U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/29/2003 - 07/30/2003
** EVENT NUMBERS **
40017 40019 40020 40024 40029 40030 40032 40033
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|General Information or Other |Event Number: 40017 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 07/25/2003|
|LICENSEE: MEMORIAL HERMANN HOSPITAL |NOTIFICATION TIME: 11:03[EDT]|
| CITY: The Woodlands REGION: 4 |EVENT DATE: 06/25/2003|
| COUNTY: STATE: TX |EVENT TIME: 12:00[CDT]|
|LICENSE#: L03772 AGREEMENT: Y |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TROY PRUETT R4 |
| |TRISH HOLAHAN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: HELEN WATKINS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INCORRECT PATIENT GIVEN A DOSE |
| |
| "On June 25, 2003, a nuclear medicine technologist gave a 243 microcurie |
| iodine-123 capsule to the wrong patient. There were two patients with the |
| same last name and middle initial but different first names in the |
| outpatient waiting room. The wrong patient responded when the technologist |
| took the patient into the nuclear medicine department, explained the |
| procedure, and had him fill out a thyroid questionnaire. After the patient |
| swallowed the capsule, he informed the technologist that he was not at the |
| hospital for a thyroid study. The patient was informed of the |
| misadministration. The licensee did not report whether the referring |
| physician was informed. |
| |
| "Cause: The technologist failed to fully identify the patient. |
| |
| "Corrective Action: The technologist was counseled. To prevent a recurrence, |
| the technologists will question the patient's full name and match their date |
| of birth in the future. The technologist will also ask the patient what |
| examination or procedure they are scheduled for before initiating any |
| test." |
| |
| Texas Incident No.: I-8042. |
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|General Information or Other |Event Number: 40019 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 07/25/2003|
|LICENSEE: DELLAVALLEY LABORATORIES |NOTIFICATION TIME: 13:00[EDT]|
| CITY: SACRAMENTO REGION: 4 |EVENT DATE: 07/25/2003|
| COUNTY: STATE: CA |EVENT TIME: 09:00[PDT]|
|LICENSE#: 3194-10 AGREEMENT: Y |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TROY PRUETT R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KENT PREDERGAST | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE |
| |
| "[The licensee] got in late from work, and failed to take the gauge to |
| storage location but instead left the gauge in the back of his pickup and |
| covered it. The gauge was covered inside the camper shell. Sometime |
| between 11 PM on 7/24/03 and 1:00 AM on 7/25/03, the pickup was stolen from |
| it's parking location. The Sacramento Police were notified on 7/25/03 and |
| the licensee will be placing an advertisement in the Sacramento Bee |
| [newspaper], offering a reward for the stolen gauge. |
| |
| "The Stolen gauge was a CPN 131, Model 503 DR, serial number H35126508 |
| containing 50 millicuries of Americium 241 Beryllium." |
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|General Information or Other |Event Number: 40020 |
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| REP ORG: NC DIV OF RADIATION PROTECTION |NOTIFICATION DATE: 07/25/2003|
|LICENSEE: REX HEALTHCARE |NOTIFICATION TIME: 13:09[EDT]|
| CITY: RALEIGH REGION: 2 |EVENT DATE: 07/14/2003|
| COUNTY: STATE: NC |EVENT TIME: [EDT]|
|LICENSE#: 092-0160-1 AGREEMENT: Y |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE BOLAND R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SHARN M. JEFFRIES | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING MISSING IODINE-125 SEEDS |
| |
| On 7/22/03 Rex Healthcare personnel discovered that five (5) I-125 seeds |
| (activity 0.384 milliCuries/ea for a total of 1.9 milliCuries) were missing. |
| The licensee conducted a search of the area between 7/22 and 7/24/03 with |
| negative results. |
| |
| NC Incident No.: 03-32 |
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|Fuel Cycle Facility |Event Number: 40024 |
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| FACILITY: WESTINGHOUSE HEMATITE |NOTIFICATION DATE: 07/28/2003|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 11:58[EDT]|
| COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 07/28/2003|
| COMMERCIAL LWR FUEL |EVENT TIME: 07:30[CDT]|
| |LAST UPDATE DATE: 07/28/2003|
| CITY: HEMATITE REGION: 3 +-----------------------------+
| COUNTY: JEFFERSON STATE: MO |PERSON ORGANIZATION |
|LICENSE#: SNM-33 AGREEMENT: N |BRUCE BURGESS R3 |
| DOCKET: 07000036 |TOM ESSIG NMSS |
+------------------------------------------------+CHRIS MILLER R3 |
| NRC NOTIFIED BY: KAREN CRAIG |JACK RAMSEY IP |
| HQ OPS OFFICER: STEVE SANDIN |JIM WHITNEY IAT |
+------------------------------------------------+JIM CREED IAT |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|PAAB 74.11(a) LOST/STOLEN SNM | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SCRAP ZIRCONIUM RODS SHIPPED TO RECYCLER IN CANADA CONTAINING U-235 FUEL |
| PELLETS |
| |
| Between 3-4 weeks ago Westinghouse Hematite shipped approximately 18,000 |
| scrap zirconium rods to Mississauga Metals and Alloys, Inc. in Brampton, |
| Ontario, Canada for recycling. Scrap zirconium rods require a 100% visual |
| inspection prior to shipment offsite to ensure that they do not contain any |
| fuel pellets. Last Thursday on 7/24/03, the recycler discovered thirty-six |
| (36) U-235 pellets (4.2 w/o) after processing about 25% of the scrap rods. |
| The individual at Mississauga responsible for contacting Westinghouse did |
| not return to work until Monday and, thus, Westinghouse was not informed |
| until 0730 CDT on 7/28/03. The pellets contain a total of six (6) grams |
| U-235. Westinghouse is dispatching staff to the recycling facility to |
| assist in determining appropriate corrective actions. |
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|Power Reactor |Event Number: 40029 |
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 07/29/2003|
| UNIT: [] [] [3] STATE: AZ |NOTIFICATION TIME: 01:42[EDT]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 07/28/2003|
+------------------------------------------------+EVENT TIME: 18:54[MST]|
| NRC NOTIFIED BY: Dan Marks |LAST UPDATE DATE: 07/29/2003|
| HQ OPS OFFICER: ERIC THOMAS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK SHAFFER R4 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
| | |
|3 A/R Y 98 Power Operation |0 Hot Standby |
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EVENT TEXT
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| RPS ACTUATION, SPECIFIED SYSTEM ACTUATION |
| |
| "On July 28, 2003, at approximately 18:54 Mountain Standard Time (MST) Palo |
| Verde Unit 3 experienced an automatic reactor trip on low DNBR [Departure |
| from Nucleate Boiling Ratio] from approximately 98% rated thermal power due |
| to reduced reactor coolant system flow when the main turbine tripped during |
| a grid perturbation. Unit 3 was at normal temperature and pressure prior to |
| the trip. All CEAs inserted fully into the reactor core. This was an |
| uncomplicated reactor trip. No emergency classification was required per the |
| Emergency Plan. No automatic ESF actuations occurred and none were required. |
| The operators initiated a manual Main Steam Isolation System (MSIS) |
| actuation, in accordance with the emergency operations procedures in |
| response to the loss of forced reactor coolant system flow. Safety related |
| buses remained energized during and following the reactor trip. The |
| Emergency Diesel Generators did not start and were not required. The offsite |
| power grid is stable. No significant LCOs have been entered as a result of |
| this event. No major equipment was inoperable prior to the event that |
| contributed to the event. |
| |
| "Unit 3 is stabilizing at approximately 520 degrees F and 2150 psia pressure |
| in Mode 3. The reactor coolant system remains in natural circulation with |
| heat removal via the atmospheric dump valves and feedwater from the |
| essential auxiliary feedwater system. The event did not result in any |
| challenges to fission product barriers and there were no adverse safety |
| consequences as a result of this event. The event did not adversely affect |
| the safe operation of the plant or the health and safety of the public. |
| |
| "Palo Verde Units 1 and 2 also observed the grid perturbation, but are |
