| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
04/02/2004 - 04/05/2004 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 40627 | Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: PALMETTO HEALTH BAPTIST HOSPITAL
Region: 1
City: Columbia State: SC
County:
License #: 076
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: ARLON COSTA | Notification Date: 03/30/2004
Notification Time: 16:30 [ET]
Event Date: 03/17/2004
Event Time: [EST]
Last Update Date: 03/30/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
KENNETH JENISON (R1)
ROBERTO TORRES (NMSS)
| Event Text SOUTH CAROLINA - AGREEMENT STATE REPORT ON PERSONNEL EXTERNAL CONTAMINATION
The following event description report (ID No. SC040001) was received at the Operations Center via facsimile:
"The SC Department of Health and Environmental Control was notified on Tuesday, March 30, 2004, by the physicist/consultant for the facility that a pharmacist in training in the nuclear pharmacy had sustained external contamination on his hand and forearm. The pharmacist was in the process of compounding Iodine-131 from a vial when a spill apparently took place. His arm and forearm were contaminated. This vent took place on Wednesday, March 17, 2004. The pharmacist did not notify anyone that this event had taken place. He performed clean up of the area and decontamination of the skin. He continued work until March 19, 2004, at which, time he performed a bioassay prior to going on vacation. He returned to work on Monday, March 29, 2004, at which time the nuclear pharmacist in charge discovered the elevated readings on the person's arm and forearm. The appropriate hospital/nuclear medicine personnel were notified. The person involved has been suspended from any and all duties involving radioactive material. The consultant for this facility is in the process of assimilating additional data and the person involved has had two whole body scans performed to determine if there was any internal uptake of the radioiodine. These scans have produced no indication of internal uptake at this point. The event is still under investigation and updates will be made through the national NMED system as they become available." |
| General Information or Other | Event Number: 40629 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOR GEO TECHNICAL
Region: 4
City: VICTORVILLE State: CA
County:
License #: 5459
Agreement: Y
Docket:
NRC Notified By: DONELLE KROJEWSKI
HQ OPS Officer: CHAUNCEY GOULD | Notification Date: 03/30/2004
Notification Time: 23:54 [ET]
Event Date: 03/30/2004
Event Time: 17:00 [PST]
Last Update Date: 04/02/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DALE POWERS (R4)
SCOTT MOORE (NMSS)
VICTOR GONZALEZ (MEX)
| Event Text STATE LICENSEE REPORTED A CPN GAUGE WAS STOLEN FROM THEIR TECHNICIAN'S TRUCK
Lor Geo Technical of Riverside, CA reported to the state of California that a CPN nuclear gauge model MC1DR serial # MD10506147 was stolen from the back of a technician's pickup truck when it was parked at a fast food restaurant in Victorville, CA. The gauge contained 10 millicuries of Cs-137 and 50 millicuries of Am-241. The local police department was notified and a reward is being offered.
* * * UPDATE 1550 EST ON 4/2/04 FROM DONELLE KRAJEWSKI TO S. SANDIN VIA EMAIL * * *
The State of California was notified on 3/31/04 that the gauge was recovered intact in a utility trench at a jobsite near the one the user had been working in on 3/30/04. The lock on the gauge handle was missing. The recovery of the gauge was also reported to the police by the user.
Notified R4DO (Powers), NMSS (Essig) and Mexico (Gonzalez) via fax. |
| Fuel Cycle Facility | Event Number: 40633 | Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: ALLEN MABRY
HQ OPS Officer: MIKE RIPLEY | Notification Date: 04/02/2004
Notification Time: 10:35 [ET]
Event Date: 04/01/2004
Event Time: 13:00 [EST]
Last Update Date: 04/02/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
JOEL MUNDAY (R2)
LINDA PSYK (NMSS)
| Event Text OUTDOOR AREA CRITICALITY WARNING SYSTEM HORN INOPERATIVE
"At approximately 1:00 p.m. on April 1, 2004 it was discovered a Criticality Warning System (CWS) horn had been rendered inoperative in an unoccupied remote outdoor area due to maintenance conducted on the system on March 31, 2004. Maintenance was conducted on the system to remove a tree that had fallen across the communication line to Data Acquisition Module (DAM) #25 which provides coverage for the outdoor process lagoon area. During maintenance activities to remove the tree, a temporary system was installed and the permanently installed system horn was disconnected. Following completion of the maintenance, the restoration effort failed to reinstall a local horn relay.
