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Event Notification Report for June 1, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/31/2007 - 06/01/2007

** EVENT NUMBERS **


43390 43391 43396 43397

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General Information or Other Event Number: 43390
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: HOLY CROSS HOSPITAL
Region: 1
City: SILVER SPRINGS State: MD
County:
License #: MD-31-001-03
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/25/2007
Notification Time: 13:01 [ET]
Event Date: 05/24/2007
Event Time: 15:40 [EDT]
Last Update Date: 05/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT - Pd-103 SOURCE BROKEN OPEN

The State provided the following information via facsimile:

"Called to report an incident at Holy Cross Hospital. At 1540 hours, on 5/24/07, in room 11 of the operating room of the hospital, the Licensee ruptured a 3.2 mCi Palladium-103 seed while conducting a patient implant therapy. Preliminary licensee evaluation indicates that the Mick Applicator jammed and failed to advance. Efforts to free the device may have led to the seed fracture. The patient therapy was halted after 60 of the 83 seeds (given in the written directive) were successfully implanted. The Oncologist has indicated that the 60 seeds implanted were adequate for successful therapy and no additional seeds would be administered. Licensee followed radiation spill procedures and radiation surveys conducted by licensee RSO showed radioactive material contamination on the Mick Applicator and surrounding absorbent chucks. Contaminated materials have been controlled and stored in nuclear the medicine department. Smears of adjacent OR surfaces and floor were negative for contamination. The OR was released at about 1900 hours that day. The licensee has notified the manufacturer of the incident. Licensee will send initial written report by CBD 5/29/07 with follow-up detailed report within 30 days."

Maryland Radioactive Material License: MD-31-001-03

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 43391
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT COWARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/27/2007
Notification Time: 18:08 [ET]
Event Date: 05/27/2007
Event Time: 11:17 [PDT]
Last Update Date: 05/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CLAUDE JOHNSON (R4)

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

MANUAL REACTOR TRIP IN MODE 3 DURING CONTROL ROD TESTING

"On May 27, 2007, at 11:17 PDT, with Diablo Canyon Power Plant (DCPP) Unit 1 in Mode 3 (Hot Standby) during day 28 of refueling outage 14, operators manually actuated the reactor protection system. All rods fully inserted.

"Operators were performing Surveillance Test Procedure (STP) R-1 C 'Digital Rod Position Indictor Functional Test'. While control bank C was being re-inserted, at 42 steps withdrawn, rod N-13 indicated position changed to 24 steps withdrawn. In response to this 18 step deviation, and in accordance with STP R-1C, operators opened the reactor trip breakers.

"At the time of the event, the reactor coolant system remained at normal operating temperature and pressure, and all other shutdown and control rod banks remained fully inserted.

"This event is being reported as an 8-hour non-emergency event in accordance with 10 CFR 50.72(b)(3)(iv)(A) for a valid actuation of the reactor protection system."

Unit-1 is maintaining temperature with atmospheric steam dumps and aux feed water. Electrical power is from 500 KV backfeed (normal electrical shutdown lineup). Control rod N-13 was being tested along with seven other control rods.

The licensee notified the NRC Resident Inspector.


* * * UPDATE ON 05/27/07 AT 2301 EDT BY JOY SKAGGS TO MACKINNON * * *

"(STP) R-1C 'Digital Position Indicator Functional Test' was re-performed on control bank C to obtain additional information.

"At 1706 hours, while control bank C was being re-inserted, at 138 steps withdrawn, rod N-13 indication dropped to 126 steps withdrawn. Rod motion was stopped to gather data. All other shutdown and control banks remained fully inserted.

"At 1725 hours, operators manually actuated a reactor trip to fully insert all control bank C rods. All rods fully inserted.

"(STP) R-1C 'Digital Rod Position Indicator Functional Test' was re-performed on control bank C for further evaluation. At 1838 hours, while control bank C was being re-inserted, at 168 steps withdrawn, rod N-13 indication dropped to 150 steps withdrawn. Rod motion was stopped to gather data. All other shutdown and control banks remained fully inserted.

"At 1840 hours, operators manually actuated a reactor trip to fully insert all control bank C rods. All rods fully inserted.

"At the time of the event, the reactor coolant system remained at normal operating temperature and pressure, and all other shutdown and control rod banks remained fully inserted." R4DO (C. Johnson) notified.

The licensee will notify the NRC Resident Inspector.

* * * UPDATE PROVIDED BY LARRY PARKER TO JEFF ROTTON AT 0951 EDT ON 05/31/07 * * *

"On May 27, 2007, in response to the initial occurrence of Rod N-13 slipping at 11:17 PDT, PG&E contacted the vendor and researched operating experience to develop a troubleshooting plan. Management approved a plan based on the vendor recommendations, which consisted of exercising all rods successfully five cycles. It was acknowledged that additional slipping events could occur requiring mitigation by opening the reactor trip breakers. Upon implementation of this plan, two similar events occurred and are described in the update above [provided on 05/27 at 2301 EDT]. Following these events, Rod N-13 was successfully cycled five times without any deviation. Reactor startup was then allowed to proceed and there have been no further rod position deviation events."

