U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/14/2003 - 08/15/2003
** EVENT NUMBERS **
39941 40055 40056 40060 40061 40063 40064 40065 40066 40067 40068 40069
40070 40071 40072 40073 40074 40075
+------------------------------------------------------------------------------+
|Hospital |Event Number: 39941 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: GUTHRIE HEALTH CARE |NOTIFICATION DATE: 06/16/2003|
|LICENSEE: GUTHRIE HEALTH CARE |NOTIFICATION TIME: 09:20[EDT]|
| CITY: SAYRE REGION: 1 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: 37-01893-01 AGREEMENT: N |LAST UPDATE DATE: 08/14/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RAYMOND LORSON R1 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOON PARK | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE |
| |
| A patient was referred for treatment, due to reoccurring prostate cancer, to |
| the hospital where he had previously had treatment. Seeds were implanted |
| around May 2001. A scan of the previous treatment of implanted seeds |
| determined that many of the seeds were not located in the prostate, but in |
| adjacent tissue where they would have been ineffective in treatment. Also, |
| a review of the records indicated a scan was performed in early 2002, but |
| was not followed up on. The patient and referring physician have been |
| informed. The hospital is conducting an investigation into the event and |
| also developing a plan to provide appropriate treatment for the patient. |
| |
| * * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * * |
| |
| Post-op dosimetry on one patient was determined to be a misadministration. |
| The dose that covered the prostate was more than 20 percent different from |
| the prescription as well as the penile bulb dose being close to 50 percent |
| of the prescription dose. Efforts are being made to contact the affected |
| patient. The licensee will continue efforts to obtain post-op dosimetry on |
| the rest of the patients related to this incident so that evaluations for |
| misadministration can be performed. |
| |
| Notified R1DO (Della Greca) and NMSS EO (Pierson). |
| |
| * * * UPDATE ON 07/25/03 AT 0921 EDT FROM JOON PARK TO JOHN MACKINNON * * * |
| |
| Post-op dosimetry for two patients were determined to be a |
| misadministration. The patients had their prostates treated some time in |
| the year 2001. The iodine-125 seeds were placed 2 to 3 centimeters below |
| the area where they were supposed to be located. The improper location of |
| the iodine-125 seeds caused more than 50% of the prescribed dose to be |
| delivered to an un-intended organ. The patients will be notified. |
| |
| Notified R1DO (Dan Holody) and NMSS EO (Trish Holahan). |
| |
| * * * UPDATE ON 07/30/03 AT 0911 EDT FROM JOON PARK TO ARLON COSTA * * * |
| |
| Two additional patients of a group of seven were identified as having |
| received a misadministration of iodine-125 to an unintended organ. The |
| patients will be notified of this misadministration. The licensee is in the |
| process of clarifying and document the issues related to this incident. |
| |
| Notified R1DO (James Moorman) and NMSS EO (Tom Essig). |
| |
| * * * UPDATE ON 08/07/03 AT 1535 EDT FROM CHARLES LEE TO NATHAN SANFILIPPO * |
| * * |
| |
| Another patient has been identified who received a misadministration of |
| iodine-125 to the prostate. The prescribed dose was 144 Gy, and it was |
| delivered using 76 seeds and 27 needles as planned prior to the implant |
| date. After reviewing the CT, which was done on Feb. 27, 2001, the V100 of |
| the prostate received 29% of the prescribed dose. The penile bulb at 72 Gy |
| received 44.8%. The licensee indicated that they have looked into 8 |
| patients who may have been misadministered, of which, one was not declared a |
| misadministration. The other seven appear in this notification. There are |
| 23 total patients that the licensee intends to review. |
| |
| Notified R1DO (Clifford Anderson) and NMSS EO (Fred Brown). |
| |
| * * * FINAL UPDATE ON 08/14/03 AT 1150 EDT BY CHARLES LEE TO JOHN MACKINNON |
| * * * |
| |
| Twelve more patients have been added to the number of patients. Patients are |
| identified by a six digit number. |
| |
| Patient# [deleted]- On this date, March 21, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 77 seeds and 26 needles as planned prior to the |
| implant, The V 100 of the prostate received 39% of the prescribed dose and |
| the V50 of the penile bulb received 88%. |
