Event Notification Report for November 1, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
10/31/2002 - 11/01/2002
** EVENT NUMBERS **
39235 39323 39325 39327 39328 39329 39333
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 39235 |
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| FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 10/01/2002|
| UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 17:44[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 10/01/2002|
+------------------------------------------------+EVENT TIME: 08:45[CDT]|
| NRC NOTIFIED BY: STEVEN A. HENRY |LAST UPDATE DATE: 10/31/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| UNANALYZED CONDITION RELATING TO CONTROL ROOM EVACUATION |
| |
| "On October 1 2002, conditions were discovered that if an evacuation of the |
| Wolf Creek Generation Station (WCGS) control room were required, due to a |
| fire, necessary steps could not be completed within committed time |
| requirements. The station is in Mode 1, at 100% power. |
| |
| "During a timed walk down of procedure OFN RP-017, 'Control Room |
| Evacuation,' it was identified that operators did not complete Phase A |
| actions of the procedure in the committed five minutes. Phase A provides |
| that control of the plant will be established at the Auxiliary Shutdown |
| Panel (ASP) and isolation of required instrumentation and other devices on |
| the ASP will be accomplished. Phase A was performed in approximately 8 |
| minutes. This does not meet our commitment to 10 CFR 50 Appendix R as |
| reflected in the WCGS Fire Protection Plan. The effect of additional time to |
| complete Phase A of the control room evacuation is being further analyzed to |
| determine the safety significance. |
| |
| "Based on the guidance provided in NUREG 1022 Revision 2, this situation |
| meets the criterion of 10CFR50.72(b)(3)(ii)(B) for an 8-hour ENS |
| notification, as it relates to being in an unanalyzed condition." |
| |
| The Licensee has implemented compensatory measures at 1900 CDT, 10/1/02. |
| |
| The licensee has notified the NRC Resident Inspector |
| |
| ****RETRACTION JEFF ISCH TO MIKE NORRIS 1429 ET 10/31/02**** |
| |
| "BASIS FOR RETRACTION: |
| |
| "A safety significance evaluation was performed for the condition described |
| above and it was determined that the circumstances do not constitute a |
| significant reduction in plant safety. This conclusion is based on the |
| results of simulator exercises that concluded that the 5 minute completion |
| time was conservative and that the actions needed to place the plant in a |
| safe condition could be performed within 8 minutes. The evaluation provides |
| reasonable assurance that operator activities taken to complete Phase A |
| actions within a 7 to 8 minute period does not result in consequences of |
| safety significance. This conclusion is further validated by comparing the |
| results with bounding conditions contained in a Westinghouse WCAP report for |
| a similar condition involving a failed open power operated relief valve |
| (PORV), as well as an engineering evaluation previously performed for both |
| PORVs spuriously opening due to a fire. Therefore, per NUREG 1022, this |
| condition is not an unanalyzed condition that significantly degrades plant |
| safety and is not required to be reported in accordance with |
| 10CFR50.72(b)(3)(ii)(B)." |
| |
| The Licensee has notified the NRC Resident Inspector. |
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|General Information or Other |Event Number: 39323 |
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| REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 10/28/2002|
|LICENSEE: CONSTRUCTION TESTING LAB |NOTIFICATION TIME: 15:23[EST]|
| CITY: METAIRIE REGION: 4 |EVENT DATE: 09/20/2002|
| COUNTY: STATE: LA |EVENT TIME: [CDT]|
|LICENSE#: LA-6427-L01 AGREEMENT: Y |LAST UPDATE DATE: 10/28/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |MELVYN LEACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SCOTT BLACKWELL | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
| | |
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EVENT TEXT
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| LOUISIANA DEPT OF ENVIRONMENTAL QUALITY AGREEMENT STATE REPORT RE: STOLEN |
| MOISTURE/DENSITY GAUGE |
| |
| "ON SEPTEMBER 20, 2002, A TROXLER 3411-B GAUGE WITH SERIAL NUMBER 4524 WAS |
| STOLEN FROM THE BACK SEAT OF A GMC EXTRA CAB TRUCK. THE GAUGE CONTAINED A |
| 8.0 mCi (MILLICURIE) SOURCE OF CS-137 AND A 40 mCi SOURCE OF AM241:BE. THE |
