U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/22/98 - 07/23/98 ** EVENT NUMBERS ** 34496 34553 34559 34560 34561 34562 34563 34564 34565 34566 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34496 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/08/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:56 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/08/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 01:15[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/22/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |RONALD GARDNER RDO | | DOCKET: 0707001 |SUSAN SHANKMAN, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: W. G. HALICKS | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |OCBA 76.120(c)(2)(i) ACCID MT EQUIP FAILS | | |OCBB 76.120(c)(2)(ii) EQUIP DISABLED/FAILS | | |OCBC 76.120(c)(2)(iii) REDUNDANT EQUIP INOP | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EQUIPMENT DISABLED OR FAILS TO FUNCTION AS DESIGNED (24-HOUR REPORT) | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE PADUCAH | | PERSONNEL: | | | | "AT 0115 CDT [ON 07/08/98], A UF6 DETECTOR IN [THE] C-315 [FACILITY] ON | | [THE #2] WITHDRAWAL POSITION FIRED [(ACTUATED)]. THIS DETECTOR IS PART OF | | THE HIGH VOLTAGE UF6 RELEASE DETECTION SYSTEM FOR UF6 CONDENSERS, | | ACCUMULATORS, AND PIPING HEATED HOUSINGS, AND [IT] SOUNDS THE BUILDING | | ALARM HORN AND AN ALARM IN THE LOCAL CONTROL ROOM TO ALERT PERSONNEL TO A | | POSSIBLE RELEASE OF HAZARDOUS MATERIAL. THE ALARM RESPONSE PROCEDURE WAS | | FOLLOWED. NO EVIDENCE OF A RELEASE WAS FOUND, BUT THE ALARM WOULD NOT | | CLEAR. WITH THIS ALARM 'LOCKED IN,' SUBSEQUENT AUDIBLE ALARMS FROM OTHER | | DETECTORS COULD NOT BE RECEIVED. THE RELEASE DETECTION SYSTEM WAS DECLARED | | INOPERABLE, AND A 'SMOKE' WATCH WAS IMPLEMENTED IN ACCORDANCE WITH | | [TECHNICAL SPECIFICATION REQUIREMENT] 2.3.4.4, ACTION A.1. THE DETECTOR IN | | ALARM WAS DISCONNECTED, AND THE SYSTEM WAS TESTED AND RESTORED TO OPERABLE | | STATUS. THE WITHDRAWAL POSITION SERVED BY THIS DETECTOR WAS REMOVED FROM | | SERVICE PENDING INVESTIGATION, MAINTENANCE, AND TESTING." | | | | PADUCAH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1133 ON 07/22/98 FROM MAURER TO TROCINE * * * | | | | THIS REPORT IS RETRACTED BASED ON THE FOLLOWING INFORMATION WHICH IS A | | PORTION OF A FACSIMILE RECEIVED FROM PADUCAH PERSONNEL: | | | | "ON 07/22/98, A PLANT NUCLEAR REGULATORY AFFAIRS EVALUATION OF THE EVENT | | WAS COMPLETED. THIS EVALUATION CONCLUDED THAT DURING THE TIME THE | | OPERATORS WERE RESPONDING TO THE ALARM IN [THE] C-315 [FACILITY], ANY | | ADDITIONAL [PROCESS GAS LEAK DETECTOR (PGLD)] ALARMS WOULD HAVE BEEN | | ANNUNCIATED ON THE LOCAL SIGNAL CONDITIONER IN [THE] C-315 [AREA CONTROL | | ROOM]. NO ADDITIONAL PGLD ALARMS WERE RECEIVED DURING THE TIME THE PGLD | | DETECTOR WAS IN ALARM. THIS OPERATOR SURVEILLANCE OF THE LOCAL SIGNAL | | CONDITIONER PRESERVED THE SAFETY FUNCTION OF THE SYSTEM TO MONITOR FOR UF6 | | OUTGASSING AND ALERT PERSONNEL. SINCE THE SAFETY FUNCTION OF THE SYSTEM | | WAS MAINTAINED, THE 10 CFR 76.120 REPORTING CRITERIA IS NOT MET AND THE | | SUBJECT NOTIFICATION IS RETRACTED." | | | | PADUCAH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | OFFICER NOTIFIED THE R3DO (WRIGHT) AND NMSS EOs (COMBS AND PICCONE). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34553 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: VETERANS ADMINISTRATION HOSPITAL |NOTIFICATION DATE: 07/21/98 | | CITY: TUCSON REGION: 4 |NOTIFICATION TIME: 17:37 [ET]| | COUNTY: STATE: AZ |EVENT DATE: 07/21/98 | |LICENSE#: 0206186-01 AGREEMENT: Y |EVENT TIME: 13:37[MDT]| | DOCKET: |LAST UPDATE DATE: 07/22/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOSEPH TAPIA RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: WILLIAMS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE TUCSON VETERANS ADMINISTRATION HOSPITAL REPORTED A MEDICAL | | MISADMINISTRATION. | | | | A PATIENT WAS TO RECEIVE 20 MILLICURIES OF TECHNICIUM 99M MPD FOR A BONE | | SCAN, BUT INSTEAD, THE PATIENT RECEIVED 20 MILLICURIES OF TECHNICIUM 99M | | DTPA, WHICH IS USED FOR KIDNEY SCANS. THE MIX UP OCCURRED BECAUSE THE TWO | | RADIOPHARMACEUTICAL KITS HAVE GREEN LABELS. THE PRESCRIBING PHYSICIAN HAS | | NOT YET BEEN NOTIFIED, BUT THE PATIENT HAS BEEN NOTIFIED. NO ADVERSE | | HEALTH AFFECTS ARE EXPECTED. | | | | *** UPDATE ON 07/22/98 @ 1402 FROM WILLIAMS TO GOULD *** RETRACTION | | | | AFTER A DISCUSSION WITH NRC REGION 4, IT WAS DETERMINED THAT THIS EVENT WAS | | NOT REPORTABLE; SO THE LICENSEE IS RETRACTING THIS EVENT NOTIFICATION. | | | | THE R4DO (TAPIA) AND NMSS EO (COMBS) WERE NOTIFIED BY THE NRC OPERATIONS | | OFFICER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34559 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/22/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 08:13 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/21/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 17:25[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/22/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |GEOFFREY WRIGHT RDO | | DOCKET: 0707001 |JOSIE PICCONE, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: M. C. MAURER | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 RESPONSE - LOSS OF ONE LEG OF THE DOUBLE CONTINGENCY | | (24-HOUR REPORT) | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM PADUCAH | | PERSONNEL: | | | | "ON 07/21/98 AT 1725 [CDT], IT WAS DETERMINED THAT A NUCLEAR CRITICALITY | | SAFETY [(NCS)] VIOLATION OCCURRED WHEN IT WAS DISCOVERED THAT BAGS [GREATER | | THAN] 5.5 GALLONS, NOT CONTROLLED IN ACCORDANCE WITH [NUCLEAR