U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/04/1998 - 12/07/1998 ** EVENT NUMBERS ** 35114 35115 35116 35117 35118 35119 35120 +------------------------------------------------------------------------------+ |Hospital |Event Number: 35114 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: WASHINGTON HOSPITAL CENTER |NOTIFICATION DATE: 12/04/1998| | CITY: Washington REGION: 1 |NOTIFICATION TIME: 11:05[EST]| | COUNTY: STATE: DC |EVENT DATE: 10/28/1998| |LICENSE#: SNM-1446 AGREEMENT: N |EVENT TIME: [EST]| | DOCKET: |LAST UPDATE DATE: 12/04/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |GLENN MEYER R1 | | |JOSEPHINE PICCONE/EO NMSS | +------------------------------------------------+STUART RUBIN, AEOD IRD | | NRC NOTIFIED BY: DR. BILLY BASS | | | HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | | |NCAR CARDIAC PACEMAKER | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF A COROTOMIC NUCLEAR-POWERED PACEMAKER CONTAINING 250 MILLIGRAMS | | (APPROXIMATELY 2.8 CURIES) OF PLUTONIUM-238 | | | | The following text is a portion of a facsimile addressed to NRC Region 1 | | (received from the licensee on 11/30/98): | | | | "Pursuant to a telephone conversation with Teresa Darden of [the NRC Region | | 1] office we are notifying you of the potential loss of a nuclear pacemaker | | containing [approximately] 250 milligrams of Pu-238. The pacemaker was | | shipped on September 15, 1998. A routine follow up phone call determined | | late in October that the manufacturer had no record of receiving the | | pacemaker. A thorough survey of the Washington Hospital Center facility has | | turned up nothing. The manufacturer is currently in [the] process of | | performing a survey of their facility to track the pacer's whereabouts. A | | trace of electronic mail records has been started with the U.S. Postal | | Service. Results are expected within 2 weeks." | | | | "Exposure levels at 1 meter from the pacemaker are about 20 microR/[hour] | | presenting no risk to public individuals who may come in contact with the | | device." The licensee stated that dose rates at the surface of the source | | are approximately 300 microR/hour. | | | | The licensee intended to ship the model-OMNISTAMCOR pacemaker from | | Washington Hospital Center to Acufix Research Institute located in Florida; | | however, it was sent to St. Jude Medical, Inc., located in Filmar, | | California. Apparently, neither Acufix Research Institute nor St. Jude | | Medical, Inc., received the shipment. | | | | (Contact the NRC Operations Center for licensee contact telephone numbers.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35115 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: BOTHWELL REGIONAL HEALTH CENTER |NOTIFICATION DATE: 12/04/1998| | CITY: SEDALIA REGION: 3 |NOTIFICATION TIME: 12:53[EST]| | COUNTY: STATE: MO |EVENT DATE: 11/12/1998| |LICENSE#: 24-16275-02 AGREEMENT: N |EVENT TIME: 12:00[CST]| | DOCKET: |LAST UPDATE DATE: 12/04/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |BRUCE BURGESS R3 | | |FRED COMBS NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: DINA CURRY | | | HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A patient received 15 teletherapy treatments each with a dosage of 264 cGy | | vice the intended 200 cGy for a total exposure of 3960 cGy. The total | | intended dose was 5000 cGy, but the treatments were stopped when the error | | was discovered. The misadministration was attributed to human error in | | calculating the dose and was discovered during a routine review on 12/3/98. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35116 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 12/04/1998| | UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 13:43[EST]| | RXTYPE: [1] CE |EVENT DATE: 12/04/1998| +------------------------------------------------+EVENT TIME: 11:44[CST]| | NRC NOTIFIED BY: DAVE BANNISTER |LAST UPDATE DATE: 12/04/1998| | HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |DALE POWERS R4 | |10 CFR SECTION: | | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | TECH SPEC REQUIRED SHUTDOWN | | | | "During the performance of a routine replacement of the 27 74/1A4 'Bus 1A4 | | OPLS (Offsite Power Low Signal) Undervoltage Relay Sensor', a question was | | raised regarding the seismic qualification of the relay. It was determined | | that the relay covers were not fully installed. | | | | "An action/request was generated for design engineering to determine if the | | relays were seismically qualified. Design Engineering Nuclear has | | determined that the relays are not seismically qualified in the current | | configuration. Therefore the OPLS relays are considered to be inoperable." | | | | The plant entered Tech. Spec. 2.0.1. requiring the plant to be in Hot | | Shutdown within 6 hours, and commenced preparation to shutdown. The plant | | initiated emergency maintenance to restore the relay covers to the design | | configuration, and as of 1233 CST, two OPLS Channels have been restored and | | Tech. Spec. 2.0.1 has been exited. | | | | At 1243 CST, all channels of OPLS were restored and declared operable. All | | applicable Technical Specification LCO action