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Event Notification Report for March 25, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/24/2005 - 03/25/2005

** EVENT NUMBERS **


41465 41507 41516 41517 41518 41519 41520 41522 41524 41525

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 41465
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: CALVIN PITTMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/07/2005
Notification Time: 08:50 [ET]
Event Date: 03/06/2005
Event Time: 11:40 [CST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
CAROLYN EVANS (R2)
TOM ESSIG (NMSS)

Event Text

SMALL HYDROGEN FLUORIDE LEAK

The following information was obtained from the Paducah Gaseous Diffusion Plant via facsimile (text in quotes);


"At 1140, on 03-6-05, the Plant Shift Superintendent was notified that the C-360 Toll and Transfer Facility Zone 1 PGLD (Process Gas Leak Detection) system (Q Safety System) on # 4 Sample Cabinet actuated. The operators evacuated to the proper assembly point. The emergency Squad entered the building and sampled for Hydrogen Fluoride and sample results were positive. The autoclave and sample cabinet UF6 lines were evacuated and purged. Operators gave bioassay sample and the results indicated an uptake of Uranium. Event investigation is ongoing.

"This event is reportable as a 24 hour event in accordance with the plant procedure UE2-RA-RE1030, Nuclear Regulatory Event Reporting (no 10 CFR section is referenced). An automatic or manual actuation of a Q safety system that results from an event or condition that has the potential for significant impact on the health or safety of personnel. Event having the potential for significant impact are those events where actual plant conditions existed that the system was designed to protect against.

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

"PGDP Problem Report No. ATRC-05-0892; PGDP Event Report No. PAD-2005-07; Worksheet
Responsible Division: Operations"


Atmospheric leak was on line between the autoclave and the sample cabinet. C-360 Toll and Transfer Facility is a stand alone facility. Operations were secured and two individuals had uptakes (Minimal risk): One had an uptake of 7.3 mg/ liter uranium and the other individual had an uptake level of 5.2 mg/ liter uranium. The limit is 5.0 mg/ liter uranium. There was no smoke (very small leak) and a slight smell of Hydrogen Fluoride caused by the leak.

* * * UPDATE 1230 EST ON 3/24/05 FROM THOMAS WHITE TO S. SANDIN * * *

This report is being retracted based on the following information received from the regulatee via fax:

"This report is being retracted. Subsequent analysis of the actuation determined that the PGLD head actuation occurred from a minor incidental release of UF6 from a valve packing that is not considered a breach of the pressure boundary. Reporting is required if the safety system actuates in response to a condition that the system is designed against and that could result in significant impact on the safety and health of personnel. The PGLD systems safety function, described in the PGDP accident analysis, is to mitigate pigtail/line failures outside of the autoclave that could cause offsite consequences. This incidental UF6 leak did not have the potential for significant impact on personnel or offsite consequences and is not what the safety system is designed to protect against. Thus, the reporting criteria were not met in this case. [The] resident inspector has been notified of this retraction."

Notified R2DO (Ayres) and NMSS (Essig).

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General Information or Other Event Number: 41507
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MARIETTA MEMORIAL HOSPITAL
Region: 3
City: MARIETTA State: OH
County:
License #: 02120850007
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/21/2005
Notification Time: 08:50 [ET]
Event Date: 03/11/2005
Event Time: 13:00 [EST]
Last Update Date: 03/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3)
JOHN HICKEY (NMSS)

Event Text

POSSIBLE MEDICAL MISADMINISTRATION

A prostate implant patient at Marietta Memorial Hospital was to have received 98 Iodine-125 seeds, 0.310 millicuries per seed, but instead received 83 iodine-125 seeds and 15 palladium-103 seeds, 1.2 millicuries each (palladium-103 is accelerator produced). The patient received 98% of the planned dose. The holders for the iodine-125 seeds and the palladium-103 seeds are similar in shape and size. The State of Ohio Bureau of Radiation Protection received the above information on 03/16/05 around 1300 hours. The Ohio Bureau of Radiation Protection is investigating this event.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41516
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JIM RUSSELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/23/2005
Notification Time: 22:29 [ET]
Event Date: 03/23/2005
Event Time: 19:56 [EST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DAVID AYRES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N Y 20 Power Operation 0 Hot Standby

Event Text

REACTOR MANUALLY TRIPPED FROM 20% POWER DURING LOAD REDUCTION.