CRITICALITY | | SAFETY APPROVAL (NCSA)] GUIDANCE, WERE IN USE AT A BOUNDARY CONTROL STATION | | (BCS) IN THE C-310-A BUILDING. THE BAGS WERE NOT BEING HANDLED OR | | CONTROLLED ACCORDING TO NCSA 3974-05. THE NCSA CONTAINS A REQUIREMENT | | WHICH PRECLUDES ANY UNATTENDED CONTAINERS LARGER THAN 5.5 GALLONS FROM | | BEING PERMITTED IN THE C-310-A BUILDING UNLESS THEY ARE RENDERED INCAPABLE | | OF ACCUMULATING LIQUIDS GREATER THAN 5 INCHES IN DEPTH OR GREATER THAN 5.5 | | GALLONS IN VOLUME. UNATTENDED CONTAINERS MAY BE RENDERED INCAPABLE OF | | ACCUMULATING LIQUID OR MATERIAL BY SEVERAL DIFFERENT METHODS, SUCH AS THE | | USE OF COVERS OVER OPENINGS OR HOLES IN THE CONTAINERS TO PREVENT THE | | ACCUMULATION OF LIQUIDS ABOVE THE 5-INCH DEPTH." | | | | "THE BCS BAGS USED IN C-310-A ARE ALL LARGER THAN 5.5 GALLONS. COVERS WERE | | BEING UTILIZED TO COMPLY WITH THE NCSA REQUIREMENT, BUT THE COVERS WERE NOT | | COMPLETELY IN PLACE, AND THE PERSONNEL WORKING IN THE AREA HAD LEFT THE | | AREA IN ORDER TO TAKE A BREAK IN A NEARBY TRUCK ALLEY. THERE WAS A | | MISCONCEPTION BY THE CONSTRUCTION SUPERVISOR OVER THE PROJECT AREA THAT | | WORKERS IN THE VICINITY OF THE BAGS WERE ADEQUATE CONTROLS. THE BAG | | CORNERS WERE REMOVED AT THE TIME OF DISCOVERY TO COMPLY WITH THE | | REQUIREMENTS. A BOUNDARY WAS ESTABLISHED IN FRONT OF THE BCS STATION." | | | | "SAFETY SIGNIFICANCE OF EVENTS: ALTHOUGH ONE LEG OF THE DOUBLE CONTINGENCY | | WAS LOST WITH THE NON-ATTENDANCE OF THE UNCOVERED BCS BAGS, NO | | RELEASE/ACCUMULATION OF MATERIAL OCCURRED WITHIN THE BAGS, AND MODERATOR | | WAS NOT ADDED. THEREFORE, THERE WAS NO POSSIBILITY FOR AN INADVERTENT | | CRITICALITY." | | | | "POTENTIAL CRITICALITY PATHWAYS INVOLVED...: NCSA 3974-05 REQUIRES THAT | | LARGE VOLUME CONTAINERS ([GREATER THAN] 5 GALLONS) BE RENDERED INCAPABLE OF | | ACCUMULATING LIQUIDS ABOVE A 5-INCH DEPTH. PRIOR TO THE DETERMINATION THAT | | THE BAGS HAD BEEN LEFT UNATTENDED, THE FACILITY OPERATIONS ASSISTANCE (FOA) | | HAD INFORMED THE CONSTRUCTION SUPERVISOR THAT A BETTER WAY TO COMPLY WITH | | THE NCSA REQUIREMENT WOULD BE TO REMOVE THE BAG CORNERS SO THAT THE BAGS | | WOULD BE RENDERED INCAPABLE OF ACCUMULATING LIQUIDS DEEPER THAN 5 INCHES. | | HOWEVER, DURING THE TIME FRAME IN WHICH THE BAGS WERE UNCOVERED AND | | UNATTENDED, A UF6 RELEASE IN CONJUNCTION WITH A SPRINKLER ACTIVATION WOULD | | HAVE BEEN REQUIRED TO CAUSE AN NCS CONCERN." | | | | "CONTROLLED PARAMETERS...: VOLUME." | | | | "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL...: NO FISSILE | | MATERIAL INVOLVED." | | | | "[NCS] CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE DEFICIENCIES: | | [NCS EVALUATION] NCSE KY/G-255, REV. 6, RELIES ON THE EXCLUSION OF LARGE | | VOLUME CONTAINERS FROM THE C-310-A BUILDING FOR ONE OF THE LEGS OF THE | | DOUBLE CONTINGENCY FOR THE PRODUCT