*** NOT FOR PUBLIC DISTRIBUTION***
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
10/12/2001 - 10/15/2001
** EVENT NUMBERS **
38381 38382 38383 38384 38385 38386
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|Hospital |Event Number: 38381 |
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| REP ORG: WASHINGTON HOSPITAL CENTER |NOTIFICATION DATE: 10/12/2001|
|LICENSEE: WASHINGTON HOSPITAL CENTER |NOTIFICATION TIME: 14:45[EDT]|
| CITY: WASHINGTON REGION: 1 |EVENT DATE: 10/12/2001|
| COUNTY: STATE: DC |EVENT TIME: 12:30[EDT]|
|LICENSE#: 0803604-03 AGREEMENT: N |LAST UPDATE DATE: 10/12/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |R1 IRC TEAM MANAGER R1 |
| |LINDA HOWELL R4 |
+------------------------------------------------+JOHN HICKEY NMSS |
| NRC NOTIFIED BY: GLENN |ANITA TURNER NMSS |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAA2 20.1906(d)(2) EXTERNAL RAD LEVELS > | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| PACKAGE CONTAINING PHOSPHOROUS-32 WITH EXTERNAL RAD LEVELS GREATER
THAN |
| LIMITS |
| |
| The Washington Hospital Center received a package from Isotex Diagnostics |
| Incorporated(Texas lic # L02999) of Friendswood, Texas that measured on |
| surface contact 48 Rads/hr using an ion chamber with the beta shield off. |
| This was over a small area of the package. At one meter with the beta |
| shield off it measured 77 millirads/hr. Both the shipper and the |
| carrier(FedEx) have been notified. The package contained 92.8 millicuries |
| of phosphorous-32 with packing label yellow-2 and transport index 0.6. |
| There was no contamination detected. They are holding the package for |
| inspection by the shipper. |
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|Fuel Cycle Facility |Event Number: 38382 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 10/12/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 15:32[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 10/11/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:44[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/12/2001|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |MICHAEL PARKER R3 |
| DOCKET: 0707001 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WALKER | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 24 HOUR 91-01 BULLETIN RESPONSE |
| |
| Four waste drums were discovered to be incorrectly characterized based on |
| incorrect laboratory analysis results. The incorrect analysis resulted from |
| failure to follow a step in the procedure and violated the single point |
| failure prevention arguments for sample characterization in NCSA 1493-33. |
| The purpose of preventing a single point failure is to maintain double |
| contingency for the case in which independent sample results are used to |
| characterize and classify waste drums as "NCS Spacing Exempt." |
| |
| The samples were later re-analyzed for both assay and U-235 content. The |
| re-analysis results demonstrated that three of the four drums in question |
| are in fact non-fissile and have been handled conservatively. The remaining |
| drum is greater than 1%, but the U-235 mass is less than the limit for |
| spacing exemption. |
| |
| NUCLEAR CRITICALITY SAFETY CONTROLS INVOLVED AND THEIR IMPACT ON
DOUBLE |
| CONTINGENCY |
| |
| Double contingency is maintained by implementing controls to ensure the |
| samples are analyzed correctly, without common mode failures. |
| |
| The first leg of double contingency is based on correctly analyzing the |
| sample for U-235 loading. Since the procedure was violated the analysis |
| result should not have been relied upon for NCS purposes. The control was |
| violated. Since there are two controls on one parameter, double contingency |
| was not maintained. |
| |
| The second leg of double contingency is based on independently analyzing the |
| sample correctly for U-235 loading. Since the procedure was violated the |
| independent analysis result should not have been relied upon for NCS |
| purposes. The control was violated. Since there are two controls on one |
| parameter, double contingency was not maintained. |
| |
| Since double contingency is based on two controls on one parameter, double |
| contingency was not maintained. |
| |
| Potential Critical Pathways: |
| |
| In order for a criticality to be possible, the mass in multiple waste drums |
| would each have to be greater than the safe mass determined for that |
| container size and these waste drums would have to be stored together or |
| re-containerized into unfavorable geometry drums. |
| |
| |
| Safety Significance: |
| |
| Double contingency for characterizing and storing "NCS Spacing Exempt" waste |
| are based on determination of U-235 mass in the drum. Both of these |
| controls were lost. However, based on re-analysis results the drums are in |
| fact non-fissile or spacing exempt. |
| |
| EXCLUSION ZONE AND POSTiNG: |
| |
| Control the area around the drum and post as follows according to |
| CP2-EG-N51031; |
| |
| Do not move fissile/potentially fissile material into or within this area |
| without NCS and PSS approval. |
| |
| NCS-INC-01 -025 |
| |
| CORRECTIVE ACTIONS: |
| |
| 1. Re-characterize the drum according to CP4-EW-WM2100 based upon the |
| re-analysis results. |
| |
| 2. Remove the ropes and postings |
| |
| The NRC Resident Inspector was informed and the DOE Representative will be |
| notified. |
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|Power Reactor |Event Number: 38383 |
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| FACILITY: THREE MILE ISLAND REGION: 1 |NOTIFICATION DATE: 10/12/2001|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 16:32[EDT]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP |EVENT DATE: 10/12/2001|
+------------------------------------------------+EVENT TIME: 12:30[EDT]|
| NRC NOTIFIED BY: MILLER |LAST UPDATE DATE: 10/12/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |R1 IRC TEAM MANAGER R1 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling Shutdow|0 Refueling Shutdow|