The licensee notified the NRC Resident Inspector. Notified R4DO (C. Cain)

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Power Reactor Event Number: 43396
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: LANCE LANE
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/31/2007
Notification Time: 10:43 [ET]
Event Date: 05/31/2007
Event Time: 02:10 [CDT]
Last Update Date: 05/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHUCK CAIN (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

LOSS OF EMERGENCY PLAN SIRENS DUE TO 69KV DISTRIBUTION SYSTEM FAULT

"At 02:10 am CDT Wolf Creek's surrounding area experienced a power loss when a fault occurred in the 69KV distribution system. Power was lost in the cities of Burlington, New Strawn and the surrounding area. Wolf Creek's emergency plan sirens are powered from substations fed from the 69 KV distribution system. Associated with this power loss, Wolf Creek initially lost power to seven [of 11 total] Emergency Sirens. Four of the sirens had power restored in approximately 5 minutes, the remaining three Emergency Sirens remained without power for greater than 2 hours. Power was restored to the area surrounding Wolf Creek at approximately 04:30 am CDT. The Coffey County Sheriff's office was kept informed of siren status in the event that they would need to make local notifications. Wolf Creek remained connected to the electrical grid through all three 345 KV lines during the loss of the 69 KV system.

"Coffey County, Kansas Department of Health and Environment, Kansas Department of Emergency Management and the Federal Emergency Management Agency Region 7 have been notified of the loss of sirens.

"The Wolf Creek Communications Group has physically verified that all sirens have been returned to service."

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 43397
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: CALVIN MANNING
HQ OPS Officer: PETE SNYDER
Notification Date: 05/31/2007
Notification Time: 23:22 [ET]
Event Date: 05/31/2007
Event Time: 16:40 [PDT]
Last Update Date: 05/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(5) - ONLY ONE SAFETY ITEM AVAILABLE
Person (Organization):
MALCOLM WIDMANN (R2)
WILLIAM RULAND (FSME)

Event Text

ONE HOUR REPORT NOTIFICATION: COMBUSTIBLE MATERIAL EXCEEDING ITEM RELIED ON FOR SAFETY (IROFS) LIMITS FOUND

"BACKGROUND:
"AREVA NP Richland routinely stores unmoderated uranium oxide powder ( < 1.0 wt.% moisture and < 1.0 wt.% moisture equivalent of approved additives) in metal 45-gallon drums with neutron absorbing inserts in warehouse #6. Metal 5-gallon pails containing no more than 18 kg of powder placed 4 per 25 inch X 25 inch metal pallet are also allowed to be stored in this warehouse in the same locations authorized to store 45-gallon drums. The option to storage of 5-gallon buckets in warehouse 6 is only occasionally used.

"EVENT DESCRIPTION:
"On May 31, 2007 at approximately 1640 PDT, a member of the AREVA safety staff completed a calculation to determine the volume of combustible material present in wooden pallets being used to store empty 45-gallon drum in the aisle between storage locations in warehouse 6. The presence of 27 wooden pallets had been observed during a previous walkthrough of the SNM storage warehouse. The volume of combustible material present in these pallets was about 56 [cubic feet]. The definition of failure of the administrative IROFS that restricts the amount of combustible material in this area is 54 [cubic feet].

"Currently the only SNM storage containers present in warehouse 6 are 45-gallon drums with neutron absorbing inserts. When these 45-gallon drums are stored in this area accidental nuclear criticality remains 'highly unlikely' even when the IROFS limiting the presence of combustible material fails.

"However, if the restriction on the amount of combustible material fails and uranium oxide powder is stored in 5-gallon containers in this warehouse only a single IROFS would be present and accidental criticality does not remain highly unlikely.

"SAFETY SIGNIFICANCE OF EVENT:
"The safety significance of this condition is low because an accidental nuclear criticality for the as-found condition (only 45-gallon drums are currently being used to store uranium oxide powder) is still highly unlikely. Note: The condition being reported is only a potential but authorized plant condition. Furthermore, the municipal fire department works closely with the AREVA emergency response organization (ERO) when they respond to plant abnormal events and emergencies. The NCS organization is an integral part of the ERO and participates in the decision making during such events if NCS concerns exist.

"There have been no known fires in this warehouse during its existence of over 20 years.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR):
"Criticality could potentially occur during firefighting if the SNM in storage looses geometry control coincident with moderation.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):
"The process parameters controlled in the various storage warehouses include geometry, mass, moderation and neutron absorbers depending upon the storage configuration.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
"Plant-wide fire controls are established to ensure that large fires that would require the intervention by the municipal fire department are highly unlikely. This assures that the potential NCS concerns relative to fire-fighting with water are compliant with regulatory requirements.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
"After discovery of the deficiency, the combustible material was removed from the warehouse. The material is currently compliant with the above listed requirements."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012