| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
03/11/2008 - 03/12/2008 ** EVENT NUMBERS ** |
 | Fuel Cycle Facility | Event Number: 44035 | Facility: BWX TECHNOLOGIES, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By:
HQ OPS Officer: PETE SNYDER | Notification Date: 03/05/2008
Notification Time: 19:10 [ET]
Event Date: 03/05/2008
Event Time: 08:00 [EST]
Last Update Date: 03/07/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
| Person (Organization):
GEORGE HOPPER (R2)
EARL EASTON (NMSS)
FUELS OUO (E-MAIL) ()
| Event Text VACUUM DAILY INSPECTIONS NOT COMPLETED
"Raschig Ring Vacuum Cleaners (RRVCs) are used within BWXT's Research and Test Reactors and Targets (RTRT) radiologically controlled area to collect floor scrubbing solutions. There are no fissile solutions present in the area. The RRVCs are checked daily to ensure the vessels are adequately filled with Raschig rings. According to the form used to document the inspection, the last time the level was verified it was noted as 'good.' However, the inspection was last performed on January 28, 2008. The RTRT foreman had recently been assigned to the area and was not aware of the requirement to perform the daily check. On the morning of March 5, 2008 the foreman realized the check had not been performed and proceeded to inspect the RRVC. The level of the rings within the vacuum cleaner was judged to be inadequate (the form does not contain specific acceptance criteria). The rings were approximately 5 inches below the level of the hose intake. There was a minimal amount of contaminated floor scrubbing solution in the vacuum cleaner at the time of discovery. Only solutions from floor scrubbing are collected with RRVCs in RTRT. Fissile solutions are not generated in the area. The RRVC was immediately removed from service pending the results of an investigation.
"The initial filling of the vacuum cleaner with Raschig rings by an operator is an Item Relied on for Safety (IROFS). The vacuum cleaner was adequately filled with Raschig rings in September of last year during the semi-annual inventory. However, at the time of event the ring level was less than adequate, resulting in a degraded IROFS. The daily inspection of the Raschig ring level is a second IROFS to ensure an adequate ring level on an ongoing basis. The failure to perform this inspection is a failure of this IROFS. The remaining IROFS is the operator controls what is collected (and therefore the U235 concentration) with the RRVC. Only contaminated floor scrubbing solutions are vacuumed within in RTRT, not fissile solutions.
"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. There was a portion of the RRVC that contained no rings, but there was only a minimal amount solution in the vacuum cleaner. However, with the degradation of one IROFS and the loss of a second, double contingency could no longer be assured.
"BWXT is making this 24 hour report in accordance with 10 CFR 70, Appendix A (b)(2), 'Loss or degradation of items relied on for safety that results in failure to meet the performance requirements of � 70.61.'
"The use of the RRVC in the RTRT area was immediately suspended by Nuclear Criticality Safety pending further investigation."
The Licensee notified the NRC Resident Inspector.
* * * UPDATE FROM C. YATES TO P. SNYDER ON 3/6/08 AT 1426 * * *
"As a result of the ongoing investigation supplemental information to this notification is being provided.
"The investigation identified that two other vacuum cleaners were not adequately filled with Raschig rings. One of these RRVCs is used within the Chemistry Lab. The ring level in this vacuum cleaner was approximately 3 inches below the level of the hose intake. The vacuum is used in the Chemistry Lab for floor scrubbing purposes. Although there are no fissile solutions in the lab, the NCS posting on the RRVC allows concentrations of up to 400 grams 235 to be collected. This is the same NCS posting on RRVCs in BWXT's Uranium Recovery facility.
"Although unlikely, it is possible that the Chem Lab RRVC could be transferred to Uranium Recovery and used to collect high concentration fissile solutions. The ring level of RRVCs used in Uranium Recovery is checked daily. Should the Chem Lab RRVC be moved to Uranium Recovery there are no documented controls to check the ring level before its use. Potentially, the Chem Lab RRVC containing an inadequate level of Raschig rings could have been used to collect a high concentration fissile solution.