Unit 4 reactor was manually tripped from 20 percent power per 4 - GOP - 103 "Power Operation to Hot Standby" (normal shutdown procedure), during a load reduction to take the unit off line. The reason for the load reduction was an oil leak of approximately 100 drops per minute on the "4B" steam generator feed pump. The reactor was tripped when directed by 4 - GOP - 103. All rods fully inserted, no relief valves lifted, and all other systems functioned normally.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM V. BARRY TO M. RIPLEY 1125 EST 03/24/05 * * *

The licensee provided the following information via facsimile (licensee text in quotes):

"Upon review, the manual reactor trip from 20 percent power is not reportable in accordance with 10 CFR 50.72(b)(2)(iv)(13) since it was part of the pre-planned sequence of reactor shutdown steps contained in procedure 4-GOP-103, "Power Operation to Hot Standby." In addition, the reactor shutdown was not required by Technical Specifications.

"The NRC Resident Inspector will be notified of this retraction."

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Power Reactor Event Number: 41517
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: PAUL WOJKIEWICZ
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/24/2005
Notification Time: 07:59 [ET]
Event Date: 03/24/2005
Event Time: 05:29 [CST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
LAURA KOZAK (R3)
ERIC BENNER (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 96 Power Operation 0 Hot Shutdown

Event Text

REACTOR AUTOMATIC SCRAM DUE TO MAIN STEAM HIGH FLOW ISOLATION SIGNAL

The licensee provided the following information via email (licensee text in quotes):

"On 3/24/05 at approximately 0529 Unit 2 received a Group 1 isolation on main steam line high flow. All Group 1 valves closed as required and the reactor scrammed. The Isolation Condenser was manually initiated to control reactor pressure. Group 2 and 3 Containment Isolations occurred as expected. Investigation as to the cause of the Group 1 isolation is in progress.

"All systems responded as required with no abnormalities noted."

The licensee also indicated that a Main Turbine Generator EHC transient occurred at the time of the isolation. All control rods fully inserted, the electrical grid is stable, and decay heat is being removed via the Isolation Condenser System.

The licensee notified the NRC Resident Inspector.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41518
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM PRZEKOP
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/24/2005
Notification Time: 08:04 [ET]
Event Date: 03/24/2005
Event Time: 07:42 [EST]
Last Update Date: 03/24/2005
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JOHN ROGGE (R1)
ERIC BENNER (NRR)
JACK CRLENJAK (IRD)
JIM DUNKET (FEMA)
FRED EVANS (DHS)

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

UNUSUAL EVENT DECLARED DUE TO LOSS OF CONTROL ROOM ANNUNCIATORS

The licensee reported an Unusual Event following a loss of all control room overhead annunciators (per EAL 8.2.1). The cause of the loss of the overhead annunciators is still being investigated. The licensee states that the plant is stable with no other problems. This licensee plans to remain at 100% power while troubleshooting the condition.

The licensee has notified the NRC Resident Inspector, State , and local government agencies.

The NRC Resident Inspector in the control room provided some additional information related to this event (0820 EST). The condition was discovered during a routine lamp check of the annunciators. When the lamps failed to clear after the check, the licensee entered its abnormal operating procedure and discovered the problem. The licensee does have compensatory means of monitoring the alarms through a control room CRT display as well as a printer that registers alarms. The resident stated that the extent of the annunciator loss is unclear.

