U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/11/2003 - 07/14/2003
** EVENT NUMBERS **
39949 39983 39990 39991 39992 39993 39994
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|General Information or Other |Event Number: 39949 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 06/19/2003|
|LICENSEE: AGI GEOTECHNICAL |NOTIFICATION TIME: 14:30[EDT]|
| CITY: VAN NUYS REGION: 4 |EVENT DATE: 06/19/2003|
| COUNTY: STATE: CA |EVENT TIME: 07:30[PDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/11/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KATHLEEN KAUFMAN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| CALIFORNIA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE |
| |
| [DELETED] , Director LA County Radiological Health Management of the CA |
| Radiological Health Branch and [DELETED] Senior Health Physicist |
| [DELETED] ) called to report that a Moisture Density Gauge (50 milli-Curies |
| Am-241 and 10 milli-Curies Cs-137) (Manufacture Campbell Pacific, Model MC1, |
| serial # 11114098) was stolen from a truck at 7:30 AM PDT. The truck was |
| at 7-11 in Torrance, California and the driver was inside the 7-11. The |
| driver noticed the missing material after he drove away from the 7-11. The |
| licensee is AGI Geotechnical [DELETED] ). The Torrance Police Department |
| was notified. |
| |
| * * * UPDATE ON 7/10/03 AT 0707 PM VIA EMAIL FROM R. GREGER * * * |
| |
| "On 6/19/03 AGI Geotechnical, a CA licensee, reported the theft that morning |
| of one of its portable nuclear gauges from a convenience store in Torrance, |
| CA. The gauge was taken from the bed of the operator's parked pick-up truck |
| by someone who apparently cut the lock on the chain that locked the gauge to |
| the pickup truck. The licensee reported the theft to the local police |
| department and placed an ad in the local press offering a reward for the |
| return of the gauge. On 7/7/03 the licensee reported having received a call |
| from an individual in response to the reward ad. The individual indicated |
| that he knew who had stolen the gauge and where it was. The licensee |
| retrieved the gauge that day and returned it to its offices in Van Nuys, CA. |
| A state inspector visited the licensee to physically inspect the gauge and |
| confirm its identity. The gauge appeared to be in a normal condition, |
| undamaged, with no evidence of a radiological hazard. However, the |
| transport case for the gauge was cracked in several places and was missing |
| DOT labels, so it would need to be replaced. The licensee will have the |
| gauge checked and leak tested by the manufacturer's service representative |
| to ensure that the radioactive source was not damaged." |
| |
| Notified TAS (Whitney) and R4DO (Kennedy). |
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|General Information or Other |Event Number: 39983 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 07/08/2003|
|LICENSEE: GUIDANT CORPORATION |NOTIFICATION TIME: 15:28[EDT]|
| CITY: PEARLAND REGION: 4 |EVENT DATE: 06/19/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L05178-000 AGREEMENT: Y |LAST UPDATE DATE: 07/08/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: HELEN WATKINS | |
| 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 |
| |
| Spill of radioactive material. On 6/19/2003, an employee inadvertently |
| dropped a vial of P-32 on the floor. The container spilled approximately |
| 2900 millicuries of P-32 on the floor while contaminating one employee and |
| several pieces of the licensee's equipment. The employee was decontaminated |
| on site. An initial clean-up wash was performed on the facility. However, |
| the radiation levels remained high. The RSO (Radiation Safety Officer) |
| directed that the floors be covered with 2 sheets of 4 ft by 8 ft plexiglas. |
| In addition, the licensee covered contaminated equipment with lead sheeting |
| to prevent the spread of contamination and elevated radiation levels in the |
| vicinity of the equipment. The licensee is waiting 10 half-lives to release |
| the facility for full use. All personnel entering the area are notified of |
| the contamination and are warned of the radiation levels and potential |
| contamination. |
| |
| The incident was not reported within 24 hours per regulations. Levels |
| exceed release criteria. The incident is being investigated. |
| |
| This incident is being reported under 10 CFR 30.50(b)(1), and Texas |
| requirement 289.202(xx)(7)(A). |
| |
| Texas incident number I-8034. |