| Patient# [deleted]- On this date, May 23, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| close was delivered using 53 seeds and 18 needles as planned prior to the |
| implant. The V100 of the prostate received 62% of the prescribed dose and |
| the V50 of the penile bulb received 57%, |
| Patient# [deleted]- On this date, December. 13, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 86 seeds and 21 needles as planned prior to the |
| implant. The V 100 of the prostate received 70% of the prescribed dose and |
| the V50 of the penile bulb received 99%. |
| Patient# [deleted]- On this date, February 22, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 77 seeds and 25 needles as planned prior to the |
| implant. The V100 of the prostate received 52.5% of the prescribed dose and |
| the V50 of the penile bulb received 80%. |
| Patient# [deleted]- On this date, March 15, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 67 seeds and 27 needles as planned prior to the |
| implant. The V 100 of the prostate received 59% of the prescribed dose and |
| the V50 of the penile bulb received 86.5%. |
| Patient# [deleted]- On this date, July 5, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 62 seeds and 21 needles as planned prior to the |
| implant. The VI 00 of the prostate received 49% of the prescribed dose. |
| Patient# [deleted]- On this date, February 8, 2001, the former physician, |
| prescribed a dose of 144-Gy to the prostate using 1-125 seeds. The |
| prescribed dose was delivered using 45 seeds and 18 needles as planned prior |
| to the implant. The V 100 of the prostate received 68% of the prescribed |
| dose. |
| Patient# [deleted]- On this date, September 5, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed |
| dose was delivered using 58 seeds and 20 needles as planned prior to the |
| implant. The V100 of the prostate received 59.5% of the prescribed dose. |
| Patient# [deleted]- On this date, May 31, 2001, the former physician, |
| prescribed a dose of 14-4Gy to the prostate using 1-125 seeds. The |
| prescribed dose was delivered using 60 seeds and 17 needles as planned prior |
| to the implant. The V1 00 of the prostate received 68% of the prescribed. |
| Dose. |
| Patient# [deleted]- On this date, January 22, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using I-125 seeds. The prescribed |
| dose was delivered using 54 seeds and 3, 8 needles as planned prior to the |
| implant. The V100 of the prostate received 73% of the prescribed dose, |
| Patient# [deleted]- On this date, January 10, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using I-125 seeds. The prescribed |
| dose was delivered using 58 seeds and 19 needles as planned prior to the |
| implant. The VI 00 of the prostate received 54% of the prescribed dose. |
| Patient# [deleted]- On this date, June 21, 2001, the former physician, |
| prescribed a dose of 144Gy to the prostate using 1-125 seeds, The prescribed |
| dose was delivered using 82 seeds 28 needles as planned prior to the |
| implant, The V 100 of the prostate received 73% of the prescribed dose. |
| |
| Notified R1DO (Glenn Meyer) & NMSS EO (Linda Psyk). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 40055 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 08/11/2003|
|LICENSEE: ARIAS & KEZAR, INC. |NOTIFICATION TIME: 16:32[EDT]|
| CITY: AUSTIN REGION: 4 |EVENT DATE: 08/08/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L04964-001 AGREEMENT: Y |LAST UPDATE DATE: 08/11/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PHIL HARRELL R4 |
| |M. WAYNE HODGES NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JIM OGDEN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - TEXAS |
| |
| "On Friday, August 11, 2003, the Licensee was transporting the gauge in a |
| Nissan Pickup truck that had a defective tailgate. The Type 7A package was |
| locked to the pickup with a chain but was held in place with a very small |
| and cheap padlock. Also in the truck were concrete samples being |
| transported for analysis. While transiting FM 471, the tailgate failed to |
| the open position when the concrete samples shifted and pushed the gauge |
| (Troxler Model 3430, Serial No. 28510, with two sealed sources - Am-241 /Be, |
| nominal 40 millicuries, Serial No. 47-25576; and Cs-137, nominal 8 |
| millicuries, Serial No. 750-2732) out of the bed and broke the lock allowing |
| the gauge to become detached from the truck. The gauge was found by a |
| member of the public laying in the middle of Highway FM471 being swerved |
| around by traffic. The member of the public stopped and picked up the |
