United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2004 > August 26

Event Notification Report for August 26, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/24/2004 - 08/26/2004

** EVENT NUMBERS **


40971 40976 40981 40982 40983 40985

To top of page
General Information or Other Event Number: 40971
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PROVIDENCE ST. JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County:
License #: CA0059-19
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2004
Notification Time: 18:41 [ET]
Event Date: 08/18/2004
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
GARY JANOSKO (NMSS)

Event Text

AGREEMENT STATE REPORT- THERAPEUTIC MISADMINISTRATION

Therapeutic misadministration from HDR [High Dose Rate brachytherapy]. Patient was scheduled for three HDR retreatments for cancer between the urethra & bladder wall. The treatment dose/fraction was supposed to be 300 cGy [centiGray] to a 7 mm radius distance from the source, & the length of the treatment plan was 3 cm. They used a Varian catheter & measuring wire. When they inserted the measuring wire, they thought they were at the end of the catheter, but they were actually about 20 cm short. The source for two treatments, on August 18 and 19, was actually located about 10 cm from the end of the penis, exterior to the body. They estimate the tumor site only got about 10 cGy, and the penis may have received approximately the same dose it would have received had the source been inserted into the correct location. The root cause appears to be an error on the part of the medical physicist. The patient is 93 years old, and both the radiation oncologist and the primary care physician believe he should not be told. The third treatment was performed correctly, and they have scheduled him for two additional treatments. They believe there will be no impact on the patient.

To top of page
General Information or Other Event Number: 40976
Rep Org: NV DIV OF RAD HEALTH
Licensee: GEOTEK, INC.
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0348-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2004
Notification Time: 12:55 [ET]
Event Date: 08/19/2004
Event Time: 16:30 [PDT]
Last Update Date: 08/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
JOHN HICKEY (NMSS)

Event Text

NEVADA: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE


"1. Event Report ID No. NV-04-005

"2. License name, address, license No: Geotek, Inc.; 8835 S. Escondido Street, Suite A; Las Vegas, Nevada 89119-3 828, 00-11-0348-01

"3. Nature of Event, Date and time of occurrence: Theft of a portable moisture/density gauge on 8/19/04, about 4:30 pm.

"4. Date notified of event by licensee or non-licensee: August 20, 2004

"5. Radionuclide, activity: Cesium 137-10 millicuries and Americium 241-50 milliCuries

"6. Any exposures (indicate short and long-term effects): Unknown

"7. Sealed source, device, etc. (make, model #, serial #): CPN-131 sealed source, CPN Model MC-3 gauge, serial number M34125837

"8. Leak test information, if applicable: Unknown

"9. Equipment (make, model #, serial #), and clear description of any equipment problems: See # 7 above

"10. Persons involved, consequences: (Deleted), no consequences known

"11. Transportation, identify shipper, package type and ID No.: N/A

"12. Abnormal Occurrence (Y/N): N

"13. Cause and contributing factors: The chain, securing the gauge case in the truck, was cut with bolt cutters and the gauge in its case was stolen

"14. Notifications: patient, physician: N/A

"15.Licensee corrective actions: Will perform investigation to determine root cause

"16.Provide status through resolution (update record when found)

"17. Notifications, local police, FBI and other States; as needed: Clark County Metropolitan Police

"18. Enforcement Actions: Under investigation

"19. Identify any possible generic safety concerns: N/A

"20. Potential for others to experience the save event: Unknown

"This incident was reported to Ms. Linda McLean, NRC Region IV, on 8/20/04 by telefax."

To top of page
Power Reactor Event Number: 40981
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: C. BAUER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/24/2004
Notification Time: 16:48 [ET]
Event Date: 08/24/2004
Event Time: 13:30 [EDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
EUGENE COBEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

NORTH PLANT VENT RADIATION MONITOR SKID TEST CONNECTION VALVE INADVERTENTLY LEFT OPEN.

