U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/10/97 - 11/12/97 ** EVENT NUMBERS ** 33133 33241 33243 33244 33245 33246 33247 33248 33249 33250 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33133 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 10/22/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 19:09 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/22/97 | +------------------------------------------------+EVENT TIME: 16:30[CDT]| |NRC NOTIFIED BY: LANE OBEREMBT |LAST UPDATE DATE: 11/11/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTROL ROOM HABITABILITY ASSUMPTIONS NOT MET | | | | IT HAS BEEN DETERMINED THAT THE NON-SAFETY STATION HEATING SYSTEM HAS BEEN | | RELIED UPON TO MAINTAIN THE CONTROL ROOM HVAC SYSTEM OPERABLE. FAILURE OF | | THE NON-SAFETY STATION HEATING SYSTEM DURING COLD WEATHER WOULD RESULT IN | | THE TRIP OF THE AUX BUILDING SUPPLY FANS DUE TO LOW TEMPERATURE. | | | | WITH NO AUX BUILDING SUPPLY FANS, POSITIVE PRESSURE IN THE CONTROL ROOM | | CANNOT BE ASSURED RELATIVE TO THE ADJACENT TURBINE BUILDING. SINCE NON | | SAFETY STATION HEATING SYSTEM IS LOST DURING A LOOP, A DESIGN BASIS | | ACCIDENT (LOCA WITH LOOP) COULD POTENTIALLY RESULT IN CONTROL ROOM | | IN-LEAKAGE, WHICH IS CONTRARY TO CONTROL ROOM HABITABILITY ASSUMPTIONS. | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE 0110 EST 11/11/97 BY DAVID SCHUELLER TO FANGIE JONES *** | | | | IT HAS BEEN DETERMINED THAT STATION HEATING SYSTEM IS NOT REQUIRED TO | | MAINTAIN THE CONTROL ROOM HVAC SYSTEM OPERABLE. DAMPERS OPDV-OV014 AND | | OFCV-OV102, IF PROPERLY OPERATING, WOULD CLOSE IN ACCIDENT MODE TO MAINTAIN | | THE PROCESS COMPUTER ROOM AT POSITIVE PRESSURE RELATIVE TO THE AUX | | BUILDING. THIS PROVIDES A BUFFER PRESSURE ZONE BETWEEN THE CONTROL ROOMS | | POSITIVE PRESSURE AND THE AUX BUILDING NEGATIVE PRESSURE, MAINTAINING THE | | CONTROL ROOM AT A POSITIVE PRESSURE DURING DESIGN BASIS LOCA OR FUEL | | HANDLING ACCIDENT. THESE DAMPERS ARE BEING SCHEDULED TO BE REPAIRED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. R3DO (M. LEACH) INFORMED | | BY OPERATIONS OFFICER. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33241 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 11/09/97 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 17:39 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/09/97 | +------------------------------------------------+EVENT TIME: 15:21[CST]| |NRC NOTIFIED BY: MARK SMITH |LAST UPDATE DATE: 11/11/97 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - BORON DILUTION PREVENTION SYSTEM INADVERTENTLY ACTUATED DURING A TEST - | | | | UNIT 1 IS IN MODE 5 (COLD SHUTDOWN) IN A REFUELING OUTAGE. | | | | WHILE PERFORMING A DISCRIMINATOR BIAS VOLTAGE DETERMINATION SURVEILLANCE | | TEST ON THE UNIT 1 SOURCE RANGE NUCLEAR INSTRUMENTS CHANNEL N31, THE | | TECHNICIAN RETURNED THE BORON DILUTION PREVENTION SYSTEM (BDPS) TEST/NORMAL | | SWITCH FROM THE TEST POSITION TO THE NORMAL POSITION. THIS CAUSED AN | | ARTIFICIAL INCREASE IN THE CHANNEL N31 COUNT