statements have been exited. | | | | The licensee notified the NRC resident inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35117 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: MARYLAND DEPT. OF THE ENVIRONMENT |NOTIFICATION DATE: 12/04/1998| | CITY: GERMANTOWN REGION: 1 |NOTIFICATION TIME: 15:31[EST]| | COUNTY: MONTGOMERY STATE: MD |EVENT DATE: 12/01/1998| |LICENSE#: MD-31-117-01 AGREEMENT: Y |EVENT TIME: 10:45[EST]| | DOCKET: |LAST UPDATE DATE: 12/04/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |GLENN MEYER R1 | | | | +------------------------------------------------+ | | NRC NOTIFIED BY: RAY MANLEY | | | HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DAMAGED TROXLER MOISTURE/DENSITY GAUGE | | | | The state of Maryland reported that a Troxler moisture/density gauge, model | | number 3430 and serial number 20927, was severely damaged at a work site in | | Germantown, MD on 12/1/98. The state responded to the scene along with | | Radiation Service Organization of Laurel, MD. The source was found | | partially shielded. After shielding the source, the gauge was packaged and | | sent to RSO's facility in Laurel. There were no personnel overexposures or | | contaminations, and the source was still intact. | | | | The cause of this accident was failure of the site engineer to maintain | | proper control of the gauge. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35118 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | LICENSEE: MARYLAND DEPT. OF THE ENVIRONMENT |NOTIFICATION DATE: 12/04/1998| | CITY: LANHAM REGION: 1 |NOTIFICATION TIME: 15:35[EST]| | COUNTY: STATE: MD |EVENT DATE: 11/30/1998| |LICENSE#: AGREEMENT: Y |EVENT TIME: 06:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/04/1998| | +-----------------------------+ | |PERSON ORGANIZATION | | |GLENN MEYER R1 | | | | +------------------------------------------------+ | | NRC NOTIFIED BY: RAY MANLEY | | | HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STOLEN TROXLER MOISTURE/DENSITY GAUGE | | | | The state of Maryland reported the theft of a Troxler moisture/density gauge | | from the Maryland State Highway Department located at 9315 Annapolis Rd., | | Lanham, MD. The gauge was a model 3440, serial number 16104. The theft has | | been reported to the Prince George's County police department. The theft | | occurred sometime between 1430 on 11/27 and 0600 on 11/30/98. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35119 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 12/05/1998| | UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 02:45[EST]| | RXTYPE: [1] W-4-LP |EVENT DATE: 12/05/1998| +------------------------------------------------+EVENT TIME: 01:25[EST]| | NRC NOTIFIED BY: STEPHEN MORRISSEY |LAST UPDATE DATE: 12/05/1998| | HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |GLENN MEYER 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 Y 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 24-HOUR REPORT IN ACCORDANCE WITH SECTION 4.1 OF THE SITE ENVIRONMENTAL | | PROTECTION PLAN | | | | A dead seal was observed to be floating in the 'B' circulating water pump | | forebay. The licensee will notify the NRC resident inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35120 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 12/05/1998| | UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 19:18[EST]| | RXTYPE: [1] GE-6 |EVENT DATE: 12/05/1998| +------------------------------------------------+EVENT TIME: 17:00[CST]| | NRC NOTIFIED BY: GREG HALVERSON |LAST UPDATE DATE: 12/05/1998| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |BRUCE BURGESS R3 | |10 CFR SECTION: | | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Cold Shutdown |0 Cold Shutdown | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - SSW RHR HEAT EXCHANGER VALVES COULD LOCK DURING A HELB OUTSIDE CONTAINMENT | | - | | | | AS PART OF THE LICENSEE "EXTENT OF CONDITION" REVIEW BEING PERFORMED FOR | | CORRECTIVE ACTIONS ON A CONDITION PREVIOUSLY IDENTIFIED IN LICENSEE | | CONDITION REPORT #1-97-07-006, THE SHUTDOWN SERVICE WATER (SSW) RESIDUAL | | HEAT REMOVAL (RHR) HEAT EXCHANGER INLET VALVE (#1E12-F014A/B) AND OUTLET | | VALVE (#1E12-F068A/B) WERE IDENTIFIED AS POTENTIALLY SUSCEPTIBLE TO | | THERMALLY INDUCED PRESSURE LOCKING DURING A HIGH ENERGY LINE BREAK (HELB) | | OUTSIDE CONTAINMENT. | | | | THE LINE BREAKS OF CONCERN ARE A REACTOR CORE ISOLATION COOLING SYSTEM LINE | | BREAK OR A MAIN STEAM/FEEDWATER SYSTEM LINE BREAK. BOTH OF THESE BREAKS | | HAVE THE POTENTIAL TO INTRODUCE SIGNIFICANT TEMPERATURE GRADIENTS IN BOTH | | RHR-A AND RHR-B PUMP/HEAT EXCHANGER ROOMS. THESE TEMPERATURE GRADIENTS | | COULD CAUSE PRESSURE LOCKING OF THE SUBJECT VALVES. | | | | SINCE THESE VALVES MUST OPEN TO PROVIDE SSW SYSTEM FLOW TO THE RHR HEAT | | EXCHANGER, THERMALLY INDUCED PRESSURE LOCKING OF THESE VALVES COULD LEAVE | | THE PLANT SUSCEPTIBLE TO A LOSS OF SUPPRESSION POOL COOLING AND/OR A LOSS OF | | CONTAINMENT SPRAY CAPABILITY DURING A HELB OUTSIDE CONTAINMENT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND IS DETERMINING | | CORRECTIVE ACTIONS. | +------------------------------------------------------------------------------+