"Throughout the maintenance, the DAM remained operable and indications of normal conditions were available. With the exception of the local horn at the remote outdoor area, all other system functions remained operable.
"Upon discovery of the local horn being disabled, the horn relay was promptly restored and tested, confirming restoration of full system operability. This condition is reported pursuant to 10CFR70.50(B)(2) as an event in which equipment designed to mitigate the effects of an incident are disabled or fails to function as designed. Incident investigation and evaluation of additional corrective actions are continuing."
"SAFETY SIGNIFICANCE OF EVENTS: Low safety significance - The potential for a criticality event in this area is highly unlikely because of the very low uranium concentration, low material density, and high levels of non-uranium materials. This is consistent with the Integrated Safety Analysis (ISA) for the area.
"POTENTIAL CRITICALITY PATHWAYS INVOLVED: There is no known process upset that would change the highly unlikely potential for a criticality in this area.
"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION ETC.): Density and Mass (concentration)
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST BASE CRITICAL MASS): N/A. Affected area is final wastewater process lagoon. Uranium concentration in the affected area is approximately [deleted] parts per million (PPM)
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEMS AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: N/A
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: System was restored to normal operation at 1300 on 4/1/04 and subsequently tested. Investigation of event and evaluation of additional corrective actions pending."
The licensee will notified the local County, the State of North Carolina, and NRC Region II. |
| Hospital | Event Number: 40634 | Rep Org: U.S. DEPT OF VA HP PROGRAM
Licensee: GREATER LOS ANGELES HEALTHCARE SYSTEM
Region: 4
City: LOS ANGELES State: CA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN M. LEINHOLDT, PHD
HQ OPS Officer: ERIC THOMAS | Notification Date: 04/02/2004
Notification Time: 17:40 [ET]
Event Date: 03/31/2004
Event Time: 12:00 [PST]
Last Update Date: 04/02/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
DALE POWERS (R4)
MICHAEL PARKER (R3)
SCOTT MOORE (NMSS)
| Event Text POSSIBLE MEDICAL EVENT
The U.S. Department of Veteran's Affairs Health Physics Program (VA NHPP) notified the NRC of the following possible Medical Event at the VA Greater Los Angeles Healthcare System (GLAHCS), 11301 Wilshire Boulevard, Los Angeles, California 90073, a master material license permittee.
"On March 31, 2004, a permanent-implant prostate brachytherapy procedure was performed. 109 Iodine-125 seeds were implanted in the patient. A number of seeds were mistakenly placed in the patient's bladder. The seeds placed in the bladder have been recovered. At this time, it appears that the dose to the prostate was more than 20 percent less than that prescribed. The VA GLAHCS has taken initial action to prevent a recurrence. The VA NHPP intends to conduct a reactive inspection next week."
The VA NHPP is in the process of verifying that the licensee notified the patient of this occurrence.
Initial action taken to prevent recurrence was to cease performing this procedure until an investigation and root cause determination are complete.
The licensee has not yet determined whether any unintended damage was done to the bladder as a result of this procedure. |
| Power Reactor | Event Number: 40635 | Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: BRIAN BLANCHE
HQ OPS Officer: STEVE SANDIN | Notification Date: 04/02/2004
Notification Time: 20:30 [ET]
Event Date: 04/02/2004
Event Time: 13:30 [CST]
Last Update Date: 04/02/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
DALE POWERS (R4)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text OFFSITE NOTIFICATION TO LOCAL GOVERNMENT AGENCY FOLLOWING SIREN ACTIVATION DURING TESTING
"One emergency siren activated for approximately one minute during planned maintenance activities. The control room was notified later and the initial determination was that the event was not reportable. However, upon further review, it was determined to be reportable due to later media and local government notification."
The licensee informed the NRC Resident Inspector. |
| Power Reactor | Event Number: 40636 | Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: WILLIAM WOODBURY
HQ OPS Officer: MIKE RIPLEY | Notification Date: 04/03/2004
Notification Time: 05:49 [ET]
Event Date: 04/03/2004
Event Time: 03:00 [EST]
Last Update Date: 04/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
JOEL MUNDAY (R2)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 22 | Power Operation | 22 | Power Operation | Event Text HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE
"During plant startup from the Brunswick Unit 1 Refueling Outage, the High Pressure Coolant Injection (HPCI) System was declared inoperable due to pump data not meeting the acceptable value of OPT-09.2, HPCI System Operability Test. With pump flow established at the reference value of 4550 gallons per minute, the actual turbine speed was 2530 rpm, outside the acceptable range of 2485-2515 rpm.
