U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/07/2003 - 08/08/2003
** EVENT NUMBERS **
40020 40049 40050 40051 40052
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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: 08/07/2003|
| 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 |
| |
| *****UPDATE ON 8/7/03 AT 1405 FROM JEFFRIES TO LAURA***** |
| |
| At 10:30 EDT on 8/7/03, the licensee found the 5 missing I-125 seeds in the |
| hospital. The seeds were found contained in a loading apparatus between two |
| autoclave valves. The licensee is doing an additional review to evaluate any |
| potential radiological exposures. |
| |
| Notified NMSS (D. Broaddus) and R2DO (S. Cahill). |
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|Power Reactor |Event Number: 40049 |
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| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 08/06/2003|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 19:12[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 08/06/2003|
+------------------------------------------------+EVENT TIME: 16:30[EDT]|
| NRC NOTIFIED BY: GEORGE STOROLIS |LAST UPDATE DATE: 08/07/2003|
| HQ OPS OFFICER: BILL GOTT +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|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 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| UNANALYZED CONDITION |
| |
| "On 8/06/2003 at 1630 hours, the Beaver Valley Power Station (BVPS) Unit 2 |
| control room was notified by Engineering that the manual operator actions |
| specified in Unit 2 post-fire procedures are not adequate for defeating a |
| potential fire-induced spurious operation of the Power Operated Relief |
| Valves (PORVs). The procedure step de-energizes the PORVs by opening |
| breakers at the d-c distribution panel. This action alone would not be |
| sufficient to prevent a cable-to-cable hot short from re-energizing the |
| circuit since the de-energized circuit is routed in cable trays with other |
| energized circuits in the affected fire areas. Preliminary reviews have |
| identified the following potentially affected fire areas: |
| |
| CB-1 Control Building Instrumentation and Relay Area |
| CB-2 Control Building Cable Spreading Room |
| CB-3 Control Building Main Control Room |
| CB-6 Control Building West Communication Room |
| CT-1 Cable Tunnel |
| CV-1 Cable Vault and Rod Control Area |
| SB-1 Emergency Switchgear Room (Orange) |
| RC-1 Reactor Containment |
| |
| "An hourly roving fire watch patrol has been established for the affected |
| fire areas as compensatory measures, with the exception of the Main Control |
| Room and the Reactor Containment area, until the condition is fully |
| evaluated and resolved. The Main Control Room is continuously manned and |
| does not require an hourly fire watch patrol. The Reactor Containment area |
| is not accessible during normal power operations and, as such, compensatory |
| measures for this area will include a once-per-shift verification of remote |
| instrumentation by operations personnel to confirm that there are no |
| abnormal conditions or indications for this area. |
| |
| "This condition was discovered during the review of manual operator actions |
| for fire-induced spurious operations to confirm the safe shutdown circuit |
| analysis is consistent with the manual actions identified in the |
| procedures. |
| |
| "This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii) as an |
| unanalyzed condition that significantly degraded plant safety since the |
| failure to assure the PORVs remain in the closed position could result in |
| the failure to meet the fire protection safe shutdown criteria. BVPS Unit 2 |
| was licensed to the NUREG 0800 Standard Review Plan 9.5.1 "Fire Protection |
| Program", and License Condition 2.F requires compliance to the provisions of |
| the approved fire protection program as described in the Final Safety |
| Analysis Report. UFSAR Section 9.5A.1.2.1.6 states that the safe shutdown |
| capability should not be adversely affected by a fire in any plant area |
| which results in spurious actuation of the redundant valves in any one |
| high-low pressure interface line. Even though there is a very low |
| likelihood of multiple shorts causing a spurious PORV actuation in an |
| ungrounded DC circuit, the existing actions to prevent re-energizing the |
| circuit and causing a spurious actuation of the PORVs is not consistent with |
| the NRC guidance for high-low pressure interface valves. |
