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Event Notification Report for July 15, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/14/2004 - 07/15/2004

** EVENT NUMBERS **


40863 40864 40869 40870 40871 40873

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General Information or Other Event Number: 40863
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SCHLUMBERGER TECHNOLOGY CORPORATION
Region: 4
City: N/A State: TX
County: PECOS
License #: L01833-000042
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR
HQ OPS Officer: ARLON COSTA
Notification Date: 07/12/2004
Notification Time: 09:29 [ET]
Event Date: 07/10/2004
Event Time: [CDT]
Last Update Date: 07/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
TRISH HOLAHAN (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT ON DOSE TO THE PUBLIC FROM EXPOSED SEALED SOURCE

"Full investigation has been started by Schlumberger. Many details missing from initial notification. Crew using a CAPSTAR rig, without a floor were working a well site in Pecos County, Texas, from the Midland office (Subsite 042). During the evening of probably 07/09/2004 the rig was moved to a new site. When setup for work it was determined by the well loggers that a sealed 1.7 curie Cs-137 source was missing from their tool. They went back to the last site and discovered the source in a pile of mud that was located 10-15 feet from the rig location. It is suspected that the source was missing for 24-36 hours. Suspect dose to the public to the rig crew/roustabouts. The logging crew was badged. No estimates are currently available. A Schlumberger management team has been dispatched from Houston (Subsite 000) to assess dose and investigate this incident. Investigation is ongoing."

TX Incident No.: I-8141

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General Information or Other Event Number: 40864
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: COMPUTALOG WIRELINE SERVICE, INC.
Region: 4
City: BRYAN MOUND STRATEGIC PET RES State: TX
County: BRAZORIA
License #: L04286-018
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR.
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/12/2004
Notification Time: 14:38 [ET]
Event Date: 07/06/2004
Event Time: [CDT]
Last Update Date: 07/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING LOST WELL LOGGING SOURCE

"After performing services to determine the oil/water contact interface and the gas/oil interface levels the wireline with the source was being retracted. The wireline was attached to 1 11/16" tool in the salt dome. During retraction, the source evidently got hung on entry to the hole to the surface. It is felt that the crew was inattentive or possibly did not use proper procedure. The 'stuck' source broke loose of the wireline at the established weak point of connection between the tool and the wireline. Retrieval of the source is deemed unrecoverable. This is the second incident of this type in the same field. The source is a Gulf Nuclear, Model CSV-F74, Cs-137, 100 millicurie source. The probable depth of this source is estimated at approximately 4,000 feet. Investigation on site continues. A written report will be submitted to this Agency [Texas Department of Health]."

Texas Incident No.: I-8142

Event Location: Bryan Mound Strategic Petroleum Reserve, Brazoria County, Texas, Well # BM 104B

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Power Reactor Event Number: 40869
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: BILL CARSKY
HQ OPS Officer: BILL GOTT
Notification Date: 07/14/2004
Notification Time: 03:55 [ET]
Event Date: 07/14/2004
Event Time: 00:45 [CDT]
Last Update Date: 07/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KENNETH RIEMER (R3)

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

Event Text

RPS AND CONTAINMENT ISOLATION ACTUATION DUE TO LOW RPV LEVEL

"On July 14, 2004, at 0045 CDT, the Clinton Power Station experienced a drop in RPV [Reactor Pressure Vessel] level from nominally 30 inches to the Level 3 (the RPS and Isolation setpoint). At this time control rods were fully inserted [see Event Notification - #40868], however, the containment isolation valves associated with this setpoint were open, and these valves automatically closed successfully.

"Level was restored to normal by automatic makeup from the condensate system.

"There were no other malfunctions. The cause for the level drop is being investigated."

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 40870
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAN MARKS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/14/2004
Notification Time: 07:35 [ET]
Event Date: 07/14/2004
Event Time: 01:35 [MST]
Last Update Date: 07/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DALE POWERS (R4)
TERRY REIS (NRR)

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

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING A MAIN GENERATOR TRIP

The following information was received from the licensee via facsimile:

"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 July 14, 2004, at approximately 01:35 Mountain Standard Time (MST) Palo Verde Unit 2 experienced a Main Generator Trip immediately followed by an automatic Reactor Trip. The reactor was at approximately 100% power and normal operating temperature and pressure prior to the event. The cause of the Main Generator Trip was most likely the result of electrical storm conditions present at the site at the time of the trip. Unit 2 was at normal operating temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. Heat removal was maintained to the condenser via the steam bypass control system. This was an uncomplicated reactor trip, No emergency classification was required per the Emergency Plan. No automatic ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The Emergency Diesel Generators did not start and were not required. The offsite power grid is stable. No LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event.