WITHDRAWAL SYSTEM. THE OTHER LEG IS | | PROVIDED BY THE UF6 RELEASE DETECTION SYSTEM, WHICH WILL ALARM TO ALERT | | OPERATORS TO INVESTIGATE AND TAKE APPROPRIATE ACTION FOR THE PORTION OF THE | | WITHDRAWAL SYSTEM LOCATED WITHIN THE C-310-A BUILDING. THIS UF6 RELEASE | | DETECTION WAS OPERABLE DURING THE PERIOD WHEN THE COVERS WERE NOT IN PLACE. | | THIS OPERATOR ACTION WOULD BE TO STOP THE RELEASE BEFORE UF6 COULD COLLECT | | IN QUANTITIES SUFFICIENT ENOUGH TO POSE A THREAT OF CRITICALITY. | | ADDITIONALLY, THE PRESENCE OF A MODERATOR, PRESUMABLY IN THE FORM OF A | | SPRINKLER SYSTEM ACTIVATION, WOULD ALSO BE REQUIRED IN CONJUNCTION WITH THE | | ACCUMULATION OF SUFFICIENT QUANTITIES OF FISSILE MATERIAL. DURING THE TIME | | IN WHICH THE COVERS WERE NOT IN PLACE OVER THE BAGS, AND THE CORNERS OF THE | | BAG WERE NOT REMOVED, AND THE WORKERS WERE NOT IN ATTENDANCE OF THE BCS | | STATION; A LOSS OF ONE LEG OF THE DOUBLE CONTINGENCY EXISTED FOR THE BCS | | BAGS INSIDE THE C-310-A BUILDING." | | | | "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM...: THE BAGS WERE RENDERED | | INCAPABLE OF ACCUMULATING MATERIAL BY MAKING HOLES IN THE CONTAINERS TO | | PREVENT THE ACCUMULATION OF LIQUIDS ABOVE A 5-INCH DEPTH. A BOUNDARY WAS | | ESTABLISHED IN FRONT OF THE BCS STATION." | | | | "THIS EVENT [WAS] SUBMITTED IN ACCORDANCE WITH SAFETY ANALYSIS REPORT, | | TABLE 6.9-1, CRITERIA A.4, AS AN NRC BULLETIN 91-01, SUPPLEMENT 1, | | REPORTABLE EVENT." | | | | PADUCAH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 34560 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WEYERHAEUSER |NOTIFICATION DATE: 07/22/98 | | CITY: VALLIANT REGION: 4 |NOTIFICATION TIME: 10:45 [ET]| | COUNTY: MCCURTAIN STATE: OK |EVENT DATE: 07/21/98 | |LICENSE#: 35-14074-02 AGREEMENT: N |EVENT TIME: 16:00[CDT]| | DOCKET: |LAST UPDATE DATE: 07/22/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOSEPH TAPIA RDO | | |JOSIE PICCONE, NMSS EO | +------------------------------------------------+FRED COMBS, NMSS EO | |NRC NOTIFIED BY: BILL CAPS | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NONR OTHER UNSPEC REQMNT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INADVERTENT EXPOSURE OF THREE INDIVIDUALS TO A 100-MILLICURIE CESIUM-137 | | SOURCE AT WEYERHAEUSER (A PAPER MILL LOCATED IN VALLIANT, OKLAHOMA) | | | | AT APPROXIMATELY 1600 CDT ON 07/21/98, THREE CONTRACTORS PERFORMING STEEL | | WORK IN THE VICINITY OF A TREE CHIP BIN (TANK) REMOVED A SOURCE HOUSING | | FROM THE LEVEL MONITOR (A KAY-RAY GAUGE CONTAINING A 100-MILLICURIE | | CESIUM-137 SOURCE). APPARENTLY, THE GAUGE (MODEL #7062B, SERIAL #21458) | | WAS IN THEIR WAY, AND THE INDIVIDUALS THOUGHT THAT THE RADIOACTIVE MATERIAL | | SIGN WAS POSTED FOR THE TANK RATHER THAN THE GAUGE. AFTER REMOVAL OF THE | | SOURCE HOUSING, THE GAUGE WAS DROPPED ONTO