U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/11/97 - 12/12/97 ** EVENT NUMBERS ** 33381 33382 33383 33384 33385 33386 33387 33388 33389 33390 33391 33392 33393 33394 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33381 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 12/11/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 00:47 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/10/97 | +------------------------------------------------+EVENT TIME: 22:55[CST]| |NRC NOTIFIED BY: SCOTT FRUIN |LAST UPDATE DATE: 12/11/97 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED RDO | |DSAF 73.71(b)(1) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFEGUARDS SYSTEM DEGRADATION RELATED TO AREA BOUNDARY. IMMEDIATE | | COMPENSATORY MEASURES TAKEN UPON DISCOVERY. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33382 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 09:10 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JAMES CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: KURT SISLER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | DURING PLANT WALKDOWN, THE LICENSEE IDENTIFIED A LOSS OF ONE NUCLEAR | | CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT IN AN AREA WITHIN THE X-330 | | PROCESS BUILDING. A MINIMUM SPACING OF FOUR FEET EDGE-TO-EDGE MUST BE | | MAINTAINED BETWEEN GROUPS (INDICATES SEALS OF 50 EACH) AND THIS WAS | | VIOLATED BETWEEN TWO GROUPS. THE REMAINING REQUIREMENTS WERE MAINTAINED. | | THE SPACING WAS IMMEDIATELY CORRECTED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33383 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 09:10 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 15:30[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JAMES CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: KURT SISLER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | DURING PLANT WALKDOWN, THE LICENSEE IDENTIFIED A LOSS OF ONE NUCLEAR | | CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT IN AN AREA WITHIN THE X-330 | | PROCESS BUILDING. A MINIMUM SPACING OF TWO FEET EDGE-TO-EDGE MUST BE | | MAINTAINED BETWEEN DRY ACTIVE WASTE (DAW) CONTAINERS/BAGS AND OTHER TYPES | | OF URANIUM BEARING EQUIPMENT OR MATERIALS PRIOR TO NONDESTRUCTIVE ASSAY | | SURVEYS. THIS SPACING WAS VIOLATED, BUT OTHER NCSA REQUIREMENTS WERE | | MAINTAINED. THE SPACING WAS IMMEDIATELY CORRECTED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33384 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 09:10 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 12:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JAMES CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: KURT SISLER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | DURING PLANT WALKDOWN, THE LICENSEE IDENTIFIED A LOSS OF ONE NUCLEAR | | CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT IN AN AREA WITHIN THE X-326 | | PROCESS BUILDING. ANY CASCADE EQUIPMENT THAT IS SHUTDOWN (MOTOR TURNED | | OFF) AND AT UF6 NEGATIVE SHALL HAVE A PLANT DRY AIR OR NITROGEN BUFFER | | EQUAL TO OR GREATER THAN 14 PSIA. CELL 27-1-4 WAS FOUND AT 13.8 PSIA. THE | | OTHER NCSA REQUIREMENTS WERE MAINTAINED. THE PRESSURE ON CELL 27-1-4 WAS | | IMMEDIATELY RESTORED TO WITHIN THE