Event Notification Report for August 22, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/21/2001 - 08/22/2001
** EVENT NUMBERS **
37999 38224
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|Fuel Cycle Facility |Event Number: 37999 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/16/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 23:53[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/16/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 19:00[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 08/21/2001|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |MICHAEL PARKER R3 |
| DOCKET: 0707001 |JOHN GREEVES NMSS |
+------------------------------------------------+NADER MAMISH IRO |
| NRC NOTIFIED BY: KEVIN BEASLEY | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| NRC BULLETIN 91-01 RESPONSE - CRITICALITY CONTROL - (4-Hour Report) |
| |
| During the revision to NCSE 052 and 039, it was discovered that the |
| condenser could potentially be pressurized greater than 35.5 psia when the |
| condenser supply and return valve are both closed without a fluorinating |
| environment in the process gas system. NCSA CAS-002/011 allow both the |
| supply and return valves to be closed when draining the condenser without a |
| fluorinating environment. NCSEs 052 and 039 rely on the condenser supply |
| valve to be closed enough to prevent the condenser from being pressurized |
| above 35.5 psia during the time the return valve is closed and maintenance |
| personnel relieve the pressure on the condenser. Based on recent |
| discussions, it was discovered that closure of the supply valve may not |
| provide sufficient isolation to prevent the condenser from being pressurized |
| above 35.5 psia with the return valve closed because of potential seat |
| leakage of the supply valve. |
| |
| The licensee has stopped all maintenance activities which could create this |
| condition. Also, samples will be taken where this maintenance has occurred |
| to check that the freon still complies with the water content limits. |
| |
| Paducah personnel notified the NRC resident inspector. |
| |
| ***** UPDATE RECEIVED AT 1500 EDT ON 06/21/01 FROM CALVIN PITTMAN TO LEIGH |
| TROCINE ***** |
| |
| The following text is a portion of a facsimile received from Paducah |
| personnel: |
| |
| "At 1900 [CDT] on [05/16/01], the Plant Shift Superintendent (PSS) was |
| notified of a deficient Nuclear Criticality Safety Evaluation. NCSAs CAS |
| 002 and CAS 011 allow both the Recirculating Cooling Water (RCW) supply and |
| return valves to be closed when draining the R-114 condenser without a |
| fluorinating environment. The NCS evaluations rely on the RCW supply valve |
| to be closed enough to prevent the condenser from being pressurized above |
| 35.5 psia during the time the RCW return valve is closed and maintenance |
| relieves the pressure on the condenser. Based on recent discussions between |
| NCS and maintenance personnel, it was discovered that closure of the RCW |
| supply valve might not provide sufficient isolation to prevent the condenser |
| from being pressurized above 35.5 psia with the return valve closed. The |
| RCW system provides cooling water to the R-114 condenser, which removes heat |
| from the freon system. The freon is used to remove the heat of compression |
| from the process gas system. The R-114 pressure is maintained above the RCW |
| pressure to form a barrier between the process gas and the RCW cooling |
| water, thus preventing moderation from occurring should a leak in the |
| condenser occur. If the RCW pressure is allowed to rise above 35.5 psia, |
| the potential exists that the RCW pressure could exceed that of the R-114 |
| pressure. At this point, an actual condition of RCW pressure greater than |
| 35.5 psia has not been identified." |
| |
| "UPDATE [on 06/20/01] ATRC 01-3248: During the Engineering review to |
| determine permanent corrective actions, additional immediate corrective |
| actions have become necessary. It has been determined that when the |
| condenser return valve is open, condenser pressure can also be affected when |
| the return header alignment is changed (i.e., closure of RCW loop isolation |
| valves, RCW building header valves, cooling tower riser valves, etc.). |
| Controls have been implemented to ensure that changes to the RCW system do |
| not impact our ability to maintain R-114 pressure above RCW pressure." |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: The controls credited for the isolation of |
| the condenser to ensure the pressure at the condenser does not exceed 35.5 |
| psia do not meet the intent of the NCSE for isolation. Therefore, the NCSE |
| analysis is deficient and double contingency is not maintained. However, |
| the probability for a criticality is unlikely due to the number of |
| conditions that must be met in order for a criticality to be possible." |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW |
| CRITICALITY COULD OCCUR): In order for a criticality to be possible, the |
| following conditions must exist. With the condenser supply and return |
| valves closed, the supply or return valve must be leaking to allow the |
| condenser pressure to exceed the minimum coolant pressure of 35.5 psia. |
| With the configuration of the supply valve closed and the return valve |
| opened, the RCW return system must be changed (i.e. closure of loop |
| isolation valves, RCW building header valves, cooling tower riser valves, |
| etc.) enough that the affected condenser pressure increased greater than |
| 35.5 psia. The process gas equipment must be at a UF6 negative and contain |
| a UO2F2 deposit greater than a critical mass. The condenser must have a |
| leak of sufficient rate and duration to allow enough water to overcome the |
| down comer allowing liquid water to enter the cooler. The cooler must also |
| have a simultaneous leak, which would allow wet coolant to leak into the |
| process gas side of the equipment at a location, which would allow |
