U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/09/2003 - 07/10/2003
** EVENT NUMBERS **
39978 39979 39985 39986 39987
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|General Information or Other |Event Number: 39978 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/07/2003|
|LICENSEE: |NOTIFICATION TIME: 11:04[EDT]|
| CITY: DENVER REGION: 4 |EVENT DATE: 07/06/2003|
| COUNTY: ARAPAHOE STATE: CO |EVENT TIME: 16:00[MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/07/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |MARISSA BAILEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GREG STASINOS | |
| HQ OPS OFFICER: GERRY WAIG | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - STOLEN ASPHALT CONTENT OVEN |
| |
| The following is taken from a facsimile sent from the Colorado Department of |
| Health and Environment: |
| |
| On 7/6/03 at 2230 MDT Robin Koons, Colorado State Department of Health and |
| Environment, was notified by the Arapahoe County Hazmat Response Team of the |
| theft of an asphalt content oven at a construction site located on Highway |
| 36, mile marker 119 - 20 miles east of Byers, CO. Arapahoe County Hazmat |
| responded to initiate an investigation into the incident. Initial |
| information and indications pointed to a moisture density gauge being |
| stolen. The moisture density gauge has been found and accounted for. The |
| asphalt content oven contains a 100 milliCurie (plus or minus 10%) Americium |
| 241:Be source. The oven is used to test for oily content in asphalt during |
| road construction process. The area is considered a crime scene and has been |
| secured. |
| |
| Colorado Case Number: 2003-372 |
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|General Information or Other |Event Number: 39979 |
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| REP ORG: TENNESSEE DIV OF RAD HEALTH |NOTIFICATION DATE: 07/07/2003|
|LICENSEE: Radiological Assistance, Consulting, |NOTIFICATION TIME: 13:09[EDT]|
| CITY: Memphis REGION: 2 |EVENT DATE: 06/26/2003|
| COUNTY: STATE: TN |EVENT TIME: 18:00[EDT]|
|LICENSE#: R-79266 AGREEMENT: Y |LAST UPDATE DATE: 07/07/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOEL MUNDAY R2 |
| |THOMAS ESSIG NMSS |
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| NRC NOTIFIED BY: Debra Shults | |
| HQ OPS OFFICER: ERIC THOMAS | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT |
| |
| "The [Tennessee Division of Radiological Health] was notified on Monday, |
| June 30, 2003 by three employees of RACE [Radiological Assistance, |
| Consulting, & Engineering] of a contamination event that occurred on June |
| 26, 2003. The employees were sorting and segregating materials contaminated |
| with low-level radioactive waste. The waste had been delivered to RACE by a |
| waste broker. The employees ended the shift and frisked for personnel |
| contamination prior to exiting the building. Several employees alarmed the |
| PCM and were decontaminated prior to release. One employee had high levels |
| of skin contamination and underwent several hours of decontamination. |
| Preliminary results from urinalyses are negative according to the licensee. |
| The employees are undergoing whole body counts today. The shop area was |
| closed for routine business and decontaminated. It was opened on Sunday, |
| June 29, 2003. DRH staff from Memphis and Nashville visited the site to |
| begin the investigation. Staff continue to investigate and will continue to |
| keep the NRC informed of the status of our investigation. This incident is |
| reportable under 1200-2-5.141 (2)(c)1(i) of 'State Regulations for |
| Protection Against Radiation.'" |
| |
| Tennessee Report ID: TN-03-100 |
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|Power Reactor |Event Number: 39985 |
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| FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 07/09/2003|
| UNIT: [] [2] [] STATE: TX |NOTIFICATION TIME: 03:05[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/09/2003|
+------------------------------------------------+EVENT TIME: 01:09[CDT]|
| NRC NOTIFIED BY: LES MILLER |LAST UPDATE DATE: 07/09/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY 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| |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
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|2 A/R Y 99 Power Operation |0 Hot Standby |
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EVENT TEXT
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| AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP BREAKER OPENING WITH |