RATE WHICH CAUSED THE FLUX | | DOUBLING MODULE IN COMPUTER CARD #NM-107 TO INITIATE A BDPS ACTUATION. | | | | AT NO TIME WAS THERE AN ACTUAL POSITIVE REACTIVITY ADDITION. | | | | THE TECHNICIAN INCORRECTLY DETERMINED THAT THE BDPS WAS BLOCKED DURING | | THE TEST DUE TO MISTAKING THE "BDPS BYPASS" ANNUNCIATOR LIGHT FOR THE | | "BDPS BLOCKED" ANNUNCIATOR LIGHT. THE TEST PROCEDURE DOES NOT SPECIFY | | WHICH ANNUNCIATOR WINDOW OR ANNUNCIATOR TITLE SHOULD BE USED TO DETERMINE | | THE STATUS TO THE BDPS DURING THE TEST. | | | | THE LICENSEE IS DETERMINING CORRECTIVE ACTIONS AND WILL REVISE THE TEST | | PROCEDURE AS NECESSARY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | ***RETRACTION ON 11/11/97 @ 1435EST BY SCOTT FRUIN TAKEN BY MACKINNON*** | | | | BYRON STATION IS RETRACTING THE ABOVE EVENT NOTIFICATION AFTER AN | | INVESTIGATION DISCOVERED THAT THIS EVENT IS NOT REPORTABLE DUE TO THE FACT | | THAT THE BORON DILUTION PREVENTION SYSTEM (BDPS) IS NOT AN ESF OR RPS | | SYSTEM. THEREFORE, THIS EVENT SHOULD HAVE NOT BEEN REPORTED PER 10 CFR | | 50.72 (b)(2)(ii). | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS | | RETRACTION. R3DO (MEL LEACH) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33243 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BLANCHARD VALLEY MEDICAL ASSOCIATES |NOTIFICATION DATE: 11/10/97 | | CITY: FINDLAY REGION: 3 |NOTIFICATION TIME: 10:55 [ET]| | COUNTY: STATE: OH |EVENT DATE: 11/03/97 | |LICENSE#: 34-18674-02 AGREEMENT: N |EVENT TIME: 10:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/10/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MEL LEACH RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+FRED COMBS (NMSS) EO | |NRC NOTIFIED BY: L. SCHROEDER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT GIVEN 15mCi OF IODINE-131 INSTEAD OF 30mCi OF IODINE-131. | | | | A PATIENT WAS TO BE GIVEN A 30mCi DOSE OF I-131, INSTEAD RECEIVED A 15mCi | | DOSE OF I-131 DESTINED FOR A SECOND PATIENT. THE MISADMINISTRATION WAS | | DISCOVERED WHEN THE SECOND PATIENT WAS TO RECEIVE THEIR DOSE AND IT WAS | | IDENTIFIED AS THE WRONG DOSAGE. THE SECOND PATIENT WAS GIVEN THE PROPER | | DOSAGE. THE FIRST PATIENT WAS CONTACTED AND CAME BACK THE NEXT DAY TO | | RECEIVE THE BALANCE OF THEIR PROPER DOSAGE. | | | | INVESTIGATION AT THE TIME OF THE IDENTIFICATION OF THE WRONG DOSE FOR THE | | SECOND PATIENT FOUND THE LEAD PIGS, WHERE THE DOSES WERE STORED, WERE | | LABELED WRONG. THE LABELS WERE REVERSED FOR THE TWO PATIENTS. THE | | MANUFACTURER SAID IT WAS NOT THEIR FAULT. | | | | IN THE FUTURE, TO PREVENT A REOCCURRENCE OF THIS TYPE OF PROBLEM, ALL | | DOSAGES WILL BE MEASURED LOCALLY PRIOR TO ADMINISTRATION TO THE PATIENT. | | | | THE PATIENT WAS INFORMED OF THIS MEDICAL MISADMINISTRATION AND IT POSES NO | | HEALTH RISK TO THE PATIENT. | | | | REGION 3, D. PESKURA WAS INFORMED BY THE LICENSEE THE DAY OF THE EVENT AND | | A WRITTEN REPORT HAS BEEN SENT TO REGION 3. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33244 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 11/10/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 17:46 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 11/10/97 | +------------------------------------------------+EVENT TIME: 13:48[EST]| |NRC NOTIFIED BY: DAN BIERBRAUER |LAST UPDATE DATE: 11/10/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JACK DURR RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DRYWELL VENT AND PURGE ISOLATION DURING THE CALIBRATION OF STACK GAS | | RADIATION MONITOR, RN-10B. | | | | WHILE PERFORMING THE CALIBRATION OF STACK GAS RADIATION MONITOR, RN-10B, AN | | INCORRECT RADIOACTIVE SOURCE WAS USED IN THE CALIBRATION. THE INCORRECT | | RADIOACTIVE SOURCE WAS MORE RADIOACTIVE THAN THE CORRECT SOURCE (LICENSEE | | DID NOT KNOW THE SOURCE USED OR THE STRENGTH OF THE SOURCE). THIS RESULTED | | IN TRIPPING BOTH STACK GAS RADIATION MONITORS RN-10B WHICH WAS UNDER TEST | | AND THE STANDBY MONITOR RN-10A. WITH BOTH MONITORS TRIPPED A DRYWELL VENT | | AND PURGE ISOLATION RESULTED WHICH IS AN ESF ACTUATION. THE TRIP HAS BEEN | | RESET AND ALL VALVES HAVE BEEN PLACED BACK TO THEIR PROPER LINEUP. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33245 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 11/10/97 | |UNIT: [1] [ ] [ ] STATE: TX |NOTIFICATION TIME: 18:50 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/10/97 | +------------------------------------------------+EVENT TIME: 17:00[CST]| |NRC NOTIFIED BY: CHARLES BOWMAN |LAST UPDATE DATE: 11/10/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP ON STEAM GENERATOR "1C" LOW-LOW WATER LEVEL. | | | | | | DURING NORMAL OPERATION WITH NO TESTING IN PROGRESS THE REACTOR TRIPPED ON | | LOW-LOW STEAM GENERATOR "1C" WATER LEVEL (THIS WAS THE FIRST OUT | | ANNUNCIATOR). THE TURBINE DRIVEN AND BOTH MOTOR DRIVEN AUXILIARY FEEDWATER | | PUMPS AUTOMATICALLY STARTED ON LOW LOW STEAM GENERATOR "1C" WATER LEVEL. NO | | STEAM GENERATOR ATMOSPHERIC OR CODE SAFETY VALVES OPENED. ALL RODS FULLY | | INSERTED INTO THE CORE. THE REACTOR COOLANT SYSTEM IS BEING MAINTAINED AT A | | Tave NO LOAD CONDITION OF 567 DEGREES F. ALL EMERGENCY CORE COOLING | | SYSTEMS AND THE EMERGENCY DIESEL GENERATORS ARE FULLY OPERABLE IF NEEDED. | | THE ELECTRICAL GRID IS STABLE. THE TURBINE DRIVEN AND BOTH MOTOR DRIVEN | | AUXILIARY FEEDWATER PUMPS WERE SECURED AFTER MAIN FEEDWATER WAS RESTORED TO | | SERVICE. ALL OTHER SYSTEMS AND COMPONENTS FUNCTIONED AS REQUIRED. | | | | INVESTIGATION INTO THE CAUSE OF THE TRIP IS UNDERWAY AT THIS TIME. THE | | LICENSEE THINKS THAT THEY HAD A MAIN GENERATOR LOSS OF LOAD [BECAUSE | | MOISTURE SEPARATOR REHEATER (MSR) RELIEF VALVES OPENED ON BOTH SIDES OF THE | | MSR] WHICH CAUSED STEAM GENERATOR "1C" LOW-LOW WATER LEVEL AND THE | | FOLLOWING REACTOR TRIP. | | | | DURING THE TRANSFER OF THE STEAM DUMPS TO THE PRESSURE CONTROL MODE, THE | | AUXILIARY FEEDWATER SYSTEM ACTUATION REACTUATED ON LOW-LOW STEAM GENERATOR | | WATER LEVEL. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33246 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 11/11/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 01:10 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/10/97 | +------------------------------------------------+EVENT TIME: 23:00[CST]| |NRC NOTIFIED BY: DAVID SCHUELLER |LAST UPDATE DATE: 11/11/97 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MELVYN LEACH RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FOR OFFSITE DOSE LIMITS TO BE EXCEEDED. | | | | DURING A REVIEW OF HANDSWITCH 0HS-AV95 DEVELOPMENT, IT WAS DISCOVERED THAT | | IN THE "CUBICAL MODE" THE EXHAUST FROM THE PIPE TUNNELS IS NOT ALIGNED | | THROUGH THE CHARCOAL FILTERS. IN THE EVENT OF A LOSS OF COOLANT ACCIDENT | | (LOCA), THE OPERATOR IS DIRECTED BY EMERGENCY PROCEDURE ES-1.3 (ALIGNMENT | | FOR RECIRCULATION) TO START THE AUXILIARY BUILDING VENTILATION (AV) SYSTEM | | CHARCOAL FANS AND PLACE THE 0HS-AV95 IN THE "CUBICAL MODE." THIS IS TO | | ENSURE THAT ALL POTENTIAL RECIRCULATION LEAKAGE IS FILTERED PRIOR TO BEING | | RELEASED WITHOUT THE RELIANCE ON THE INSTALLED RADIATION MONITORS TO | | AUTOMATICALLY ALIGN THE SYSTEM FOR FILTERING. THE POTENTIAL EXISTS THAT A | | RELEASE MAY BE OUTSIDE OF THE DESIGN BASIS OFFSITE DOSE ANALYSIS AND EXCEED | | 10CFR100 LIMITS IF THE SYSTEM ONLY RESPONDS TO A HIGH RADIATION SIGNAL. | | THIS IS DEPENDENT ON THE TIME DELAY BASED ON EXHAUST AIR FLOW TRAVEL TIME | | AND THE RESPONSE TIME OF THE MONITOR TO DETECT AND CHANGE THE EXHAUST PATH | | THROUGH THE CHARCOAL FILTERS. PARALLEL TASKS HAVE BEGUN TO DETERMINE THE | | IMPACT ON OFFSITE DOSE AND PREPARE A PLANT MODIFICATION TO CORRECT THIS | | DEFICIENCY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33247 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MCLAREN REGIONAL MEDICAL CENTER |NOTIFICATION DATE: 11/11/97 | | CITY: FLINT REGION: 3 |NOTIFICATION TIME: 15:11 [ET]| | COUNTY: GENESEE STATE: MI |EVENT DATE: 11/10/97 | |LICENSE#: 21-04171-04 AGREEMENT: N |EVENT TIME: 10:15[EDT]| | DOCKET: |LAST UPDATE DATE: 11/11/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MEL LEACH RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: TOM KUMPURIS | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT GIVEN 4.6 mCi OF IODINE-131 INSTEAD OF 8.0 mCi. | | | | A CONSULTING MEDICAL PHYSICIST FOR THE McLAREN REGIONAL MEDICAL CENTER | | LOCATED IN FLINT, MICHIGAN, GAVE THE FOLLOWING REPORT: | | | | A PATIENT WAS TO HAVE RECEIVED 8 mCi OF IODINE-131 FOR A HYPERTHYROID | | CONDITION. A VIAL CONTAINING TWO CAPSULES WAS GIVEN TO THE PATIENT. AFTER | | THE PATIENT LEFT THE MEDICAL CENTER, IT WAS DISCOVERED THAT ONE CAPSULE | | REMAINED IN THE VIAL. THE TECHNICIAN ASSIGNED TO ADMINISTER THE IODINE-131 | | SAID THAT SHE HAD ASSAYED THE CAPSULE TWICE BEFORE GIVING THE PATIENT THE | | CAPSULE (THE MEASURED IODINE-131 ACTIVITY OF THE CAPSULE WAS 7.9 mCi). THE | | SHIPPING PAPERS FOR THE VIAL INDICATED THAT THE TOTAL ACTIVITY OF THE TWO | | CAPSULES IN THE VIAL WAS 8.1 mCi. THE LICENSEE CALLED THE MANUFACTURER | | (BRACCO DIAGNOSTIC LOCATED IN PRINCETON, NEW JERSEY) AND ASKED THEM