* * * UPDATE FROM LICENSEE (PRZEKOP) TO NRC (HUFFMAN) AT 10:55 EST ON 3/24/05 * * *

The licensee terminated from the Unusual Event at 10:50 EST. The licensee stated that the annunciator system has been repaired and reset and verified to be operable. No information on the specific nature of the problem or repairs affected to restore the system to operable was provided.

The NRC Resident Inspector, State, and local authorities have been notified by the licensee. R1DO (Rogge), NRR (Benner), IRD (Crlenjak), FEMA (DUNKET), and DHS (EVANS) were notified.

* * * UPDATE FROM LICENSEE (S. SAUER) TO NRC (J. KNOKE) AT 15:21 EST ON 3/24/05 * * *

UNUSUAL EVENT RETRACTED

The licensee faxed the following update:

"Upon further investigation and testing it was determined that the annunciator system was always functional; redundant capability of the annunciators was unavailable. Plant equipment information was always available to Operators during this time period (07:42 to present), and as such the emergency condition did not exist and the Unusual Event is retracted."

The NRC Resident Inspector, State, and local authorities will be notified by the licensee. Notified R1 (Rogge), IRD (Crlenjak), NRR (Berkow), FEMA (Dunket), and DHS (Evans).

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Other Nuclear Material Event Number: 41519
Rep Org: DEPT OF NAVY RADIATION SAFETY CMTE
Licensee: DEPT OF NAVY RADIATION SAFETY CMTE
Region: 1
City: CRYSTAL CITY State: VA
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: LINO FRAGEOSE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/24/2005
Notification Time: 09:49 [ET]
Event Date: 03/02/2005
Event Time: [EST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN ROGGE (R1)
TOM ESSIG (NMSS)

Event Text

RECEIPT OF RADIOACTIVE MATERIAL WITHOUT PROPER CONTROL

An 89 curie Iridium-192 Gamma Radiography Camera (Model 660) was received at a Naval warehouse in Guam without proper controls or receipt inspection. The Navy Master Materials licensee representative states that the radiography camera was sent by AEA (the camera vendor) to a submarine tender stationed in Guam without preshipment notification or any request for the camera by Naval personnel stationed on the tender. The camera was received by the warehouse on March 2, 2005, and placed in warehouse storage without procedural control related to the receipt of radioactive materials. On March 14, 2005, during unrelated survey of materials in the warehouse, the camera was discovered. The submarine tender radiographer was contacted and performed receipt inspection and survey and determined that there is not radiological problems and the camera source is in its proper safe storage position. This event is still under investigation and a 30 day written followup report will be prepared. The licensee is reporting this event under 10 CFR 20.2201(a)(1) because the material was not under proper control from March 2 through March 14, 2005.

The licensee has notified the NRC regional inspector (Masnyk-Bailey) and NRC HQ (Bhachu).

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Other Nuclear Material Event Number: 41520
Rep Org: DEPT OF NAVY RADIATION SAFETY CMTE
Licensee: DEPT OF NAVY RADIATION SAFETY CMTE
Region: 1
City: CRYSTAL CITY State: VA
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: LINO FRAGEOSO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/24/2005
Notification Time: 09:49 [ET]
Event Date: 03/23/2005
Event Time: 10:45 [EST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN ROGGE (R1)
TOM ESSIG (NMSS)

Event Text

FAILURE OF SAFETY EQUIPMENT ON RADIOGRAPHY CAMERA

A representative for the Navy's master material license reported a safety equipment failure of a Gamma Radiography Camera with a 16 curie Iridium-192 source (Model 660) that was being used at the Norfolk Naval Shipyard. After an exposure with the camera had been completed, the radiographer was retracting the source and could not lock it into its safe position. After a second attempt, the radiographer was able to lock the source in place manually - the locking ring did not lock automatically as designed. The radiographer noted that the retraction cable on the camera had also become disconnected from the camera. The camera is being returned to the vendor (AEA) for inspection and repair.