| package and placed in his vehicle and transported it to his residence at |
| [address deleted], Helotes, Texas. He opened the package which was not |
| secured by a locking device. There is no indication that the member of the |
| public exposed the sources. He made notification to the Helotes Fire |
| Department who in turn notified the Texas Department of Health's Public |
| Health Region 8, Radiation Control Office in San Antonio. The Public Health |
| Region responded with a Radioactive Materials Inspector who determined that |
| the gauge was intact and appeared to have no damage. The Licensee was |
| notified and retrieved the gauge." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 40056 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: KENTUCKY DEPT OF RADIATION CONTROL |NOTIFICATION DATE: 08/12/2003|
|LICENSEE: UNIVERSITY OF KENTUCKY |NOTIFICATION TIME: 14:10[EDT]|
| CITY: LEXINGTON REGION: 2 |EVENT DATE: 06/23/2003|
| COUNTY: FAYETTE STATE: KY |EVENT TIME: 15:30[CDT]|
|LICENSE#: 203-021-72 AGREEMENT: Y |LAST UPDATE DATE: 08/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID AYRES R2 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROB GRESHAM | |
| HQ OPS OFFICER: ERIC THOMAS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT |
| |
| "On June 23, 2003 at 3:30 PM the [University of Kentucky] radiation safety |
| office received a call from an AU [Authorized User] in the Dept. of Biology, |
| because a shipment of I-125, triiodothyronine, 100 microcuries, had not been |
| received. Upon review of the records it was found that the package had |
| arrived on June 18, 2003, and had measured 10 [millirem]/hr at the surface, |
| 0.1 [millirem]/hr @ 1meter, and no external contamination. The Radiation |
| Safety Office shipping paper record shows the I-125 package was included for |
| delivery to room 109, Research Building 3, on June 19. The required |
| signature of receipt for the package was not obtained. With the DOT |
| shipping labels removed, the greatest likelihood is that the package was put |
| into the ordinary trash. A thorough search of the Radiation Safety Office |
| facilities and vehicles was conducted on June 23. On June 24, the |
| authorized user's lab was searched, including use of a low energy NAI (Tl) |
| detector, as well as all labs where deliveries were made on June 19. No |
| trace of the package or contents has been found. It was concluded that the |
| highest probability was that the package entered the normal waste stream and |
| went to a landfill. Once in a landfill, the I-125 will be sequestered from |
| any contact, and will be essentially non-radioactive in 1.65 years. |
| Assuming worst case scenarios, the dose rate to the torso would be about 10 |
| [millirem]/hr or less, and would have to be held against the body |
| continuously by a single individual for 10 hours to produce a dose in excess |
| of 100 [millirem]. Additionally there is no indication or likelihood of |
| intentional or accidental ingestion of the contents since this is not |
| intended for human use. However, if the entire 100 microcuries were |
| ingested by a single individual, as sodium iodide, the thyroid dose would be |
| 78 rem, and the effective dose would be 2.4 rem. While no thyroid dose |
| information has been found for the triiodothyronine form, the effective |
| dose from ingestion of 100 microcuries would be 17 [millirem]. Surveys are |
| conducted on a continual basis, if the package did not go to a landfill it |
| would likely be found during monthly use area surveys or quarterly |
| supervisory surveys. No NOV was issued based on the corrective actions |
| taken by licensee to correct deficiencies prior to report completion." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 40060 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION DATE: 08/14/2003|
|LICENSEE: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION TIME: 09:00[EDT]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 07/01/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 08/14/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GLENN MEYER R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT FORREST | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING SOURCE AT UNIVERSITY OF PENNSYLVANIA |
| |
| "During a routine sealed source inventory in July 2003, a technician from |
| the University of Pennsylvania's Office of Environmental Health and |
| Radiation Safety (EHRS) found that a Hewlett-Packard 6890 gas chromatograph |
| (GC) containing a generally licensed 15 millicuries source of Ni-63 was |
