUSUAL EVENT DECLARED

"A discretionary UE has been declared for PB (Peach Bottom) U/2 (Unit 2) and U/3 (Unit 3) due to a dual unit transient that has resulted in both unit's scramming with a Group 1 (Main Steam Isolation Valve closure) PCLS isolation.

"An electrical transient caused all 4KV emergency buses to be powered by the diesel generators. One diesel generator (E2) subsequently tripped leaving 6 of 8 (3 per unit) buses energized.

"Off-site power is available. Preparations for transfer back to off-site power is in progress. The U/3 (Unit 3) "D" SRV (Safety relief valve) opened and did not close until electrically deenergized. The SRV is closed at this this time.'

Both reactors scrammed at 0132 EDT.

NRC Resident Inspectors, State and Local were notified by the licensee.

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