U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/04/2003 - 08/05/2003
** EVENT NUMBERS **
39399 39972 40035 40042 40046
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39399 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 11/22/2002|
| UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 21:17[EST]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 11/22/2002|
+------------------------------------------------+EVENT TIME: 16:50[CST]|
| NRC NOTIFIED BY: JOHN J. REIMER |LAST UPDATE DATE: 08/04/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 97 Power Operation |97 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE |
| |
| "This report is being made pursuant to 10CFR50.72(b)(3)(v)(D), Event or |
| Condition that could have prevented fulfillment of a Safety Function needed |
| to Mitigate the Consequences of an Accident. During inspection of the High |
| Pressure Core Spray (HPCS) 2VY02A area cooler, missing sheet metal screws |
| were discovered. This could have prevented the High Pressure Core Spray |
| System (HPCS), a single train safety system, from performing its design |
| function during a seismic event. This also made the Division 3 Diesel |
| Generator inoperable. This is reportable as an 8 hour ENS notification. |
| |
| "The required actions of Technical Specification (TS) 3.5.1 were entered on |
| 11/22/02 at 1650 when the system was made inoperable. TS 3.8.1 does not |
| require Division 3 Diesel Generator operability if HPCS is declared |
| inoperable. Preparations to replace the missing sheet metal screws are in |
| progress. All other Emergency Core Cooling Systems are operable at this |
| time. An extent of condition review will be performed on all divisions for |
| both units." |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
| |
| |
| * * * UPDATE ON 11/23/02 @ 1333 BY CLARK TO GOULD * * * |
| |
| "Subsequent to ENS notification EN #39399, repairs were affected to the HPCS |
| area cooler (2VY02A) and the system was returned to operable. An extent of |
| condition inspection was performed on the remaining Unit 1 and Unit 2 |
| divisional area coolers. During these inspections it was discovered that |
| the Unit 1, Division 2 area cooler (1VY03A) was also missing several sheet |
| metal screws. The system was removed from service, repaired and returned |
| to operable. No problems were discovered on either of the two remaining |
| Unit 1 divisional area coolers. |
| |
| During inspection on Unit 2, the Division 2 area cooler (2VY03A) was missing |
| all of its sheet metal screws. At the time of discovery of the Division 2 |
| inoperability, the HPCS (Division 3) area cooler had already been repaired |
| and declared operable. It was determined however, that at some point both |
| the HPCS (Division 3) and Division 2 Emergency Core Cooling System (ECCS) |
| injection subsystems were under these conditions simultaneously. Per |
| Technical Specification (TS) 3.5.1 Bases when this combination of ECCS |
| subsystems are inoperable, the plant is in a condition outside of the design |
| basis. |
| |
| Investigation of equipment and maintenance history will be performed to |
| determine if any additional periods existed with multiple divisions under |
| these conditions simultaneously. At this time all divisional area coolers |
| on both Units have been inspected. Those with deficiencies have been |
| repaired and declared operable." |
| |
| The NRC Resident Inspector was notified. |
| |
| Reg 3 RDO (Clayton) was informed. |
| |
| * * * RETRACTION ON 08/10/03 AT 1556 FROM LARRY R. BLUNK TO ARLON COSTA * * |
| * |
| |
| "THIS REPORT CONCERNED THE DISCOVERY THAT THE COOLING COIL MOUNTING SCREWS |
| FOR A NUMBER OF DIVISIONAL AREA COOLERS ON BOTH UNITS 1 AND 2 WERE NOT |
| INSTALLED, WHICH COULD HAVE RENDERED THE ASSOCIATED ECCS SYSTEMS INOPERABLE |
| DURING A SEISMIC EVENT. |
| |
| "STRUCTURAL ANALYSES HAVE BEEN COMPLETED THAT DEMONSTRATE THAT THE SUBJECT |
| DIVISIONAL COOLERS WERE OPERABLE WITH THE COOLING COIL MOUNTING SCREWS NOT |
| INSTALLED. |
| |
| "THIS EVENT IS THEREFORE NOT REPORTABLE UNDER 10 CFR 50.72 (B)(3)(II) |
| 'DEGRADED OR UNANALYZED CONDITION,' OR 10 CFR 50.72 (B)(3)(V)(D), 'EVENT OR |
| CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION NEEDED |
| TO MITIGATE THE CONSEQUENCES OF AN ACCIDENT.' |
| |
| "THE SENIOR RESIDENT INSPECTOR HAS BEEN NOTIFIED." |
| |
| Notified the R3DO (Christine Lipa). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39972 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 07/02/2003|
| UNIT: [1] [2] [] STATE: TN |NOTIFICATION TIME: 00:17[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/01/2003|
+------------------------------------------------+EVENT TIME: 18:45[EDT]|
