U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/12/2003 - 05/13/2003
** EVENT NUMBERS **
39838 39840 39841 39842
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|Power Reactor |Event Number: 39838 |
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| FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 05/12/2003|
| UNIT: [1] [] [] STATE: SC |NOTIFICATION TIME: 03:28[EDT]|
| RXTYPE: [1] W-3-LP |EVENT DATE: 05/12/2003|
+------------------------------------------------+EVENT TIME: 01:02[EDT]|
| NRC NOTIFIED BY: EDDIE BYARS |LAST UPDATE DATE: 05/12/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |PAUL FREDRICKSON R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO MAIN GENERATOR OUTPUT BREAKER |
| OPENING |
| |
| Main Generator output breaker opened after receiving Main Generator voltage |
| regulator # 1 (core 1) & # 2 (core 2) alarms causing an automatic turbine |
| trip followed by an automatic reactor trip (first out annunciator was over |
| temperature differential temperature). All rods fully inserted into the |
| core. Both motor driven auxiliary feedwater pumps were manually started to |
| maintain reactor coolant temperature and proper steam generator water |
| levels. Steam is being dumped to the main condenser. Emergency Operating |
| procedure 1.0 entered and then Emergency Operating procedure 1.1, Reactor |
| Recovery Procedure was entered. All emergency core cooling systems and the |
| emergency diesel generators are fully operable if needed. The licensee |
| believes that the main generator exciter breaker opened before the main |
| generator output breaker opened. No work was going on in the area of the |
| main generator when the output breaker opened. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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|Other Nuclear Material |Event Number: 39840 |
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| REP ORG: STATE OF MISSOURI |NOTIFICATION DATE: 05/12/2003|
|LICENSEE: MISSOURI DEPT. OF TRANSPORTATION |NOTIFICATION TIME: 14:57[EDT]|
| CITY: JEFFERSON CITY REGION: 3 |EVENT DATE: 05/10/2003|
| COUNTY: COLE STATE: MO |EVENT TIME: 18:00[CDT]|
|LICENSE#: 24-20415-01 AGREEMENT: N |LAST UPDATE DATE: 05/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |SONIA BURGESS R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BETH BROWN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
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EVENT TEXT
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| LOST AND THEN RECOVERED TROXLER ASPHALT CONTENT GAUGE |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| "On Saturday evening, May 10, 2003, at approximately 6:00 pm [CDT], a |
| tornado wiped out a trailer at an asphalt plant that contained an asphalt |
| nuclear gauge 3241 [Troxler]. The gauge was in its gray shipping container |
| that was locked inside a metal case, which was bolted to the floor. The |
| gauge was found about 100 feet from the trailer site out of the metal box, |
| but the gray shipping case was still intact. It did not appear to be |
| damaged. The contractor, Chester Bross Construction Company, found the gauge |
| and stored it in their plant shack with their gauge. Their Safety Director, |
| [DELETED], also came up on Sunday morning and took readings. Neither gauge |
| appeared to be leaking." |
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|Hospital |Event Number: 39841 |
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| REP ORG: TRIPLER ARMY MEDICAL CENTER |NOTIFICATION DATE: 05/12/2003|
|LICENSEE: TRIPLER ARMY MEDICAL CENTER |NOTIFICATION TIME: 17:32[EDT]|
| CITY: HONOLULU REGION: 4 |EVENT DATE: 05/12/2003|
| COUNTY: STATE: HI |EVENT TIME: 11:00[HST]|
|LICENSE#: 53-00458-04 AGREEMENT: N |LAST UPDATE DATE: 05/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LINDA SMITH R4 |
| |SONIA BURGESS R3 |
+------------------------------------------------+MELVYN LEACH NMSS |
| NRC NOTIFIED BY: MAJ. ARTHUR MORTON, USA |MATT HAHN IAT |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
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EVENT TEXT
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| NUCLEAR MATERIAL MISSING DURING SHIPMENT |
| |
| |
| The following information was received from the licensee via facsimile: |
| |
| "An order for 150 milli-curies (mCi) of iodine-131 was placed with |
| Mallinckrodt on May 9, 2003. The package was received by the Nuclear |
| Pharmacist,[DELETED], on May 12, 2003 and indicated that the package had |
| 154.10 mCi of iodine-131 but was measured to contain only 54.0 mCi of |
| iodine-131. |
| |
| "At 11:00 [HST] the Nuclear Pharmacist paged me and I immediately went to |
| the Nuclear Pharmacy laboratory. I verified that the dose calibrator was |
| set on I-131and inquired about the package receipt procedures. The Nuclear |
| Pharmacist indicated that the package was in excellent condition with no |
| sign of physical damage. The package was received in a timely manner, |
| metered and swiped without incident. The package contained two vials |
| supposedly containing 140.00 mCi and 14.10 mCi of iodine-131 for a total of |
| 154.10 mCi. The contents of the package appeared to be intact. The Nuclear |
| Pharmacist combined the two vials and assayed the dose in the dose |
| calibrator for an iodine ablation therapy but measured only 54.0 mCi of |
| I-131. |
| |