REQUIREMENT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33385 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 09:10 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:15[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JAMES CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: KURT SISLER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | DURING PLANT WALKDOWN, THE LICENSEE IDENTIFIED A LOSS OF ONE NUCLEAR | | CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT IN AN AREA WITHIN THE X-326 | | PROCESS BUILDING. ANY CASCADE EQUIPMENT THAT IS SHUTDOWN (MOTOR TURNED | | OFF) AND AT UF6 NEGATIVE SHALL HAVE A PLANT DRY AIR OR NITROGEN BUFFER | | EQUAL TO OR GREATER THAN 14 PSIA. CELL 27-7-16 WAS FOUND TO BE LESS THAN | | 14 PSIA. THE OTHER NCSA REQUIREMENTS WERE MAINTAINED. THE PRESSURE ON | | CELL 27-7-16 WAS IMMEDIATELY RESTORED TO WITHIN THE REQUIREMENT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33386 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 09:10 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 15:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JAMES CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: KURT SISLER | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | DURING PLANT WALKDOWN, THE LICENSEE IDENTIFIED A LOSS OF ONE NUCLEAR | | CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT IN AN AREA WITHIN THE X-333 | | PROCESS BUILDING. COOLANT (R-114) SYSTEM PRESSURE MUST BE MAINTAINED ABOVE | | THE UF6 AND THE RECIRCULATING COOLING WATER (RCW) PRESSURES. ON CELL | | 32-7-10 THE COOLANT PRESSURE (2.5 PSIA), WHILE GREATER THAN THE UF6 | | PRESSURE (1.75 PSIA), WAS LESS THAN THE RCW PRESSURE (14.4 PSIA). THE | | OTHER NCSA REQUIREMENTS WERE MAINTAINED. THE SYSTEM PRESSURE WAS | | IMMEDIATELY INCREASED TO 15.4 PSIA TO BE IN COMPLIANCE WITH THE NCSA | | REQUIREMENT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33387 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 12:17 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/10/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JIM CREED RDO | | DOCKET: 0707002 |FRED COMBS EO | +------------------------------------------------+FRANK CONGEL (IRD) AEOD | |NRC NOTIFIED BY: RICK LARSON | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 24 HOUR NOTIFICATION. | | | | AT 1400 HOURS, ON 12/10/97, IT WAS DISCOVERED THAT ONE CONTINGENCY OF THE | | DOUBLE CONTINGENCY CONTROL OF NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA)-PLANT 011.001 "USE OF PORTABLE HEPA VENTILATION UNITS FOR SPECIFIC | | MAINTENANCE ACTIVITIES" HAD BEEN VIOLATED. PART "B" ITEM # 6 OF THIS NCSA | | REQUIRES "ALL OTHER URANIUM-BEARING MATERIAL, INCLUDING OTHER UNITS, SHALL | | BE KEPT AT LEAST TWO FEET EDGE-TO-EDGE FROM THE UNIT. THE HOSE LEADING TO | | THE INLET OF THE UNIT SHALL BE EXEMPT FROM THE REQUIREMENT." THIS | | REQUIREMENT (SPACING) WAS VIOLATED WHEN TWO HEPA UNITS WERE FOUND TO HAVE | | LESS THAN TWO FEET OF SPACING BETWEEN THEM. THE OTHER CONTINGENCY, MASS IN | | FILTER LESS THAN 350 GRAMS OF URANIUM-235, WAS NOT VIOLATED. THE LOSS OF | | ONE (1) NCS CONTROL IS REPORTABLE TO THE NRC AS DEFINED IN PROCEDURES | | UE2-RA-RE1030, APPENDIX "D", SECTION "A", PARAGRAPH 4(a). THERE