"The filling of the vacuum cleaner with Raschig rings in accordance with American Nuclear Society Standard 8.5 is an Item Relied on for Safety (IROFS). The standard states, 'The level of the solution shall not exceed the level of uniformly packed rings.' The Chem Lab vacuum cleaner was not adequately filled with Raschig rings according to the standard. This IROFS was degraded. A second IROFS for the RRVC is the operator inspects the Raschig ring level according to ANS 8.5. The standard states, 'Raschig rings shall be inspected periodically to demonstrate their continued criticality control properties.' One of the required tests accounts for settling over time. The standard further states, 'If settling is detected, rings meeting specifications of this standard shall be added to restore full packing.' This second IROFS had failed given the level of the rings in the Chem Lab RRVC at the time of discovery. As such, no IROFS as documented in the Integrated Safety Analysis Summary remained. Double contingency had been lost.
"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. There was a portion of the RRVC that contained no rings, but there was only a minimal amount of solution in the vacuum cleaner. However, with the degradation of one IROFS and the loss of a second, double contingency could no longer be assured.
"BWXT is making this 1 hour report in accordance with 10 CFR 70, Appendix A, (a)(4)(ii) - An event or condition such that no items relied on for safety, as documented in the Integrated Safety Analysis summary, remain available and reliable in an accident sequence evaluated in the Integrated Safety Analysis, to perform their function: Prevent a nuclear criticality accident."
Notified R2DO (Hopper), NMSS (Easton) and Fuels OUO Group (e-mail).
* * * UPDATE FROM B. COLE TO P. SNYDER ON 3/7/08 AT 1752 * * *
The following "additional supplemental information is being provided to Event Notification #44035 as a result of the ongoing investigation.
"During the investigation of Event Notification #44035, a concern was expressed about the ability of a RRVC to suction solution above the level of the Raschig rings. It is BWXT's opinion that it is possible to collect solution above the level of the Raschig rings in the vacuum cleaner.
"The criticality safety of the RRVCs is based on American Nuclear Society Standard 8.5, 'Use of Borosilicate-glass Raschig Rings as a Neutron Absorber in Solutions of Fissile Material.' The standard states, 'The level of the solution shall not exceed the level of uniformly packed rings.' It is BWXT's opinion that it is credible for the solution to exceed the level of the Raschig rings in the RRVC.
"There is no immediate risk of a criticality or threat to the safety of workers or the public. It is BWXT's opinion that under certain conditions there is a potential for high concentration SNM bearing solutions to be collected above the level of the Raschig rings. According to internal spill procedures this condition is not likely, but is credible. As such, this potential condition is an unanalyzed condition where double contingency is lost.
"BWXT is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of �70.61.
"The use of all RRVCs at the BWXT facility was immediately suspended by Nuclear Criticality Safety pending further investigation."
Notified R2DO (Hopper), NMSS (Easton), and Fuels OUO Group (E-mail). |
| General Information or Other | Event Number: 44039 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CITGO REFINING & CHEMICAL CO., L.P.
Region: 4
City: CORPUS CHRISTI State: TX
County: NUECES
License #: L00243-000
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: HOWIE CROUCH | Notification Date: 03/06/2008
Notification Time: 12:30 [ET]
Event Date: 03/05/2008
Event Time: [CST]
Last Update Date: 03/07/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHUCK CAIN (R4)
SANDRA WASTLER (FSME)
| Event Text TEXAS AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILURE
"On March 5, 2008 at 3:43 p.m., the agency [Texas Department of State Health Services] received a telephone call from the licensee reporting that the manufacturer was performing a gauge update replacement change on their level gauges when he discovered the shutter was stuck in the open position for this particular gauge. The manufacturer representative quickly removed the level gauge and took it to a remote area for closer examination.
"The initial thought was that the shutter was just stuck open, but upon closer examination, the manufacturer representative discovered that the shutter door was badly damaged by severe heat from the weather and could not be fixed on-site.
"The manufacturer representative then constructed and installed a temporary shield for the gauge and reported readings at 12 inches away of 4-7 Mr/hour. The licensee reports that the gauge has been placed in a sequestered area, with area caution signs and a 24-hour person surveillance while they await the Type A transport container ordered by the manufacturer representative for safe transport back to his company for repair or replacement.
"The licensee reports that the leak test performed was negative. The licensee also stated that this gauge has been in service for approximately 11 years without any problems. Since the licensee had the manufacturer out at their facility taking their 5010 series gauges out and replacing them with new series, the gauge is now in the possession/ownership of the gauge manufacturer.