| |
| "The NRC resident inspector has been notified." |
| |
| * * * UPDATE ON 8/7/03 AT 1726 EDT FROM D. SOMMERS TO E. THOMAS * * * |
| |
| "On 8/07/03 at 1515, the following additional areas were identified as being |
| potentially affected by this condition: |
| |
| CV-2 Cable vault and Rod Control Area (East) |
| CV-3 Cable vault and Rod Control Area (Elev 755'6") |
| SB-2 Emergency Switchgear Room (Purple) |
| SB-3 Service Bldg. Cable Tray Area |
| ASP Alternative Shutdown Panel Room |
| |
| "Interim compensatory measures in the form of hourly roving watch patrols |
| have been expanded to include the above noted areas until the condition is |
| fully evaluated and resolved. |
| |
| "The NRC Resident Inspector has been notified." |
| |
| Notified the Region 1 Duty Officer (C. Anderson) |
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|Power Reactor |Event Number: 40050 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 08/07/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 13:07[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 08/07/2003|
+------------------------------------------------+EVENT TIME: 11:31[EDT]|
| NRC NOTIFIED BY: DAVID NOYES |LAST UPDATE DATE: 08/07/2003|
| HQ OPS OFFICER: ERIC THOMAS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: |DAVID SKEEN NRR |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION |TIM MCGINTY IRO |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| OFFSITE NOTIFICATION |
| |
| "At approximately 1131 [EDT] on August 7, 2003, an error during prompt alert |
| notification system testing resulted in all sirens in the town of Duxbury, |
| Massachusetts to wail for 15 to 20 seconds. Appropriate state and local |
| authorities have been notified. Investigation into the cause is |
| continuing." |
| |
| The NRC Resident Inspector has been notified. |
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|Other Nuclear Material |Event Number: 40051 |
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| REP ORG: DEPARTMENT OF THE NAVY |NOTIFICATION DATE: 08/07/2003|
|LICENSEE: DEPARTMENT OF THE NAVY |NOTIFICATION TIME: 13:35[EDT]|
| CITY: ARLINGTON REGION: 2 |EVENT DATE: 06/03/2003|
| COUNTY: STATE: VA |EVENT TIME: [EDT]|
|LICENSE#: 45-23645-01NA AGREEMENT: N |LAST UPDATE DATE: 08/07/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |STEPHEN CAHILL R2 |
| |JACK WHITTEN R4 |
+------------------------------------------------+DOUG BROADDUS NMSS |
| NRC NOTIFIED BY: CAPT DAVE FARRAND | |
| HQ OPS OFFICER: BILL GOTT | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|ISAF 30.50(b)(2) SAFETY EQUIPMENT FAILUR| |
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EVENT TEXT
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| RADIOGRAPHIC EXPOSURE DEVICE FAILURE |
| |
| "Description of the equipment problem. On June 3, 2003, gamma radiography |
| operations using an AEA Technology/QSA Model 660A exposure device in a |
| permanent radiography facility at Shore Intermediate Maintenance Activity |
| were being performed under the authority of Naval Radioactive Materials |
| Permit (NRMP) No. 0465918--A1NP. On the tenth exposure of the day the |
| radiographer attempted to retract the radiographic source into the |
| radiographic exposure device. The radiographer placed the drive cable brake |
| in the "off" position and rapidly cranked the source in the retract |
| direction. The number of turns coming in matched the number of turns going |
| out. The permanent facility gamma alarm shut off, however the radiographer |
| did not hear the locking slide mechanism engage which is normally heard |
| clearly when retracting the source. When attempting to re-expose the source |
| as required by the operating procedure, the source did expose again. The |
| Radiation Safety Officer was present and directed the radiographer to |
| retract the source again. As with the first attempt to retract the source, |
| the slide bar did not click in the safe position. Again and the gamma alarm |
| shut off. The Radiation Safety Officer entered the permanent facility with, |
| an operating survey meter. The locking slide bar indicated green (safe) but |
| it was not locked in that position. The Radiation Safety Officer approached |
| the device and observed a reading of approximately 8 millirem/hour on the |
| front of the device and 10 millirem/hour on the back of the device. She |
| exited the permanent facility and discussed the situation with the |
