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Event Notification Report for November 24, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2003 - 11/24/2003

** EVENT NUMBERS **


40296 40334 40337 40339 40341 40345 40346 40347 40348 40349 40350

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Power Reactor Event Number: 40296
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ADAM MILLER
HQ OPS Officer: GERRY WAIG
Notification Date: 11/04/2003
Notification Time: 15:50 [ET]
Event Date: 11/04/2003
Event Time: 14:30 [EST]
Last Update Date: 11/24/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RICHARD BARKLEY (R1)

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

Event Text

PRESSURIZER HEATER BUNDLE DIAPHRAGM PLATE DEGRADED CONDITION

"On November 4, 2003, during the TMI Unit 1 15th (T1R15) refueling outage, an inspection of the Pressurizer Heater Bundle (PHB) Diaphragm Plate was completed. This Inspection identified a leak path emanating from the lower Pressurizer Heater Bundle.

"The initial indication of a potential Reactor Coolant System (RCS) leak was boric acid residue located between the PHB Diaphragm Plate and the PHB Cover Plate. Initially the leak was believed to be from a seal weld, which is considered comparable to a gasket leak. Following disassembly of the PHB Cover Plate and performance of NDE, it was determined that the pathway was through the edge of the PHB Diaphragm Plate. This degraded condition of the PHB Diaphragm Plate is indicative of a RCS pressure boundary leak. This notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A)."

The licensee provided the following pre-refuel outage information:
RCS Leak Rate = less than 0.1 gallons per minute
Activity = 0.45 microcuries/milliliter
TS [Technical Specifications] Limits: No leakage (3.1.6.4)
Secondary System Activity = less than 1E-10 microcuries/milliliter

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 11/24/03 AT 0114 EST FROM JOHN SCHORK TO HOWIE CROUCH * * *

"Subsequent to the initial report made on 11/4/03, the Pressurizer Heater Bundle (PHB) Diaphragm Plate was repaired. On November 23, 2003 during performance of post-maintenance testing inspections with the plant in Hot Shutdown, steam was observed emanating from either the seal weld or the PHB diaphragm plate.

"This update is being made to EN 40296 because the observed leak is being conservatively classified as a leak from the Primary System Pressure Boundary and is being addressed in a manner consistent with TMI Technical Specifications 3.1.6.4 and 3.1.6.6. An evaluation of the safety implications of the leak has been initiated. A condition report has been generated to capture all of the actions that have been and will be taken in response to the leak.

"The plant is being taken to cold shutdown in order to perform an inspection and repair of the leak. The plant continues to be subcritical with all control rods fully inserted and the Reactor Coolant System boron concentration is at the refueling boron concentration. The plant continues to remain in the T1R15 refueling outage.

"The NRC TMI-1 Sr. Resident Inspector has been notified of the leak. No other notifications were made to the State, Local or other governmental agencies. No press release has been issued regarding the event. The cause and corrective action to repair the leak will be addressed in the licensee event report being submitted in response to EN 40296.

"The location of the leak observed on November 23, 2003 is in the immediate vicinity of the lower Pressurizer Heater Bundle. There has been no determination of the volumetric leak rate. The leak consists [of] steam wisping from the location. The start date of the leak is November 23, 2003 and the leak was initially observed during hot shutdown checks at 1930 hours on November 23, 2003. There has been no radiological release to the environment as a result of this leak."

The licensee has notified the NRC Senior Resident Inspector.

Notified R1DO (John Rogge) and NRR (William Ruland).

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General Information or Other Event Number: 40334
Rep Org: NV DIV OF RAD HEALTH
Licensee: NV DEPARTMENT OF TRANSPORTATION
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-14-0404-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/18/2003
Notification Time: 14:13 [ET]
Event Date: 11/15/2003
Event Time: [PST]
Last Update Date: 11/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
ROBERTO TORRES (NMSS)

Event Text

NEVADA STATE LICENSEE REPORTED A STOLEN TROXLER GAUGE

The Nevada Department of Transportation notified the Nevada Division of Rad Health on 11/17/03 that on 11/15/03 a Troxler 4640B, s/n 2361 was stolen out of a field lab trailer. The gauge was secured in the trailer, but the thief was able to defeat the locks and barriers. The gauge contained 8 millicuries of Cs-137. Notifications were made to the local police, the FBI and other states of the stolen gauge.