| missing from a laboratory undergoing renovations. EHRS contacted faculty and |
| staff associated with the laboratory trying to locate the instrument. After |
| an extensive search, it was determined that the GC was most likely sent to a |
| scrap metal dealer. According to NUREG-1717, Systematic Radiological |
| Assessment of Exemptions for Source and Byproduct Materials, the dose to any |
| individual from a scrapped Ni-63 gas chromatograph source would be less than |
| 0.01 millisievert (1 millirem)" |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40061 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 10:57[EDT]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 09:10[CDT]|
| NRC NOTIFIED BY: ETHAN TREPTOW |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |SONIA BURGESS R3 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| EP SIRENS OUT OF SERVICE IN KEWAUNEE COUNTY |
| |
| "At 0910 on August 14, It was reported to the Control Room that all thirteen |
| Kewaunee County sirens had a communications problem that rendered them out |
| of service. The percent siren coverage population lost is 68.52%. The State |
| and County have been notified of the siren failures. The siren vendor has |
| been contacted to begin troubleshooting the problem. |
| |
| "This is being reported under 10 CFR 50.72(b)(3)(xiii) as any event that |
| results in a major loss of emergency assessment capability, offsite response |
| capability, or offsite communications capability (loss of greater than 50% |
| of emergency sirens). It is also being reported under 10 CFR 50.72(b)(2)(xi) |
| as any event or situation, related to the health and safety of the public or |
| onsite personnel, or protection of the environment, for which a news release |
| is planned or notification to other government agencies has been or will be |
| made." |
| |
| The NRC resident inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40063 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 16:33[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:10[EDT]|
| NRC NOTIFIED BY: JOE KOTAR |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |SONIA BURGESS R3 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 |
| MINUTES. |
| |
| Automatic reactor scram due to a loss of offsite power. All rods fully |
| inserted. Supplying power to vital buses via emergency diesel generators. |
| All system operating properly. |
| |
| NRC Resident Inspector was notified of the event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40064 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 17:10[EDT]|
| RXTYPE: [1] CE |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:07[EDT]|
| NRC NOTIFIED BY: VANDENALLE |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |SONIA BURGESS R3 |
|10 CFR SECTION: | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| POWER GRID DISTURBANCE OCCURRED RESULTING IN A MOMENTARY DROP IN VOLTAGE |
| |
| At 1607 EDT a significant electrical power grid disturbance occurred |
| resulting in a momentary drop in voltage at the site, including both 2400 |
| VAC safety busses 1C and 1D. The reduced voltage on the 2400VAC safety |
| busses caused both emergency diesel generators to auto start, but not load. |
| The plant is stable at pre-event conditions. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40065 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 18:16[EDT]|
| RXTYPE: [1] GE-2 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:11[EDT]|
| NRC NOTIFIED BY: CIGANIK |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GLENN MEYER R1 |
|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 Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| REACTOR SCRAM FROM 100% POWER DUE TO OFF SITE ELECTRICAL GRID INSTABILITY |
| |
| Reactor scram from 100% due to off site electrical grid instability, but did |
| not lose off site power. Reactor conditions at 1730 are normal reactor |
| water level, reactor pressure 850-1000psig, MSIV's closed and all recirc |
| pumps are off and reactor is in hot shutdown with all rods inserted. |
| |
| The NRC Resident Inspector |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40066 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 17:34[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 17:00[EDT]|
| NRC NOTIFIED BY: MORAN |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |HYMAN FEMA |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |STUART RICHARDS NRR |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| NOUE WAS DECLARED AT 1700 DUE TO LOSS OF OFFSITE POWER |
| |