"Gauge information: Texas Nuclear - Manufacturer, Model# - 5010A, Serial #- B-405, 1000 mCi in 1997
"Source information: Am-241 1000 mCi in 1997, Serial # - AO366, Mfg: Texas Nuclear
"Call to licensee's RSO for clarification on gauge information. He reported that the gauge is locked inside the Type A container and the Type A container is locked inside a caged storage area. The manufacturer will ship it out to their Sugar Land, Texas facility sometime today."
Texas Incident#: I-8489
* * * UPDATE FROM LATISCHA HANSON TO HOWIE CROUCH @ 1315 EST ON 03/07/08 * * *
"On 03/07/08 at 10:48 a.m., Incident Investigation Program (IIP) called the gauge manufacturer representative back and was able to speak with him. He stated the damage was from heat, but not from the weather; it was from the extreme heat of the coke vessel the gauge was attached to, which can reach temperatures up to ~900�F. He told IIP that the shutter carousel has plastic which can change forms and melt within a couple of hours. He cannot estimate when this could have occurred between 11/20/07 and 03/5/08. He stated that he was still at the location, waiting for the transport truck to load the gauge and send it to his facility, Thermo Measuretech.
"On 03/07/08 at 11:00 am., II [Incident Investigator] placed a telephone call to the licensee's Radiation Safety Officer (RSO) to clarify when the gauge was last checked and if there was any possibility of public exposure between the time they last checked it and the gauge change on 03/05/08. He stated that there was absolutely no possibility of public exposure, due to the following facts:
"1) The coke drum vessel has extreme heat and the gauge housing is mounted in a wire cage within four inches of the vessel and also has a rain cover. He stated no one goes up there unless they are performing the gauge check.
"Besides the extreme heat of the vessel, there is an air gap that someone would have to stick their hand through to get to the gauge housing and he can't think of a situation where someone would want to reach through the heat and air gap to get to the gauge.
"2) He told us the last gauge check was on 11/20/07 and it was noted that the shutter door was hard to close, but that is not unusual due to the extreme vessel heat, dirt and grime that collect on it while there. He told us they perform this check every 3-5 years and this is the only time someone is in contact with the gauge.
"IIP asked him if he would fax us a copy of the November 2007 check. He affirmed he would. He stated that there were 5 other gauges that were exchanged, so we asked if he would include those gauges serial numbers for us as well.
"He reminded us that the normal operating position for the shutter is in the open position.
"3) The RSO updated us with the gauge transport process. He stated the truck was delayed yesterday due to their area experiencing high winds and hail storms and was expected in sometime today.
"IIP will continue to update this report with any additional information as it becomes available."
Notified R4DO (Cain) and FSME (Flannery). |
| General Information or Other | Event Number: 44040 | Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: LOUISIANA HEART HOSPITAL
Region: 4
City: LACOME State: LA
County: ST. TAMMANY PARISH
License #: LA-10747-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: HOWIE CROUCH | Notification Date: 03/06/2008
Notification Time: 15:29 [ET]
Event Date: 03/05/2008
Event Time: [CST]
Last Update Date: 03/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHUCK CAIN (R4)
SANDRA WASTLER (FSME)
| Event Text LOUISIANA AGREEMENT STATE REPORT - PERSONNEL ANNUAL OVEREXPOSURE
Received the following information from the State of Louisiana via facsimile:
The licensee, Louisiana Heart Hospital in LaCome, LA., submitted a High Exposure Report to the State concerning one of their physicians. The physician's exposure by badge was 5,244 mrem for the 2007 calendar year. The cause of the overexposure was attributed to high workloads in the Cardiac Catherization Labs during the period.
Corrective actions taken include double badging the individual, including the addition of a waist badge beneath his lead apron, using additional shielding/distance and using special equipment such as pull-down lead shields.