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General Information or Other Event Number: 40337
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/18/2003
Notification Time: 17:59 [ET]
Event Date: 11/17/2003
Event Time: [PST]
Last Update Date: 11/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
JOHN GREEVES (NMSS)

Event Text

PATIENT RECEIVED AN OVERDOSE DURING A BRACHYTHERAPY PROCEDURE

The licensee's RSO reported on 18 November 2003, that a patient, at Swedish Medical Center, Providence Campus, was scheduled to receive an intravascular Brachytherapy procedure that involved the use of a NOVOSTE Beta-Cath device. The device, Serial Number ZB638, employed a total activity of 2907 Megabecquerels (78.56 millicuries) of Strontium 90/Yttrium 90, in a sealed source-train, Serial Number 91837. The cardiologist was unable to insert the source-train for the treatment because, as reported by the RSO, it was into a small artery and the routing did not follow a direct path. This resulted in a 143 second, 13.78 Gray (1378 Rad), exposure to healthy patient tissue.

The source-train was partially inserted into the patient when the cardiologist experienced difficulty. A 143 second exposure time elapsed before the cardiologist withdrew the source-train even though medical center procedure requires the sources to immediately be withdrawn once a problem is understood. The delay apparently occurred as the cardiologist first worked to fully insert the source-train and then discussed correcting the problem with the oncologist.

The cause of the exposure was failure to follow established procedures. The cardiologist has been suspended from further licensed activities until the details of the event are fully understood. It is anticipated that no health affects to the patient will be realized as a result of the exposure. A DOH staff health physicist will pursue additional details of the event. There is no media attention at this time.

Patient and referring physician were notified.

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General Information or Other Event Number: 40339
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GOLDER ASSOCIATES INC
Region: 1
City: MCINTYRE State: GA
County:
License #: GA1205-1
Agreement: Y
Docket:
NRC Notified By: LIZ SEALE (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/19/2003
Notification Time: 13:37 [ET]
Event Date: 11/18/2003
Event Time: 16:00 [EST]
Last Update Date: 11/19/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
ROBERTO TORRES (NMSS)

Event Text

PORTABLE TROXLER GAUGE RUN OVER BY BULLDOZER

A portable Troxler Model 3411B S/N 6581, was run over by a bulldozer on 11/18/03. The probe was intact and was returned to inside of the gauge housing and moved to a secure location to be leak tested and transported back to the office awaiting recommendations from Troxler. The gauge contained 40 millicuries Am-241 and 8 millicuries Cs-137. A second licensee, Englehard #Ga178-1, was also involved.

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General Information or Other Event Number: 40341
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ATL INC
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ-07-116
Agreement: Y
Docket:
NRC Notified By: AUBRY GODWIN
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/19/2003
Notification Time: 16:50 [ET]
Event Date: 11/18/2003
Event Time: 13:00 [MST]
Last Update Date: 11/19/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
TOM ESSIG (NMSS)
VICTOR GONZALEZ (MEX)

Event Text

STOLEN MOISTURE-DENSITY GAUGE

The Arizona Agency was informed on 11/19/03 @ 1230 of a stolen moisture density gauge which was taken when the pickup truck it was in was stolen. The gauge was a CPN Model MC3, S/N M390404988 containing 10 millicuries of Cs-137 and 40 millicuries of Am:Be-241. Avondale, AZ police are investigating (report # 0327274) the incident. A press release will be issued and the licensee will notify the FBI, States of CA, NV, NM, CO and the Country of Mexico.

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Power Reactor Event Number: 40345
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID SEENEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/20/2003
Notification Time: 18:43 [ET]
Event Date: 11/20/2003
Event Time: 17:00 [CST]
Last Update Date: 11/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KRISS KENNEDY (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

LOSS OF SPDS FOR GREATER THAN 8 HOURS

"During the performance of the control room logs CKL ZL-003 the updating of the SPDS [Safety Parameter Display System] program on the Nuclear Plant Information System (NPIS) computer system was noted to have not changed state. With the recent restoration of the condenser off gas monitor GE RE-092 the computer log had not updated and indicated that the computer was not updating. A review of the computer services backlogs indicates the program has not updated since 11/14/2003 @ 10:29 [CST].

