U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/30/2003 - 06/02/2003
** EVENT NUMBERS **
39883 39884 39891 39893 39894 39895 39896 39897 39898
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|General Information or Other |Event Number: 39883 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 05/27/2003|
|LICENSEE: GUIDANT CORPORATION |NOTIFICATION TIME: 10:17[EDT]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 05/23/2003|
| COUNTY: STATE: TX |EVENT TIME: 15:50[CDT]|
|LICENSE#: L05178-000 AGREEMENT: Y |LAST UPDATE DATE: 05/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JONES R4 |
| |LAWRENCE DOERFLEIN R1 |
+------------------------------------------------+TOM ESSIG NMSS |
| NRC NOTIFIED BY: OGDEN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MALFUNCTION OF A HIGH DOSE RATE AFTERLOADER |
| |
| During a heart procedure at the Union Memorial Hospital in Maryland with a |
| Galileo III (HDR - High dose rate afterloader) device using a Phosphorus - |
| 32 source wire, of up to 600 millicuries, a malfunction occurred with the |
| active wire in place in the patient's heart. When the source was to be |
| retracted the source would not retract. The physician utilized the machine |
| interrupt to try to get the source to move to the shielded position and it |
| failed. The physician then pushed the system STOP button to get the source |
| to retract and it also failed to perform the retraction. The physician then |
| moved to the hand-wheel to retract the source, but this function also |
| malfunctioned. At this point the physician pulled the entire catheter and |
| dropped it to the Operating Room floor. The power cord was then removed |
| from the wall receptacle depriving the machine of power and then the source |
| retracted to the fully shielded position. The licensee was informed that |
| this would constitute a Therapy Event within the State of Texas and the |
| state would need a complete report and an emergency read of all badged |
| personnel in the OR during the procedure. The Licensee responded that the |
| machine was not within the State of Texas. A report to the state of Texas |
| is still required by License Condition # 16 due to failure of the drive |
| mechanism of the GALILEO III to retract the source to safe storage until the |
| fourth emergency procedure was performed. |
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|General Information or Other |Event Number: 39884 |
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| REP ORG: NEW MEXICO RAD CONTROL PROGRAM |NOTIFICATION DATE: 05/27/2003|
|LICENSEE: SPECTRATEK SERVICES |NOTIFICATION TIME: 12:49[EDT]|
| CITY: ALBUQUERQUE REGION: 4 |EVENT DATE: 05/23/2003|
| COUNTY: STATE: NM |EVENT TIME: 16:30[MDT]|
|LICENSE#: TA-172-21 AGREEMENT: Y |LAST UPDATE DATE: 05/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JONES R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+CAUDLE JULIAN R2 |
| NRC NOTIFIED BY: WILLIAM FLOYD | |
| 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 |
| |
| On 5/22/2003, the licensee sent a shipment of radioactive material to Elite |
| Airfreight in Houston, TX. On 5/23/2003 at approximately 1630 MDT, Elite |
| Airfreight contacted the licensee to inform them that only 2 of the 3 boxes |
| of radioactive material in the shipment had arrived in Houston. The |
| licensee contacted Federal Express, who tracked the missing package to the |
| Fedex facility in Memphis, TN. Fedex planned to send the missing package to |
| Houston on 5/24/2003. As of 5/27/2003, the package still had not arrived in |
| Houston. The licensee contacted Fedex again, and was told the package was |
| still in Memphis, and would be shipped to Houston today (5/27/2003). |
| |
| The missing package is a 12X12X12 inch fiberboard box containing 40 |
| millicuries of Antimony-124, and has a Transportation Index of 4. This |
| event is state of New Mexico event number NM03-02. |
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|Power Reactor |Event Number: 39891 |
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 05/30/2003|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 00:43[EDT]|
| RXTYPE: [1] CE |EVENT DATE: 05/29/2003|
+------------------------------------------------+EVENT TIME: 21:18[CDT]|
| NRC NOTIFIED BY: DON KURTTI |LAST UPDATE DATE: 05/30/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| 161 KV WAS DECLARED INOPERABLE DUE TO THE PREDICTED POST TRIP VOLTAGE BELOW |
| SETPOINT |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| " [Abnormal Operating Procedure] AOP-31 '161KV GRID MALFUNCTIONS' was |
| entered due to the predicted post trip 161 KV voltage dropping to 160.6 KV |