"Initial Safety Significance Evaluation: Minimal since the Automatic Depressurization System (ADS), the Low Pressure Coolant Injection System (LPCI), and the Core Spray System are Operable. In addition the Reactor Core Isolation Cooling System (RCIC) is Operable.
"Corrective Actions: Engineering to evaluate the test results and determine corrective actions."
The licensee will notify the NRC Resident Inspector. |
| Power Reactor | Event Number: 40637 | Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TIM SHELTON
HQ OPS Officer: STEVE SANDIN | Notification Date: 04/03/2004
Notification Time: 13:17 [ET]
Event Date: 04/03/2004
Event Time: 13:14 [EST]
Last Update Date: 04/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
JOEL MUNDAY (R2)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text NOTIFICATION TO VIRGINIA DEQ CONCERNING A CHEMICAL SPILL
"Notification made to State Department of Environmental Quality (DEQ) for a chemical spill of Calgon H-901-g going into onsite waters."
Approximately 500 gallons of chemicals containing Bromine used to treat service water spilled onsite. A portion of the spill entered the drainage system and was released offsite. The licensee attributes the spill to a mechanical failure on their brominator system and is in the process of cleaning up the material onsite.
The licensee informed the NRC Resident Inspector. |
| Power Reactor | Event Number: 40639 | Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JASON MIKULKA
HQ OPS Officer: STEVE SANDIN | Notification Date: 04/03/2004
Notification Time: 14:10 [ET]
Event Date: 04/03/2004
Event Time: 10:50 [EST]
Last Update Date: 04/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
| Person (Organization):
KENNETH JENISON (R1)
|
| 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 VALID ACTUATION OF AUXILIARY FEEDWATER SYSTEM DURING MAINTENANCE
"This is an 8-hour notification being made to report that a valid ESF Auxiliary Feed actuation occurred. Salem Unit 1 is in mode 5 with RHR providing shutdown cooling. '11' Aux Feed Pump was in service to fill '13' and '14' steam generators for wet lay-up conditions. Actual levels were low in both '13' and '14' steam generators but jumpers were installed on steam generator narrow range level channel III and IV to prevent an ESF actuation. On 4/03/04 at 1050 AM, a breaker effecting reactor protection system channel III was cleared and tagged as part of preparations to remove 1C 4KV vital bus from service. The actual low level in '13' and '14' steam generators along with the power loss to channel III caused 2 out of 3 logic to be satisfied and initiated an AFW actuation. '11' Auxiliary Feed Pump remained running. '12' Auxiliary Feed Pump auto started. '13' Auxiliary Feedwater Pump was removed from service prior to the actuation and did not start. The '13' and '14' steam generators continued to fill. '11' and '12" Auxiliary Feed Valves (11AF21 and 12AF21) were closed and no level rise was observed. The breaker was restored and reactor protection system channel III was placed back in service. All auto start signals cleared after power was restored and the '12' Aux Feed Pump was stopped at 1101. There were no unusual or unexpected plant response from the actuation. All safety systems and equipment performed as expected. Entry into mode 6 is expected this afternoon and progress of the refueling outage is expected to continue. There were no personnel injured."