"This condition is being reported as a Loss of Emergency Preparedness under 10CFR50.72(b)(3)(xiii). The loss of NPIS affects Safety Parameter Display System (SPDS). SPDS is considered a significant portion of the WCGS emergency assessment capability. Because SPDS has been lost for longer than a short period of time, Wolf Creek Nuclear Operating Corporation is making this notification pursuant to 10CFR50.72(b)(3)(xiii). There is no other loss of normal procedures and are taking local readings of equipment normally monitored by the NPIS computer. Current plant status is still Mode 5, 0%."

The licensee notified the NRC resident inspector.

* * * UPDATE PROVIDED TO JEFF ROTTON FROM DAVE DEES ON 11/21/2003 AT 1255 * * *

SPDS function was restored at time of initial notification and no other compensatory measures are required.

The licensee notified the NRC resident inspector. Notified Kriss Kennedy - Region 4 Duty Officer.

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Hospital Event Number: 40346
Rep Org: ALBERT EINSTEIN MEDICAL CENTER
Licensee: ALBERT EINSTEIN MEDICAL CENTER
Region: 1
City: Philadelphia State: PA
County:
License #: 37-00448-19
Agreement: N
Docket:
NRC Notified By: KAREN COLUCCI
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/21/2003
Notification Time: 13:48 [ET]
Event Date: 11/20/2003
Event Time: 17:00 [EST]
Last Update Date: 11/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BRIAN MCDERMOTT (R1)
JOHN GREEVES (NMSS)

Event Text

TOTAL DOSE DELIVERED DIFFERS FROM PRESCRIBED DOSE BY MORE THAN 20 PERCENT

On 10/16/2003, patient underwent surgery to implant 89 I-125 seeds for treatment of prostate cancer. X-rays taken after surgery appeared to be normal. On 11/17/2003, a routine follow up CT scan was performed and the results were made available to Radiation Oncology on 11/20/2003. Review of the CT scan showed that approximately 80% of the implanted seeds were in adjacent tissue and not in the intended location. The original prescribed dose to the prostate was 145 Gray. The estimated dose to the prostate with the existing seed location is 18.6 Gray. On 11/21/2003, the medical center left multiple messages with the patient providing applicable contact numbers. The treating physician has been notified. The hospital will be conducting an investigation into the cause of the error and determining appropriate treatment for the patient.

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General Information or Other Event Number: 40347
Rep Org: U. S. AIR FORCE
Licensee: U. S. AIR FORCE
Region: 1
City: WASHINGTON State: DC
County:
License #: 42-23539-01
Agreement: N
Docket:
NRC Notified By: DAVID PUGH
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/21/2003
Notification Time: 14:32 [ET]
Event Date: 11/14/2003
Event Time: [EST]
Last Update Date: 11/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BRIAN MCDERMOTT (R1)
KRISS KENNEDY (R4)
JOHN GREEVES (NMSS)

Event Text

LOST RADIOACTIVE CHEMICAL DETECTOR

On 11/14/2003, an APD-2000 chemical detector with a 10 millicurie Ni-63 source was discovered to be missing from its storage location. The detector was stored with the Fire Department for Westover Air Reserve Base in Massachusetts. It is not known when the detector was last accounted for through inventory and the ongoing search for the last 7 days has provided no results. The search is continuing and an investigation will be conducted to determine the cause of the loss and potential corrective actions to prevent reoccurrence.

Licensee is going to contact NRC Region 4 to report loss.

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Power Reactor Event Number: 40348
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: PHIL ROSE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/21/2003
Notification Time: 15:46 [ET]
Event Date: 11/21/2003
Event Time: 09:10 [EST]
Last Update Date: 11/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID AYRES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R N 0 Hot Standby 0 Hot Standby

Event Text

CONTROL BANK "C" RODS TRIPPED DUE TO INCORRECT DIGITAL ROD POSITION INDICATION (DRPI)