Additionally, the licensee will review the individual's exposure quarterly to adjust workload and/or corrective actions. |
| General Information or Other | Event Number: 44043 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NOT APPLICABLE
Region: 4
City: COMPTON State: CA
County: LOS ANGELES
License #:
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: HOWIE CROUCH | Notification Date: 03/07/2008
Notification Time: 14:03 [ET]
Event Date: 03/06/2008
Event Time: 09:30 [PST]
Last Update Date: 03/07/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHUCK CAIN (R4)
CINDY FLANNERY (FSME)
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text CALIFORNIA AGREEMENT STATE REPORT - LOST LICENSED MATERIAL
Received the following information from the State of California via fax:
"A person contacted the California Radiologic Health Branch (RHB) on 03/06/08 to report that the radiation detector at the Compton Transfer Station had alarmed from a bin that had come from FedEx at 5927 W. Imperial, [Los Angeles] (near LAX); the reading was 22.8 kcpm, with a background of [approximately] 3.4 kcpm. [A RHB Investigator] went that afternoon, and after sorting through the bin contents, found an [approximately] 13 mCi Cs-137 source. The source is [about] 1/4 inch long and 1/8 inch in diameter. The radiation measurement was about 50 mrem/hr at one foot (measured using a Bicron microrem meter and a Keithley 36150). [The RHB Investigator] placed the source in a lead pig and secured it in the trunk of his car.
"On 3/7/08, [RHB Investigators] discussed the incident with the Manager at the Fed Ex Imperial location, [the Manager of] FedEx Dangerous Goods, and other FedEx employees in Dangerous Goods. [An RHB Investigator] advised them that [RHB Investigators] would be there later today (03/07/08) to survey the facility to make sure there aren't any other sources, and that Fed Ex is to interview their employees to try and determine how the source came to be in the bin, and from whom it had come."
California RHB will continue to investigate this incident and has assigned incident report number 5010-030608 to this event.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source. |
| Power Reactor | Event Number: 44050 | Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MARK IHLENFELDT
HQ OPS Officer: JEFF ROTTON | Notification Date: 03/10/2008
Notification Time: 23:59 [ET]
Event Date: 03/10/2008
Event Time: 18:13 [CDT]
Last Update Date: 03/11/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
MARK RING (R3)
|
| 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 HPCI INOPERABLE
"During performance of the quarterly high pressure coolant injection (HPCI) Surveillance Test, a technical specification step could not be completed due to observed system water flow and discharge pressure oscillations. These oscillations are presently under investigation. The tech spec step involved establishing flow conditions at a certain discharge pressure. The problem is either with the test return system or the control system. A formal troubleshooting plan is being developed to determine the root cause and corrective action required to re-establish operability of the HPCI system. The system remains inoperable due to the problem found during testing. If the problem is found to be caused by the control system, then it could have potentially impacted the ability of the HPCI system to mitigate the consequences of an accident."
HPCI is currently in a 14 day Tech Spec 3.5.1.h LCO.
The licensee notified the NRC Resident Inspector. The licensee will be notifying the Minnesota Duty Officer. |
| Power Reactor | Event Number: 44051 | Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOM POETZSCH
HQ OPS Officer: STEVE SANDIN | Notification Date: 03/11/2008
Notification Time: 11:06 [ET]
Event Date: 01/24/2008
Event Time: 03:35 [EDT]
Last Update Date: 03/11/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
| Person (Organization):
GEORGE HOPPER (R2)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text 60 DAY REPORT - INVALID ACTUATION OF THE NUCLEAR SERVICE WATER SYSTEM
"This 60-day optional report as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10 CFR 50.73 (a)(2)(iv)(A) to describe an invalid actuation of a specified system, specifically the Nuclear Service Water System (NSWS).
"While performing changeout of a Nuclear Service Water (RN) current module, there was an unexpected auto swap from the normal heat sink (Lake Wylie) to the ultimate heat sink {Standby Nuclear Service Water Pond (SNSWP)} occurred and the system responded as designed. Work was stopped when notified by Operations.
"This event occurred when technicians attempted to isolate power to the module prior to replacing. Unable to do so, they decided to perform a changeout under hot conditions. While tracing power utilizing wire tabs, the technicians did not identify that removing wire from terminal 12 of the module disturbs the power path to other channels. The channel associated with the bad module remained in the trip condition throughout, and when power to other channels was disturbed, the logic for a swap from the normal heat sink to the ultimate heat sink was completed and the automatic swap occurred as designed. This event was entered into the site corrective action program for evaluation."
The licensee will inform local and state agencies and has informed the NRC Resident Inspector. | |