Event Notification Report for October 02, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/01/2007 - 10/02/2007
Power Reactor
Event Number: 43683
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KEN TIEFENTHAL
HQ OPS Officer: JASON KOZAL
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KEN TIEFENTHAL
HQ OPS Officer: JASON KOZAL
Notification Date: 10/03/2007
Notification Time: 10:42 [ET]
Event Date: 10/02/2007
Event Time: 19:08 [EDT]
Last Update Date: 10/03/2007
Notification Time: 10:42 [ET]
Event Date: 10/02/2007
Event Time: 19:08 [EDT]
Last Update Date: 10/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
RAY POWELL (R1)
RAY POWELL (R1)
| 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 | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY - NON-LICENSED SUPERVISOR
A non-licensed employee supervisor had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been placed on administrative hold. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
A non-licensed employee supervisor had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been placed on administrative hold. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
Fuel Cycle Facility
Event Number: 43686
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: M.C. PITMAN
HQ OPS Officer: JOHN KNOKE
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: M.C. PITMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/03/2007
Notification Time: 14:35 [ET]
Event Date: 10/02/2007
Event Time: 14:06 [CDT]
Last Update Date: 10/03/2007
Notification Time: 14:35 [ET]
Event Date: 10/02/2007
Event Time: 14:06 [CDT]
Last Update Date: 10/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
CAROLYN EVANS (R2)
GREG MORELL (FSME)
CAROLYN EVANS (R2)
GREG MORELL (FSME)
RELEASE DETECTION SYSTEM (PGLD) DECLARED INOPERABLE
"At 1406 CDST, on 10-02-07 the Plant Shift Superintendent (PSS) was notified that an alarm was received for the C-333, Unit 6, Cell 4, UF6 Release Detection (PGLD) System. Operators responded and found that the READY and MANUAL lights for this system were not illuminated. This PGLD System contains detectors that cover C-333, Unit 6, Cell 4, and Section 2 of the cell bypass piping. At the time of this alarm, some areas of Section 2 of the cell bypass were operating above atmospheric pressure. TSR 2.4.4.1 requires that at least the minimum number of detector heads in each defined section of the cell bypass are operable during steady state operations above atmospheric pressure. With the Unit 6, Cell 4, PGLD System inoperable, only 2 of the required 3 heads in Section 2 of the cell bypass were operable. This PGLD System was declared inoperable, TSR LCO 2.4.4.1 .C.1 was entered and a continuous smoke watch was put in place within one hour. An investigation is ongoing and at this point a wire was found that had failed with visible insulation damage. Engineering has determined that the system would not have been able to perform its intended safety function when this alarm came in. This event is reportable as a 24 hour event in accordance with 10 CFR 76.1 20(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function."
This event is similar to EN#43670 on 09/27/07.
The NRC Senior Resident Inspector has been notified of this event.
"At 1406 CDST, on 10-02-07 the Plant Shift Superintendent (PSS) was notified that an alarm was received for the C-333, Unit 6, Cell 4, UF6 Release Detection (PGLD) System. Operators responded and found that the READY and MANUAL lights for this system were not illuminated. This PGLD System contains detectors that cover C-333, Unit 6, Cell 4, and Section 2 of the cell bypass piping. At the time of this alarm, some areas of Section 2 of the cell bypass were operating above atmospheric pressure. TSR 2.4.4.1 requires that at least the minimum number of detector heads in each defined section of the cell bypass are operable during steady state operations above atmospheric pressure. With the Unit 6, Cell 4, PGLD System inoperable, only 2 of the required 3 heads in Section 2 of the cell bypass were operable. This PGLD System was declared inoperable, TSR LCO 2.4.4.1 .C.1 was entered and a continuous smoke watch was put in place within one hour. An investigation is ongoing and at this point a wire was found that had failed with visible insulation damage. Engineering has determined that the system would not have been able to perform its intended safety function when this alarm came in. This event is reportable as a 24 hour event in accordance with 10 CFR 76.1 20(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function."
This event is similar to EN#43670 on 09/27/07.
The NRC Senior Resident Inspector has been notified of this event.