THE GROUND. IT WAS REPORTED | | THAT THE INDIVIDUALS MOVED APPROXIMATELY 8 TO 10 FEET AWAY FROM THE BEAM | | AND THAT THEY LEFT THE AREA APPROXIMATELY 20 MINUTES LATER. CONTROL ROOM | | PERSONNEL RECEIVED INDICATION OF INCREASED RADIATION IN THE VICINITY OF THE | | TANK AND THOUGHT THAT THERE WAS A PROBLEM WITH THE RADIATION MONITOR. AS A | | RESULT, AN ELECTRICIAN WAS SENT TO INVESTIGATE THE PROBLEM. THE SHIFT | | ELECTRICIAN RECOGNIZED A PROBLEM WITH THE GAUGE, LEFT THE AREA, AND | | NOTIFIED THE CONTROL ROOM AT APPROXIMATELY 1945 CDT ON 07/21/98. (THE | | LICENSEE REPORTED THAT THIS EVENT TOOK PLACE AT SHIFT TURNOVER TIME.) | | | | PROCEDURES REQUIRE THAT THE SHUTTER BE LOCKED CLOSED BEFORE THE GAUGE IS | | REMOVED. THE RADIATION SAFETY OFFICER IS ALSO REQUIRED TO BE PRESENT. | | THESE PROCEDURES WERE NOT FOLLOWED. | | | | THE CONTRACTORS WHO REMOVED THE GAUGE FROM THE TANK WERE NOT WEARING | | THERMOLUMINESCENT DOSIMETERS. HOWEVER, THE LICENSEE HAS PERFORMED A | | WORST-CASE ESTIMATE FOR THEIR EXPOSURE. IF THE WORKERS HAD REMAINED 12 | | INCHES AWAY FROM THE SOURCE FOR THE ENTIRE 20-MINUTE TIME FRAME, IT IS | | ESTIMATED THAT THEY WOULD HAVE RECEIVED AN EXPOSURE OF 116 MILLIREM. THE | | LICENSEE DOES NOT CONSIDER THESE EXPOSURES TO BE OVEREXPOSURES. | | | | THE LICENSEE NOTIFIED THE NRC REGION 3 OFFICE (CHUCK CAIN). (REFER TO THE | | HOO LOG FOR A SITE CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34561 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. FRANCIS MEDICAL CENTER |NOTIFICATION DATE: 07/22/98 | | CITY: PITTSBURGH REGION: 1 |NOTIFICATION TIME: 13:12 [ET]| | COUNTY: STATE: PA |EVENT DATE: 07/21/98 | |LICENSE#: 37-01072-01 AGREEMENT: N |EVENT TIME: 14:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/22/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KATHLEEN MODES RDO | | |FRED COMBS, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: SURGENT | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF TWO IODINE-125 SEEDS AT ST. FRANCIS MEDICAL CENTER IN PITTSBURGH, | | PENNSYLVANIA | | | | THE ST. FRANCIS MEDICAL CENTER REPORTED THAT A PATIENT HAD 71 IODINE-125 | | SEEDS IMPLANTED FOR A PROSTATE TREATMENT. UPON THE COMPLETION OF THIS | | TREATMENT, 5 SEEDS WERE RECOVERED FROM HIS BLADDER AND ONLY 64 SEEDS WERE | | DETECTED BY X-RAY. A COMPLETE SEARCH WAS MADE OF THE ROOM, BEDDING, | | CLOTHING OF THE ATTENDING MEDICAL PERSONNEL, AND THE INSTRUMENTS THAT WERE | | USED, BUT THE TWO MISSING SEEDS COULD NOT BE FOUND. LICENSEE PERSONNEL | | ALSO TOOK ANOTHER X-RAY AND STILL DID NOT SEE THE TWO MISSING SEEDS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34562 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: GE NUCLEAR ENERGY |NOTIFICATION DATE: 07/22/98 | | RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 13:47 [ET]| |COMMENTS: LEU CONVERSION (UF6 TO UO2) |EVENT DATE: 07/21/98 | | LEU FABRICATION |EVENT TIME: 14:00[EDT]| | LWR COMMERICAL FUEL |LAST UPDATE DATE: 07/22/98 | | CITY: WILMINGTON REGION: 2 +-----------------------------+ | COUNTY: NEW HANOVER STATE: NC |PERSON ORGANIZATION| |LICENSE#: SNM-1097 AGREEMENT: Y |MARK LESSER RDO | | DOCKET: 07001113 |FRED COMBS, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: PAULSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 RESPONSE (24-HOUR REPORT) | | | | DURING ROUTINE ANNUAL SHUTDOWN ACTIVITIES, IT WAS DETERMINED THAT A MASS | | CONTROL ASSOCIATED WITH FLUORIDE WASTE TREATMENT VESSEL V-108 HAD BEEN | | DEGRADED. | | | | THE DOUBLE CONTINGENCY CRITICALITY SAFETY BASIS OF V-108 RELIES ON BOTH | | MASS AND DENSITY CONTROLS. A 9.5-KG URANIUM MASS CONTROL IS MAINTAINED BY | | A 25-PPM URANIUM CONCENTRATION LIMIT ON THE FEED TO THE V-108 VESSEL. | | SAMPLING AND IN-LINE URANIUM MONITORS ARE USED TO VERIFY THIS CONCENTRATION | | LIMIT. THE 25-PPM URANIUM LIMIT WAS EXCEEDED, AND THE MAXIMUM | | CONCENTRATION IN V-108 WAS DETERMINED TO BE 37.5 PPM URANIUM, WHICH | | CORRESPONDS TO 14.2 KG URANIUM IN V-108. ALTHOUGH THE INTERNAL PROCEDURAL | | LIMITS WERE EXCEEDED, THE MASS IN THE VESSEL REMAINED BELOW THE SAFE BATCH | | VALUE OF 15.9 KG URANIUM AT 5% ENRICHMENT. THE INDEPENDENT CONTROL ON | | DENSITY REMAINED LESS THAN 1.2 G/CC AT ALL TIMES, THUS NO UNSAFE CONDITION | | EXISTED. | | | | THE MASS CONTROL WAS REESTABLISHED WITHIN 4 HOURS. THIS EVENT IS DUE TO | | DEGRADATION OF THE MASS CONTROL ON V-108. | | | | THE NRC RESIDENT INSPECTOR AND APPLICABLE STATE AND LOCAL AGENCIES WILL BE | | INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34563 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 07/22/98 | |UNIT: [1] [ ] [ ] STATE: MA |NOTIFICATION TIME: 16:13 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 07/22/98 | +------------------------------------------------+EVENT TIME: 15:18[EDT]| |NRC NOTIFIED BY: SULLIVAN |LAST UPDATE DATE: 07/22/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KATHLEEN MODES 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 +------------------------------------------------------------------------------+ | OUTSIDE AIR TEMPERATURE HAS EXCEEDED THE DESIGN TEMPERATURE FOR THE | | EMERGENCY DIESEL GENERATORS (EDG). | | | | OUTSIDE AIR TEMPERATURE HAS EXCEEDED 88øF, PLACING THE PLANT OUTSIDE ITS | | DESIGN BASIS AS DESCRIBED IN THE PLANT'S FINAL SAFETY ANALYSIS REPORT, AND | | IT IS EXPECTED TO EXCEED THIS VALUE AGAIN BETWEEN NOW AND THE END OF THE | | SUMMER. ALL FUTURE OCCURRENCES OF TEMPERATURES EXCEEDING 88øF WILL BE | | DOCUMENTED. | | | | THE EDGs ARE OPERABLE, AND AN ENGINEERING EVALUATION HAS BEEN WRITTEN | | RECOMMENDING THAT THE EDGs BE CONSIDERED OPERABLE UP TO AN OUTSIDE | | TEMPERATURE OF 95øF. IF OUTSIDE TEMPERATURES