"On Tuesday 8/24/04 at 1330 hours, a test connection valve on the North Plant Vent radiation monitor skid was identified to have been inadvertently left open. This configuration issue appears to have occurred sometime on 8/19/04 following corrective maintenance on the North Plant Vent radiation monitor skid. With this valve left open, the process flow path for the skid was effectively diluted as room air was drawn into the normal process flow from the North Plant Ventilation ductwork. The physical location of the valve left open on the skid was such that the High/Low Noble Gas Range Monitors Iodine Sampler and Particulate Sampler would have been affected by this oversight. Technical Specification section 3.3.7.5 for Accident Monitoring as well as Offsite Dose Calculation Manual section 3.3.7.11 would have been applicable for the condition described. The preplanned alternate method of monitoring (sampling) the parameters was not established. This is in contrary to the requirements of Technical Specifications and the Off Site Dose manual. This condition has been corrected and the North Plant Vent radiation monitor skid is currently operable. Though alternate sampling capability was available, it was not recognized that it was required. Should an accident have occurred during the time that the valve was open emergency assessment capability would have been compromised. This report is being made under Hope Creek Event Classification Guide RAL# 11.7.1.c in accordance with 10CFR50.72(b)(3)(xiii)."

Local authorities will be notified of this by the licensee."

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

To top of page
General Information or Other Event Number: 40982
Rep Org: GENERAL ELECTRIC COMPANY
Licensee: GENERAL ELECTRIC COMPANY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JASON S. POST
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/24/2004
Notification Time: 17:36 [ET]
Event Date: 08/24/2004
Event Time: [EDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
EUGENE COBEY (R1)
JOEL MUNDAY (R2)
ERIC DUNCAN (R3)
WILLIAM JOHNSON (R4)
VERN HODGE (NRR)

Event Text

PART 21 REPORTABLE CONDITION AND 60-DAY INTERIM REPORT NOTIFICATION: NON-CONSERVATIVE SAFETY LIMIT MINIMUM CRITICAL POWER RATIO

Global Nuclear Fuel (GNF) and GE Nuclear Energy (GENE) have determined that the current GNF process for determination of the Safety Limit Minimum Critical Power Ratio (SLMCPR) can result in a non-conservative SLMCPR. GENE has historically used a non-conservative SLMCPR impact of 0.01 as the threshold for reportability under 10CFR21. A preliminary screening evaluation has been completed for all plants operating with a SLMCPR calculated by GNF to determine those that have a nonconservative impact of 0.01 or greater. Verification has been completed for those plants that the screen showed to have a non-conservative SLMCPR impact of 0.01 or greater. Verification has not been completed for the plants that the screen showed had an impact of less than 0.01 or were unaffected, thus requiring a 60-Day Interim Report notification pending verification completion.

The plants for which GNF calculates the SLMCPR are identified [below]. Those plants for which the preliminary screen indicated that the current SLMCPR is unaffected are identified as a 60-Day Interim Report. Upon completion of verification (assuming the results of the screen are confirmed) the status of these plants will be changed to Not Reportable. GENE will provide a follow-up report to the NRC by September 29, 2004. The plants for which the current SLMCPR is non-conservative by 0.01 or greater are identified as a Reportable Condition under 10CFR21.21(d). These plants will take action to address the Reportable Condition.

GNF has notified all plants that have been confirmed to be affected. The plants that have a non-conservative SLMCPR for current plant operation will take action to mitigate the potential impact. Depending on the specific circumstances, mitigating actions to protect the SLMCPR may include increasing the OLMCPR to assure compliance with the low flow calculated SLMCPR. In some cases sufficient conservatism may exist in the OLMCPR at low flow to bound the increased SLMCPR. Each affected plant will notify the NRC and take appropriate action if their Technical Specifications are affected.

There are no actions necessary for the plants that are unaffected pending completion of verification. If, in the course of verification, GNF determines that there is an impact, the affected utility will be notified immediately. GNF will complete the verification and GENE, will provide a follow-up letter to the NRC by September 29, 2004.

Affected and 60-Day Interim Notification Plants:

60-Day Interim Report: Clinton, Oyster Creek, Brunswick 1, Brunswick 2, Nine Mile Point 2, Fitzpatrick (60-Day interim report for current operation, Reportable Condition for SLMCPR licensing submittal), Pilgrim, Vermont Yankee, Dresden 2, Dresden 3, LaSalle 1, LaSalle 2, Limerick 1, Limerick 2, Peach Bottom 2, Peach Bottom 3, Quad Cities 1, Quad Cities 2, Perry 1, Duane Arnold, Monticello, Hope Creek, Hatch 1, Hatch 2, Browns Ferry 2

Reportable Condition: Nine Mile Point 1, Fermi 2, Fitzpatrick (60-Day interim report for current operation, Reportable Condition for SLMCPR licensing submittal), Cooper.