Agreement State
Event Number: 46861
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City: NONE PROVIDED State: NY
County:
License #: NONE PROVIDED
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: NONE PROVIDED
Region: 1
City: NONE PROVIDED State: NY
County:
License #: NONE PROVIDED
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 14:03 [ET]
Event Date: 10/02/2007
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2011
Notification Time: 14:03 [ET]
Event Date: 10/02/2007
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - PATIENT RECEIVED TWICE THE PRESCRIBED DOSE
The following report was received via fax.
"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.
"The licensee reported on 10/3/2007 that on 10/2/2007, a patient received 4 mCi 131 Iodine for a whole body scan instead of the 2 mCi that was ordered. The error was discovered after the radiopharmacy tried to reconcile their orders and shipments and found that a vial with 4 mCi [milliCurie] of 131 Iodine was missing and called the hospital. The nuclear medicine department staff inspected the waste sent from the department to the environmental services section of the hospital and found that the box they had sent did trigger an alarm and had been isolated. On closer inspection, they found one vial containing 2 mCi Iodine 131. An extra vial of Iodine 131 of 4 mCi (meant for another order) had been placed by the nuclear pharmacy in the box and sent along with the 2 vials of 2 mCi each. The technologist retrieved this mCi vial and one 2 mCi vial and gave the 4 mCi iodine capsule to the patient.
"The NM [Nuclear Medicine] technologist had retrieved 2 vials from the box on 10/2/2007. The order was for 2 vials, one for the patient dose and the other the standard. Failures: 1. She failed to verify that the labels on the dose vials matched the labels on the shipping box. 2. She failed to read the label on the vial containing the capsule that she gave to the patient. 3. She failed to assay the patient dose using the dose calibrator. 4. She failed to survey the box before sending it to the environmental services for disposal. All 4 failures are in violation of the licensee's protocol for the use of radioactive materials.
"The authorized user physician believes that the dose of 4 mCi for a whole body scan is still within the range in use at the facility and does not expect any harm to the patient as result of this event. A health physicist was consulted and doses to various organs were estimated and documented. To prevent a recurrence, they have implemented a TlME OUT protocol for administration of RAM [radioactive material], which requires that 2 technologists must agree on the correctness of the activity, assay and document it on both a hard copy log and the computer in the hot lab.
"These steps are adequate.
"This event is closed."
New York Event Number: NY-11-03
New York State DOH Internal Tracking Number 566
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.
The following report was received via fax.
"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.
"The licensee reported on 10/3/2007 that on 10/2/2007, a patient received 4 mCi 131 Iodine for a whole body scan instead of the 2 mCi that was ordered. The error was discovered after the radiopharmacy tried to reconcile their orders and shipments and found that a vial with 4 mCi [milliCurie] of 131 Iodine was missing and called the hospital. The nuclear medicine department staff inspected the waste sent from the department to the environmental services section of the hospital and found that the box they had sent did trigger an alarm and had been isolated. On closer inspection, they found one vial containing 2 mCi Iodine 131. An extra vial of Iodine 131 of 4 mCi (meant for another order) had been placed by the nuclear pharmacy in the box and sent along with the 2 vials of 2 mCi each. The technologist retrieved this mCi vial and one 2 mCi vial and gave the 4 mCi iodine capsule to the patient.
"The NM [Nuclear Medicine] technologist had retrieved 2 vials from the box on 10/2/2007. The order was for 2 vials, one for the patient dose and the other the standard. Failures: 1. She failed to verify that the labels on the dose vials matched the labels on the shipping box. 2. She failed to read the label on the vial containing the capsule that she gave to the patient. 3. She failed to assay the patient dose using the dose calibrator. 4. She failed to survey the box before sending it to the environmental services for disposal. All 4 failures are in violation of the licensee's protocol for the use of radioactive materials.
"The authorized user physician believes that the dose of 4 mCi for a whole body scan is still within the range in use at the facility and does not expect any harm to the patient as result of this event. A health physicist was consulted and doses to various organs were estimated and documented. To prevent a recurrence, they have implemented a TlME OUT protocol for administration of RAM [radioactive material], which requires that 2 technologists must agree on the correctness of the activity, assay and document it on both a hard copy log and the computer in the hot lab.
"These steps are adequate.
"This event is closed."
New York Event Number: NY-11-03
New York State DOH Internal Tracking Number 566
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.