| radiographer. The Radiation Safety Officer then directed the radiographer |
| to maintain control of the crank assembly handle and she entered the |
| permanent facility with a survey meter and pushed the slide bar to the red |
| (expose) position. The Radiation Safety officer exited the permanent |
| facility and instructed the radiographer to retract the source to the fully |
| locked position. The retraction was successful and the slide bar was heard |
| to click to the fully green (safe) position. The Radiation Safety Officer |
| checked her self-indicating pocket dosimeters which both indicated zero |
| exposure. |
| |
| "The source was transferred to an AEA 650L source changer on June 4, 2003. |
| A "dummy" source was installed in the exposure device and the locking slide |
| bar was placed in various positions to experiment and recreate the scenario. |
| Frequently during these tests, the radiographers were not able to lock the |
| slide into place without unlocking the drive cable crank assembly and |
| applying minimal pressure towards the expose position. This is considered a |
| neutral position and not an exposed position. With minimal pressure the |
| slide bar mechanism easily locked into the exposed position. |
| |
| "Cause of each incident. The cause of the incident appears to be twofold. |
| Primarily the compression springs for the posi-lock may have been |
| excessively worn. Secondarily, the Shore Intermediate Maintenance Activity, |
| San Diego operating procedure did not call for them to unlock the crank |
| assembly cable lock prior to rotating the selector ring to the operate |
| position and pushing the posi-lock slide bar from the green (retracted) |
| position to the red (operate) position as stated in the most recent AEA |
| exposure device manual. We believe that the faulty springs were the main |
| factor as the posi-lock slide bar can be pushed to the red position with the |
| crank assembly cable lock in the "on" position but that procedure may have |
| contributed to the excessive wear on the compression springs. |
| |
| "Name of the manufacturer and model number of equipment involved in the |
| incident. The equipment involved in the incident was manufactured by AEA |
| Technology/QSA and consisted of a Model 660A exposure device, serial number |
| A4450 with a 13.6 curie Ir-192 source. |
| |
| "Place, date and time of the incident. The incident occurred at Shore |
| Intermediate Maintenance Activity, San Diego, California in a permanent |
| facility on June 3, 2003. |
| |
| "Actions taken to establish normal operations. The Radiation Safety Officer |
| entered the permanent facility and manually pushed the locking slide bar to |
| the unlocked (red) position. The Radiation Safety Officer exited the |
| permanent facility and instructed the radiographer to attempt to retract the |
| source. The source was successfully retracted to the fully locked position |
| and the locking slide bar was heard to lock. |
| |
| "Corrective actions taken or planned to prevent recurrence. Shore |
| Intermediate Maintenance Facility, San Diego replaced the compression |
| springs for the posi-lock assembly on the exposure device. Additionally, |
| they have changed their operating procedure to unlock the crank assembly |
| cable lock prior to rotating the selector ring to the operate position and |
| pushing the posi-lock slide bar from the green (retracted) position to the |
| red (operate) position." |
| |
| The licensee notified R2 (Diaz). |
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|Power Reactor |Event Number: 40052 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 08/07/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 16:49[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 08/07/2003|
+------------------------------------------------+EVENT TIME: 09:15[EDT]|
| NRC NOTIFIED BY: DAVID NOYES |LAST UPDATE DATE: 08/07/2003|
| HQ OPS OFFICER: ERIC THOMAS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
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| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 COMM/ASMT/RESPONSE |
| |
| At 0915 EDT on 8/7/03, during testing of the Prompt Alert Notification |
| Sirens, 44 of 112 (39 percent) of the sirens were found to be inoperable due |
| to a failed radio repeater. The repeater was repaired, and all sirens |
| declared fully operable at 1010 EDT on 8/7/03. |
| |
| The NRC Resident Inspector was informed of this event. |
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