U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/27/1998 - 10/28/1998 ** EVENT NUMBERS ** 34956 34959 34960 34961 34962 34963 +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 34956 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 10/25/1998| | UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 14:00[EDT]| | RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 10/25/1998| +------------------------------------------------+EVENT TIME: 14:00[EDT]| | NRC NOTIFIED BY: PHIL SANTINI |LAST UPDATE DATE: 10/27/1998| | HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |LAURIE PELUSO RDO | |10 CFR SECTION: |STUART RICHARDS EO | |NINF INFORMATION ONLY |LARRY NICOLSON, R1 IAT | | |JOHN DAVIDSON, NMSS IAT | | |RICHARD ROSANO, NRR IAT | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |2 N -1 99 Power Operation |99 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PLANNED TAX PROTEST HELD IN FRONT OF FACILITY | | | | AT ABOUT 2:OO PM, A DEMONSTRATION WAS HELD IN FRONT OF THE GATES OF THE | | INDIAN POINT 2 NUCLEAR POWER PLANT AS PART OF A PROTEST CONCERNING A | | PROPOSED TAX WRITE-OFF FOR THE CONSOLIDATED EDISON COMPANY THAT IS INCLUDED | | ON THE NOVEMBER BALLOT. THE DEMONSTRATION, ATTENDED BY ABOUT 800 PEOPLE, WAS | | PEACEFUL AND LASTED APPROXIMATELY 30 MINUTES. | | | | THE LICENSEE HAS INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE ON 10/27/98 AT 0838 EST BY FANGIE JONES * * * | | | | TO CORRECT THE TEXT OF THE EVENT NOTIFICATION, IT SHOULD SAY ".. A PROPOSED | | TAX FILING BY THE CONSOLIDATED EDISON COMPANY." IT IS NOT A BALLOT ISSUE. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Other Nuclear Material |Event Number: 34959 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: OHIO STATE UNIVERSITY |NOTIFICATION DATE: 10/27/1998| | CITY: COLUMBUS REGION: 3 |NOTIFICATION TIME: 12:00[EST]| | COUNTY: STATE: OH |EVENT DATE: 10/15/1998| |LICENSE#: 34-00293-02 AGREEMENT: N |EVENT TIME: 14:00[EST]| | DOCKET: |LAST UPDATE DATE: 10/27/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |JAMES CREED R3 | | |LARRY CAMPER NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: R PETERSON | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT RECEIVED 5000 CENTIGRAYS INSTEAD OF 4000 CENTIGRAYS | | | | THIS INCIDENT OCCURRED AT OHIO STATE UNIVERSITY ARTHUR JAMES CANCER HOSPITAL | | LOCATED IN COLUMBUS, OHIO. | | | | A TEMPORARY BRACHYTHERAPY PROCEDURE WAS PERFORMED ON A PATIENT. ON 10/17/98 | | A PATIENT RECEIVED IMPLANTS WITH A TOTAL ACTIVITY OF 193.5 MILLICURIES | | (90.75 MILLICURIES OF CESIUM-137 AND 102.75 MILLICURIES OF IRIDIUM-192). ON | | 10/17/98 THE IMPLANTS WERE TAKEN OUT OF THE PATIENT (SEEDS WERE IN THE | | PATIENT FOR 50 HOURS). TODAY, 10/27/98, DURING A QUALITY ASSURANCE AUDIT BY | | THE MEDICAL PHYSICIST STAFF IT WAS DISCOVERED THAT THE PATIENT HAD RECEIVED | | 5000 CENTIGRAYS INSTEAD OF 4000 CENTIGRAYS. THE PATIENT RECEIVED A HIGHER | | DOSE THAN EXPECTED BECAUSE THEY USED A DIFFERENT TREATMENT PLANNING | | COMPUTER. THE OLD TREATMENT PLANNING COMPUTER REQUIRES INFORMATION FOR | | CESIUM-137 TO BE UNITS OF MILLIGRAM RADIUM EQUIVALENT AND THEIR NEW | | TREATMENT PLANNING COMPUTER REQUIRED THE INFORMATION