| continuing to operate in Mode 1 at approximately 98% rated thermal power. |
| The cause of the perturbation is believed to be associated with switching in |
| a nearby Hassayampa yard by Salt River Project. A fossil power plant in the |
| vicinity also tripped off line during the grid perturbation event. |
| |
| "The [NRC] Senior Resident Inspector was informed of the Unit 3 reactor trip |
| and this notification. The Senior Resident Inspector has arrived on-site to |
| observe response to the reactor trip." |
| |
| * * * UPDATE 1437 EDT ON 7/29/03 FROM RAY BUZARD TO S. SANDIN * * * |
| |
| The following information was provided as an update: |
| |
| "This is a follow-up notification to the automatic reactor trip event |
| reported on July 28, 2003 (ENS # 40029) for Palo Verde Unit 3. The plant |
| remains stable in Mode 3 at approximately 585 degrees and 2250 psia. Reactor |
| coolant system (RCS) forced circulation has been restored with two reactor |
| coolant pumps (RCP) in operation. Heat removal remains via the atmospheric |
| dump valves and the non-essential auxiliary feedwater pump is supplying |
| steam generator feedwater. Off-site power has been restored and is supplying |
| non-class loads. |
| |
| "An RCS leak of approximately 1.7 gallons per minute has been identified |
| through the seal on RCP 2A. Vacuum has been restored to the main condenser |
| and activities are in progress to cool the plant down to Mode 5, Cold |
| Shutdown, using the steam bypass control system, to facilitate RCP 2A seal |
| replacement. The date of restart has not been established. |
| |
| "The Resident Inspector was informed of this notification." |
| |
| Notified R4DO(Shaffer). |
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|Power Reactor |Event Number: 40030 |
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| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 07/29/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 14:48[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/29/2003|
+------------------------------------------------+EVENT TIME: 14:01[EDT]|
| NRC NOTIFIED BY: NOEL KEMM |LAST UPDATE DATE: 07/29/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |JAMES NOGGLE R1 |
|10 CFR SECTION: |BOB DENNIG NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |NADER MAMISH IRO |
| |MIKE EACHES FEMA |
| |ANDREA HEINTZELMAN DHS |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| UNIT 1 DECLARED AN UNUSUAL EVENT DUE TO THE LOSS OF 500KV OFFSITE POWER |
| |
| "Experienced breaker failure of 500 KV 1-5 breaker. The protective function |
| of this took out 500 KV bus section 1. All 4 KV vital buses deenergized and |
| were repowered by the emergency diesel generators. Also 2 of 4 group buses |
| deenergized. Auxiliary feedwater pumps started on steam generator low |
| levels. This all resulted in a reactor trip. The source of the failure has |
| yet to be determined. Reactor coolant temperature is being controlled by |
| turbine bypass valves." |
| |
| The licensee informed state/local agencies and the NRC resident inspector. |
| |
| * * * UPDATE ON 7/29/03 AT 1803 EDT FROM NOEL KEMM TO BILL GOTT * * * |
| |
| "500 KV bus section one energized. 4KV vital bus 1B energized from offsite |
| power by 13 station power transformer. Restoration of 1A and 1C 4KV vital |
| buses from offsite power in progress. Initial problem appears to be a |
| ground problem with 1-5 500 KV breaker and subsequent breaker failure relay |
| scheme." |
| |
| The licensee has notified the NRC Resident Inspector and Region 1 IRC. |
| |
| * * * UPDATE ON 7/29/03 AT 2103 EDT FROM MARK FIOCCO TO GERRY WAIG * * * |
| |
| "Current Plant Status: 500 KV Bus section one energized . 4KV vital buses 1B |
| and 1C energized from offsite power by 13 station power transformer. |
| Restoration of 1A 4KV vital bus from offsite power in progress." |
| |
| The licensee has not notified the NRC Resident Inspector. The HQ Operatiions |
| Officer notified NRC Region 1 IRC. |
| |
| * * * UPDATE ON 7/29/03 AT 2201 EDT FROM MARK FIOCCO TO GERRY WAIG * * * |
| |
| "Status Update: All 4KV vital buses energized from 13 station power |
| transformer. Restoration of second source of offsite AC power is in |