| GAUGE WAS STOLEN BY BREAKING THE LOCK ON THE SIDE REAR WINDOW OF THE TRUCK. |
| THE GAUGE WAS NOT CHAINED TO THE TRUCK. THE FACILITY HAS CHANGE ITS |
| PROCEDURES TO PREVENT THIS TYPE OF EVENT FROM OCCURRING AGAIN." |
| |
| "CONSTRUCTION TESTING LAB, 3008 5TH STREET, METAIRIE, LA" |
| |
| "STOLEN FROM 1995 GMC EXTRA CAB TRUCK" |
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|General Information or Other |Event Number: 39325 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 10/28/2002|
|LICENSEE: LITTLE COMPANY OF MARY HOSPITAL |NOTIFICATION TIME: 23:33[EST]|
| CITY: TORRANCE REGION: 4 |EVENT DATE: 10/25/2002|
| COUNTY: LOS ANGELES STATE: CA |EVENT TIME: 14:30[PDT]|
|LICENSE#: 1258-19 AGREEMENT: Y |LAST UPDATE DATE: 10/28/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |MELVYN LEACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT GREGER | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
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+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT - MISSING IODINE- 125 SEEDS |
| |
| The Medical Physicist from Little Company of Mary Hospital called to report |
| the loss of 5 Iodine-125 seeds of approximately 0.4 millicuries each. The |
| facility was doing an implant for the treatment of prostate cancer and had |
| cut the strips in half (5 seeds each). After having implanted 9 strips they |
| were unable to locate the tenth piece. They surveyed the room and trash and |
| did not find the missing seeds. The patient was fluoroscoped and x-rayed, |
| the implanted seeds were counted and verified with what had been implanted. |
| A representative from Amersham was present during the procedure and it was |
| not determined if the tube shipped was half empty. |
| |
| The seeds came in steel tubes of 10. It is possible that one steel tube |
| only had 5 when sent. Implant performed at 11:00 on 10/24/02. The tubes |
| were counted, but not opened until the procedure (sterile) was initiated. |
| |
| The licensee kept looking for the missing Iodine-125 seeds and today, |
| October 28, 2002, concluded that the event was reportable and notified the |
| State of CA today at 1458 hours PST. |
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|General Information or Other |Event Number: 39327 |
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| REP ORG: FLORIDA BUREAU OF RADIATION CONTROL |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: ROBERT BOISSONEAULT ONCOLOGY INSTITUT|NOTIFICATION TIME: 13:04[EST]|
| CITY: LACANTO REGION: 2 |EVENT DATE: 10/22/2002|
| COUNTY: STATE: FL |EVENT TIME: [EDT]|
|LICENSE#: 2155-1 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KERRY LANDIS R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHARLES ADAMS | |
| HQ OPS OFFICER: MIKE RIPLEY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE - MEDICAL MISADMINISTRATION |
| |
| "On 10-22-02 the patient was undergoing the first of six fraction therapy |
| using a HDR source in the cervix. The source was misplaced by approximately |
| 2 centimeters. The dose received was 800 Rem instead of the prescribed dose |
| of 500 Rem. On 10-28-02 the error was discovered during planning for the |
| second fraction, and it was reported the same day. The patient and physician |
| have been notified. No long term health effect is expected and the |
| prescribed treatment is continuing. Licensee will submit a letter of |
| explanation within 15 days. Florida is continuing it's investigation." |
| |
| Florida Incident No. FL02-161 |
| Isotope used was 9.961 Curies Ir-192. |
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|General Information or Other |Event Number: 39328 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: ALPHA TESTING, INC. |NOTIFICATION TIME: 13:44[EST]|
| CITY: DALLAS REGION: 4 |EVENT DATE: 10/28/2002|
| COUNTY: STATE: TX |EVENT TIME: 06:30[CDT]|
|LICENSE#: L03411 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JAMES H. OGDEN Jr. | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT - STOLEN NUCLEAR DENSITY GAUGE |
| |
| |
| "A company technician returned to the office at 6:30 a.m. after an extended |
| job in Brundidge, Alabama. He was in the office to return to operations at |
| the Dallas, office and was beginning to unload his truck and return his |
| equipment to the office. He unlocked his gauge (Troxler Model 3411B, Serial |
| # 6819) and placed it on the tailgate of the truck. He walked into the |
| office to get a chain and lock to secure the gauge in the company storage |
