U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/25/2003 - 02/26/2003
** EVENT NUMBERS **
39600 39601 39606 39607 39616 39617 39618 39619 39620
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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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|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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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 39617 |
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| FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 02/25/2003|
| UNIT: [3] [4] [] STATE: FL |NOTIFICATION TIME: 06:56[EST]|
| RXTYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 02/25/2003|
+------------------------------------------------+EVENT TIME: 06:15[EST]|
| NRC NOTIFIED BY: BRIAN McILNAY |LAST UPDATE DATE: 02/25/2003|
| HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHARLES R. OGLE R2 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3 N Y 60 Power Operation |60 Power Operation |
|4 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| DEGRADED PLANT ACCESS DUE TO CAR ACCIDENT ON SITE ACCESS ROAD |
| |
| "One car accident on access road to plant, however offsite. Degraded |
| emergency responder access." |
| |
| The licensee will notify the NRC Resident Inspector. |
| |
| * * * * RETRACTION RECEIVED AT 1059 EST ON 2/25/03 FROM MCILNAY TO RIPLEY * |
| * * |
| |
| "Upon further review and in accordance with the guidance provided by |
| NUREG-1022, Rev. 2, Section 3.2.13, Loss of Emergency Preparedness |
| Capabilities, Turkey Point is retracting the NRC notification made under |
| 10CFR 50.72(b)(3)(xiii) 0656 on February 25, 2003. As discussed in |
| NUREG-1022, Loss of Offsite Response Capability considerations, NRC |
| notification is required when a major loss of offsite response capability |
| occurs. A major loss of offsite response capability is considered to include |
| loss of plant access for other than a short time for events that causes the |
| access road to be impassible. The Turkey Point access road was limited to |
| one lane (out of a normal two lane access) for 79 minutes, but at all times |
| was accessible." |
| |
| Notified R2 DO (C. Ogle). |
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|Power Reactor |Event Number: 39618 |
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| FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 02/25/2003|
| UNIT: [1] [] [] STATE: SC |NOTIFICATION TIME: 15:11[EST]|
| RXTYPE: [1] W-3-LP |EVENT DATE: 02/25/2003|
+------------------------------------------------+EVENT TIME: 14:10[EST]|
| NRC NOTIFIED BY: ROBERT F. RAY |LAST UPDATE DATE: 02/25/2003|
| HQ OPS OFFICER: ERIC THOMAS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WALTER RODGERS R2 |
|10 CFR SECTION: | |
|DDDD 73.71(b)(1) SAFEGUARDS REPORTS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| PHYSICAL SECURITY EVENT |
| |
| Unescorted access granted inappropriately. Immediate compensatory measures |
| taken upon discovery. Licensee notified NRC Resident Inspector. Refer to |
| HOO log for additional details. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 39619 |
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| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 02/25/2003|
| UNIT: [2] [3] [] STATE: NY |NOTIFICATION TIME: 15:28[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 02/25/2003|
+------------------------------------------------+EVENT TIME: 07:50[EST]|
| NRC NOTIFIED BY: CHARLIE HOCK |LAST UPDATE DATE: 02/25/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JOHN KINNEMAN R1 |
|10 CFR SECTION: |JOHN ZWOLINSKI NRR |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE|MICHAEL JOHNSON NRR |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| LOSS OF ALL EMERGENCY SIRENS |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| "Indian Point Energy Center (IPEC) Units 2 and 3 is making an eight-hour |
| non-emergency notification in accordance with 10CFR50.72(b)(3)(xiii). |
| |
| "On February 25, 2003, at 0752 hrs [EST] an investigation revealed that the |
| siren control system had apparently become inoperable at approximately 0650 |
| hrs. This condition affected the ability to sound all of the 154 sirens in |
| the four counties of Orange, Putman, Rockland and Westchester for a period |
| of 3 hours and 17 minutes. The siren system was successfully corrected, |
| tested and returned to service at 1016 hrs. |
| |
| "The NRC Resident Inspector was notified of this event." |
| |
| No state, local, or other government agencies were notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39620 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 02/26/2003|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 02:05[EST]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 02/26/2003|
+------------------------------------------------+EVENT TIME: 00:17[CST]|
| NRC NOTIFIED BY: FRANSON |LAST UPDATE DATE: 02/26/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |THOMAS KOZAK R3 |
|10 CFR SECTION: |MICHAEL JOHNSON NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |PATRICK HILAND IRO |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS |AUSTIN FEMA |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| PLANT ENTERED A NOUE DUE TO BOTH EMERGENCY DIESEL GENERATORS BEING DECLARED |
| INOPERABLE |
| |
| The licensee declared an unusual event at 0026 CST due to both Emergency |
| Diesel Generators being inoperable resulting in the loss of on-site power |
| capability. At 0017 the "B" Diesel Generator failed to start during an |
| attempt to verify operability as required by TS 3.7.b.2 since the "A" Diesel |
| Generator was out of service for maintenance. They are investigating the |
| cause for the no start of the "B" Diesel Generator. The plant has 6 hrs to |
| be in hot standby and the following 6 hrs to hot shutdown. |
| |
| The NRC Resident Inspector will be notified. State and local agencies were |
| notified and there may be a press release. |
+------------------------------------------------------------------------------+