| progress. Making preparation to terminate Unusual Event." The licensee has |
| notified the NRC Resident Inspector. |
| |
| * * * UPDATE ON 7/29/03 AT 2211 EDT FROM MARK FIOCCO TO GERRY WAIG * * * |
| |
| The Licensee terminated Notice of Unusual Event (NOUE) on 07/29/03 at 2211 |
| hours EDT. The licensee has notified the NRC Resident Inspector. |
| |
| The HQ Operatiions Officer notified FEMA (Butch Stiendurf) and DHS (Ed |
| Welch) of the NOUE termination. |
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|Power Reactor |Event Number: 40032 |
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| FACILITY: HARRIS REGION: 2 |NOTIFICATION DATE: 07/29/2003|
| UNIT: [1] [] [] STATE: NC |NOTIFICATION TIME: 20:59[EDT]|
| RXTYPE: [1] W-3-LP |EVENT DATE: 07/29/2003|
+------------------------------------------------+EVENT TIME: 20:00[EDT]|
| NRC NOTIFIED BY: ROBERT WORRELL |LAST UPDATE DATE: 07/29/2003|
| HQ OPS OFFICER: BILL GOTT +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAMES MOORMAN R2 |
|10 CFR SECTION: |PHILIP BROCHMAN NSIR |
|BSUR 20.1906(d)(1) SURFACE CONTAM LEVELS >|DANIEL GILLEN NMSS |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| SURFACE CONTAMINATION LEVELS ABOVE LIMITS |
| |
| "This report is generated due to finding smearable contamination on the |
| spent fuel shipping cask. Smearable contamination in excess of 10CFR71.87 |
| requires a one hour report. Due to 10CFR21, we cannot disclose further |
| information over non-secure communications." |
| |
| The licensee informed the NRC Resident Inspector. |
| |
| Additional information can be obtained from the NRC Operations Center. |
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|Power Reactor |Event Number: 40033 |
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 07/29/2003|
| UNIT: [] [2] [] STATE: AZ |NOTIFICATION TIME: 21:13[EDT]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 07/29/2003|
+------------------------------------------------+EVENT TIME: 15:16[MST]|
| NRC NOTIFIED BY: DUANE KANITZ |LAST UPDATE DATE: 07/29/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHUCK CAIN R4 |
|10 CFR SECTION: |PAT GWYNN RA |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|WILLIAM BECKNER NRR |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 98 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNIT 2 WAS MANUALLY TRIPPED AFTER A STUCK OPEN SPRAY VALVE FAILED TO CLOSE |
| |
| "On July 29, 2003, at approximately 1518 Mountain Standard Time (MST) Palo |
| Verde Unit 2 plant operators manually tripped the reactor from approximately |
| 98% rated thermal power due to reduced reactor coolant system pressure when |
| a pressurizer spray valve opened and failed to close on operator demand. |
| Unit 2 was at normal temperature and pressure prior to the trip. All CEAs |
| inserted fully into the reactor core. This was an uncomplicated reactor |
| trip. No emergency classification was required per the Emergency Plan. |
| Containment Isolation and Safety Injection Actuation Signals were received |
| following the manual reactor trip per design. Safety related buses remained |
| energized during and following the reactor trip. No significant LCOs have |
| been entered as a result of this event. The pressurizer spray valve that |
| initiated the event was being placed in service following maintenance. |
| |
| "Unit 2 is stabilized in Mode 3 at approximately 564 degrees F and 2200 |
| psia. The reactor coolant system remains in natural circulation with heat |
| removal via Steam Bypass Control to the main condenser. The event did not |
| result in any challenges to fission product barriers and there were no |
| adverse safety consequences as a result of this event. The event did not |
| adversely affect the safe operation of the plant or the health and safety of |
| the public. |
| |
| "The Resident Inspector was informed of the Unit 2 reactor trip and this |
| notification. The Resident Inspector is onsite to observe response to the |
| reactor trip. |
| |
| "The reactor coolant pumps were secured after the trip to stop continued |
| spray flow and depressurization per the alarm response procedure. The |
| offsite electrical power grid is stable." |
+------------------------------------------------------------------------------+
