U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/21/2003 - 02/24/2003
** EVENT NUMBERS **
39512 39594 39598 39599 39608 39609 39610 39611
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|General Information or Other |Event Number: 39512 |
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| REP ORG: ROCKBESTOS-SUPRENANT CABLE CORP. |NOTIFICATION DATE: 01/15/2003|
|LICENSEE: ROCKBESTOS-SUPRENANT CABLE CORP. |NOTIFICATION TIME: 16:42[EST]|
| CITY: EAST GRANBY REGION: 1 |EVENT DATE: 01/14/2003|
| COUNTY: STATE: CT |EVENT TIME: [EST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 02/21/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| |THOMAS DECKER R2 |
+------------------------------------------------+DAVID HILLS R3 |
| NRC NOTIFIED BY: RICHARD C. BROWN |GARY SANBORN R4 |
| HQ OPS OFFICER: HOWIE CROUCH |JACK FOSTER NRR |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INITIAL NOTIFICATION OF 10 CFR PART 21 DEFECT/FAILURE TO COMPLY |
| |
| "The following information is supplied in accordance with the requirements |
| of 10 CFR 21. |
| "I. Name and address of individual informing the Commission: |
| |
| [Deleted] |
| |
| "II. Identification of the basic component supplied which fails to comply or |
| contains a defect: |
| |
| "The KXL 760D insulation system (chemically crosslinked only) provided in |
| some of the Firewall III cables manufactured from January 1992 thru June |
| 1995 may include an alternate resin which was not part of the baseline |
| qualification testing. |
| |
| "III. Identification of the firm supplying the basic component which fails |
| to comply or contains a defect: |
| |
| "The Rockbestos-Surprenant Cable Corp., East Granby, CT facility. |
| |
| "IV. Nature of the defect or failure to comply and the safety hazard which |
| is created: |
| |
| "Nature of Defect: An alternate resin material may have been substituted in |
| the insulation system for Firewall III cables (chemically crosslinked cables |
| only). |
| Potential Hazard: The chemically cured insulation system utilizing KXL 760D |
| for cables manufactured from January 1992 thru June 1995 may not be |
| enveloped by qualification report QR5804. |
| |
| "V. The date on which the information of such defect or failure to comply |
| was obtained: |
| |
| "On the basis of our evaluation it was determined on January 14, 2003 that a |
| defect or failure to comply as defined by 10 CFR 21 existed. |
| |
| "VI. The number and location of all basic components which contain a defect |
| or falls to comply: |
| |
| "The number and location of all basic components which may contain a defect |
| or fail to comply is yet to be determined. |
| |
| "VII. The corrective action which has been, is being, or will be taken; the |
| name of the individual or organization responsible for the action; and the |
| length of time that has been or will be taken to complete the action: |
| |
| "Based on testing and analysis, both resin suppliers indicated that both |
| resins were quite similar and they were not able to distinguish or identify |
| one resin from the other. Documented evidence of their conclusion has been |
| requested. Rockbestos-Surprenant has instituted a similarity analysis |
| program on both resins that is expected to be completed by March 14, 2003. |
| Preliminary test results indicate that the two resins are indistinguishable. |
| A full report will be available upon completion of the similarity analysis |
| program. |
| |
| " VIII. Any advice related to the defect or failure to comply about the |
| basic component that has been, is being, or will be given to purchasers: |
| |
| "Purchasers will be advised not to install any Firewall III cables that |
| employ the chemically cured insulation material that were manufactured from |
| January 1992 thru June 1995 until the results of the similarity program are |
| known. Further advice will be provided at that time." |
| |
| * * * * WRITTEN NOTIFICATION UPDATE RECEIVED BY LETTER ON 2/21/03 BY MIKE |
| RIPLEY * * * |
| |
| The following changes to Sections VII and VIII were provided in the written |
| notification: |
| |
| "VII. The corrective action which has been, is being, or will be taken; the |
| name of the individual or organization responsible for the action; and the |
| length of time that has been or will be taken to complete the action: |
| |
| "Rockbestos-Surprenant has implemented a two step process to evaluate the |
| potential effect on baseline qualification arising from use of the alternate |
| resin. |
| |
| "Step 1: |
| |
