U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/24/2003 - 02/25/2003
** EVENT NUMBERS **
39598 39599 39600 39601 39606 39607 39612 39614 39616
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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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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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|General Information or Other |Event Number: 39600 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 02/20/2003|
|LICENSEE: KEITHLY INSTRUMENTS, INC. |NOTIFICATION TIME: 15:31[EST]|
| CITY: CLEVELAND REGION: 3 |EVENT DATE: 02/19/2003|
| COUNTY: STATE: OH |EVENT TIME: [EST]|
|LICENSE#: GENERAL LIC. AGREEMENT: Y |LAST UPDATE DATE: 02/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN MADERA R3 |
| |TOM ESSIG NMSS |
+------------------------------------------------+JOHN DAVIDSON IAT |
| NRC NOTIFIED BY: MIKE SNEE | |
| 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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| LOST AIR IONIZER |
| |
| The following report was received by fax from the Ohio Department of |
| Health: |
| |
| "The Bureau received a report of a lost generally licensed air ionizer |
| [static eliminator]. The device was [an] NRD, LLC model P-2021-8101, serial |
| # A2BP733. The device contained a Po-210 source with an activity of 1.25 |
| [millicuries] on 2/20/03." |
| |
| The loss was attributed to inadequate training. |
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|General Information or Other |Event Number: 39601 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 02/20/2003|
|LICENSEE: SCOTT PROCESS SYSTEMS, INC. |NOTIFICATION TIME: 15:32[EST]|
| CITY: HARTVILLE REGION: 3 |EVENT DATE: 01/08/2003|
| COUNTY: STATE: OH |EVENT TIME: 12:00[EST]|
|LICENSE#: OH-0332077000 AGREEMENT: Y |LAST UPDATE DATE: 02/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN MADERA R3 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MIKE SNEE | |
| 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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| ABNORMAL RADIOGRAPHY SOURCE RETRIEVAL |
| |
| The following information was received by fax from the Ohio Department of |
| Health: |
| |
| "The licensee reported [an] abnormal radiography source retrieval due to a |
| crimped guide tube. A test piece fell on the guide tube during radiography |
| operations in the licensee's radiography vault. The licensee's source |
| retrieval procedure was implemented and the source was successfully |
| retrieved. A total of 3 [millirem] was received by 2 individuals during |
| this operation." |
| |
| The source was Ir-192, 83 Curies, manufactured by AEA Technologies, model |
| number 424-9, serial number 07686B. The radiography camera is a Model 880 |
| manufactured by AEA Technologies, serial number D1163. |
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|General Information or Other |Event Number: 39606 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 02/20/2003|
|LICENSEE: UNIVERSITY OF CALIFORNIA MEDICAL CENT|NOTIFICATION TIME: 19:12[EST]|
| CITY: ORANGE REGION: 4 |EVENT DATE: 02/20/2003|
| COUNTY: STATE: CA |EVENT TIME: 13:49[PST]|
|LICENSE#: 0278-30 AGREEMENT: Y |LAST UPDATE DATE: 02/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |ROBERT PIERSON NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GERRY FELDMAN | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| CALIFORNIA AGREEMENT STATE REPORT FOR MEDICAL EVENT AT UNIVERSITY OF |
| CALIFORNIA |
| |
| "I took a call on a therapeutic misadministration from the RSO for UCIMC (LN |
| 0278-30). The incident involved the administration (via injection) of Y-90 |
| microspheres (25 microns) for the treatment of unresectable hepatic |
| carcinoma. The intended dosage was 96.2 millicuries, and the administered |
| dosage was approximately 38.48 millicuries (i.e., an underdose of 60%). |
| |
| "The delivery system consists of an injection system, connected to the vial |
| containing the microspheres, which has one line leading to a receiving vial, |
| and another to the patient. The direction of the flow is determined by |
| position of the valve connecting these two lines. Just beyond the vial |
| containing the microspheres there are also two mounted detectors (like small |
| pocket chambers), which give a visual indication when the microspheres begin |
| moving out of the vial. |
| |
| "The physicist was priming the system prior to a scheduled treatment. When |
| the priming reaches the point that the microspheres begin to exit the vial, |
| the valve is turned to direct the flow from the "receiving vial" to the |
| patient. In this case, the physicist accidentally over-primed the system and |
| about 60% of the activity washed in the receiving vial. The physician, an |
| authorized user, was also present during the treatment. They completed this |