WAS NO LOSS | | OR RELEASE OF HAZARDOUS/RADIOACTIVE MATERIAL OR RADIOACTIVE/RADIOLOGICAL | | CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 33388 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BITTNER ENGINEERING |NOTIFICATION DATE: 12/11/97 | | CITY: ESCANABA REGION: 3 |NOTIFICATION TIME: 14:00 [ET]| | COUNTY: STATE: MI |EVENT DATE: 12/11/97 | |LICENSE#: 21-26010-01 AGREEMENT: N |EVENT TIME: 13:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/11/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JIM CREED RDO | | |FRED COMBS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: HAMP WARING | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NDAM DAMAGE MEASURE GAUGE | | |BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PART OF A SOURCE ROD FROM A TROXLER MOISTURE DENSITY GAUGER WAS FOUND | | UNDERNEATH THE SOIL LAB COUNTER. | | | | THE RADIATION SAFETY OFFICER (RSO) OF TROXLER CALLED BITTNER ENGINEERING | | LOCATED AT 1113 SOUTH 10th STREET, ESCANABA, MI., AND INFORMED THEM THAT | | THE DAMAGED TROXLER MOISTURE DENSITY GAUGE THAT THEY HAD BEEN SENT WAS | | MISSING THE LAST 4.5" OF THE SOURCE ROD (THE LAST 2" OF THE SOURCE ROD | | CONTAINS THE CESIUM AND AMERICIUM SOURCES). ON 10/14/97 THE DAMAGED TROXLER | | MOISTURE DENSITY GAUGE HAD BEEN BROUGHT BACK FROM THE SITE WHERE IT HAD | | BEEN DAMAGED (RUN OVER) AND INSPECTED IN THE BITTNER ENGINEERING SOIL LAB. | | WHILE THE TROXLER MOISTURE DENSITY GAUGE WAS BEING INSPECTED IN THE LAB, | | THE LAST 4.5" OF THE SOURCE ROD CAME OFF AND ROLLED UNDERNEATH THE COUNTER | | IN THE SOIL LAB WITHOUT ANYBODY KNOWING ABOUT IT. | | | | TODAY (12/11/97), AFTER THE RSO OF TROXLER HAD NOTIFIED THEM THAT PART OF | | THE SOURCE ROD WAS MISSING, THE BROKEN SOURCE ROD WAS FOUND UNDERNEATH THE | | COUNTER IN THE SOIL LAB. THE LICENSEE FOUND THE MISSING SOURCE USING AN OLD | | CIVIL DEFENSE GEIGER COUNTER. THE GEIGER COUNTER WENT OFF SCALE WHEN IT WAS | | WITHIN ONE TO THREE INCHES OF THE SOURCE ROD (HE DID NOT KNOW WHAT SCALE HE | | WAS READING OR WHAT THE RADIATION LEVEL READINGS WERE. ALL HE KNEW IS THAT | | THE GEIGER COUNTER WENT OFF SCALE). THE LICENSEE PLACED A BAG OF SAND ON | | TOP OF THE SOURCE ROD AN THEN ISOLATED THE SOIL ROOM. THE LICENSEE SAID | | THAT IN THE LAST SEVEN WEEKS THE SOIL LAB HAS BEEN USED FOR A TOTAL OF 8 | | HOURS BETWEEN TWO EMPLOYEES. THE RSO OF TROXLER WILL HELP THE LICENSEE | | CALCULATE THE DOSE THAT THESE TWO EMPLOYEES RECEIVED FROM THE SOURCE ROD. | | THE LAST TWO INCHES OF THE SOURCE ROD CONTAINS CESIUM-137 AND | | AMERICIUM-241. | | | | THE CURRENT ACTIVITY OF THE CESIUM-137 IS 5.1 mCi AND THE CURRENT ACTIVITY | | OF THE AMERICIUM-241 IS 39 mCi. THE SERIAL NUMBER OF THE CESIUM-137 SOURCE | | IS 406326 AND THE SERIAL NUMBER OF THE AMERICIUM-241 SOURCE IS 475488. THE | | TROXLER MOISTURE DENSITY GAUGE MODEL NUMBER IS 3411 "B" AND ITS SERIAL | | NUMBER IS 9019. THE LICENSEE WILL INFORM THE TWO EMPLOYEES THAT HAD BEEN IN | | THE SOIL LAB WITH THE BROKEN OFF SOURCE ROD THAT THEY COULD HAD BEEN | | EXPOSED. | | | | ALL FILM BADGE READINGS FOR THE LAST TWO MONTHS HAVE NOT SHOWN THAT ANYONE | | HAD RECEIVED ANY UNEXPECTED RADIATION EXPOSURE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33389 