| "Because the two resins are so similar, locating finished cable for testing |
| was not immediately feasible. In order to completely explore this avenue, |
| samples containing both the qualified and alternate resins were sent by |
| Rockbestos-Surprenant to both resin manufacturers to use whatever methods |
| available to differentiate their resin in the finished material. If an |
| analytical method could be found to identify the resin used, |
| Rockbestos-Surprenant would look to the utilities to find inventory |
| containing the alternate resin. Based on the cable available, an appropriate |
| test program could be established to document qualification. Both suppliers |
| have indicated, however, that they were not able to identify their resin in |
| the sample provided. |
| |
| "Step 2 |
| |
| "Based on the limited availability of the alternate resin (discontinued in |
| 1995) a similarity analysis program has been established by |
| Rockbestos-Surprenant which is running in parallel with Step 1 that will |
| compare the two resins. The program has been designed to address electrical |
| performance, dielectric strength, physical properties, heat aging to end of |
| life condition, irradiation with 200 Mrad exposure, and moisture absorption. |
| FTIR scans will be generated for both finished samples including the |
| starting resins for comparison. Testing is scheduled to be completed by |
| March 14, 2003. Preliminary test results indicate that the two resins are |
| indistinguishable. A frill report will be available upon completion of the |
| test comparison program. |
| |
| "Additionally, third party testing consideration is being given regarding a |
| proposed test program designed for analysis and identification of the |
| resins. The submitted test program is currently being evaluated by |
| Rockbestos-Surprenant. |
| |
| " VIII. Any advice related to the defect or failure to comply about the |
| basic component that has been, is being, or will be given to purchasers: |
| |
| "Purchasers are being advised not to install Firewall III cables that employ |
| the chemically cured insulation material that was manufactured from January |
| 1992 thru June 1995 until the results of the test comparison program are |
| known. Further advice will be provided at that time." |
| |
| Notified R1 DO (C. Anderson), R2 DO (C. Ogle), R4 DO (J. Madera), R4 DO (K. |
| Kennedy), NRR (J. Foster), NMSS (R. Torres) |
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|General Information or Other |Event Number: 39594 |
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| REP ORG: MISSISSIPPI DIV OF RAD HEALTH |NOTIFICATION DATE: 02/18/2003|
|LICENSEE: SOUTHERN INSPECTION SERVICES |NOTIFICATION TIME: 09:36[EST]|
| CITY: MOSS POINT REGION: 2 |EVENT DATE: 02/17/2003|
| COUNTY: STATE: MS |EVENT TIME: [CST]|
|LICENSE#: MS-747-01 AGREEMENT: Y |LAST UPDATE DATE: 02/18/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES R. OGLE R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: B. J. SMITH | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| AGREEMENT STATE - RADIATION WORKER EXCEEDED TEDE DOSE LIMIT |
| |
| "Description of Incident: On the afternoon of February 14, 2003, DRH |
| received a call from Sonny Mallette with Southern Inspection Services, |
| concerning a radiographer receiving a TEDE for calendar year 2002 exceeding |
| 5 rem. Mr. Mallette stated that the employee had received 4722 mrem |
| [millirem] by the end of the 11th report for 2002, and they had watched his |
| dosimeter readings closely, but when they received the end of year report he |
| had gone over the 5 rem limit [5,066 millirem]. He stated that the dose was |
| received in work situations where shielding and distance are at a minimum. |
| One setup involved shooting up in a oil drilling rig derrick where no |
| shielding is available." |
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|General Information or Other |Event Number: 39598 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 02/19/2003|
|LICENSEE: ENGINEERING CONSULTING SERVICES, LTD.|NOTIFICATION TIME: 16:56[EST]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 02/19/2003|
| COUNTY: HARRIS STATE: TX |EVENT TIME: 08:45[CST]|
|LICENSE#: L05451-000 AGREEMENT: Y |LAST UPDATE DATE: 02/19/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+JOHN DAVIDSON IAT |
| NRC NOTIFIED BY: JAMES H. OGDEN, JR. | |
| HQ OPS OFFICER: ERIC THOMAS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE |
| |
| "The gauge was in use on February 18, 2003. At close of business, the |