| The plant lost off site power due to grid disturbance which resulted in a |
| reactor trip from 100% power. The NOUE was declared because of loss of off |
| site power was greater than 15 minutes. |
| |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40067 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 16:39[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:25[EDT]|
| NRC NOTIFIED BY: MARK COX |LAST UPDATE DATE: 08/15/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 |
| MINUTES. |
| |
| Automatic reactor scram due to a loss of offsite power. All rods fully |
| inserted. Supplying power to vital buses via emergency diesel generators. |
| All systems operating properly. |
| |
| NRC Resident Inspector was notified of the event by the licensee. |
| |
| * * * UPDATE 2340EDT ON 8/14/03 FROM ANDY MIHALIK TO S.SANDIN * * * |
| |
| The following information was provided as an update: |
| |
| "RPS Actuation (loss of flow) due to loss of offsite power. Auto actuation |
| of AFW in response to the unit trips. Auto start & load of Emergency Diesel |
| Generators in response to the loss of offsite power." |
| |
| The licensee informed the state/local authorities and the NRC resident |
| inspector. Notified R1IRC. |
| |
| *****UPDATE ON 8/15/03 AT 0226 FROM CELENTANO TO GOTT***** |
| |
| The licensee exited the Unusual Event at 0210 upon confirmation of a stable |
| off-site power. |
| |
| Notified R1 IRC and FEMA(Heyman). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40068 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: GINNA REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 16:46[EDT]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:12[EDT]|
| NRC NOTIFIED BY: PAUL HARRIS |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 |
| MINUTES. |
| |
| Automatic reactor trip due to a loss of offsite power. All rods fully |
| inserted into the core. All emergency systems operated as expected. |
| |
| NRC Resident Inspector was of this event by the licensee. |
| |
| * * * UPDATE 0510EDT ON 8/15/03 FROM McCOY TO S.SANDIN * * * |
| |
| Unit exited the UE at 2108EDT on 8/14/03 after restoration of offsite power. |
| The licensee informed state.local agencies and the NRC resident inspector. |
| Notified R1IRC and FEMA(Heyman). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40069 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [] [3] [] STATE: NY |NOTIFICATION TIME: 16:50[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:23[EDT]|
| NRC NOTIFIED BY: MESSINA |LAST UPDATE DATE: 08/15/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|3 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 |
| MINUTES. |
| |
| Automatic reactor scram due to a loss of offsite power. All rods fully |
| inserted. Supplying power to vital buses via emergency diesel generators. |
| All systems operating properly. |
| |
| NRC Resident Inspector was notified of the event by the licensee. |
| |
| * * * UPDATE 2340EDT ON 8/14/03 FROM ANDY MIHALIK TO S.SANDIN * * * |
| |
| The following information was provided as an update: |
| |
| "RPS Actuation (loss of flow) due to loss of offsite power. Auto actuation |
| of AFW in response to the unit trips. Auto start & load of Emergency Diesel |
| Generators in response to the loss of offsite power. Unit 3 also |
| experienced a second AFW auto start during the event. Unit 3 also entered |
| Tech Spec LCO 3.0.3 for loss of two offsite circuits and one EDG inoperable. |
| #31 EDG was declared inoperable when its associated Fuel oil storage tank |
| inventory decreased below required." |
| |
| The licensee informed the state/local authorities and the NRC resident |
| inspector. Notified R1IRC. |
| |
| *****UPDATE ON 8/15/03 AT 0226 FROM CELENTANO TO GOTT***** |
| |
| The licensee exited the Unusual Event at 0210 upon confirmation of a stable |
| off-site power. |
| |
| Notified R1 IRC and FEMA(Heyman). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40070 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DAVIS BESSE REGION: 3 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 16:54[EDT]|
| RXTYPE: [1] B&W-R-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:10[EDT]|
| NRC NOTIFIED BY: DON BONDY |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |SONIA BURGESS R3 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO A LOSS OF OFFSITE POWER. |
| |
| All systems operated as expected. Decay Heat pumps are available if |
| needed. |
| |
| NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40071 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 17:15[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:35[EDT]|