To top of page
Power Reactor Event Number: 40983
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN MENG
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/24/2004
Notification Time: 17:36 [ET]
Event Date: 08/24/2004
Event Time: 09:17 [CDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ERIC DUNCAN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

HIGH PRESSURE CORE SPRAY (HPCS) DECLARED INOPERABLE

At 1128 hours on 8/23/04, the Division 3 Essential Switchgear Heat Removal System (VX) was removed from service and declared inoperable for performance of system flow verification and balance. The test includes an as found flow check on the Division 3 Essential Switchgear Heat Removal System Condensing Unit, rendering the Division 3 VX safety-related chiller 1VX06CC INOPERABLE. The non-safety VX subsystem remained OPERABLE during the test.

"At 0917 hours on 8/24/04, the non-safety Division 3 VX Heat Removal Supply Fan 1VX04CC, tripped due to the breaker for the safety-related fan being removed for replacement. The Main Control Room received alarm 5042-6A, Auto Trip Pump/Fan. Since both the safety and non-safety subsystems of VX were unavailable Operators declared the High Pressure Core Spray (HPCS) System inoperable per Technical Specification 3.7.2, Action A.1.

"At 1153 hours, the breaker replacement was complete, 1VX04CC was restored to service, and the HPCS System was declared OPERABLE.

"The VX System maintains safety-related switchgear, battery and inverter room, and cable spread areas within the design temperature limits of the equipment. The VX system is support system for the HPCS System. With both subsystems of the VX System out of service, the HPCS System may not have been capable of performing its safety function to provide Emergency Core Cooling, aid in depressurization and maintain reactor vessel water level following a loss of coolant accident.

"An engineering evaluation is currently in progress to determine if the HPCS System would have been capable of performing its safety function with both safety and non-safety subsystems of VX out of service.

"This issue is being reported in accordance with 10CFR50.72(b)(3)(v)(D), as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function needed to mitigate the consequences of an accident."

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

To top of page
Fuel Cycle Facility Event Number: 40985
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: CARL SNYDER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/25/2004
Notification Time: 09:44 [ET]
Event Date: 08/24/2004
Event Time: 10:05 [EDT]
Last Update Date: 08/25/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
JOEL MUNDAY (R2)
TOM ESSIG (NMSS)

Event Text

24 HOUR 91-01 RESPONSE BULLETIN

An incorrect valve line-up caused a batch from the solvent extraction system to be pumped to the uranyl nitrate bulk storage tank without having the necessary sample results for grams U-235 per liter, percent free acid, and pH. It was determined that approximately 38 gallons of uranyl nitrate at 4.6 grams U-235, 8 percent free acid, and a pH of 1 was pumped to the bulk storage tank. These parameters meet the requirements for an authorized pumpout. The bulk storage tank contained approximately 1600 gallons of uranyl nitrate at approximately 1.4 grams U-235 per liter, 11.6 percent free acid, and a pH of 1.

Double contingency protection for the bulk storage tank is based on concentration control. Concentration control is based upon maintaining uranyl nitrate that is pumped to the tanks at less than 5 grams U-235/liter. The pH is maintained at a value of less than 2 to ensure that the uranyl nitrate stays in solution. The percent free acid is maintained at greater than 4 percent to ensure that the uranyl nitrate stays in solution and depresses the freezing temperature of the solution to prevent concentration by freezing.

It has been determined that less than previously documented double contingency protection remained for the system and that greater than a safe mass was involved, but a sufficient number of controls that were lost were restored within 4 hours. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a 24-hour notification.

Summary of Activity

All pumpouts to bulk storage tanks were stopped immediately upon recognition. This action was initiated by operators monitoring system performance.

Samples for grams U-235/liter, pH, and %free acid were taken to ensure the tanks were in specification.

Before the end of the shift, sample results for grams U-235/liter, pH, and %free acid were confirmed to be acceptable.

At the beginning of each shift, operators are being informed of the incident.

The procedure is being modified immediately to incorporate an additional peer check.

Independent locks will be installed to require separate individuals to unlock the valve prior to pumpout.

Conclusions

Loss of double contingency protection occurred.

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.

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

Notification was the result of an event, not a deficient NCS analysis.

A causal analysis will be performed.

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