"Unit 2 Is stable at normal operating temperature and pressure in Mode 3. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The [NRC] Senior Resident Inspector was informed of the Unit 2 reactor trip."

No primary or secondary power-operated or manual relief valves lifted as a result of the plant transient. Units 1 and 3 were unaffected by the trip on Unit 2. Offsite power was maintained to Unit 2 safety busses throughout the event.

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Hospital Event Number: 40871
Rep Org: UNION HOSPITAL
Licensee: UNION HOSPITAL
Region: 3
City: TERRE HAUTE State: IN
County:
License #: 13-16457-01
Agreement: N
Docket:
NRC Notified By: DEAN TAYLOR
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/14/2004
Notification Time: 15:05 [ET]
Event Date: 03/29/2004
Event Time: [CST]
Last Update Date: 07/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
KENNETH RIEMER (R3)
SCOTT MOORE (NMSS)

Event Text

SHIPMENT OF IODINE-125 IMPLANTATION SEEDS FOUND TO BE ONE SEED SHORT OF EXPECTED

On 03/29/04, the licensee received a shipment of I-125 prostate implantation seeds (0.587 millicuries unshielded activity per seed) from the manufacturer, Amersham Biosciences of Chicago, IL. The shipment records indicated that 102 seeds were shipped. Upon receipt, the licensee performed an inventory of the shipment which confirmed that only 101 seeds were actually present (one of the pre-loaded cartridges contained 14 seeds rather than 15 as expected). The cartridges were still sealed and sterile-wrapped indicating that the missing seed was not the result of tampering or damage during shipment. Amersham replied to the licensee's inquiry on 05/21/04 indicating that their records indicated that the shipment did contain 102 seeds. Corrective actions for improved shipment accounting are being developed.

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Fuel Cycle Facility Event Number: 40873
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: TOM WHITE
HQ OPS Officer: BILL GOTT
Notification Date: 07/14/2004
Notification Time: 23:45 [ET]
Event Date: 07/14/2004
Event Time: 13:00 [CDT]
Last Update Date: 07/15/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
BRIAN BONSER (R2)
C.W. (BILL) REAMER (NMSS)

Event Text

CRITICALITY CONTROL 24-HOUR (BULLETIN 91-01) REPORT

"At 1300 [CDT] on 7/14/04, the Plant Shift Superintendent (PSS) was notified that a cylinder, which was to be washed, was determined to contain heel material. The cylinder had been filled a single time with natural material at Honeywell (2/2001) since its last wash in 8/1999. An examination of the associated Nuclear Material Control and Accountability (NCM&A) data and cylinder card indicated that the only other filling was in 9/1982 with depleted material at C-315. The cylinder was fed to the cascade in 9/2003 at C-337-A.

"A total of 4 gas over solid samples were taken of the cylinder and all indicated that the cylinder contains material. Nuclear Criticality Safety Evaluation 085 and Nuclear Criticality Safety Analysis 400-012 establish double contingency to ensure that a fissile cylinder is not washed in the non-fissile cylinder wash facility.

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

"PGDP Assessment and Tracking Report No. ATR 04-2756; PGDP Event Report No. PAD 2004-019; Responsible Division: Operations.

"SAFETY SIGNIFICANCE OF EVENTS:
"NMC&A showed this cylinder contained a heel of around 8 lbs. Gas over solid sampling determined this non-fissile cylinder contained fissile material and could not be washed. Although the cylinder was not washed, an unlikely failure occurred that allowed fissile material to enter a cylinder controlled as non-fissile.

"CONTROLLED PARAMETERS:
"The process condition relied upon for double contingency for this scenario is enrichment.

"NUCLEAR CRITICALITY SAFETY CONTROL OR CONTROL SYSTEMS AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
"The first leg of double contingency relies on a gas over solid sample of the cylinder to demonstrate that the cylinder contains non-fissile material prior to washing.

"The second leg of double contingency relies on an argument that back- or cross-feeding at C-337A is unlikely to result in a significant amount of fissile material to be transferred to the cylinder. Since fissile material was found in the cylinder after it was fed at C-337A, this unlikely argument appears to have failed. However, the cylinder was not washed, maintaining this parameter.

"Although the parameter was maintained, double contingency is based on two controls on one parameter and one of the controls (unlikely argument) failed. Therefore double contingency was not maintained.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
"1. Correct NMC&A database for this cylinder to show the correct assay in the cylinder and that the cylinder is fissile."

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012