| cabinet. He walked back to the truck to get the gauge and discovered that |
| the gauge and the concrete air meter were missing from the truck. He |
| contacted the dispatcher, who had not yet arrived at the office, to notify |
| the company RSO. Notifications were made to the Bureau of Radiation |
| Control, the Dallas Police Department (Police Report # 823204L - a copy has |
| not been received yet), and three local nuclear gauge repair centers |
| (Richardson & Associated, Component Sales - Houston, and Troxler Labs, |
| Arlington). The gauge has not been located. Source Serial #'s are: Cs-137, |
| 10 millicuries, S/N CC3975, and AmBE-241, 40 millicuries, S/N CCA3132. The |
| BRC is still investigating the incident." |
| |
| "Company truck with Logo, Texas Licensee # 5ND G59" |
| |
| "Texas Incident No.: I-7945" |
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|General Information or Other |Event Number: 39329 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 10/29/2002|
|LICENSEE: WOODWARD REGIONAL HOSPITAL |NOTIFICATION TIME: 15:19[EST]|
| CITY: woodward REGION: 4 |EVENT DATE: 10/28/2002|
| COUNTY: STATE: OK |EVENT TIME: 15:00[CDT]|
|LICENSE#: OK-21269-01 AGREEMENT: Y |LAST UPDATE DATE: 10/29/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLAUDE JOHNSON R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: M. BRODERICK | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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+------------------------------------------------------------------------------+
EVENT TEXT
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| FOLLOW-UP PATIENT GIVEN INCORRECT PREP DRUG |
| |
| |
| Woodward Regional Hospital was doing an Iodine-131 follow-up scan for |
| residual Thyroid on cancer patient. A nurse injected the patient with the |
| incorrect prep drug, non radioactive drug, prior to the patient being |
| administered 4 millicuries of Iodine-131. The caller believes that the |
| patient was given the incorrect prep drug on October 28, 2002 and today, |
| October 29, 2002, was administered the 4 millicuries of Iodine-131 before |
| given the scan. After the scan was performed it was discovered that the |
| patient was given the incorrect prep drug for the scan. The State of |
| Oklahoma is investigating this event. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 39333 |
+------------------------------------------------------------------------------+
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 10/31/2002|
| UNIT: [1] [] [] STATE: AZ |NOTIFICATION TIME: 11:04[EST]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 10/31/2002|
+------------------------------------------------+EVENT TIME: 05:45[MST]|
| NRC NOTIFIED BY: DONALD STRAKA |LAST UPDATE DATE: 10/31/2002|
| HQ OPS OFFICER: MIKE RIPLEY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLAUDE JOHNSON R4 |
|10 CFR SECTION: |TERRY REIS NRR |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 19 Power Operation |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| UNIT 1 MANUALLY TRIPPED DUE TO HIGH SULFATE CONCENTRATIONS IN THE STEAM |
| GENERATORS |
| |
| "On October 31 2002, at approximately 05:45 MST Palo Verde Unit 1 |
| experienced a manual reactor trip from approximately 19% rated thermal power |
| due to high sulfate concentrations in the steam generators. Unit 1 was at |
| normal temperature and pressure prior to the trip. All CEAs inserted fully |
| into the reactor core. This was an uncomplicated reactor trip. No ESF |
| actuations occurred and none were required. Safety related buses remained |
| energized during and following the reactor trip. The offsite power grid is |
| stable. No significant LCOs have been entered as a result of this event. No |
| major equipment was inoperable prior to the event that contributed to the |
| event. |
| |
| "Unit 1 is stable at normal operating temperature and pressure in Mode 3. |
| The event did not result in any challenges to fission product barriers and |
| there were no adverse safety consequences as a result of this event. The |
| event did not adversely affect the safe operation of the plant or the health |
| and safety of the public." |
| |
| The licensee stated that the trip was initiated at the recommendation of the |
| Chemistry Manager. The licensee continues to investigate the reason for the |
| high sulfate concentration and an estimated restart date was not given. |
| |
| The licensee notified the NRC Resident Inspector. |
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