| treatment, and the physician is still reviewing whether it is necessary to |
| perform another treatment to reach the prescribed dosage, or whether this |
| treatment will be adequate as it stands. |
| |
| "The licensee is awaiting a report from the physician and physicist as to |
| what might have caused this to occur. At the present time, they think it may |
| simply be that the physicist did not respond quickly enough to the |
| indication on the detectors that activity was passing out of the isotope |
| vial. That is, it may simply be a slow reflex problem. The manufacturer |
| happened to be on site at the time of the incident, and indicated there had |
| been two similar previous events (one allegedly at a hospital in PA), but no |
| further details on the events were obtained by the licensee." |
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|General Information or Other |Event Number: 39607 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 02/20/2003|
|LICENSEE: ALTA BATES MEDICAL CENTER |NOTIFICATION TIME: 15:00[EST]|
| CITY: BERKELEY REGION: 4 |EVENT DATE: 02/20/2003|
| COUNTY: STATE: CA |EVENT TIME: [PST]|
|LICENSE#: 0517-01 AGREEMENT: Y |LAST UPDATE DATE: 02/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |ROBERT PIERSON NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MELVA CLARIDGE | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| CALIFORNIA AGREEMENT STATE REPORT FOR MEDICAL EVENT AT ALTA BATES MEDICAL |
| CENTER |
| |
| "Received a call today at about 1430 hours from [ ] who is one of Alta |
| Bate's medical physicists (therapy department), to report a therapeutic |
| misadministration involving I-125. The regular RSO is on leave. The patient |
| was prescribed 0.35 millicuries I-125 for a brachytherapy procedure |
| (prostate implant; involving 80+ seeds) on 2/19/03, but received 0.52 |
| millicuries, or an estimated 50% overdosage, because the calculation [was] |
| done incorrectly." |
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|Hospital |Event Number: 39612 |
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| REP ORG: FAIRFAX HOSPITAL |NOTIFICATION DATE: 02/24/2003|
|LICENSEE: FAIRFAX HOSPITAL |NOTIFICATION TIME: 07:45[EST]|
| CITY: FALLS CHURCH REGION: 2 |EVENT DATE: 02/21/2003|
| COUNTY: FAIRFAX STATE: VA |EVENT TIME: 12:15[EST]|
|LICENSE#: 4517128-01 AGREEMENT: N |LAST UPDATE DATE: 02/24/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES R. OGLE R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GARY TALKINGTON | |
| HQ OPS OFFICER: YAMIR DIAZ | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
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EVENT TEXT
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| LOST RADIOPHARMACEUTICAL DEVICE CONTAINING TECHNETIUM-99 |
| |
| On 2/21/03 at approximately 1030 EST, the radio-pharmacy in the Nuclear |
| Medicine Department of the Fairfax Hospital received a shipment of radio |
| pharmaceuticals. As they were preparing to administer a dose to a patient, |
| they discovered that one syringe containing 10 millicuries of |
| Technetium-99M Mag-3 was missing. The licensee stated that the dose was |
| listed on the in-processing documents as received. The licensee's current |
| assumption is that either the dose was not actually shipped or that it was |
| misplaced within the laboratory. The licensee plans on continuing to |
| investigate the whereabouts of the device. |
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|Power Reactor |Event Number: 39614 |
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| FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 02/24/2003|
| UNIT: [] [2] [] STATE: AL |NOTIFICATION TIME: 15:36[EST]|
| RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 02/24/2003|
+------------------------------------------------+EVENT TIME: 11:17[CST]|
| NRC NOTIFIED BY: DON SMITH |LAST UPDATE DATE: 02/24/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHARLES R. OGLE R2 |
|10 CFR SECTION: | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Shutdown |0 Hot Shutdown |
| | |
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EVENT TEXT
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| AUTOMATIC REACTOR SCRAM DUE TO LOW REACTOR WATER LEVEL |
| |
| The following information was received from the licensee via facsimile: |
| |
| "At 1117 [CST] on 02/24/2003 with Unit 2 in MODE 3 (Control Rods fully |
| inserted), a full reactor scram signal (RPS) [Reactor Protection System] was |
| received due to low reactor water level. The lowest level observed was 1.6 |
| [inches] with a scram set point of 2 [inches]. All expected PCIS [Primary |
| Containment Isolation Systems] Isolations, GROUP 2 (RHR S/D cooling) |
| [Residual Heat Removal], GROUP 3 (RWCU) [Reactor Water Clean-Up), GROUP 6 |
| (Ventilation) & GROUP 8 (TIP) [Transverse Incore Probes] were received |
| along with the auto start of 'B' CREVS [Control Room Emergency Ventilation |