The licensee will inform the Lower Alloways Creek Township (LAC) and has informed the NRC Resident Inspector. |
| Other Nuclear Material | Event Number: 40640 | Rep Org: WESTERN SOIL
Licensee: WESTERN SOIL
Region: 1
City: SAN JUAN State: PR
County:
License #: 52-21368-01
Agreement: N
Docket:
NRC Notified By: MAX LARACUENTE
HQ OPS Officer: BILL GOTT | Notification Date: 04/03/2004
Notification Time: 15:55 [ET]
Event Date: 04/03/2004
Event Time: 02:00 [EST]
Last Update Date: 04/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)
| Event Text STOLEN MOISTURE DENSITY GAUGE
A truck containing a CPN moisture density gauge was stolen from an employee's home in Puerto Rico. The truck and gauge were stolen between 0200 - 0300 EST on 04/03/04. The truck was recovered without the gauge. A report was filed with the police, and the local media was informed. A reward for the gauge's return has been offered. The gauge contains 10 millicuries Cs-137 and 50 millicuries Am-241. The gauge's serial number is MD10606200. |
| Fuel Cycle Facility | Event Number: 40641 | Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: MIKE RIPLEY | Notification Date: 04/05/2004
Notification Time: 01:40 [ET]
Event Date: 04/04/2004
Event Time: 14:30 [CDT]
Last Update Date: 04/05/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
| Person (Organization):
JOEL MUNDAY (R2)
SCOTT MOORE (NMSS)
| Event Text BULLETIN 91-01 CRITICALITY CONTROL
"At 1430, on 04-04-04 the Plant Shift Superintendent was notified of a violation of Nuclear Criticality Safety (NCS) control in the C-333 process building. While preparing for start up of the C-333 #1 High Speed Purge and Evacuation (P & E) pump, operations discovered that the delta pressure (DP) alarm instrument line to the RCW supply was unattached and the isolation valve was closed. With the RCW instrument line not attached, both DP alarms for this pump were not functional and therefore not able to perform their safety function, violating a safety related item (SRI) in NCSE 039. The SRI requires that both DP alarms be functional while the P & E is isolated from the cascade. The purpose of the SRI Is to alert the operator to take actions within a 28-hour timeframe to prevent wet R-114 from leaking into the process gas system. The DP alarms had been nonfunctional for more than 28 hours when discovered. Both DP alarms were put back in service and the R-114 sampled and found dry within 4 hours of discovery, therefore, re-establishing double contingency.
"The Senior NRC Resident Inspector has been notified of this event."
"PGDP Problem Report No, ATR-04-1342; PGDP Event Report No. PAD-2004-09; Event Worksheet #40641 Responsible Division: Operations
"SAFETY SIGNIFICANCE OF EVENTS: While the R-114 was demonstrated to be dry, both DP alarms relied on for double contingency were disabled without the knowledge of the operators.
"POTENTIAL CRITICALITY PATHWAYS INVOLVED: In order for a criticality to occur, an unsafe mass uranium deposit would have to be present in the process gas system, an R-114 leak to the process gas system would have to occur, the R-114 would have to contain an unacceptable amount of moisture ( i.e. greater than 10 kg of water) and moderate the deposit.
"CONTROLLED PARAMETERS (MASS, MODERATION, G5OMETRY, CONCENTRATION, ETC): Double contingency is maintained by implementing two controls on moderation.
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL: No known mass of licensed material exists In the #1 High Speed Purge and Evacuation pump.
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency is based on the DP switch alarming to alert the operator to take action to either verify the R-114 Is dry or to isolate the RCW and remove the R-114 from the system in order to prevent water from leaking into the process gas system. This DP alarm was not maintained as functional. The DP alarm was put back in service and the R-114 was sampled and found to be dry. The SRI was not maintained and the control was violated but the process condition was maintained.
"The second leg of double contingency is based on the independent DP switch alarming to alert the operator to take action to either verify the R-114 is dry or to isolate the RCW and remove the R-114 from the system in order to prevent water from leaking into the process gas system. The independent DP alarm was not maintained as functional. The independent DP alarm was put back in service and the R-114 was sampled and found to be dry. The SRI was not maintained and the control was violated but the process condition was maintained. This re-established double contingency.
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: Both DP switches were returned to service and the R-114 was sampled and found to be dry on 04-04-04 at 1655." |
| Power Reactor | Event Number: 40642 | Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM HUFFORD
HQ OPS Officer: MIKE RIPLEY | Notification Date: 04/05/2004
Notification Time: 04:02 [ET]
Event Date: 04/05/2004
Event Time: 01:30 [EDT]
Last Update Date: 04/05/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
| Person (Organization):
KENNETH JENISON (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text LOSS OF SAFETY FUNCTION FOR EMERGENCY DIESEL GENERATORS DURING SURVEILLANCE TESTING
"At 0030 [ET] during setup for Unit 1 Division 1 LOCA/LOOP Surveillance testing, the controlling procedure required making the Loss of Power instrumentation for the 1A and 1C ESS buses inoperable. The specification has a 1 hour time limit for restoration, or the associated Diesel Generators must be declared inoperable. Due to delays during the setup of equipment the time requirements were not met, and the associated Diesel Generators were declared inoperable at 0130. The Susquehanna Safety Analysis requires three operable Diesel Generators to safely shutdown. Therefore, this condition is reportable for Unit 2 under 10CFR50.72(b)(3)(v). Unit 1 is in Mode 5 and therefore not impacted. The Loss of Power instruments were restored, and the Diesel Generators declared operable at 0223."
The licensee notified the NRC Resident Inspector. | |