A 30 day written followup report will be provided. The licensee has notified the NRC regional inspector (Masnyk-Bailey) and NRC HQ (Bhachu). The licensee stated that this report was being provided to the NRC under 10 CFR 34.101(a))(3).

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General Information or Other Event Number: 41522
Rep Org: ST. BARNABAS HEALTH CARE SYSTEM
Licensee: NUCLETRON, INC
Region: 1
City: LIVINGSTON State: NJ
County:
License #: 29-01608-03
Agreement: N
Docket:
NRC Notified By: DAVID STEIDLEY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/23/2005
Notification Time: 23:05 [ET]
Event Date: 07/06/2004
Event Time: 12:00 [EST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN ROGGE (R1)
TOM ESSIG (NMSS)
M. BEARDSLEY (R1)

Event Text

PART 21 REPORT ON BRACHYTHERAPY DEVICE (MICROSELETRON-HDR)

On July 6, 2004, while performing routine QC tests prior to patient treatment, the High Dose Rate afterloading brachytherapy device (microSeletron-HDR) failed to retract. With Nucletron service personnel on the phone giving technical support, the RSO entered the room and manually retracted the 6.7 Ci of Ir- 192 source. His whole body exposure was subsequently found to be 7 mRem and ring badge <10 mRem.

The device, which is manufactured by Nucletron, Inc, was found to have a defective "TU MPU PCB" board. After replacement and testing, the device was returned to operating status for future patient treatment.

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Power Reactor Event Number: 41524
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVID BOWMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/24/2005
Notification Time: 17:50 [ET]
Event Date: 03/24/2005
Event Time: 09:30 [CST]
Last Update Date: 03/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 85 Power Operation 85 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"Minimum Switchyard Voltage Requirements Not Met

"On March 24, 2005, at 0930 hours, Quad Cities was notified that the switchyard voltage was below that required to ensure that offsite power would remain available following a design basis accident. Both sources of off-site power were declared inoperable. The appropriate Technical Specification required actions were taken for both units. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"A preliminary engineering assessment indicates that one source of offsite power was available. Additional confirmatory reviews are being performed to determine if the safety function was preserved.

"At this time, grid/switchyard voltage has been restored."

Minimum switchyard voltage required is 348.4 KV. The analyzed minimum voltage which prompted notification to the NRC was 347.5 KV. Switchyard voltage at the time of this report was ~359 KV.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 41525
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD DESANCTIS
HQ OPS Officer: WESLEY HELD
Notification Date: 03/25/2005
Notification Time: 01:53 [ET]
Event Date: 03/24/2005
Event Time: 20:15 [EST]
Last Update Date: 03/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN ROGGE (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

REACTOR COOLANT LEAKAGE OUTSIDE CONTAINMENT EXCEEDING DESIGN BASIS

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"This is an 8-hour notification being made to report exceeding the design basis for the reactor coolant leakage outside of containment. The event is being reported under paragraph (b)(3)(v) of 10CFR50.72. An event or condition that could have prevented mitigating the consequences of an accident.

"On 03/24/05 at 2015 operators discovered that a closed manual discharge valve for the positive displacement charging pump was leaking through allowing Reactor Coolant System to leak back to the refueling water storage tank. The leakage was 0.34 gallons per minute. This leakage is greater than the UFSAR limit for ECCS leakage outside containment.

"With leakage greater than the UFSAR allowed limits (greater than 3800 cc/hr), GDC-19 limits for control room habitability cannot be assured.

"Actions were taken and the leakage was stopped at 2040. The affected positive displacement charging pump is not a safety related pump and is not required for accident mitigation; however it is in the ECCS recirculation flow path during the cold leg injection phase of the accident mitigation.

"The licensee will notify the NRC Resident Inspector of this event."

The licensee will be notifying local authorities. The licensee reported that the event had no impact on Unit 1.

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