| operator locked the gauge handle, placed it in its transportation case, and |
| locked the case with chain and lock to a projection inside a Conex |
| container. The Conex was then padlocked closed for the evening. When the |
| operator arrived on-site the following morning, (February 19, 2003), he |
| discovered that all contractor Conexes had been broken into and basically |
| all Conexes on the site had been 'cleaned out.' The Houston Police |
| Department was notified, arrived on site, and took statements from all |
| personnel suffering a loss. The stolen gauge was a Troxler Model 3430, |
| Serial No.: 20385, containing two sources: a 1.48GBq/40 milicuries (+/- 10%) |
| Am-241:Be source, Serial No.: 47-15863, and a 0.30 GBq/8 millicuries (+/- |
| 10%) Cs-137 source, Serial No.: 75-1733. The site is believed to be located |
| in Harris County. The gauge and sources were last leak tested on August 5. |
| 2002, with negative leakage results." |
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|General Information or Other |Event Number: 39599 |
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| REP ORG: OR DEPT OF HEALTH RAD PROTECTION |NOTIFICATION DATE: 02/19/2003|
|LICENSEE: LONGVIEW INSPECTION |NOTIFICATION TIME: 17:44[EST]|
| CITY: MILWAUKIE REGION: 4 |EVENT DATE: 02/19/2003|
| COUNTY: CLACKAMAS STATE: OR |EVENT TIME: [PST]|
|LICENSE#: OR-90621 AGREEMENT: Y |LAST UPDATE DATE: 02/19/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: EDWIN WRIGHT | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - RADIOGRAPHER RECEIVED GREATER THAN 5 REM ANNUAL |
| LIMIT FOR 2002 |
| |
| During QA audit of licensee by Oregon Department of Human Services, |
| Radiation Protection Services, it was determined that one radiographer |
| employed by the licensee had exceeded his 2002 annual dose limit by |
| approximately 800 millirem. This discrepancy was evident by the difference |
| between pocket ion dosimeter and TLD readings. Oregon Radiation Protection |
| Services continues to investigate. |
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|Power Reactor |Event Number: 39608 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 02/21/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 02:30[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 02/21/2003|
+------------------------------------------------+EVENT TIME: 00:25[EST]|
| NRC NOTIFIED BY: ENGLAND |LAST UPDATE DATE: 02/21/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |70 Power Operation |
| | |
| | |
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EVENT TEXT
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| REACTOR IS BEING SHUT DOWN DUE TO ONE RECIRCULATION LOOP BEING INOPERABLE |
| |
| "On 2/20/03 @ 0525 PNPS experienced a trip/lockout of 1 of their 2 Recirc MG |
| sets. This caused Reactor Power to decrease to 70% of rated. All other |
| safety and nonsafety plant equipment functioned normally after the Recirc |
| MG trip. Due to our Facility Operating Licenses PNPS entered an Active LCO |
| for One Recirculation Loop Inoperable. The License states, 'The Reactor |
| shall not be operated with one recirculation loop out of service for more |
| than 24 hours. With the reactor operating, the plant shall be placed in a |
| hot shutdown condition within 24 hours unless the loop is sooner returned to |
| service.' |
| |
| "After extensive trouble shooting activities PNPS decided that the loop will |
| not be returned to service in the required time frame and has commenced a |
| normal shutdown to hot shutdown condition on 2/21/03 @ 0025. Reactor |
| Power at the time of commencement of shutdown was 37%." |
| |
| The licensee believes the cause was due to a field lead breaking off the |
| slip rings. Estimated down time is 5 to 8 days. |
| |
| |
| The NRC Resident Inspector was notified and the licensee may notify the |
| media. |
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|Power Reactor |Event Number: 39609 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 02/21/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 08:10[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 02/21/2003|
+------------------------------------------------+EVENT TIME: 04:24[EST]|
| NRC NOTIFIED BY: ENGLAND |LAST UPDATE DATE: 02/21/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 27 Power Operation |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| REACTOR WAS MANUALLY SCRAMMED FROM 27% POWER |
| |
| On 2/21/03 @ 0424 PNPS was making preparations to scram using an approved |