| NRC NOTIFIED BY: KEN STEVENS |LAST UPDATE DATE: 08/04/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JOEL MUNDAY R2 |
|10 CFR SECTION: |HAROLD CHRISTENSEN R2 |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION |ROBERTA WARREN TAS |
|NINF INFORMATION ONLY | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNACCOUNTED FOR SECURITY WEAPON |
| |
| Unaccounted for security weapon. Immediate compensatory measures taken upon |
| discovery. TVA security and NRC Resident Inspector notified. Refer to HOO |
| Log for additional details. |
| |
| * * * UPDATE ON 07/02/03 AT 0150 FROM HERBERT EAVES TO ARLON COSTA * * * |
| |
| TVA Police made offsite notification on 07/01/03 at 2300 EDT to the National |
| Crime Information Center pertaining to the unaccounted for security weapon. |
| The NRC Resident Inspector will be notified of this event update. |
| |
| * * * UPDATE on 07/03/03 AT 1526 EDT FROM BONNIE SCHMETZLER TO MACKINNON * * |
| * |
| |
| Security weapon not found on site. Investigation being continued by TVA |
| police. The NRC Resident Inspector will be notified of this update. R2DO |
| (Joel Munday) & NSIR (Roberta Warren) notified. |
| |
| * * * UPDATE ON 08/04/03 AT 1648 FROM MITCH TAGGERT TO ARLON COSTA * * * |
| |
| Unaccounted for security weapon was found. Plant security is investigating |
| the incident. Refer to HOO Log for additional details. |
| |
| The NRC Resident Inspector will be notified. Notified R2DO (James Moorman) |
| and TAS (Matt Kormann). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 40035 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: MA RADIATION CONTROL PROGRAM |NOTIFICATION DATE: 07/30/2003|
|LICENSEE: WHEELABRATOR |NOTIFICATION TIME: 12:56[EDT]|
| CITY: DORCHESTER REGION: 1 |EVENT DATE: 07/30/2003|
| COUNTY: STATE: MA |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/30/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES NOGGLE R1 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARIO IANNACCONE | |
| HQ OPS OFFICER: BILL GOTT | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT ON DAMAGED GENERALLY LICENSED LEVEL GAUGE |
| |
| "On 7/28/03 Wheelabrator became aware that a TN [Texas Nuclear] Level Gauge, |
| Cs-137 100 mCi [milli Curie] [Model Number: 5197] SN # B728 (SS&D No. |
| TX634D119B) had gone missing. Plant was in shutdown and work was being |
| performed on the associated hopper. The gauge was removed not following |
| standard procedure. A search of the premises was conducted with negative |
| results. A consultant was hired, and located the gauge in a scrap metal |
| pile on the morning of 7/30/03. The shielding was partially melted away, it |
| was surmised that the gauge may have passed through the boiler. The |
| consultant performed radiation surveys and placed the gauge in a metal |
| container in the storage area. The manufacturer was contacted, arrangements |
| will be made to return the gauge. |
| |
| "Cause description: Gauge removed from frame to accommodate work taking |
| place on hopper (steel replacement). |
| |
| "Precipitating factor: Not secured in storage area; typically used a secure |
| holding area prior to shipping/installation." |
| |
| State Event Number: MA 03-0023 |
| |
| Wheelabrator is located at 100 Salem Turnpike, Saugus, MA. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 40042 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 07/31/2003|
|LICENSEE: RUSH COPLEY MEDICAL CENTER |NOTIFICATION TIME: 17:50[EDT]|
| CITY: AURORA REGION: 3 |EVENT DATE: 07/28/2003|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: IL-01207-01 AGREEMENT: Y |LAST UPDATE DATE: 08/01/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE BURGESS R3 |
| |DANIEL GILLEN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL EVENT |
| |
| The following information was received via e-mail from the Illinois |
| Department of Nuclear Safety: |
| |
| "Abstract: |
| |
| "The agency [Illinois Department of Nuclear Safety] received a call July 29, |
| 2003 from a nuclear medicine technician, at Rush Copley Medical Center in |
| Aurora, IL [deleted]. She reported that a patient who was to receive a 4 |
| milliCi unit dose of Tl-201 [Thallium-201] for a heart test instead received |
| a 4 milliCi unit dose of I-131 [Iodine-131] on July 28, 2003. |
| |
| "Circumstances surrounding the event, as reported by the technician, |
| indicate that both the exterior lead container and syringe were labeled as |
| being Tl-201. Although the injection occurred the previous day it was not |
| determined that I-131 was involved until after the gamma cameras used for |
| patient imaging were checked a second time on the morning of July 29th. |
| Service engineers had been called to the site both days to inspect the |
| cameras after both failed attempts to image the patient. The cause became |