EXCEED 95øF, BOTH EDGs WILL | | BE DECLARED INOPERABLE. | | | | THE EDGs ARE RATED FOR 2,600 KW CONTINUOUS AND 2,860 KW FOR 2 HOURS IN A | | 24-HOUR PERIOD. THESE RATINGS ARE BASED ON A MAXIMUM OUTSIDE TEMPERATURE | | OF 88øF. | | | | ENGINEERING EVALUATION 97-EE-19, REV. 3, DETERMINED THAT OPERATION ABOVE | | THE DESIGN LIMIT OF 88øF IS ACCEPTABLE UP TO 95øF. AT OUTSIDE TEMPERATURES | | ABOVE 95øF, SOME EDG AND EDG SUBSYSTEM TEMPERATURE LIMITS MAY BE EXCEEDED. | | IN ADDITION TO THE IMPACT ON ENGINE COMPONENTS, THIS EVALUATION INCLUDES | | THE IMPACT OF HIGHER THAN DESIGN OUTSIDE AIR TEMPERATURE ON EDG FUEL | | CONSUMPTION AND ELECTRICAL CABINET COMPONENTS. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34564 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 07/22/98 | |UNIT: [1] [2] [ ] STATE: SC |NOTIFICATION TIME: 18:38 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/22/98 | +------------------------------------------------+EVENT TIME: 17:50[EDT]| |NRC NOTIFIED BY: BRISSON |LAST UPDATE DATE: 07/22/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK LESSER RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INADEQUATE TESTING METHOD FOR AUXILIARY BUILDING VENT SYSTEM SURVEILLANCE | | | | DURING THE REVIEW OF AUXILIARY BUILDING VENTILATION TECHNICAL SPECIFICATION | | SURVEILLANCE REQUIREMENTS, IT WAS DETERMINED THAT THE CURRENT TESTING | | METHOD IS INADEQUATE, THEREBY MAKING THE VENT SYSTEM INOPERABLE. IN | | ACCORDANCE WITH THE 18-MONTH SURVEILLANCE, THE SYSTEM SHALL BE VERIFIED TO | | MAINTAIN THE EMERGENCY CORE COOLING SYSTEM PUMP ROOM AT A NEGATIVE PRESSURE | | RELATIVE TO ADJACENT AREAS. THIS IS CURRENTLY DONE BY SMOKE TESTING THE | | DOORS PROVIDING ACCESS TO THE ROOMS. THIS, HOWEVER, DOES NOT DEMONSTRATE | | THE PRESSURE RELATIONSHIP BETWEEN THESE ROOMS AND ADJACENT DUCT SHAFTS, | | PIPE TRENCHES, AND MECHANICAL PENETRATION ROOM. | | | | THE PLANT IS IN A 24-HOUR LIMITING CONDITION FOR OPERATION (LCO) ACTION | | STATEMENT TO TEST PROPERLY ALL FOUR TRAINS OF THE VENT SYSTEM OR AT LEAST | | GET ONE TRAIN ON EACH UNIT VERIFIED OPERABLE AND THEN ENTER A 7-DAY LCO | | ACTION STATEMENT. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34565 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 07/22/98 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 18:42 [ET]| |RX TYPE: [1] CE |EVENT DATE: 07/22/98 | +------------------------------------------------+EVENT TIME: 17:08[CDT]| |NRC NOTIFIED BY: MATZKE |LAST UPDATE DATE: 07/22/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOSEPH TAPIA 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 THE POST-ACCIDENT SAMPLING SYSTEM (PASS) TO BE | | OUTSIDE ITS DESIGN BASIS. | | | | ON 06/25/98, THE PASS RETURN VALVE TO THE REACTOR COOLANT DRAIN TANK FAILED | | TO OPEN WHILE RUNNING THE PASS. THIS RESULTED IN