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DR. JOSE DELEON |NOTIFICATION DATE: 12/11/97 | | CITY: RIO PIEDRAS REGION: 2 |NOTIFICATION TIME: 14:12 [ET]| | COUNTY: STATE: PR |EVENT DATE: 07/03/96 | |LICENSE#: 52-19206-01 AGREEMENT: N |EVENT TIME: 00:00[AT ]| | DOCKET: |LAST UPDATE DATE: 12/11/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HAAG RDO | | |BOB PIERSON EO | +------------------------------------------------+ | |NRC NOTIFIED BY: JOSE DELEON | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A TOTAL OF NINE PATIENTS RECEIVED DOSES OF á RADIATION IN EXCESS OF THAT | | PRESCRIBED DUE TO INCORRECT SOURCE INFORMATION DURING THE PERIOD FROM | | 4/22/95 THROUGH 7/3/96. DR. DeLEON REPORTED THAT HE WAS ATTEMPTING TO TREAT | | THE PATIENTS WITH 2,000 RAD DOSES OF RADIATION, AND THAT HE WAS INFORMED | | THAT THE PATIENTS SHOULD BE EXPOSED TO THE SOURCE FOR 60 SECONDS, ALTHOUGH | | THE CORRECT EXPOSURE TIME WAS 26 SECONDS. DR DeLEON STATED THAT ALTHOUGH | | THE PATIENTS RECEIVED MORE DOSE THAN PRESCRIBED, THE TREATMENT WINDOW WAS | | 1,000 TO 6,000 RADS. THE TREATMENT MACHINE IS NO LONGER BEING USED. | | | | NRC REGION 2 INSPECTORS ARE AT THE LICENSEE'S FACILITY. | | | | ***UPDATE BY Dr ANGLE TORRES AT 1516 EST ON 12/11/97 TAKEN BY MACKINNON*** | | | | Dr ANGLE TORRES, CHIEF OF NUCLEAR MEDICINE, OF RYDER HOSPITAL LOCATED IN | | HUMACAO, PUERTO RICO CALLED IN THE SAME EVENT WRITTEN ABOVE. HE SAID THAT | | HE WAS REQUESTED TO CALL THE SAME EVENT IN BY AN NRC REGION 2 INSPECTOR. | | THE ONLY DIFFERENCE IN INFORMATION FROM THE ABOVE INFORMATION IS THAT | | APPROXIMATELY 19 MEDICAL MISADMINISTRATIONS OCCURRED BETWEEN APRIL 1995 AND | | JULY 1996 INVOLVING APPROXIMATELY (MAYBE LESS THAN) 17 PATIENTS. THE SOURCE | | OF THE BETA RADIATION WAS FROM A STRONTIUM-90 EYE APPLICATOR. Dr. ANGLE | | TORRES' NRC LICENSEE NUMBER IS 52-21026-01. R2DO (PAUL FREDRICKSON) & NMSS | | EO (FRED COMBS) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33390 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 12/11/97 | |UNIT: [ ] [2] [ ] STATE: CA |NOTIFICATION TIME: 14:34 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/11/97 | +------------------------------------------------+EVENT TIME: 11:15[PST]| |NRC NOTIFIED BY: BRUCE LEWIS |LAST UPDATE DATE: 12/11/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WESTINGHOUSE IFBA FUEL DESIGN ISSUE FOLLOWUP | | | | ON DECEMBER 11, 1997, WESTINGHOUSE INFORMED PG&E THAT PLANT SPECIFIC | | ANALYSIS HAD BEEN COMPLETED THAT PREDICTED FUEL ROD PELLET-TO-CLAD GAP | | REOPENING FOR UNIT 2 AT A BURNUP OF 18,000 MWD/METRIC TON. THIS BURNUP | | OCCURRED FOR UNIT 2 ON APPROXIMATELY SEPTEMBER 1, 1997. PG&E HAS COMPLETED | | AND APPROVED A PLANT SPECIFIC OPERABILITY EVALUATION BASED ON THE | | WESTINGHOUSE GENERIC SAFETY ASSESSMENT OF THE EFFECTS OF INCORPORATING | | REVISED MODELS FOR CLAD OXIDATION OF ZIRC-4 FUEL CLADDING AND HELIUM | | RELEASE IN INTEGRAL FUEL BURNABLE ABSORBER (IFBA) FUEL RODS. THE | | OPERABILITY EVALUATION CONCLUDED THAT THE WESTINGHOUSE GENERIC SAFETY | | ASSESSMENT BOUND DIABLO CANYON UNIT 2. | | | | UNIT 1 IS IN THE FIRST OF ITS FUEL CYCLE AND THIS ISSUE WILL NOT BE | | APPLICABLE UNTIL MAY 1998, UNDER THE BOUNDING ANALYSIS PREVIOUSLY