| "At 11:20 I notified Mallinckrodt of the discrepancy, and then at 11:30 I |
| notified the NRC Operations Center to report the missing licensed material |
| in accordance with 10 CFR Part 20.2201(a)(1)(i). I will also contact the |
| shipper, MMS Courier, and the Army Medical Command as well as any local or |
| state notifications that are required." |
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|Fuel Cycle Facility |Event Number: 39842 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/12/2003|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 23:08[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/12/2003|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 09:00[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/12/2003|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |SONIA BURGESS R3 |
| DOCKET: 0707001 |MELVYN LEACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: THOMAS WHITE | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| LOSS OF ONE OF TWO CONTROLS ON MODERATION |
| |
| NRC BULLETIN 91-01 24 HOUR NOTIFICATION |
| |
| The following information was received from the licensee via facsimile: |
| |
| "At 0900 on 5/12/03, the Plant Shift Superintendent (PSS) was notified that |
| differential pressure transmitter inputs for three Freezer/Sublimers, |
| U/2(Unit # 2) C/B (Cell B), U3 C/B and U/4 C/B located in C-337, were |
| installed incorrectly. The transmitter (PDT-338) measures the differential |
| pressure between the R-114 (freon) and the Recirculating Cooling Water |
| (RCW). NCSA CAS-001 requires that the pressure differential between the |
| R-114 and RCW pressures be such that the R-114 pressure is at least 2.0 psia |
| above the RCW pressure. This would preclude the introduction of a moderator |
| (RCW) into the process side of the system. The correct configuration of |
| these inputs has the pressure tap on the inlet line to the |
| condenser/reboiler. For Freezer/Sublimers U/2 C/B, U/3 C/B and U/4 C/B the |
| pressure tap is located on the outlet line from the condenser/reboiler. As |
| installed, the low differential pressure-alarm may not come in until after |
| the R-114 pressure and RCW pressure at the inlet of the Condenser/Reboiler |
| have exceeded the NCS limit. At 1040 on 5/12/03, the PSS was notified by |
| Nuclear Criticality Safety that one of the two controls on moderation had |
| been lost. |
| |
| The System Engineer identified four additional Freezer/Sublimers, two in |
| C-331 and two in C-335, with the same problem. These Freezer/Sublimer units |
| were out-of-service and the RCW had been drained prior to the walk-down. , |
| |
| |
| SAFETY SIGNIFICANCS OF EVENTS: |
| |
| Although high side Condenser/Reboiler pressure readings could not be taken |
| due to incorrect installation of an AQ-NCS pressure instrument, the |
| integrity of the F/S tubes has been maintained. All of the |
| Condenser/Reboilers had the RCW drained by 1345 hours on 5-12-03. thus |
| re-establishing double contingency. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(s) OF HOW |
| CRITICALITY COULD OCCUR) |
| |
| In order for a criticality to be possible, an unsafe mass of uranium would |
| have to be present within the Freezer/Sublimer unit and a moderator would |
| have to enter through the Freezer/Sublimer and Condenser/Reboiler tubes. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,ETC.) |
| |
| Double contingency is maintained by implementing two controls on |
| moderation. |
| |
| |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITICAL MASS): |
| |
| For the 20 MW Freezer/Sublimers, less than a safe mass of uranium, at less |
| than or equal to (LEU) U235. |
| For the 10 MW Freezer/Sublimers, less than a safe mass of uranium, at less |
| than or equal to (LEU) U235 |
| |
| |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIFNCIES |
| |
| The first leg of double contingency relies on Freezer/Sublimer and |
| Condenser/Reboiler tube integrity. Since high UF6 pressure alarms or other |
| operational indicators, caused by leaking R-114 into the Freezer/Sublimer, |
| have not been received on the Freezer/Sublimer units, the integrity of the |
| Freezer/Sublimer tubes has been maintained. Therefore, this leg of double |
| contingency was maintained. |
| |
| The second leg of double contingency relies on the differential pressure |
| between the R-114 and RCW, controlling the differential pressure such that |
| the R-114 is maintained at least 2.0 psi above the RCW precludes the |
| introduction of RCW to the process side of the unit. Monitoring the RCW |
| pressure on the outlet to the Condenser/Reboiler, instead of the inlet, does |
| not give correct differential pressure readings. Therefore. This leg of |
| double contingency was not maintained. |
| |
| Even though the moderation parameter was maintained through integrity of the |
| Freezer/Sublimer and Condenser/Reboiler tubes, double contingency Is based |
| on two controls on moderation. Thus, double contingency was not maintained. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLFMENTED: |
| |
| 1. Drain Condenser/Reboiler RCW for the affected Freezer/Sublimer units. |
| Completed at 1345 on 5-12-03. |
| 2. Correct the installation of the pressure taps In accordance with the |
| approved Engineering drawings. Complete prior to returning Freezer/Sublimors |
| to service |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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