| on the PCMMINT [Personal Computer Monitoring of Missouri, Iowa and Nebraska |
| Transmission] computer monitoring program. 161 KV was declared inoperable |
| due to the predicted post trip voltage being below the 160.7 KV setpoint. |
| Tech Spec 2.7(2)C, 72 hour LCO was entered. Both emergency diesel |
| generators are operable. |
| |
| "Main generator VARS [Volt-Amperes Reactive] were raised from 100 to 150 |
| MVARS lagging in an attempt to raise predicted post trip voltage. Predicted |
| voltage rose above 161 KV for approx. 5 minutes and then lowered below 161 |
| KV again to 160.8 KV and is now fluctuating. System Operations was notified |
| and stated that 161 KV actual voltage remained at approx. 164 KV and that |
| the electrical grid was stable. |
| |
| "Design Engineering was notified and hypothesizes that MAPP [Mid-America |
| Power Pool] values into PCMMINT program may not be valid and that they will |
| attempt to validate the inputs." |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39893 |
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| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 05/30/2003|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 15:21[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/30/2003|
+------------------------------------------------+EVENT TIME: 13:30[CDT]|
| NRC NOTIFIED BY: EDWARD HARRISON |LAST UPDATE DATE: 05/30/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 93 Power Operation |93 Power Operation |
| | |
| | |
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EVENT TEXT
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| RECEIPT OF CONTAMINATED MATERIAL IN EXCESSOF 10 CFR 71.87 LIMITS |
| |
| "On May 30, 2003 at 1330 CDT Duane Arnold Energy Center (DAEC) confirmed |
| receipt of a material shipment with removable surface contamination that |
| exceeded the limits of 10 CFR 71.87 (20.1906 d.1) of 22,000 dpm/100 square |
| cm. The shipment, a transfer cask intended for future dry storage, had |
| 23,496 dpm/100 square cm of non-fixed external contamination. The |
| contamination was found upon receipt of the cask during routine receipt |
| surveys. This shipment was a surface contaminated object (SCO), with less |
| than type A quantity of radioactive material." |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39894 |
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| FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 05/30/2003|
| UNIT: [1] [] [] STATE: VT |NOTIFICATION TIME: 16:54[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/30/2003|
+------------------------------------------------+EVENT TIME: 08:30[EDT]|
| NRC NOTIFIED BY: KEN ROBINSON |LAST UPDATE DATE: 05/30/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LAWRENCE DOERFLEIN R1 |
|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 99 Power Operation |99 Power Operation |
| | |
| | |
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EVENT TEXT
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| SECURITY GUARD POSTED WITHOUT PROPER EQUIPMENT |
| |
| A plant security officer was stationed at a security post without all |
| equipment required to properly man that post. Immediate compensatory |
| measures were taken upon discovery. The licensee notified the NRC Resident |
| Inspector. Refer to the Headquarters Operations Officer Log for additional |
| details. |
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|Power Reactor |Event Number: 39895 |
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| FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 05/30/2003|
| UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 22:36[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 05/30/2003|
+------------------------------------------------+EVENT TIME: 18:55[CDT]|
| NRC NOTIFIED BY: DAVE DEES |LAST UPDATE DATE: 05/30/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| LOSS OF OFF-SITE EMERGENCY NOTIFICATION SIRENS AT WOLF CREEK |
| |
| "At 1755 CST 5/30/2003 power was lost to the Otter Creek and Jacobs Creek |
| Emergency Notification sirens. Lake Siren #2 has been out of service since |
| 5/28/2003 due to lightning damage. Station procedures consider the loss of |
| three or more Emergency Notification Sirens for greater than one hour a |
| major loss of emergency assessment capability reportable under |
| 50.72(b)(3)(xiii). |
| |
| "At 2108 CST station monitoring equipment indicated that power had been |
| restored to the Otter Creek and Jacobs Creek Sirens." |
| |
| The licensee has notified the NRC Resident Inspector and local authorities. |
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|Power Reactor |Event Number: 39896 |