| evident when a gamma camera flood source that had been made from what was |
| thought to be the remaining Tl-201 material in the syringe from 7/29/2003 |
| showed peaks consistent with I-131. The assayed amount from Monday's |
| records showed the dose to be within the expected range for a typical 4 |
| milliCi Tl-201 diagnostic doses and as such, was considered to be normal. |
| The technician indicated that the patient involved had been contacted by the |
| referring physician, the onsite oncologists, the hospital Administrator and |
| lawyer and was informed as to what had happened. The hospital has arranged |
| to perform routine blood analysis throughout the year to monitor any changes |
| in thyroid activity. |
| |
| "The RSO [Radiation Safety Officer] and oncologist at the facility, |
| [deleted], were then contacted by the Agency. He indicated that it is very |
| unlikely that any changes will be noted in the patient. He reports that the |
| dose administered, is only slightly larger than that typically ordered for |
| whole body scans using I-131. Regardless, they have offered to provide |
| routine blood testing of the patient throughout the year for T3, T4 and T7 |
| thyroid hormones levels as part of a follow up evaluation. |
| |
| "A call was then made to the Medi Physics/Amersham Health, [deleted] Wood |
| Dale pharmacy facility where the doses had been prepared the previous |
| Friday. [Deleted], Corporate RSO indicated that they were in the process of |
| determining what had occurred but it appeared that when prescriptions and |
| labels were taken from the computer system a 4 milliCi Tl-201 prescription |
| was mistakenly put in with 4 other prescriptions for 4 milliCi unit doses of |
| I-131 to be filled. Subsequently, the Tl-201 request was mistakenly filled |
| as an I-131 prescription. The difference in nuclides was not noted by the |
| pharmacist when the pre-generated Tl-201 labels were applied to the syringe |
| and lead container which now held I-131. |
| |
| "The Agency sent an investigator to the medical center on the morning or |
| July 30 to observe the labeling on the container and syringe, receipt |
| records, gamma camera QA tests and to verify by gamma spectrum analysis the |
| presence of I-131 as well as to conduct preliminary interviews to obtain |
| additional facts. The investigation then moved on to the pharmacy to |
| continue their review of the event. Based on those visits, the information |
| obtained largely confirmed the preliminary notification. The Agency is |
| continuing its investigation of the matter and is expecting reports to be |
| filed by both parties according to regulatory requirements. |
| |
| "Preliminary estimates of EDE to the whole body of 355 Rem and 11,672 Rad to |
| the thyroid based on ICRP 53 modeling assuming 55% uptake and standard man |
| conditions has been calculated. Similar preliminary estimates based on the |
| package insert assuming 25% uptake resulted in 1,628 Rads and 5,328 Rads |
| respectively. The two estimates vary widely because of unknown factors |
| associated with the patient's condition. NRC Operations Center was notified |
| of the event at 17[50] on 31 July 2003 and assigned Event Number 40042." |
| |
| *** UPDATED AT 1705 EDT ON 8/1/03 FROM KLINGER TO CROUCH *** |
| |
| Last paragraph of above report was amended to read as follows: |
| |
| "Preliminary estimates of dose to the thyroid range from 5,300 Rads to |
| 11,700 Rads. The two estimates vary widely because of unknown factors |
| associated with the patient's condition. NRC Operations Center was notified |
| of the event at 1750 E.S.T on 31 July 2003 and assigned Event Number |
| 40042." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40046 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HADDAM NECK REGION: 1 |NOTIFICATION DATE: 08/04/2003|
| UNIT: [1] [] [] STATE: CT |NOTIFICATION TIME: 10:44[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 08/04/2003|
+------------------------------------------------+EVENT TIME: 10:15[EDT]|
| NRC NOTIFIED BY: MICHAEL HEYL |LAST UPDATE DATE: 08/04/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Decommissioned |0 Decommissioned |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL |
| PROTECTION |
| |
| |
| APPROXIMATELY ONE TEASPOON OF DIESEL FUEL OIL CONTACTED THE SOIL WHEN THE |
| RAIN WASHED IT OFF THE TOP OF A PORTABLE FUEL OIL TANK. THE AREA WAS |
| CLEANED UP. THE PORTABLE FUEL OIL TANK WAS MOVED TO A PAVED SURFACE. THE |
| LICENSEE NOTIFIED THE STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL |
| PROTECTION OF THE OIL SPILL. |
| |
| NRC RESIDENT INSEPCTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. |
+------------------------------------------------------------------------------+
