U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/02/98 - 09/03/98 ** EVENT NUMBERS ** 34722 34724 34725 34726 34727 34728 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34722 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 09/01/98 | |UNIT: [3] [ ] [ ] STATE: LA |NOTIFICATION TIME: 17:36 [ET]| |RX TYPE: [3] CE |EVENT DATE: 09/01/98 | +------------------------------------------------+EVENT TIME: 16:00[CDT]| |NRC NOTIFIED BY: MEIKLEJOHN |LAST UPDATE DATE: 09/02/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |IAN BARNES RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |WILLIAM BATEMAN EO | | |DEPUY FEMA | | |ROSEMARY HOGAN IRD | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE PLANT DECLARED AN UNUSUAL EVENT DUE TO THE DECLARATION BY ST CHARLES | | PARISH OF A HURRICANE WARNING. THE PLANT WILL START SHUTTING DOWN | | APPROXIMATELY 12HRS PRIOR TO THE ESTIMATED ARRIVAL OF TROPICAL STORM EARL. | | | | THE RESIDENT INSPECTOR WAS NOTIFIED. | | | | * * * UPDATE 1019EDT ON 9/2/98 FROM MARK CHAISSON TO S.SANDIN * * * | | | | THE LICENSEE TERMINATED THE UNUSUAL EVENT AT 0908CDT AFTER THE HURRICANE | | WARNINGS WERE LIFTED. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | NOTIFIED R4DO(BARNES), EO(STOLZ), IRD(HOGAN) AND FEMA(SWEETSER). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34724 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 09/02/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 01:41 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 09/01/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 10:00[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 09/02/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |ROGER LANKSBURY RDO | | DOCKET: 0707001 |JOHN SURMEIER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: W.F. CAGE | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING USE OF EQUIPMENT NOT ANALYZED | | FOR IN THE APPLICABLE NUCLEAR CRITICALITY SAFETY EVALUATION (NCSE). | | | | "ON 9/1/98 AT 1000CDT, A PRE-FILTER WAS DISCOVERED IN THE C-360 UF6 SAMPLE | | CABINET VENTILATION SYSTEM. THE APPLICABLE NCSE FOR THIS OPERATION | | (KY/S-241) DOES NOT INCLUDE ANALYSIS FOR THE USE OF A PRE-FILTER. FIELD | | OBSERVATIONS PERFORMED IN RESPONSE TO THIS INCIDENT CONFIRMED THAT THERE | | WAS NO INDICATION OF FISSILE MATERIAL ACCUMULATION ON THE PRE-FILTER OR THE | | HEPA SYSTEM FILTER ENCLOSURE. THE SYSTEM WAS FLAGGED OFF TO INSURE | | MAINTAINING SPACING FROM FISSILE/POTENTIALLY FISSILE MATERIALS, TAGGED 'DO | | NOT OPERATE', DECLARED INOPERABLE BY THE PLANT SHIFT SUPERINTENDENT, AND | | NUCLEAR CRITICALITY SAFETY WAS NOTIFIED TO INVESTIGATE. | | | | "THIS EVENT IS SUBMITTED IN ACCORDANCE WITH SAFETY ANALYSIS REPORT TABLE | | 6.9-1, CRITERIA A.4.a AS AN NRC BULLETIN 91-01, SUPPLEMENT 1." | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34725 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: GARDEN CITY HOSPITAL |NOTIFICATION DATE: 09/02/98 | | CITY: GARDEN CITY REGION: 3 |NOTIFICATION TIME: 11:35 [ET]| | COUNTY: WAYNE STATE: MI |EVENT DATE: 09/01/98 | |LICENSE#: 21-04072-01 AGREEMENT: N |EVENT TIME: 23:30[EDT]| | DOCKET: |LAST UPDATE DATE: 09/02/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROGER LANKSBURY RDO | | |DON COOL EO | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. LUTSIC | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PATIENT UNDERGOING TREATMENT FOR STAGE IV CANCER RECEIVED A VARIATION IN | | EXCESS OF 50% OF THE PRESCRIBED PALLIATIVE DOSE. | | | | AT 2330EDT ON 9/1/98 A NURSE DURING ROUNDS DISCOVERED THAT A FEMALE PATIENT | | UNDERGOING TREATMENT FOR ENDOMETRIAL CANCER HAD REMOVED HER APPLICATOR | | CONTAINING THREE (3) CESIUM-137 SOURCES; 17.76 mCi, 25.05 mCi AND 25.0 mCi. | | THE PATIENT RECEIVED ONLY 278 OF THE 580 mGRAM RADIUM EQUIVALENT HOURS | | DOSE. THE PRESCRIBING PHYSICIAN DOES NOT PLAN ON RESCHEDULING TREATMENT | | SINCE THE THERAPY WAS PALLIATIVE IN NATURE TO MINIMIZE BLEEDING. THE | | LICENSEE INFORMED REGION 3(JONES). | | | | SEE HOO LOG FOR CONTACT INFORMATION. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34726 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 09/02/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 13:41 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 09/01/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:30[EDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 09/02/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |ROGER LANKSBURY RDO | | DOCKET: 0707002 |FRED COMBS NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: LARSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 24 HOUR 91-01 BULLETIN RESPONSE | | | | WHILE PERFORMING UPGRADES, LABORATORY PERSONNEL DISCOVERED A NONCOMPLIANCE | | WITH NCSA_PLANT-045.A01 "SAFE VOLUME CONTAINERS" CONTROL "A" REQUIREMENT #5 | | (SPACING) WAS NOT MAINTAINED FOR CONTINGENCY EVENT A/B.7.1. CONTROL "B" | | WAS MAINTAINED THROUGH OUT. THE SPACING VIOLATION OCCURRED WHEN A 2S | | SAMPLE CONTAINER WAS PLACED IN A GLOVEBOX NEXT TO A NOMINAL 1 LITER METAL | | BEAKER USED TO HOLD SCRAP PARTS FROM 2S SAMPLE CONTAINER REPAIRS. | | THIS AFFECTED ROOM 114 IN BUILDING X-710. | | | | THE LOSS OF THE SPACING CONTROL FOR THIS OPERATION HAS A LOW SAFETY | | SIGNIFICANCE. THIS OPERATION WAS NOT OPERATING AT THIS TIME AND IT IS | | UNLIKELY THAT THE CONTAINER HAD GREATER THAN 350 GRAMS OF URANIUM. | | | | THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR | | RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT. | | | | CORRECTIVE ACTION CONSISTED OF SYSTEM TAGOUT UNDER GROUP MANAGER'S CONTROL. | | | | THE RESIDENT INSPECTOR AND DOE SITE REPRESENTATIVE WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34727 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: METCALF INSTITUTE OF RAD ONCOLOGY |NOTIFICATION DATE: 09/02/98 | | CITY: ORANGE REGION: 1 |NOTIFICATION TIME: 16:07 [ET]| | COUNTY: STATE: NJ |EVENT DATE: 07/27/98 | |LICENSE#: 29-03038-02 AGREEMENT: N |EVENT TIME: 12:50[EDT]| | DOCKET: |LAST UPDATE DATE: 09/02/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |DAVID LEW RDO | | |FRED COMBS NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: BARBA | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE METCALF INSTITUTE OF RADIATION ONCOLOGY AT THE HOSPITAL CENTER IN | | ORANGE, N.J. REPORTED AN INCIDENT WHERE A PATIENT WHO WAS SCHEDULED TO BE | | GIVEN BRACHYTHERAPY FOR A PERIOD OF 72 HRS, STARTING ON 7/27/98, REMOVED | | THE TREATMENT SOURCE AFTER 53.5 HRS ON 7/29/98. THERE WAS NO CONTAMINATION | | AND THE SOURCE WAS COLLECTED AND SECURED IN THEIR LABORATORY. THERE WERE | | NO ADVERSE AFFECTS TO THE PATIENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34728 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 09/02/98 | |UNIT: [1] [ ] [ ] STATE: MA |NOTIFICATION TIME: 18:40 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 09/02/98 | +------------------------------------------------+EVENT TIME: 18:30[EDT]| |NRC NOTIFIED BY: SULLIVAN |LAST UPDATE DATE: 09/02/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DAVID LEW 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS DETERMINED THAT THE EMERGENCY DIESEL GENERATOR (EDG) FUEL | | OIL TANKS MAY BE INSUFFICIENT TO SUPPORT OPERATION OF BOTH EDGs DURING A | | DESIGN BASIS LOCA. | | | | THE TECH SPEC 3.9.A.3 MINIMUM REQUIREMENT OF 19,800 GALLONS PER EDG TANK | | (39,600 GALLONS TOTAL) IS INSUFFICIENT TO SUPPORT THE LOADS ASSUMED TO BE | | OPERATING FOR SEVEN DAYS WHEN BOTH EDG's ARE RUNNING IN RESPONSE TO THE | | DESIGN BASIS LOCA WITH LOSS OF OFFSITE POWER AS DESCRIBED IN UFSAR | | 14.5.3.1.2. THIS WAS DISCOVERED DURING REVISION TO SR CALCULATION S&SA 55 | | "MINIMUM ONSITE DIESEL FUEL REQUIREMENT". THIS REPRESENTS A CONDITION | | OUTSIDE DESIGN BASIS. | | | | PRELIMINARY CALCULATION INDICATES THAT THE TOTAL QUANTITY OF FUEL CONSUMED | | BY BOTH EDG's OVER SEVEN DAYS IS APPROXIMATELY 44,200 GALLONS. THIS VALUE | | IS PRELIMINARY AND, AT THE TIME OF THIS REPORT, NOT YET VERIFIED. THEY | | PRESENTLY HAVE MORE THAN THE REQUIRED 44,200 GALLONS OF FUEL OIL ON HAND, | | SO THEY ARE NOT IN ANY LCO ACTION STATEMENT. | | | | IN ADDITION, THIS PROBLEM WAS NOT IDENTIFIED DURING THE ROOT CAUSE ANALYSIS | | PERFORMED FOR PROBLEM REPORT 98.9052 WHICH WAS WRITTEN FOR A SIMILAR ISSUE | | REGARDING ONSITE EDG FUEL CAPACITY. | | | | THE POSSIBLE CAUSE FOR THIS CONDITION IS THAT THE DESIGN BASIS FOR THE | | SEVEN DAY SUPPLY HAS NOT BEEN AMENDED OVER THE YEARS TO INCLUDE ANY IMPACTS | | FROM CHANGES TO THE PHYSICAL PLANT. | | | | THE LICENSEE NOTIFIED THE RESIDENT INSPECTOR AND WILL NOTIFY THE STATE. | +------------------------------------------------------------------------------+