"On Friday November 21, 2003, the V.C. Summer Nuclear Station was performing rod position testing in preparation for plant start-up, following refueling outage-14. The testing is in accordance with STP-106.002 Rod Position Indication Operational Test. Control Bank 'C' was being withdrawn. Per STP-106.002, RCS boron concentration was verified adequate to ensure Keff less than or equal to 0.95. When Control Bank 'C' reached 36 steps Digital Rod Position Indication system (DRPI) indication for rod M-4 went to 18 steps. At 0835, Control Rod motion was stopped and Abnormal Operating Procedure (AOP)-403.5, Stuck or Misaligned Control Rod, was entered after reviewing the AOP applicability versus current plant condition. At 0910 while taking action per the AOP, it was determined that both channels of DRPI were not functioning properly and per Tech Spec 3.10.5 the Rx Trip Breakers were immediately opened (manual actuation of the Reactor Protection System - reactor scram). Emergency Operating Procedure (EOP)-1.0, Reactor Trip, was entered. At 0915 EOP-1.0, was exited with the plant stable in Mode 3 (Hot Standby).

"At this time it appears there was failure in the DRPI system.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(IV)(A), a valid actuation of the Reactor Protection System (RPS)."

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

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Power Reactor Event Number: 40349
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JOHN GUNN
HQ OPS Officer: GERRY WAIG
Notification Date: 11/22/2003
Notification Time: 04:30 [ET]
Event Date: 11/21/2003
Event Time: 22:53 [MST]
Last Update Date: 11/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KRISS KENNEDY (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

VALID ACTUATION OF THE "A" EMERGENCY DIESEL GENERATOR DURING TESTING

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On November 21, 2003, at approximately 22:53 Mountain Standard Time, Palo Verde Nuclear Generating Station Unit 2 experienced a valid actuation (start) of the 'A' Emergency Diesel Generator (EDG). Unit 2 had been performing testing of the capability to parallel the EDG 'A' with the Gas Turbine Generator #1 (alternate AC Power source for station blackout.) The Train 'A' 4.16 Kv bus had been successfully transferred to the EDG and loads carried by the EDG for approximately 5 minutes. When the EDG speed control was taken from 'droop' mode (load sharing) to 'isochronous' mode (fixed frequency,) the EDG output breaker tripped opened, resulting in a valid Loss of Power (LOP) signal based on undervoltage on the Train 'A' bus. The EDG resupplied the bus in the LOP mode.

"Offsite power remained available to both safety buses throughout the event. The other (Train 'B') safety bus is being supplied by offsite power and its EDG is operable. The offsite electrical grid is stable.

"Palo Verde Unit 2 is shutdown and defueled in its 11th refueling outage. No other ESF actuations occurred and none were required. There were no structures, systems, or components that were inoperable at the time of discovery that contributed to this condition. There were no failures that rendered a train of a safety system inoperable and no failures of components with multiple functions were involved. The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public.

"Troubleshooting will be conducted to determine the cause of the EDG output breaker opening."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40350
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN KONOVALCHICK
HQ OPS Officer: GERRY WAIG
Notification Date: 11/23/2003
Notification Time: 06:48 [ET]
Event Date: 11/23/2003
Event Time: 05:19 [EST]
Last Update Date: 11/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JOHN ROGGE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 0 Startup 0 Hot Standby

Event Text

REACTOR WAS MANUALLY TRIPPED AFTER A CONTROL ROD DROPPED DURING LOW POWER PHYSICS

"During performance of low power physics testing for dynamic rod worth measurements, control rod bank D was being withdrawn. At control bank D position of 209 steps, control rod 1D4 dropped into the reactor core. The control room crew entered the abnormal operating procedure for a dropped [control] rod at 0507. Based upon the dropped control rod causing the reactor to go subcritical, the abnormal operating procedure directs that all [control] rods to be inserted. Based upon the control bank D not being fully withdrawn and not in the proper bank overlap due to low power physics testing, the Control Room Supervisor directed the reactor to be [manually] tripped. The crew entered the emergency operating procedure at 0519. All equipment functioned as designed and all major equipment is available. [The crew] exited the emergency operating procedures at 0538. The plant is currently stable in mode 3 at normal operating temperature and pressure.

"The cause of the drop rod is reported to be a blown fuse on the stationary coil. All reactor coolant pumps are in service and decay heat removal is through the steam dumps to the condenser."

All control rods fully inserted when the reactor was manually tripped. Feedwater to the steam generators is being supplied by the auxiliary feedwater system.

The licensee has notified the NRC Resident Inspector and will be notifying the LAC (Lower Alloways Creek) Township.

Page Last Reviewed/Updated Friday, March 30, 2012
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