| System] and the three SBGT [Standby Gas Treatment] Trains. This low water |
| level event is believed to be a result of manual closure of 2C RFP [Reactor |
| Feed Pump] Discharge valve (2-FCV-3-5) and the slow response of the RFP |
| BYPASS valve (2-FCV-3-53) |
| |
| "This event is reportable per 10CFR50.72 (b)(3)(iv)(A) as 'Any event or |
| condition that results in valid actuation of RPS & PCIS as described in (1) |
| & (2) below'." |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39616 |
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| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 02/24/2003|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 17:02[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 02/24/2003|
+------------------------------------------------+EVENT TIME: 15:48[EST]|
| NRC NOTIFIED BY: PETE SENA |LAST UPDATE DATE: 02/25/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |JOHN KINNEMAN R1 |
|10 CFR SECTION: |NADER MAMISH IRO |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |TERRY REIS NRR |
|ACCS 50.72(b)(2)(iv)(A) ECCS INJECTION |ZENNOT EPA |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|BOB SUMMER R1 |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT|DAVE KERN R1 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
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EVENT TEXT
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| UNUSUAL EVENT DUE TO MAIN STEAM LINE ISOLATION WITH SAFETY INJECTION |
| |
| The following information was received from the licensee via facsimile: |
| |
| "At 1548 [EST], on 2/24/03, Beaver Valley Unit 1 experienced an automatic |
| reactor trip and safety injection on low steam line pressure. An automatic |
| main steam line isolation also occurred and all three main steam line |
| isolation valves shut. After the automatic actions occurred, operators |
| noted that all three steam generator pressures appeared normal. Operators |
| were dispatched to investigate in the field and found no indications of a |
| steam leak. |
| |
| "Emergency procedure E-0, Response to Reactor Trip and Safety Injection, was |
| entered at 1548. At 1600, the Shift Manager declared an unusual event. |
| Initial notifications to state and local agencies were complete at 1609. |
| Per procedure E-0, after meeting Safety Injection termination criteria, the |
| Boron Injection Tank was isolated at 1603 and Safety Injection was |
| terminated. |
| |
| "Initial review of computer information revealed that closure of the 'C' |
| main steam isolation valve is the probable cause of the reactor trip, safety |
| injection and main steam isolation. |
| |
| "The gaseous release occurred due to tritium in the secondary and the fact |
| that the turbine driven auxiliary feed pump is in service. No protective |
| action recommendations were made. |
| |
| "All systems and equipment functioned as designed." |
| |
| Technical Support Center is staffed but not activated. All control rods |
| inserted into the core. The electrical grid is stable. Unit 1 is stable. |
| Core cooling is being accomplished via auxiliary feedwater and steam |
| generator atmospheric dump valves. There is previously identified steam |
| generator "B" tube leakage of less than 0.1 gallons per day. |
| |
| The NRC Resident Inspector has been notified. |
| |
| * * * UPDATE AT 1735 EST ON 2/24/03 BY HOWIE CROUCH * * * |
| |
| The licensee has terminated the Unusual Event. They have re-established a |
| pressurizer steam bubble. The plant and electrical grid is stable. Decay |
| heat removal is via auxiliary feedwater and the steam generator atmospheric |
| steam dumps. |
| |
| Notified FEMA, EPA, R1DO (Kinneman), DIRO (Mamish) and NRR EO (Reis). |
| |
| * * * UPDATE AT 0300 EST ON 2/25/03 TO MIKE RIPLEY FROM P. SENA * * * |
| |
| The licensee updated the event classification 10 CFR sections and current |
| plant status. |
| |
| "At 1735 [2/24/03], the Unusual Event was terminated. This was based upon |
| termination of the safety injection, completion of emergency operating |
| procedure actions, and stabilization of plant conditions. This was |
| previously communicated to the NRC Operations Center at 1740. |
| |
| "As of 0245, on 2/25/03, Unit 1 remains in mode 3. Heat removal Is via the |
| steam generator atmospheric steam release valves. All main steam isolation |
| valves remain shut as the event investigation continues. The preliminary |
| initiator of the event remains the inadvertent closure of "C" Main Steam |
| Isolation Valve. The offsite release (due to tritium activity in the |
| secondary) has been calculated and determined to be of minimal/no effect on |
| the public. The projected whole body dose was 5.12E-7 mrem [millirem]. |
| This is equivalent to 3.41 E-6 percent of the yearly Offsite Dose |
| Calculation Manual Limit." |
| |
| Notified FEMA, EPA, R1DO (Kinneman), DIRO (Mamish) and NRR EO (Reis) |
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