PERFORMED | | BY WESTINGHOUSE. | | | | ADDITIONALLY, IN THE INFORMATION ONLY REPORT MADE ON NOVEMBER 14, 1997 | | (EVENT # 33185), PG&E INFORMED THE NRC THAT THE CORRECTED FUEL MODEL | | IDENTIFIED THE POTENTIAL FOR CLADDING OXIDATION TO EXCEED 12% PRE-ACCIDENT | | FUEL OXIDATION SCREENING CRITERIA ON JANUARY 9, 1998 FOR UNIT 2. THE 12% | | OXIDATION LIMIT ASSURES THAT THE SUM OF PRE-ACCIDENT AND POST-LOCA | | OXIDATION WILL NOT EXCEED THE 10CFR 50.46 CRITERION OF 17%. WESTINGHOUSE | | HAS DETERMINED THAT THIS DATE HAS BEEN EXTENDED TO CORRESPOND TO A FUEL | | BURNUP OF 23,800 MWD/METRIC TON BY COMPLETING CYCLE SPECIFIC CORROSION | | ANALYSIS. THIS BURNUP WILL BE REACHED ON OR AFTER JANUARY 23, 1998. | | WESTINGHOUSE IS PERFORMING ADDITIONAL ANALYSIS TO DETERMINE THE AMOUNT OF | | TRANSIENT (i.e., LOCA) OXIDATION, WHICH IS EXPECTED TO DEMONSTRATE THAT THE | | SUM OF THE PRE-TRANSIENT OXIDATION AND THE TRANSIENT OXIDATION WILL NOT | | EXCEED THE 17% CLAD OXIDATION CRITERIA FOR UNIT 2 CYCLE 8. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33391 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 12/11/97 | |UNIT: [3] [ ] [ ] STATE: LA |NOTIFICATION TIME: 16:09 [ET]| |RX TYPE: [3] CE |EVENT DATE: 12/10/97 | +------------------------------------------------+EVENT TIME: 20:00[CST]| |NRC NOTIFIED BY: GREG SCOTT |LAST UPDATE DATE: 12/11/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURREY RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOCAL FIRE DEPARTMENT PERSONNEL AND VEHICLES WERE ALLOWED ACCESS TO THE | | PROTECTED AREA WITHOUT BEING SEARCHED. IMMEDIATE COMPENSATORY MEASURES | | TAKEN UPON DISCOVERY. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33392 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/11/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:56 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/11/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[CST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/11/97 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |JIM CREED RDO | | DOCKET: 0707001 |BOB PIERSON EO | +------------------------------------------------+ | |NRC NOTIFIED BY: MATT MAURER | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 4 HOUR NOTIFICATION. | | | | NON-REUSABLE SEAL PARTS FOUND IN 30 AND 55 GALLON CONTAINERS. THEY SHOULD | | HAVE BEEN IN 5.5 GALLON CONTAINERS. | | | | NUCLEAR CRITICALITY SAFETY APPROVAL (NCSA) 3973-27 PROVIDES NCS CONTROLS | | AND REQUIREMENTS FOR PROCESS GAS SEAL DECONTAMINATION. THE NCSA/E IS | | APPLICABLE IN THE C-400 (CHEMICAL CLEANING AND DECONTAMINATION) FACILITY. | | THE SEAL DISASSEMBLY AND DECONTAMINATION AREA IS LOCATED ON THE WEST SIDE | | OF THE C-400 FACILITY. THE NCS ASSOCIATED WITH THIS OPERATION EVALUATED: | | | | -STORAGE OF SEALS IN THEIR RESPECTIVE SEAL CANISTER | | -DISASSEMBLY AND DECONTAMINATION OF THE SEAL (IN A FISSILE CONTROL AREA), | | -STORAGE OF UNUSABLE SEAL PARTS AND WASTE IN MAXIMUM 5.5 GALLON WASTE | | CONTAINERS (SPACED 2 FEET EDGE-TO-EDGE FROM OTHER POTENTIALLY FISSILE | | MATERIAL). | | | | AS-FOUND CONDITION: | | | | NON-REUSABLE SEAL PARTS HAVE BEEN CONSOLIDATED INTO GREATER THAN 5.5 GALLON | | CONTAINERS (30 AND 55 GALLON) AND STORED IN THE C-400 RECEIVING