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| FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 05/31/2003|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 01:07[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 05/30/2003|
+------------------------------------------------+EVENT TIME: 22:00[CDT]|
| NRC NOTIFIED BY: KEN LEFFEL |LAST UPDATE DATE: 05/31/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 92 Power Operation |92 Power Operation |
| | |
| | |
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EVENT TEXT
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| LOSS OF COMMUNICATION DUE TO UNAVAILABILITY OF SIRENS |
| |
| "At about 2200 [CDT] on 5/30/03, greater than 25% of the CPS [Clinton Power |
| Station] notification sirens became unavailable due to a loss of AC power. |
| Fourteen sirens are unavailable at this time [due to inclement weather], |
| eleven constitutes 25% lost for greater than one hour." |
| |
| The licensee has notified the State Police, will notify the NRC Resident |
| Inspector and is in the process of restoring availability of the inoperable |
| sirens. |
| |
| *** UPDATE AT 0555 EDT ON 5/31/03 FROM KEN LEFFEL TO ARLON COSTA *** |
| |
| Availability was restored to all sirens, except four. The licensee will |
| notify the NRC Resident Inspector. |
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|Fuel Cycle Facility |Event Number: 39897 |
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| FACILITY: WESTINGHOUSE HEMATITE |NOTIFICATION DATE: 05/31/2003|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 13:40[EDT]|
| COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 05/28/2003|
| COMMERCIAL LWR FUEL |EVENT TIME: 16:30[CDT]|
| |LAST UPDATE DATE: 05/31/2003|
| CITY: HEMATITE REGION: 3 +-----------------------------+
| COUNTY: JEFFERSON STATE: MO |PERSON ORGANIZATION |
|LICENSE#: SNM-33 AGREEMENT: N |MARK RING R3 |
| DOCKET: 07000036 |MELVYN LEACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KEVIN HAYES | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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| | |
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EVENT TEXT
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| NRC BULLETIN 91-01, 4 HOUR REPORT |
| |
| The following is taken from a facsimile report from the licensee to the NRC |
| Operations Center. |
| |
| "Short Description/Event Title: Enriched uranium rods mixed with Maine |
| Yankee boron carbide poison rods. |
| |
| "Consequences - details: This material was always within our control. The |
| identification and tracking of the material was deficient. Additionally, the |
| necessary controlled parameters to assure nuclear safety were not |
| established or maintained for the specific location and configuration in |
| which the rods were stored. |
| |
| "Immediate action taken: Rod downloading personnel were instructed to obtain |
| the pin-stamped number from each rod that is determined to contain uranium, |
| which will aid subsequent investigation. The remaining rods in the storage |
| box were evaluated for extent of condition, and the potentially containing |
| uranium have been segregated to an approved location to further ensure their |
| favorable configuration. Key personnel at Hematite and Columbia were also |
| informed of the issue. |
| |
| "Full Description: Three uranium-bearing fuel rods were identified at |
| approximately 1630 hours on May 28, 2003 as part of a zircaloy scrap |
| recovery project. The scrap recovery effort is being conducted inside the |
| rod loading room of Building 230, and involves tubing from a Maine Yankee |
| fuel fabrication campaign conducted by the previous owner, ABB, in 1997. The |
| fuel was never shipped to Maine Yankee due to that plant's subsequent |
| shutdown. The fuel rods were opened by ABB, and the enriched uranium pellets |
| were recovered during the first quarter of 1998. The boron carbide (B4C) |
| poison rods were not opened at that time. The B4C rods are now being |
| downloaded by a Westinghouse sub-contractor for recovery of the zircaloy |
| cladding. When opened, three rods from the last box to be downloaded were |
| found to contain uranium pellets rather than B4C, Because of the potential |
| of finding at least some pellets, all operations were being conducted under |
| appropriate radiological controls. An additional 21 rods from that last box |
| that have been identified as suspect due to their weight difference. They |
| have been put aside at an approved location, but not yet opened for |
| verification. |
| |
| "Additionally, a separate box of rods containing what appears to be depleted |