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|Power Reactor |Event Number: 39990 |
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| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 07/11/2003|
| UNIT: [1] [] [] STATE: VA |NOTIFICATION TIME: 13:24[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/16/2003|
+------------------------------------------------+EVENT TIME: 07:14[EDT]|
| NRC NOTIFIED BY: BARRY GARBER |LAST UPDATE DATE: 07/11/2003|
| HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |THOMAS DECKER R2 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling Shutdow|0 Refueling Shutdow|
| | |
| | |
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EVENT TEXT
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| INVALID EMERGENCY DIESEL START SIGNAL |
| |
| "The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not |
| considered a Licensee Event Report. |
| |
| "With the unit in refueling shutdown and defueled, a loss of the 1B DC |
| Electrical Bus occurred during maintenance activities associated with the 1B |
| Battery performance test. The current leads from a load bank to the |
| positive (+) terminal of the 1B Battery were being disconnected. |
| |
| "The Unit 1J Emergency AC Bus degraded and undervoltage protection relays, |
| powered from the 1B DC Bus, deenergized and provided a start signal for the |
| #3 Emergency Diesel Generator (EDG). The #3 EDG started, however, the |
| diesel did not load on the Unit 1J AC Bus due to the loss of control power |
| to Unit 1J AC Bus circuit breakers. The signal to start the #3 EDG on the |
| emergency AC electrical power system was considered invalid because the Unit |
| 1 Emergency AC Bus did not experience an actual degraded/undervoltage |
| condition. |
| |
| "Maintenance, Operations, and Engineering conducted a walkthrough of the |
| restoration actions and step sequence and at 1252 hours, re-energized the 1B |
| DC Bus. At 1550 hours, all loads were restored on 1B DC Bus. |
| |
| "The direct cause of the loss of the 1B DC Bus was the disconnection of the |
| wrong battery discharge cables. A root cause evaluation is being |
| performed." |
| |
| The licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39991 |
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| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 07/11/2003|
| UNIT: [1] [] [] STATE: VA |NOTIFICATION TIME: 13:30[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/23/2003|
+------------------------------------------------+EVENT TIME: 17:55[EDT]|
| NRC NOTIFIED BY: BARRY GARBER |LAST UPDATE DATE: 07/11/2003|
| HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |THOMAS DECKER R2 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling Shutdow|0 Refueling Shutdow|
| | |
| | |
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EVENT TEXT
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| INVALID EMERGENCY DIESEL START SIGNAL |
| |
| "The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not |
| considered a licensee Event Report. |
| |
| "With the unit in refueling shutdown and defueled, a loss of the 1B DC |
| Electrical Bus occurred during maintenance activities associated with the 1B |
| Main Station Battery performance test. The DC Bus voltage went to zero as a |
| result of the 1B-1 battery charger not assuming the load after the current |
| sharing parallel charger 1B-2 was placed in stand-by. |
| |
| "The Unit 1J Emergency AC Bus degraded and undervoltage protection relays, |
| powered from the 1B DC Bus, deenergized and provided a start signal for the |
| #3 Emergency Diesel Generator (EDG). The #3 EDG started, however, it did |
| not load on the Unit 1J AC Bus due to the loss of control power to Unit 1J |
| AC Bus circuit breakers. The signal to start the #3 EDG on the emergency AC |
| electrical power system was considered invalid because the Unit 1 Emergency |
| AC Bus did not experience an actual degraded/undervoltage condition. |
| |
| "Operations personnel stripped the 1B DC Bus in accordance with abnormal |
| procedures and restored the vital busses via manual transfer switches. |
| Aligning the 1B-2 battery charger to the stripped bus reenergized the 1B DC |
| Bus. |
| |
| "The direct cause of the loss of the 1B DC Bus was the failure of the 1B-1 |
| battery charger to pick up the load on the 1B DC Bus. A root cause |
| evaluation is being performed." |
| |
| The licensee notified the NRC Resident Inspector. |
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|Hospital |Event Number: 39992 |