BOOTH AND | | IN C-746-Q1 (SEAL STORAGE CAGE). | | | | IN REVIEWING THE AS FOUND CONDITION, IT WAS DETERMINED THAT THE OPERATION | | DEVIATED FROM THE ANALYSIS PROCESS DESCRIPTION AND REPRESENTED AN | | UNAUTHORIZED FISSILE MATERIAL OPERATION. THE AS-FOUND CONDITION DOES NOT | | COMPLY WITH THE DOUBLE CONTINGENCY PRINCIPLE. STORAGE OF POTENTIALLY | | FISSILE COMPONENTS IN 30 GALLON OR 55 GALLON CONTAINERS HAS NOT BEEN SHOWN | | TO BE SAFE, THEREFORE NEITHER LEG OF DOUBLE CONTINGENCY CAN BE SHOWN. | | | | SAFETY SIGNIFICANCE OF EVENTS: | | | | THE PHYSICAL CHARACTERISTICS OF THE SEAL SUB COMPONENTS DO NOT READILY | | SUPPORT LARGE ACCUMULATIONS OF URANIUM BEARING MATERIAL. THE SEAL SUB | | COMPONENTS DO NOT CONTAIN LARGE CAVITIES THAT WOULD FACILITATE HOLDUP OF | | FISSILE MATERIAL. THEREFORE, TYPICAL SEALS WOULD CONTAIN ONLY A DUSTING OF | | URANIUM BEARING MATERIAL. DUE TO THE INABILITY OF THE SEAL TO CONTAIN LARGE | | AMOUNTS OF URANIUM, THE RATION OF FISSILE MATERIAL TO METAL WOULD BE | | EXPECTED TO BE VERY LOW. FOR INSTANCE A LARGE DRUM OF SEAL COMPONENTS COULD | | CONTAIN AS MUCH AS A THOUSAND POUNDS OF METAL AND ONLY A FEW POUNDS OF | | FISSILE MATERIAL. REGARDING THE SEAL DRUM, STORED IN C-746-Q1, PREPARATIONS | | FOR EVENTUAL SHIPPING INCLUDED DRUM MASS ANALYSIS. THE ANALYSIS INCLUDED | | STATISTICALLY REPRESENTATIVE SMEARS TAKEN FOR 49 DRUMS AND RESULTED IN A | | WORSE CASE DRUM MASS OF 100 GRAMS OF URANIUM (U-238 & U-235). BASED ON | | CURRENT INFORMATION THE SEALS STORED IN C-746-Q1 ARE BELIEVED TO HAVE BEEN | | WASHED PRIOR TO CONTAINERIZATION IN THE LARGE DRUMS, AND THEREFORE ARE | | EXEMPT FROM NCS CONTROLS. THEREFORE SAFETY SIGNIFICANCE IS EXPECTED TO BE | | LOW. | | | | ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL: | | | | THE AMOUNT OF FISSILE MATERIAL IS UNKNOWN FOR THE DRUMS IN C-400. THE DRUMS | | IN C-746-Q1 HAVE BEEN SHOWN TO HAVE WORSE CASE URANIUM HOLDUP OF 100 GRAMS | | OF URANIUM AT 2 WEIGHT PERCENT U-235. THE ENRICHMENT IS LESS THAN 2 WEIGHT | | PERCENT U-235. THE EXPECTED FORM OF MATERIAL IS UO2F2. | | | | | | CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: | | | | THE AFFECTED AREAS WERE EVACUATED, SECURED AND POSTED. NCS CONTINUES TO | | EVALUATE THE CONFIGURATION IN ORDER TO DEVELOP APPROPRIATE GUIDANCE FOR | | ESTABLISHING DOUBLE CONTINGENCY AND ENSURING A SAFE CONFIGURATION EXISTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 33393 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CANBERRA INDUSTRIES, CT |NOTIFICATION DATE: 12/11/97 | | CITY: IDAHO FALLS REGION: 4 |NOTIFICATION TIME: 21:32 [ET]| | COUNTY: STATE: ID |EVENT DATE: 12/11/97 | |LICENSE#: AGREEMENT: N |EVENT TIME: 13:30[MST]| | DOCKET: |LAST UPDATE DATE: 12/11/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOHN PELLET RDO | | |BOB PIERSON (NMSS) EO | +------------------------------------------------+FRANK CONGEL (IRD) AEOD | |NRC NOTIFIED BY: KEN WHITHAM/MR. HOLMES |ROSS SCARANO RIV | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNSHIELDED 10 mCi Eu-152 SOURCE (STRONG GAMMA EMITTER) WAS FOUND IN THE | | BACK OF A FEDERAL EXPRESS TRUCK. | | | | A SHIPMENT OF 3 EUROPIUM-152 (10 mCi EACH) SOURCES WAS SHIPPED FROM | | CANBERRA INDUSTRIES, MERIDEN, CT., TO