| | |
| | |
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EVENT TEXT
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| DISCOVERY OF A THROUGH-WALL LEAK AROUND 8 THERMOCOUPLE NOZZLES
(REACTOR |
| COOLANT SYSTEM PRESSURE BOUNDARY LEAK) |
| |
| On October 11 and 12, 2001, following shutdown for a scheduled refueling |
| outage, three Mile Island Unit 1 (TMI-1) performed a visual inspection of |
| the Reactor Vessel (RV) Thermocouple (TC) nozzles per NRC Bulletin 2001-01. |
| The inspection revealed evidence of boric acid buildup around all eight (8) |
| TCs nozzles. At approximately 1230 on October 12, 2001, Engineering |
| evaluation of the visual inspection results confirmed that the boron |
| deposits around the eight TCs indicate a Reactor Coolant System (RCS) |
| pressure boundary leak. This condition is consistent with industry |
| experience with Primary Water Stress Corrosion Cracking (PWSCC) in reactor |
| vessel head nozzles that have been evaluated as part of the NRC Generic |
| Letter 97-01 and NRC Bulletin 2001-01. TMI-1 plans to perform repairs |
| during the current refueling outage. Since the condition resulted in |
| leakage through the RCS pressure boundary, it is being reported as a |
| non-emergency [8-hour] report in accordance with 10 CFR 50.72(b)(3)(ii)(A) |
| and 50.73(a)(2)(ii)(A). |
| |
| Results from the CRDM nozzle inspection have not yet been submitted. |
| |
| The NRC resident inspector has been notified. |
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|Hospital |Event Number: 38384 |
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| REP ORG: PARK VIEW HOSPITAL |NOTIFICATION DATE: 10/12/2001|
|LICENSEE: PARK VIEW HOSPITAL |NOTIFICATION TIME: 17:37[EDT]|
| CITY: Ft. WAYNE REGION: 3 |EVENT DATE: 10/11/2001|
| COUNTY: STATE: IN |EVENT TIME: 16:45[CST]|
|LICENSE#: 13-01284-02 AGREEMENT: N |LAST UPDATE DATE: 10/12/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MICHAEL PARKER R3 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: AGNEW | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| PARK VIEW HOSPITAL REPORTED A MEDICAL MISADMINISTRATION |
| |
| During an intravascular bracytherapy treatment with strontium-90 to a heart |
| artery, a possible medical misadministration occurred at the completion of |
| the treatment. At the conclusion of this treatment, not all the sources |
| returned to the Novoste applicator. The sources were seen to have left the |
| vessel and heart within the appropriate time(5 sec), but they did not all |
| return to the device. Another attempt to remove the sources was made, but |
| was unsuccessful, so the entire treatment catheter was removed(within 18 |
| secs) from the patient as per their emergency procedures. The physician |
| and manufacturer of the device did not consider this as a medical |
| misadministration, however an NRC inspector felt that it was for that |
| additional 18 secs to remove the treatment catheter. This incident occurred |
| 8/27/01. It was decided not to notify the patient because of the patient's |
| condition. |
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|Power Reactor |Event Number: 38385 |
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| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 10/14/2001|
| UNIT: [] [2] [] STATE: CA |NOTIFICATION TIME: 12:14[EDT]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 10/14/2001|
+------------------------------------------------+EVENT TIME: 01:59[PDT]|
| NRC NOTIFIED BY: KUNDSON |LAST UPDATE DATE: 10/14/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LINDA HOWELL R4 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Standby |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE REACTOR COOLANT SYSTEM LEAKAGE |
| |
| During an inspection, while the plant was in shutdown mode 3, a dry white |
| residue was discovered on a loop 2 hot leg spare thermowell plug. Being |
| conservative they looked at this condition as a possible RCS pressure |
| boundary leakage while in an operating mode. However, there was no active |
| leak from the spare thermowell plug. The plant has 36 hours to be in mode |
| 5. They will determine the type of repair work necessary to remedy the |
| problem. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 38386 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 10/14/2001|
| UNIT: [1] [] [] STATE: VA |NOTIFICATION TIME: 12:27[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 10/14/2001|
+------------------------------------------------+EVENT TIME: 11:45[EDT]|
| NRC NOTIFIED BY: LOCASCIO/WOODZELL |LAST UPDATE DATE: 10/14/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |R2 IRC TEAM MANAGER R2 |
|10 CFR SECTION: |GENE IMBRO NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |ZAPATA FEMA |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Intermediate Shut|0 Intermediate Shut|
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| REACTOR COOLANT SYSTEM BOUNDARY LEAKAGE |
| |
| During an inspection, while the plant was in intermediate shutdown (2235 |
| lbs. pressure), an unisolable leak at the "A" loop hot leg temperature |
| element was detected (at 0530 hrs) measuring 3 drops/min. On the second |
| entry (at 0940 hrs) when pressure was 400 lbs. no active leak was detected. |
| The plant entered an NOUE at 1145 and TS action statement to be in cold |
| shutdown within 30 hours was initiated. Since the plant was already in |
| intermediate shutdown, it should be in cold shutdown within 2-3 hours. |
| |
| The NRC Resident Inspector was notified along with State and local |
| agencies. |
| |
| |
| * * * UPDATE ON 10/14/01@ 1621 FROM LOCASCIO TO GOULD * * * |
| |
| The plant went to below cold shutdown at 1620 at which time the NOUE was |
| terminated. |
| |
| The NRC Resident Inspector was notified. State and local agencies will be |
| notified. |
| |
| Notified Reg 2 IRC Team manager, EO(Imbro) and FEMA(Ciboch) |
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