| Shut Down procedure and experienced a Recirc Pump Runback of the only Recirc |
| MG set in service. Computer generated Core Flow indicated approximately 17 |
| Mlbm/Hr and 25% Reactor Power. The Operator at the Controls calculated |
| Reactor Power and Flow using the PNPS Power to Flow (P/F) Map. Indications |
| on the P/F Map showed a value in the OPERATION PROHIBITED REGION (17% |
| Reactor Power and 14 Mlbm/Hr Flow). Per PNPS procedures, intentional |
| operation in this area is prohibited and you must immediately restore to |
| within the analyzed operation area. This area is not part of the Reactor |
| Instability Region. These discrepancies were noted by the Shift Manager who |
| directed the Reactor to be Scrammed. All other safety and nonsafety plant |
| equipment functioned normally after the Reactor Scram. All rods fully |
| inserted, no ECCS actuated and no relief valves lifted. |
| |
| |
| The NRC Resident Inspector was notified. |
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|Hospital |Event Number: 39610 |
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| REP ORG: U.S. DEPT OF VETERANS AFFAIRS |NOTIFICATION DATE: 02/21/2003|
|LICENSEE: VA MEDICAL CENTER, DENVER, CO |NOTIFICATION TIME: 17:27[EST]|
| CITY: Denver REGION: 4 |EVENT DATE: 02/21/2003|
| COUNTY: STATE: CO |EVENT TIME: 09:00[MST]|
|LICENSE#: 05-01401-02 AGREEMENT: Y |LAST UPDATE DATE: 02/21/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DR. EDWIN LEIDHOLDT (PhD) | |
| HQ OPS OFFICER: ERIC THOMAS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| POSSIBLE MEDICAL EVENT |
| |
| During an intravascular brachiotherapy procedure, several Strontium-90 |
| sources (approx. 60 millicuries) were used. The sources were deployed from |
| the transfer device and were not seen at the desired treatment on the |
| patient. The sources were withdrawn back into the transfer device. The |
| physician does not believe that the sources entered the patient on this |
| initial attempt, but there was a possible dose at a location other than the |
| treatment site in excess of the limits in 10 CFR 30.3045(a)(iii). |
| |
| After retraction, the sources were successfully deployed into the patient |
| and verified by the physician via a fluoroscope. Adverse effects on the |
| patient are not expected. |
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|Power Reactor |Event Number: 39611 |
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| FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 02/22/2003|
| UNIT: [1] [] [] STATE: LA |NOTIFICATION TIME: 05:30[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 02/22/2003|
+------------------------------------------------+EVENT TIME: 01:23[CST]|
| NRC NOTIFIED BY: RICKY MAYEUX |LAST UPDATE DATE: 02/22/2003|
| HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 91 Power Operation |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| MANUAL REACTOR TRIP DUE TO MAIN TURBINE ELECTRO-HYDRAULIC OIL LEAK |
| |
| "At 0123 [CST] a manual scram was inserted with the unit at 91% power in |
| coastdown. Main Electro Hydraulic Control sump level low alarm was |
| received. Cavitation of Main Electro Hydraulic control pumps and report of |
| a leak around the main turbine front standard were received from the field. |
| Manual scram was inserted. A previous condition existed on Feed regulating |
| valve C with the valve not able to close more than 80% open. A level 8 |
| signal was received tripping reactor feed pumps. At 0136 Reactor Core |
| Isolation Cooling was initiated. A reactor level 3 signal was received |
| isolating Suppression Pool Cleanup isolation valves. Reactor feed pump was |
| restarted [and] received a level 8 second time due to leak by of feed |
| regulation valves. A second level 3 was received after the second level 8. |
| Reactor level is being controlled 10 to 51 inches with Reactor core |
| isolation cooling. Outboard main steam isolation valves were closed for |
| pressure control. Pressure control is on main steam line drains." |
| |
| "Upon further review of plant data, it has been determined a 3rd reactor |
| water level 8 trip was received prior to RCIC stabilizing level." |
| |
| All control rods fully inserted and the electrical system responded |
| normally. The licensee notified the NRC Resident Inspector. |
| |
| *****UPDATE ON 2/22/03 at 18:00 FROM WILLIAMSON TO LAURA***** |
| |
| The RCIC system has been shutdown and the normal feed water system placed |
| back into service to maintain reactor veesel water level. |
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