TO | | CHECK THEIR RECORDS TO FIND OUT THE ACTIVITY OF EACH CAPSULE IN THE VIAL | | THAT HAD BEEN SHIPPED TO THEM. BRACCO DIAGNOSTIC CHECKED THEIR SHIPPING | | PAPERS AND INVENTORY AND INFORMED McLAREN REGIONAL MEDICAL CENTER TODAY | | (11/11/97) THAT THE TOTAL ACTIVITY OF THE TWO CAPSULES WAS 8.1 mCi. ONE | | CAPSULE CONTAINED 4.6 mCi OF IODINE-131 AND THE OTHER CAPSULE IN THE VIAL | | CONTAINED 3.5 mCi OF IODINE-131. THE LICENSEE CHECKED THE ACTIVITY OF THE | | REMAINING CAPSULE IN THE VIAL AND FOUND THAT IT CONTAINED 3.5 mCi OF | | IODINE-131. THEREFORE, THE PATIENT HAD RECEIVED 4.6 mCi OF IODINE-131 | | INSTEAD OF 8.0 mCi OF IODINE-131. | | | | THE LICENSEE HAS BEEN TRYING TO CONTACT THE PATIENT BUT AT THE PRESENT TIME | | THEY HAVE NOT BEEN ABLE TO REACH THE PATIENT. THE PATIENTS' PHYSICIAN HAS | | BEEN NOTIFIED OF THE MEDICAL MISADMINISTRATION. THE PATIENT WILL BE ASKED | | TO RETURN TO McLAREN REGIONAL MEDICAL CENTER TO RECEIVE THE REMAINING 3.5 | | mCi OF IODINE-131. THIS MEDICAL MISADMINISTRATION HAS NO ADVERSE AFFECT ON | | THE PATIENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 33248 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CASE WESTERN RESERVE UNIVERSITY |NOTIFICATION DATE: 11/11/97 | | CITY: CLEVELAND REGION: 3 |NOTIFICATION TIME: 16:23 [ET]| | COUNTY: CUYAHOGA STATE: OH |EVENT DATE: 10/31/97 | |LICENSE#: 34-00738-04 AGREEMENT: N |EVENT TIME: 16:00[EDT]| | DOCKET: |LAST UPDATE DATE: 11/11/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MEL LEACH RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: DAVID SEDWICK | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PREPARATION ROOM LOCATED IN THE WASTE FACILITY IS CONTAMINATED WITH P-32. | | | | THE FOLLOWING INFORMATION WAS PROVIDED BY THE RADIATION SAFETY OFFICER FOR | | CASE WESTERN RESERVE UNIVERSITY: | | | | ON OCTOBER 31, 1997, A PLASTIC BOTTLE WRAPPED IN PLASTIC WAS TAKEN TO THE | | WASTE FACILITY (A RESTRICTED AREA) IN A WASTE CART. THE PLASTIC BOTTLE | | CONTAINED 7 mCi OF P-32 WHICH WAS USED TO LABEL CELLS IN A RESEARCH | | LABORATORY. THE PLASTIC BOTTLE WAS REMOVED FROM THE WASTE CART IN THE | | PREPARATION ROOM LOCATED IN THE WASTE FACILITY. THE PERSON WHO HAD REMOVED | | THE BOTTLE CONTAINING THE P-32 WAS WEARING GLOVES AND WHEN HE WAS FRISKING | | OUT, IT WAS FOUND THAT THE GLOVES HAD P-32 CONTAMINATION ON THEM BUT THE | | PERSON WEARING THE GLOVES WAS NOT CONTAMINATED. IT WAS DISCOVERED THAT | | APPROXIMATELY 15 ęCi OF P-32 DRIPPED ONTO THE FLOOR OF THE WASTE FACILITY | | PREPARATION ROOM. THE LICENSEE HAS BEEN TRYING TO DECONTAMINATE THE FLOOR | | OF THE PREPARATION ROOM WITH VERMICULITE WITH LIMITED SUCCESS SINCE OCTOBER | | 31. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33249 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 11/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 16:30 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 11/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 18:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 11/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |MEL LEACH RDO | | DOCKET: 0707002 |CHARLEY HAUGHNEY EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: STEVE MAY | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PROPER SPACING BETWEEN PARTS WITH HIDDEN CAVITIES NOT MAINTAINED | | | | THIS EVENT IS BEING REPORTED AS A 24 HOUR CALL PER NRC BULLETIN 91-01. | | | | AT 1800 HOURS, ON 11/10/97, IT WAS DISCOVERED THAT A NUCLEAR CRITICALITY | | SAFETY APPROVAL (NCSA) REQUIREMENT WAS NOT BEING MET IN THE X-333 LAW | | FACILITY. NCSA-PLANT 048.A00 LISTS TWO (2) NUCLEAR CRITICALITY SAFETY | | CONTROLS. THE FIRST CONTROL (ADMINISTRATIVE) REQUIRES SPACING BETWEEN ITEMS | | (2 FEET) IF THERE IS HIDDEN CAVITIES IN THE OBJECTS (PIGTAILS, VALVES, | | etc.) WITH POTENTIAL VOLUME, AND THE SECOND CONTROL (ADMINISTRATIVE) | | REQUIRES MODERATION CONTROL. THE FIRST CONTROL WAS VIOLATED WHEN ITEMS | | STORED TOGETHER IN A WIRE BASKET SPACED UNDER THE MINIMUM REQUIREMENT OF 2 | | FEET. THE SECOND CONTROL (MODERATION) WAS MAINTAINED THROUGHOUT THIS EVENT. | | THE LOSS OF ONE CONTROL (SPACING) MAKES THIS EVENT REPORTABLE TO THE NRC | | VIA A 24 HOUR EVENT NOTIFICATION PER NUCLEAR REGULATORY EVENT REPORTING | | PROCEDURE UE2-RA-RE1030, APPENDIX D, CRITERIA A, PARAGRAPH 4a. THERE WAS NO | | RELEASE OF HAZARDOUS MATERIALS OR RADIOLOGICAL CONTAMINATION EXPOSURE | | ASSOCIATED WITH THIS EVENT. | | | | SAFETY SIGNIFICANCE OF EVENT: | | | | LOSS OF ONE (ADMINISTRATIVE) CONTROL, WHILE MAINTAINING THE SECOND | | (ADMINISTRATIVE) CONTROL. IT WOULD TAKE A VIOLATION OF BOTH ADMINISTRATIVE | | CONTROLS TO ACCUMULATE SUFFICIENT VOLUME AND MODERATE THAT POTENTIAL MASS. | | | | ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS | | LIMIT AND % WORST CASE CRITICAL MASS): | | | | FORM OF MATERIAL: URANIUM HEXAFLUORIDE WITH AVERAGE ENRICHMENT OF UP TO | | 10wt %. | | | | CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: | | | | IMMEDIATELY SPACED TO LIMIT VOLUME. CHECKED OTHER LOCATIONS WHICH USES | | PIGTAILS TO ASSURE COMPLIANCE. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33250 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 11/11/97 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 19:49 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 11/11/97 | +------------------------------------------------+EVENT TIME: 17:13[CST]| |NRC NOTIFIED BY: JAMES BOYLE |LAST UPDATE DATE: 11/11/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | HIGH PRESSURE CORE SPRAY (HPCS) DECLARED INOPERABLE | | | | DURING PERFORMANCE OF INSERVICE TESTING (PERFORMED QUARTERLY) HPCS MINIMUM | | FLOW VALVE FAILED TO OPEN. HPCS WAS DECLARED INOPERABLE AND THE LICENSEE | | ENTERED TECHNICAL SPECIFICATION 3.5.1 (14 DAYS TO RETURN HPCS TO SERVICE) | | LIMITING CONDITION OF OPERATION. REACTOR CORE ISOLATION COOLING IS OPERABLE | | AND THE REST OF THE EMERGENCY CORE COOLING SYSTEMS ARE FULLY OPERABLE, IF | | NEEDED. THE LICENSEE IS INVESTIGATING WHY THE MINIMUM FLOW VALVE DID NOT | | OPEN. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+