THE UPSTREAM WASTE | | DISPOSAL SYSTEM CONTAINMENT ISOLATION VALVE, HCV-500A, EXPERIENCING A BODY | | TO BONNET LEAK. THE PASS SEQUENCE BEING RUN INVOLVED DRAWING A LIQUID | | REACTOR COOLANT SYSTEM SAMPLE IN THE ACCIDENT MODE. THE PASS DISCHARGES TO | | THE WASTE DISPOSAL SYSTEM. VALVE HCV-500A WAS DECLARED INOPERABLE AND SHUT | | PER TECHNICAL SPECIFICATIONS AS REQUIRED. VALVE HCV-500A WAS SUBSEQUENTLY | | REPAIRED, TESTED, AND RETURNED TO SERVICE ON 06/26/98. THE PASS RETURN | | VALVE TO THE REACTOR COOLANT DRAIN TANK HAS ALSO BEEN REPAIRED. | | | | IN THE COURSE OF PERFORMING A FAILURE ANALYSIS IN CONJUNCTION WITH | | RESOLVING THE ISSUE, A DESIGN DEFICIENCY WITH THE PASS INTERFACE WITH THE | | WASTE DISPOSAL SYSTEM WAS DISCOVERED. THE PASS IS CAPABLE OF DISCHARGING A | | SAMPLE AT 450øF AND 2,100 PSIG. THE WASTE DISPOSAL SYSTEM CONTAINMENT | | ISOLATION VALVES ARE RATED AT 300øF (MAXIMUM) AT 90 PSIG AND 120øF AT 150 | | PSIG. THEREFORE, THE PASS HAS THE POTENTIAL TO CHALLENGE THE INTEGRITY OF | | THE WASTE DISPOSAL SYSTEM CONTAINMENT ISOLATION VALVES. | | | | THE PASS LIQUID SAMPLE SEQUENCES CONTINUE TO BE INOPERABLE. THE PASS | | LIQUID SEQUENCES ARE PROHIBITED FROM USE, AND THE PLANT IS CURRENTLY WITHIN | | ITS DESIGN BASIS. A DESIGN CHANGE IS PRESENTLY BEING PREPARED TO CORRECT | | THE PROBLEM. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 34566 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: US AIR FORCE RADIOISOTOPE COMMITTEE |NOTIFICATION DATE: 07/22/98 | | CITY: KIRTLAND AIR FO REGION: 4 |NOTIFICATION TIME: 19:38 [ET]| | COUNTY: STATE: NM |EVENT DATE: 07/22/98 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 16:30[MDT]| | DOCKET: |LAST UPDATE DATE: 07/22/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOSEPH TAPIA RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: HICKS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE U.S. AIR FORCE RADIOISOTOPE COMMITTEE RECEIVED A REPORT THAT FOUR | | TRITIUM EXIT SIGNS WERE DAMAGED AT KIRTLAND AIR FORCE BASE, NEW MEXICO. | | | | DURING THE DEMOLITION OF AN OLD HOSPITAL AT KIRTLAND AIR FORCE BASE, NEW | | MEXICO, A DUMP TRUCK RAN OVER AND SMASHED FOUR TRITIUM EXIT SIGNS. THERE | | WERE 27 SIGNS IN THE HOSPITAL, AND THE 23 UNDAMAGED SIGNS, ALONG WITH THE | | DAMAGED SIGNS, WERE PLACED IN A LOCKED STORAGE AREA. THE SIGNS WERE MADE | | BY SAUNDER ROE (NOW SRB), AND ARE MODEL "SAFETY-10." | | | | AT THIS TIME, THE LICENSEE IS NOT SURE IF ANY EXPOSURES OCCURRED BUT PLANS | | TO HAVE THE CONTRACTOR IDENTIFY PERSONNEL WHO WERE NEAR THE SIGNS. THE | | LICENSEE ALSO PLANS TO PERFORM A STUDY TO COME UP WITH AN EXPOSURE | | ASSESSMENT FOR THESE INDIVIDUALS. THE DAMAGED SIGNS WERE WRAPPED IN PLASTIC | | PRIOR TO BEING PLACED IN STORAGE. | +------------------------------------------------------------------------------+