| INITIATION OF AUXILIARY FEEDWATER SYSTEM AFTER THE TRIP |
| |
| "At 0109 hrs. CDT, Unit 2 reactor tripped due to opening of RCP [Reactor |
| Coolant Pump] 2-04 breaker resulting in "Rx >48% 1/4 loop flow low trip". |
| Cause of the breaker opening is unknown and under investigation. All |
| systems responded as required. Auxiliary Feed Water auto-start occurred due |
| to steam generator shrink, both motor driver AFW pumps and Turbine Driven |
| AFW pump started (ESF)." |
| |
| All rods inserted into the core during the trip. The electrical grid is |
| stable. There were no power-operated or manual relief valve lifts during |
| the transient. The other unit was not affected by the transient. Decay |
| heat is being removed via steam generator blowdown and AFW. The plant is |
| maintaining at NOP/NOT in mode 3 until the cause of the breaker trip is |
| known and repaired. Pressurizer pressure control is in automatic. There is |
| no identified primary-to-secondary leakage. |
| |
| The licensee has informed the NRC Resident Inspector. |
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|Hospital |Event Number: 39986 |
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| REP ORG: UNIVERSITY OF WISCONSIN - MADISON |NOTIFICATION DATE: 07/09/2003|
|LICENSEE: UNIVERSITY OF WISCONSIN |NOTIFICATION TIME: 18:07[EDT]|
| CITY: Madison REGION: 3 |EVENT DATE: 07/09/2003|
| COUNTY: Dane STATE: WI |EVENT TIME: 13:00[CDT]|
|LICENSE#: 48-09843-18 AGREEMENT: N |LAST UPDATE DATE: 07/09/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHRIS MILLER R3 |
| |SUSAN FRANT NMSS |
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| NRC NOTIFIED BY: RONALD BRESELL | |
| HQ OPS OFFICER: ERIC THOMAS | |
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|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 |
| |
| At 1300 CDT on 7/9/03, an underadministration of Yttrium-90 (Y-90) occurred |
| at the University of Wisconsin Hospital in Madison, WI. A patient being |
| treated for secondary liver cancer was to receive a dose of approximately 50 |
| millicuries of Y-90. The dose was delivered using a SIRTECH (Selective |
| Radiation Implantation) to pulse microspheres of Y-90 from a vial into the |
| liver via a needle and catheter. |
| |
| During the procedure, the SIRTECH did not develop enough pressure to deliver |
| the entire dose to the patient, and only about 8 percent of the Y-90 was |
| delivered to the patient (between 3-4 millicuries). The remainder of the |
| Y-90 microspheres were contained within the vial. |
| |
| There was no adverse affect on the patient due to this underadministration, |
| and the licensee is still investigating how to prevent a re-currence. The |
| patient was notified of the underadministration. |
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|Power Reactor |Event Number: 39987 |
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| FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 07/10/2003|
| UNIT: [] [2] [3] STATE: IL |NOTIFICATION TIME: 04:03[EDT]|
| RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 07/09/2003|
+------------------------------------------------+EVENT TIME: 22:00[CDT]|
| NRC NOTIFIED BY: RON WIGGINS |LAST UPDATE DATE: 07/10/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHRIS MILLER R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
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|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
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|2 N Y 99 Power Operation |99 Power Operation |
|3 N Y 99 Power Operation |99 Power Operation |
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EVENT TEXT
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| CONTROL ROOM HVAC REFRIGERATION AND CONDENSING UNIT TRIPPED DURING |
| SURVEILLANCE TEST |
| |
| "At 2200 hours on July 9, 2003, the B Control Room HVAC Refrigeration and |
| Condensing Unit (RCU) tripped and would not stay running during surveillance |
| testing. The RCU is a single train system and therefore is reportable per |
| SAF 1.8 and LS-AA-1400, Event Reporting Guidelines Section 3.2.7. The RCU |
| is required to operate during a design basis accident to remove heat from |
| the Main Control Room. The Air Filtration Unit (AFU) of CREVS [Control Room |
| Emergency Ventilation System] remains operable. This places both units in a |
| 30 day LCORA [Limiting Condition for Operation Required Action] per Tech |
| Spec 3.7.5 Required Action A.1." |
| |
| The licensee has notified the NRC Resident Inspector. |
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