| uranium were also identified about two weeks ago. The preliminary |
| determination of the contents being depleted uranium is based on their |
| physical characteristics and markings. These rods are still under |
| investigation to confirm that they contain depleted uranium. |
| During the period of storage, this material was stored in the warehouse |
| portion of Building 230, which is located within the fenced and protected |
| area of the site. This material was always within our control, but the |
| identification and tracking of the material was deficient. In response to |
| this issue the following actions have been taken: |
| |
| "A review of the reporting requirements of 10 CFR Parts 70.50, 74.11, 73.71 |
| and Appendix G of Part 73 established that this issue does not meet the |
| requirements for formal reporting. Nevertheless, a courtesy call was placed |
| this afternoon to the D&D Project Manager at NRC Region III. A high level |
| CAPS item, has been established for tracking of all actions taken regarding |
| this matter. A Root Cause Analysis will also be conducted. Consideration was |
| given to whether this issue should be treated as an extension of the Kardex |
| issue that was the subject of a separate report, but it appears that it |
| would be appropriate to treat this matter separately due to the differing |
| circumstances. Arrangements have been made to have an independent review |
| conducted at the site to determine if additional measures should be taken in |
| locating material. This is expected to occur next week. |
| |
| "Plant management initially assessed this situation as unreportable to the |
| NRC for material control aspects as noted above. It was also assessed as not |
| reportable under NRC Bulletin 91-01, Supplement 1, 'Reporting Loss of |
| Criticality Safety Controls,' because of the following criticality safety |
| aspects: |
| |
| "The as-found condition was bounded by existing analysis for rod channel |
| boxes formerly used in the manufacture of fuel rods; The as-found condition |
| was safe due to the extensive amount of absorber, in the form of B4C rods, |
| surrounding the uranium rods; The as-found condition was safe due to the |
| inability for introducing moderator because a lid was secured on the storage |
| box. The box was stored on a cantilever rack that further precluded the |
| possibility of flooding. |
| |
| "Nevertheless, a courtesy call was placed within 24-hours of discovery to |
| the facility's Project Manager at NRC Region III. Further review has |
| determined that the as-found condition was not bounded by the rod channel |
| box analysis, but is bounded by fuel assembly analyses. Additionally, the |
| situation is now assessed as reportable under Bulletin 91-01 because the |
| necessary controlled parameters to assure nuclear safety were not |
| established or maintained for the specific location and configuration in |
| which the rods were stored. A formal 91-01 report, Number 39897, has |
| therefore been made to the facility's NRC Project Manager and the NRC |
| Operations Center." |
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|Power Reactor |Event Number: 39898 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 06/01/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 11:00[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 06/01/2003|
+------------------------------------------------+EVENT TIME: 08:50[EDT]|
| NRC NOTIFIED BY: MCDONNELL |LAST UPDATE DATE: 06/01/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LAWRENCE DOERFLEIN R1 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 98 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| REACTOR SCRAM FROM 98% POWER DUE TO LOAD REJECTION |
| |
| "At 0850 EST [6/1/03] Pilgrim Station received a full reactor scram from |
| 98.5% power from the Main Generator lockout relay tripping. The Main |
| Generator lockout relay caused both 345 KV output breakers to open and |
| caused a load reject scram. |
| |
| "All systems operated as designed. Received expected alarms and isolations |
| [as follows]: Group 2 C PCIS, Primary Containment Isolations, Reactor |
| Building isolation, Group 6 (Reactor Water clean up isolation). Isolations |
| [were] due to normal post scram level shrink to +2 inches. Isolations occur |
| at +12. |
| |
| "Preliminary indications are a fault on Unit Aux. Transformer." |
| |
| All control rods fully inserted. There was no ECCS actuation and the lifted |
| Safety Relief valves seated properly. The unit is currently stable in the |
| hot standby mode of operation. |
| |
| The NRC Resident Inspector was notified. |
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