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| REP ORG: WASHINGTON UNIVERSITY |NOTIFICATION DATE: 07/11/2003|
|LICENSEE: WASHINGTON UNIVERSITY |NOTIFICATION TIME: 16:58[EDT]|
| CITY: ST. LOUIS REGION: 3 |EVENT DATE: 07/09/2003|
| COUNTY: STATE: MO |EVENT TIME: 15:30[CDT]|
|LICENSE#: 24-00167-11 AGREEMENT: N |LAST UPDATE DATE: 07/11/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK RING R3 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SUSAN LANGHORST | |
| HQ OPS OFFICER: MIKE RIPLEY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
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EVENT TEXT
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| MEDICAL EVENT |
| |
| The Radiation Safety Officer at Washington University reported that an under |
| dose of a radiopharmaceutical (Sm-153 Quadramet) was administered to a |
| patient on 07/09/03. The under dose was discovered at 1600 CDT on 7/10/03 |
| when it was determined that a significant amount of the radiopharmaceutical |
| had leaked from the syringe. The licensee determined that 54 millicuries |
| out of the planned 55.8 millicuries had leaked from the syringe such that |
| less than 4% of the planned dose was administered. The licensee will be |
| notifying the referring physician when he returns to his office on Monday, |
| 07/14/03. The licensee assumes the physician will then notify the patient. |
| |
| The licensee will provide a written report to Region 3. |
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|Power Reactor |Event Number: 39993 |
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| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 07/11/2003|
| UNIT: [] [2] [] STATE: WI |NOTIFICATION TIME: 23:57[EDT]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/11/2003|
+------------------------------------------------+EVENT TIME: 20:09[CDT]|
| NRC NOTIFIED BY: RICK ROBBINS |LAST UPDATE DATE: 07/11/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|10 CFR SECTION: |TAD MARSH NRR |
|ACCS 50.72(b)(2)(iv)(A) ECCS INJECTION | |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Standby |0 Hot Standby |
| | |
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EVENT TEXT
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| MANUAL SAFETY INJECTION DUE TO PRESSURIZER LOW LEVEL |
| |
| Unit 2 was in mode 3 with the main feedwater regulating valve controllers in |
| automatic. Upon closure of the reactor trip breakers in preparation for |
| critical approach, the main feed regulating valves opened causing a cooldown |
| of the reactor coolant system (RCS) and pressurizer low level. The operator |
| response sequence included a manual reactor trip and manual safety |
| injection. There was no actual safety injection and the charging pumps made |
| up for the RCS shrinkage due to the cooldown. Steam generator levels |
| remained within their normal band range. A shutdown margin calculations was |
| performed and verified satisfactorily. All plant systems functioned as |
| required and the unit is currently stable in mode 3. The NRC Resident |
| Inspector was in the Control Room during this incident. |
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|Power Reactor |Event Number: 39994 |
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| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 07/14/2003|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 01:57[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 07/13/2003|
+------------------------------------------------+EVENT TIME: 22:00[EDT]|
| NRC NOTIFIED BY: HARRY GILES |LAST UPDATE DATE: 07/14/2003|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| HPCI SYSTEM INOPERABLE AT FERMI 2 |
| |
| "On 7/13/2003 at 2200 hours, while performing the HPCI Pump Time Response |
| and Operability Test, the HPCI main steam supply outboard containment |
| isolation valve, E4150F003, failed to close. The E4150F003 was declared |
| inoperable and the HPCI main steam supply inboard containment isolation |
| valve, E4150F002, was closed and de-activated per Technical Specifications. |
| Isolating the HPCI main steam supply rendered HPCI inoperable. The E4150F003 |
| the was documented per the site corrective action process. All other ECCS |
| equipment and RCIC are operable. This is being reported under |
| 10CFR50.72(b)(3)(v)(D)." |
| |
| The licensee notified the NRC Resident Inspector. The licensee entered the |
| applicable 14 day LCO for the HPCI system inoperability and initiated |
| maintenance troubleshooting. |
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