U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/09/97 - 12/10/97 ** EVENT NUMBERS ** 33369 33370 33371 33372 33373 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33369 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 12/09/97 | |UNIT: [ ] [2] [3] STATE: CA |NOTIFICATION TIME: 01:32 [ET]| |RX TYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 12/08/97 | +------------------------------------------------+EVENT TIME: 19:10[PST]| |NRC NOTIFIED BY: TODD COOK |LAST UPDATE DATE: 12/09/97 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | |BLAINE MURRAY, R4 IAT | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PLANT SECURITY EVENT - | | | | PHYSICAL ASSAULT ON A CONTRACTOR INSIDE THE UNIT 2 AUXILIARY FEEDWATER | | BUILDING. COMPENSATORY MEASURES FULLY IMPLEMENTED WITHIN LICENSEE | | SPECIFIED TIME LIMITS. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33370 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/09/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 13:28 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/08/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:15[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/09/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JOHN JACOBSON RDO | | DOCKET: 0707002 |LARRY CAMPER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: LARSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT DISCOVERED THE LOSS OF ONE NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) CONTROL. | | | | EMPLOYEES CONDUCTING SELF-ASSESSMENT WALK-DOWNS TO ASSURE COMPLIANCE WITH | | NCSA DISCOVERED NONCOMPLIANCE WITH NCSA-PLANT018.A01 IN ROOMS 120, 163, | | 224, AND 254 WHEN CONTAINERS OF DRY ACTIVE WASTE (DAW) WERE FOUND IN | | VIOLATION OF REQUIREMENT #5. THIS REQUIREMENT STATES THAT DAW CONTAINERS | | WITH A CAPACITY OF 55 GALLONS OR LESS SHALL BE SPACED AT LEASED TWO FEET | | EDGE TO EDGE FROM URANIUM BEARING EQUIPMENT/MATERIAL. VIOLATION OF THIS | | REQUIREMENT CONSTITUTES THE LOSS OF ONE CONTROL (CONTROL "A") IN THE DOUBLE | | CONTINGENCY CONTROL MATRIX, FOR CONTINGENCY EVENT B.4.1. CONTROL "B" (NO | | LIQUID, NO VISIBLE URANIUM IN CONTAINERS WITH A NORMAL CAPACITY OF 55 | | GALLON OR LESS AND DAW WITH VISIBLE URANIUM SHALL BE PLACED IN CONTAINERS | | WITH AN INTERNAL DIAMETER ó 5.25) WAS MAINTAINED THROUGHOUT THIS EVENT AND | | SPACING DEFICIENCIES WERE IMMEDIATELY CORRECTED. THERE WAS NO LOSS OR | | RELEASE OF HAZARDOUS MATERIALS OR RADIOACTIVE/RADIOLOGICAL CONTAMINATION | | EXPOSURES ASSOCIATED WITH THIS EVENT. | | | | THE RESIDENT INSPECTOR AND DOE WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33371 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/09/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 13:28 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/08/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 16:30[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/09/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JOHN JACOBSON RDO | | DOCKET: 0707002 |LARRY CAMPER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: LARSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT DISCOVERED THE LOSS OF ONE NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) CONTROL. | | | | EMPLOYEES PERFORMING SELF-ASSESSMENT WALK-DOWNS TO ASSURE COMPLIANCE WITH | | NCSA DISCOVERED A NONCOMPLIANCE WITH NCSA 0710-006.A00 WHEN TWO SAMPLE | | CONTAINERS CONTAINING DECONTAMINATION SOLUTION RESIDUALS WERE FOUND IN ROOM | | 111 WITHOUT ANY U-235 ENRICHMENT AND MASS LABELLING AS REQUIRED IN | | REQUIREMENT #7 ON THIS NCSA. WITH THIS REQUIREMENT NOT BEING MET, IT | | CONSTITUTES THE LOSS OF ONE CONTROL AS DEFINED IN THE DOUBLE CONTINGENCY | | CONTROL MATRIX, CONTINGENCY EVENT A/B.1.1, CONTROL "A" WHICH REQUIRES NCSA | | REQUIREMENTS #5 AND #7 BE MET IN ORDER TO MAKE-UP THE CONTROL "A". CONTROL | | "B" (SPACING AND PLACEMENT OF EMPTIED CONTAINERS) WAS MAINTAINED THROUGHOUT | | THIS EVENT AND SAMPLE CONTAINERS WERE IMMEDIATELY LABELLED AS A CORRECTIVE | | MEASURE. THERE WERE NO RELEASES OF HAZARDOUS MATERIALS OR RADIOLOGICAL | | CONTAMINATION EXPOSURES ASSOCIATED WITH THIS EVENT. | | | | THE RESIDENT INSPECTOR AND DOE WERE INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33372 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/09/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 13:28 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/08/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:20[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/09/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JOHN JACOBSON RDO | | DOCKET: 0707002 |LARRY CAMPER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: LARSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT DISCOVERED THE LOSS OF ONE NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) CONTROL. | | | | EMPLOYEES CONDUCTING SELF-ASSESSMENT WALK-DOWNS TO ASSURE COMPLIANCE WITH | | NCSA DISCOVERED NONCOMPLIANCE WITH NCSA-0710-012.A01 IN ROOM 135 WHEN | | DRIRITE (SPILL ABSORBENT MATERIAL) WAS FOUND TO BE IN VIOLATION OF | | REQUIREMENT #12. THIS REQUIREMENT STATES THAT SAMPLE CONTAINERS SHALL NOT | | BE FILLED TO AN INSIDE HEIGHT EXCEEDING 1.5" WHEN STORED IN A "SAFE" SLAB | | ARRAY. VIOLATION OF THIS REQUIREMENT CONSTITUTES THE LOSS OF ONE CONTROL | | (CONTROL "A") IN THE DOUBLE CONTINGENCY CONTROL MATRIX FOR CONTINGENCY | | EVENT A/B.4.1. CONTROL "B" UNLIKELY EVENT #1 (THAT AN ENTIRE ARRAY WOULD | | ALL BE ABOVE THE 1.5" HEIGHT LIMIT) WAS NOT VIOLATED. THE 1.5" SLAB | | GEOMETRY WAS IMMEDIATELY RESTORED. THERE WAS NO LOSS OR RELEASE OF | | HAZARDOUS MATERIALS OR RADIOLOGICAL/RADIOACTIVE CONTAMINATION EXPOSURES | | ASSOCIATED WITH THIS EVENT. | | | | THE RESIDENT INSPECTOR AND DOE WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33373 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SYNCOR INTERNATIONAL CORPORATION |NOTIFICATION DATE: 12/09/97 | | CITY: CHARLOTTE REGION: 2 |NOTIFICATION TIME: 13:40 [ET]| | COUNTY: STATE: NC |EVENT DATE: 12/05/97 | |LICENSE#: 060-0794-1 AGREEMENT: Y |EVENT TIME: 17:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/09/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |PAUL FREDRICKSON RDO | | |LARRY CAMPER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: EADDY(N.C. DENR) | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE N.C. DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES WAS NOTIFIED BY | | SYNCOR INTERNATIONAL CORPORATION OF A MISLABELED RADIOPHARMACEUTICAL DOSE | | THAT WAS SENT TO GASTON MEMORIAL HOSPITAL IN GASTONIA N.C. | | | | THE PRESCRIBED DOSE TO BE ADMINISTERED TO THE PATIENT WAS 25-30 MILLICURIES | | OF TECHNETIUM-99M SESTAMIBI (CARDIOLITE) FOR HEART IMAGING. UPON VERIFYING | | THE PATIENT, THE DOSE AND SELECTING THE APPROPRIATE SYRINGE, THE PATIENT | | RECEIVED THE IV INJECTION. WHEN THE INTENDED STRUCTURE (THE HEART) WAS NOT | | VISUALIZED, THE TECHNICIAN THEN RE-VERIFIED THE RADIOPHARMACEUTICAL. ONCE | | IT WAS ESTABLISHED THE PATIENT WAS CORRECTLY INJECTED PER THE WRITTEN | | DIRECTIVE AND THE LABEL ON THE SYRINGE, THE PHARMACY WAS NOTIFIED. THE | | SYRINGE WAS RETURNED TO THE PHARMACY AND IT WAS DETERMINED THAT THE SYRINGE | | HAD CONTAINED TECHNETIUM-99M MDP INSTEAD OF SESTAMIBI. THE PRESCRIBING | | PHYSICIAN WAS NOTIFIED OF THE EVENT AND THE PATIENT WAS RELEASED. THE | | LICENSEE IS IMPLEMENTING A REDUNDANT SYSTEM FOR VERIFYING PREPARATION OF | | RADIOPHARMACEUTICAL UNIT DOSES TO PREVENT RECURRENCE. | +------------------------------------------------------------------------------+