| NRC NOTIFIED BY: HELKER |LAST UPDATE DATE: 08/15/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 MINUTES. |
| |
| |
| Automatic reactor scram due to a loss of offsite power. All rods fully |
| inserted into the core. All emergency core cooling systems are operating |
| properly and the emergency diesel generators are operating properly. |
| |
| NRC Resident Inspector was notified of this event by the licensee. |
| |
| *****UPDATE 8/15/03 AT 0145 TO LAURA***** |
| |
| Offsite electrical power was restored. The licensee exited the Unusual Event |
| at 0123. Notified R1IRC and FEMA(Heyman). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40072 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 17:17[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:11[EDT]|
| NRC NOTIFIED BY: TIM PAGE |LAST UPDATE DATE: 08/15/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |GLENN MEYER R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO A LOSS OF OFFSITE POWER. |
| |
| Automatic reactor scram due to a loss of offsite power. All rods fully |
| inserted into the core. All emergency core cooling systems and the |
| emergency diesel generators are operating properly. |
| |
| NRC Resident Inspector was notified of this event by the licensee. |
| |
| *****UPDATE ON 8/15/03 AT 0035 FROM PAGE TO LAURA***** |
| |
| Reactor vessel pressure is 93 psig. Plant electrical loads have been |
| shifted back to offsite power and the EDGs were secured. The licensee exited |
| the Unusual Event at 0039. The licensee tentatively plans to remain shutdown |
| for a brief period to do some maintenance work. |
| |
| Notified R1IRC and FEMA(Heyman). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40073 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [2] [3] [] STATE: NY |NOTIFICATION TIME: 18:49[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:25[EDT]|
| NRC NOTIFIED BY: FINUCAH |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GLENN MEYER R1 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N N 0 Hot Shutdown |0 Hot Shutdown |
|3 N N 0 Hot Shutdown |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| EMERGENCY SIRENS LOST IN FOUR COUNTIES |
| |
| Emergency sirens lost in four counties due to a loss of power. At |
| approximately 1830 hours power starting to be returned to the sirens. |
| |
| NRC Resident Inspector notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40074 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: GINNA REGION: 1 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 20:07[EDT]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:11[EDT]|
| NRC NOTIFIED BY: Roy Gillow |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GLENN MEYER R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| REACTOR TRIP/AUXILIARY FEEDWATER ACTUATION |
| |
| Received grid disturbance that caused reactor trip at 1611. The trip |
| occurred due to over temperature delta set point being reached from load |
| swings experienced on the generator. Subsequently in the recovery process, |
| the Auxiliary Feedwater Pumps auto started from a signal from the Main |
| Feedwater Pumps being secured. As a result of grid problems it was noted |
| that Ginna did not meet the required number of emergency sirens (greater |
| than 25% of sirens without power). |
| |
| |
| NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40075 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 08/14/2003|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 20:08[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 08/14/2003|
+------------------------------------------------+EVENT TIME: 16:10[EDT]|
| NRC NOTIFIED BY: KEVIN DAHM |LAST UPDATE DATE: 08/14/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |SONIA BURGESS R3 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |HYMAN FEMA |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT ENTERED AN NOUE DUE TO THE LOSS OF OFF SITE POWER |
| |
| The reactor scrammed from 100% power due to fluctuations occurring on the |
| main generator and a loss of off site power. All rods fully inserted and |
| all MSIV's closed. Reactor level is being maintained in the normal band of |
| 173 to 214 inches using RCIC. Reactor pressure is being controlled via |
| SRV's in lo-lo set mode between 905 and 1017 psig. Isolations occurred as |
| expected for level 2 and level 3. HPCI and RCIC started on level 2 signal. |
| HPCI has been shutdown but is available. All 4 EDG's started and loaded. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