DOE LOCATED AT IDAHO FALLS, IDAHO. | | WHEN THE SHIPMENT ARRIVED AT THE DOE SITE, IT WAS NOTED THAT THE BOX WAS | | DAMAGED. THE BOX, WHICH WAS MARKED AS A RADIOACTIVE III SHIPMENT WAS TAKEN | | TO ANOTHER ROOM AND SURVEYED. WHEN THE BOX WAS OPENED IT WAS DISCOVERED | | THAT ONE OF THE THREE CAPS ON THE LEAD PIG THAT HOLDS THE SOURCES INSIDE | | THE LEAD PIG WAS LOOSE AND THAT THE Eu-152 SOURCE ASSOCIATED WITH IT WAS | | NOT INSIDE THE LEAD PIG. DOE DID NOT TAKE POSSESSION OF THE SHIPMENT SINCE | | THE BOX WAS DAMAGED. | | | | THE FED EX DRIVER AND TRUCK WERE FOUND FOUR HOURS LATER (1730 MST) IN IDAHO | | FALLS. A SURVEY OF THE INSIDE OF THE TRUCK FOUND THE UNSHIELDED SOURCE IN | | THE BACK OF THE TRUCK. THE CONTACT READING OF THE Eu-152 ACCORDING TO ITS | | SHIPPING PAPERS WAS 5 REM/HR. THE RADIATION READING OF THE SOURCE ON FLOOR | | IN THE BACK OF THE TRUCK FROM 30 CENTIMETERS WAS 325 MREM/HR. THE SOURCE | | WAS NOT BREACHED AND NO CONTAMINATION WAS FOUND IN THE TRUCK. THE DRIVER, | | WHEN DRIVING THE TRUCK, WAS ABOUT 25 FEET FROM THE SOURCE. THE FED EX | | DRIVER ENTERED THE BACK OF THE TRUCK 4 OR 5 TIMES AND EACH TIME HE WAS NOT | | IN THE BACK OF THE TRUCK LONGER THAN 1 MINUTE. THE CLOSEST THAT THE DRIVER | | APPROACHED THE UNSHIELDED SOURCE WAS APPROXIMATELY TWO FEET. | | | | THE DOE CALLERS SAID THAT THEY DID NOT KNOW HOW THE EUROPIUM-152 GOT OUT OF | | THE LEAD PIG AND THEY DID NOT KNOW HOW LONG THE SOURCE HAD BEEN IN THE BACK | | OF THE TRUCK. DOE IS TALKING WITH FED EX ABOUT THIS INCIDENT. | | | | SEE HOO LOG BOOK FOR PHONE NUMBERS AND THE FED EX AIR BILL NUMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33394 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 12/12/97 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 01:05 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/11/97 | +------------------------------------------------+EVENT TIME: 22:30[EST]| |NRC NOTIFIED BY: DONALD ROLAND |LAST UPDATE DATE: 12/12/97 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM TRAPP 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 +------------------------------------------------------------------------------+ | FAILURE OF FLOWRATE TO REACH MINIMUM REQUIRED ON START OF HPCI. | | | | LICENSEE, DURING COMPLETION OF A SYSTEM OUTAGE WINDOW ON THE HIGH PRESSURE | | COOLANT INJECTION (HPCI) SYSTEM, MEASURED FLOW RESPONSE TIME AS 32.3 | | SECONDS, WITH AN ACCEPTANCE CRITERIA OF 5000 GPM IN 29.5 SECONDS. THE TIME | | WAS FURTHER CONFIRMED AS 32.1 SECONDS AS MEASURED BY THE GENERAL ELECTRIC | | TRANSIENT ANALYSIS AND RECORDING SYSTEM. REVIEW OF THE SYSTEM RESPONSE | | NOTED AN ANOMALOUS STROKE OF THE STEAM ADMISSION VALVE. THE VALVE STROKED | | TO 85% OPEN AND STAYED THERE FOR ABOUT 16.5 SECONDS THEN POPPED FULL OPEN. | | PREVIOUS TEST TRACES SHOW THE VALVE STROKING FULL OPEN WITHOUT STOPPING. | | | | THERE HAVE BEEN NO KNOWN ACTIVITIES PERFORMED ON THIS VALVE DURING THE WORK | | WINDOW. ENGINEERING AND VALVE TEAM PERSONNEL ARE REVIEWING THE TEST TO | | DETERMINE THE CAUSE AND REPAIRS. THE SYSTEM WILL REMAIN INOPERABLE PENDING | | THE OUTCOME OF THE EVALUATION, ALL OTHER EMERGENCY CORE COOLING SYSTEMS | | REMAIN OPERABLE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+