| moderation of the deposit." |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| Double contingency for this scenario is established by implementing two |
| controls for moderation." |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITICAL MASS): Maximum assay of 5.5 wt. % U235" |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: The first leg of [the] double contingency |
| is based on isolation of the RCW condenser by closing the supply valve to |
| maintain the condenser pressure less than 35.5 psia. Based on discussions |
| with maintenance personnel, the current leak rates of the supply valve may |
| be greater than the amount assumed to ensure the condenser pressure does not |
| exceed 35.5 psia when the return valve is closed. Also, when the return |
| valve is open, the RCW return system could be changed (i.e., closure of loop |
| isolation valve, RCW building header valves, cooling tower riser valves, |
| etc.). Therefore, the intent of this control has not been met, and this leg |
| of double contingency was not maintained." |
| |
| "The second leg of [the] double contingency is based on the independent |
| verification of the isolation of the supply valve and when the return valve |
| is required to be open, verification that the return valve is open. Since |
| adequate isolation of the supply valve cannot be ensured based on |
| verification of supply valve closure or return valve open, when required, |
| the intent of this independent verification control was not met. Therefore, |
| this leg of double contingency was not maintained." |
| |
| "Since isolation of the RCW condenser with the supply valve closed and the |
| return valve closed or opened may not meet the intent of the isolation |
| requirement to maintain the condenser pressure less than 35.5 psia, these |
| controls are deficient and double contingency has not been maintained." |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| Until the NCSEs and NCSAs can be revised and additional controls |
| established:" |
| |
| "Condenser Return Valve Closed" |
| |
| "1. All maintenance activities related to closing the condenser return |
| valve on a system, which is at a UF6 negative, have been stopped. This does |
| not apply to systems that are not connected to the supply line or the C-310 |
| TOPS Boosters." |
| |
| "2. The coolant systems for condensers, which had the return valve closed |
| without a fluorinating environment present, will be sampled in accordance |
| with NCSA CAS-002 to verify the CFC-114 still complies with the water |
| content limits." |
| |
| "3. The return [valves] on condensers, which currently have the return |
| valve closed, fluorinating environment removed (at a UF6 negative), and is |
| connected to the supply line, will be opened." |
| |
| "RCW Building Return System (based on ATRC-01-3248)" |
| |
| "4. The plant power level will be maintained below 400 MW until NCSE |
| changes are completed and/or necessary controls are implemented or specific |
| evolutions are evaluated by NCS and approval is given." |
| |
| "5. Both building RCW return header valves to a given header will not be |
| closed." |
| |
| "6. At least 3 cooling tower risers for every large pump and 2 risers for |
| every small pump will be kept in service." |
| |
| "7. Respective building RCW bypasses will be closed before isolating an RCW |
| system loop." |
| |
| "8. For any auxiliary systems not protected by a delta P alarm (i.e., A-310 |
| Booster, A-335 Booster, C-337 B Booster) except the C-310 TOPS Booster, any |
| activity that requires verification that the condenser return valve is open |
| will also verify other valves in the return path to the applicable RCW |
| return header are also open." |
| |
| Paducah personnel notified the NRC resident inspector. The NRC operations |
| officer notified the R3DO (Bruce Jorgensen) and NMSS EO (Patricia |
| Holahan).] |
| |
| * * * UPDATE 1705EDT ON 8/21/01 FROM CALVIN PITTMAN TO S. SANDIN * * * |
| |
| The following information was provided as an update: |
| |
| "The plant has completed and approved a USQD [Unreviewed Safety Question |
| Determination] to allow the plant power level to be increased to 850 MW." |
| |
| The NRC resident inspector has been informed. Notified R3DO(Gardner) and |
| NMSS(Essig). |
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|Hospital |Event Number: 38224 |
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| REP ORG: WYOMING MEDICAL CENTER |NOTIFICATION DATE: 08/21/2001|
|LICENSEE: WYOMING MEDICAL CENTER |NOTIFICATION TIME: 15:56[EDT]|
| CITY: CASPER REGION: 4 |EVENT DATE: 08/20/2001|
| COUNTY: NATRONA STATE: WY |EVENT TIME: 11:00[MDT]|
|LICENSE#: 49-00152-02 AGREEMENT: N |LAST UPDATE DATE: 08/21/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BILL JONES R4 |
| |BRIAN SMITH NMSS |
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| NRC NOTIFIED BY: THOMAS A. CHEREWICK | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION INVOLVING AN UNDERDOSE DUE TO PERSONNEL ERROR |
| |
| On July 10, 2001 and elderly female patient received approximately 250 |
| instead of the 500 centigray prescribed as a boost dose for urinary cancer. |
| The device involved was a Wang applicator 3 centimeter in diameter with a |
| hemispherical head containing a Cs-137 source. This was an adjunct |
| procedure to surgery. The patient will be informed and there is no remedial |
| treatment necessary or planned. The licensee discovered this error on |
| 8/20/01 in a review while planning similar treatment for another patient. |
| The following actions have been taken to preclude recurrence: all point dose |
| calculations done by hand will include the dose prescription point and a |
| planned treatment will include a review of previous treatments utilizing |
| this particular applicator. The licensee attributes the underdose to |
| personnel error and has discussed this report with the NRC Region 4 office |
| (Whitten). |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021