FOR CESIUM-137 TO BE | | UNITS OF MILLICURIES. UNFORTUNATELY IT WAS ASSUMED THAT THE INFORMATION | | ENTERED WAS IN THE UNITS OF MILLIGRAM RADIUM EQUIVALENT. THE PATIENT WAS | | IMPLANTED WITH 36.3 MILLIGRAM RADIUM EQUIVALENT INSTEAD OF 36.3 MILLICURIES. | | THE TOTAL ACTIVITY OF CESIUM-137 IMPLANTED WAS 90.75 MILLICURIES RATHER THAN | | 36.3 MILLICUIRES OF CESIUM-137. | | | | THE PATIENT WAS SUPPOSED TO HAVE RECEIVED A DOSE RATE OF 80 CENTIGRAYS PER | | HOUR FOR 50 HOURS BUT INSTEAD HE RECEIVED A DOSE RATE OF 100 CENTIGRAYS PER | | HOUR FOR 50 HOURS. | | | | THE PATIENT'S PHYSICIAN WILL BE INFORMED OF THIS MEDICAL MISADMINISTRATION. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Other Nuclear Material |Event Number: 34960 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: KLEINFELDER, INC. |NOTIFICATION DATE: 10/27/1998| | CITY: PUEBLO REGION: 4 |NOTIFICATION TIME: 13:00[MST]| | COUNTY: STATE: CO |EVENT DATE: 10/27/1998| |LICENSE#: 958-01 AGREEMENT: Y |EVENT TIME: 10:00[MST]| | DOCKET: |LAST UPDATE DATE: 10/27/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |PELLET, JOHN R4 | | | | +------------------------------------------------+ | | NRC NOTIFIED BY: LARRY FRANK | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TROXLER MOISTURE DENSITY GAUGE RUN OVER AND DAMAGED (SOURCES INTACT). | | | | NOTIFIED BY THE NATIONAL RESPONSE CENTER THAT A MOISTURE DENSITY GAUGE HAD | | BEEN RUN OVER IN WALSENBURG, CO. | | | | NUCLEAR REGULATORY COMMISSION OPERATIONS CENTER CALLED KLEINFELDER INC., | | LOCATED IN PUEBLO, CO. A TROXLER MOISTURE DENSITY GAUGE, MODEL # 3430 (8 | | MILLICURIES OF CESIUM-137 AND 40 MILLICURIES OF AMERICIUM-241/BERYLLUM) WAS | | DAMAGED BY A ROLLER. THE MOISTURE DENSITY GAUGE OUTSIDE PLASTIC CASE WAS | | BROKEN AND THE ELECTRONICS FOR THE GAUGE WAS DAMAGED. THE TROXLER MOISTURE | | DENSITY GAUGE WAS SURVEYED FOR ABNORMAL RADIOACTIVITY LEVELS AND IT WAS | | FOUND THAT THE SOURCES CONTAINED INSIDE THE TROXLER MOISTURE DENSITY GAUGE | | WERE NOT DAMAGED. WALSENBURG, CO. IS LOCATED ABOUT 50 MILES FROM PUEBLO, CO. | | THE TROXLER MOISTURE DENSITY GAUGE WILL BE SHIPPED BACK TO KLEINFELDER | | INC., LOCATED IN PUEBLO, CO., AND THEN IT WILL BE SHIPPED BACK TO THE | | TROXLER COMPANY IN NC. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 34961 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 10/27/1998| | UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 13:00[EST]| | RXTYPE: [1] W-4-LP |EVENT DATE: 10/27/1998| +------------------------------------------------+EVENT TIME: 13:00[EST]| | NRC NOTIFIED BY: KILBY |LAST UPDATE DATE: 10/27/1998| | HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |CONTE, RICHARD R1 | |10 CFR SECTION: | | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N -1 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION MADE TO NATIONAL MARINE FISHERIES SERVICE IN | | GLOUCESTER, MA. | | | | A SEAL SKULL WAS DISCOVERED IN SEABROOK STATION'S SCREEN WASH DEBRIS TODAY. | | THE SKULL APPEARS TO BE AT LEAST SEVERAL WEEKS OLD. THIS 24-HOUR | | NOTIFICATION IS MADE IN ACCORDANCE WITH SECTION 4.1 OF THE ENVIRONMENTAL | | PROTECTION PLAN, APPENDIX B OF OPERATING LICENSE. THE NATIONAL MARINE | | FISHERIES SERVICE IN GLOUCESTER, MASSACHUSETTS HAS BEEN NOTIFIED UNDER THE | | MARINE MAMMAL PROTECTION ACT. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 34962 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: GINNA REGION: 1 |NOTIFICATION DATE: 10/27/1998| | UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 14:00[EST]| | RXTYPE: [1] W-2-LP |EVENT DATE: 10/27/1998| +------------------------------------------------+EVENT TIME: 10:00[EST]| | NRC NOTIFIED BY: D PETERSON |LAST UPDATE DATE: 10/27/1998| | HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: |CONTE, RICHARD R1 | |10 CFR SECTION: | | |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 -1 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PARTICULATE MONITOR INCREASED TO ITS ALARM SETPOINT. | | | | THE CONTROL ROOM AIR PARTICULATE MONITOR R37 INCREASED TO ITS ALARM | | SETPOINT. AT THE TIME OF THE ALARM THE CONTROL ROOM VENTILATION SYSTEM WAS | | ALREADY IN RECIRCULATION AS A RESULT OF WORK ON THE CONTROL ROOM NOBLE GAS | | MONITOR. | | | | THE REASON WHY PARTICULATE MONITOR R37 INCREASED TO ITS ALARM SETPOINT WAS | | DUE TO A TEMPERATURE INVERSION. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 34963 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 10/27/1998| | UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 14:00[CST]| | RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 10/27/1998| +------------------------------------------------+EVENT TIME: 13:00[CST]| | NRC NOTIFIED BY: K YATES |LAST UPDATE DATE: 10/27/1998| | HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |CREED, JAMES R3 | |10 CFR SECTION: |HODGE, VERN NRR | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | |2 N -1 99 Power Operation |99 Power Operation | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | HIGH PRESSURE COOLANT INJECTION (HPCI) GLAND SEAL LEAK OFF (GSLO) LEVEL | | SWITCHES FAILURE. | | | | THIS PART 21 WAS FACSIMILED TO THE NRC HEADQUARTERS OPERATION CENTER | | | | "ON MAY 4, 1998, AT 0433 HOURS, WHILE PERFORMING DRESDEN OPERATING | | SURVEILLANCE (DOS) 2300-09, HPCI GSLO DRAIN PUMP AND CONDENSER HOTWELL LEVEL | | CONTROL FUNCTIONAL TEST, THE HOTWELL DRAIN PUMP EXHIBITED ERRATIC OPERATION | | AND RESULTED IN A HOTWELL LOW LEVEL. " | | | | CAUSE OF THE EVENT | | | | "THE ROOT CAUSE OF THIS EVENT WAS A MANUFACTURER DESIGN DEFICIENCY OF THE | | INSTALLED HPCI GSLO CONDENSER HOTWELL LEVEL CONTROL SWITCHES (NRC CAUSE | | CODE B). THE SWITCHES FAILED DUE TO A COMBINATION OF INSUFFICIENT MAGNET | | STRENGTH AND TOO MUCH TRAVEL IN THE FLOAT MECHANISM TO CONSISTENTLY ACTUATE | | THE FLOAT MICROSWITCH." | | | | CORRECTIVE ACTIONS: | | | | "THE UNIT 2 HPCI GSLO HOTWELL PUMP START/STOP LEVEL SWITCHES WERE REPLACED | | WITH OEM MODIFIED DESIGN SWITCHES, AND SATISFACTORILY TESTED. | | | | "THE UNIT 3 HPCI GSLO HOTWELL PUMP START/STOP LEVEL SWITCHES WERE REPLACED | | WITH OEM MODIFIED DESIGN SWITCHES, AND SATISFACTORILY TESTED. | | | | "THE PARTS REQUISITION SYSTEM (SI SYSTEM) WAS UPDATED TO SPECIFY THE | | MODIFIED OEM SWITCHES ENHANCED WITH STRONGER MAGNETS AND FLOAT STOPS." | +------------------------------------------------------------------------------+