25880 Federal Register / Vol. 63, No. 90 / Monday, May 11, 1998 / Notices

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Dated: May 6, 1998.

Andrew J. Hartman,

Director, NIFL.

[FR Doc. 98–12422 Filed 5–8–98; 8:45 am]

BILLING CODE 6055–01–M

NUCLEAR REGULATORY

COMMISSION

Report to Congress on Abnormal

Occurrences Fiscal Year 1997

Dissemination of Information

Section 208 of the Energy

Reorganization Act of 1974 (Pub. L. 93–

438) identifies an abnormal occurrence

(AO) as an unscheduled incident or

event that the Nuclear Regulatory

Commission (NRC) determines to be

significant from the standpoint of public

health or safety. The Federal Reports

Elimination and Sunset Act of 1995

(Pub. L. 104–66) requires that AOs be

reported to Congress on an annual basis.

During fiscal-year 1997, six events that

occurred at facilities licensed or

otherwise regulated by the NRC and the

Agreement States were determined to be

AOs. These events are discussed below.

As required by Section 208, the

discussion for each event includes the

date and place, the nature and probable

consequences, the cause or causes, and

the action taken to prevent recurrence.

Each event is also being described in

NUREG–0090, Vol. 20, ‘‘Report to

Congress on Abnormal Occurrences,

Fiscal Year 1997.’’ This report will be

available at NRC’s Public Document

Room, 2120 L Street N.W. (Lower

Level), Washington, D.C., about three

weeks after the publication date of this

Federal Register Notice.

97–1 Loss of Two of Three High

Pressure Injection Pumps at Oconee

Nuclear Station Unit 3

One of the AO reporting criteria notes

that a major deficiency in design,

construction, control, or operation

having significant safety implications

requiring immediate remedial action

can be considered an AO.

Date and Place—May 3, 1997; Oconee

Unit 3, a pressurized water nuclear

reactor plant designed by Babcock and

Wilcox Company, operated by the Duke

Energy Corporation (formerly known as

Duke Power Company), and located

about 8 miles north of Clemson, South

Carolina.

Nature and Probable Consequences—

On May 3, 1997, the Oconee Unit 3

reactor was shut down and the reactor

coolant system (RCS) was being cooled

down for inspection of the high pressure

injection (HPI) discharge piping. The

need for the inspection resulted from

RCS leakage from a weld crack in the

HPI makeup piping on Unit 2. Reactor

pressure was approximately 270 psig,

RCS temperature was approximately

205° F, one reactor coolant pump (RCP)

was running, and the Low Pressure

Injection System was being used to cool

down the RCS. Makeup water to the

RCS to compensate for the temperature

decrease was being supplied from the

letdown storage tank (LDST) by one of

the three HPI pumps. Makeup to the

LDST consisted of periodic batch

additions as needed. These plant

conditions were below the point where

the technical specifications required

that the HPI system must be operable;

that is, required to mitigate a smallbreak loss-of-coolant accident.

Plant cool-down evolutions appeared

to be normal until the ‘‘B’’ HPI pump

started to cavitate and makeup flow to

the reactor coolant system was lost. A

RCP seal water (which is also supplied

by the HPI pump) low-flow signal

automatically started the ‘‘A’’ HPI

pump. However, it also began to

cavitate. (The third HPI pump is not

designed to automatically start on this

signal and remained in the standby

condition.) The operators stopped both

pumps and began troubleshooting the

problem. A Notification of Unusual

Event was declared when it was

recognized that the pumps would be

inoperable past the shift that was on

duty. Unit 3 pressure and temperature

were stabilized and there was no

immediate concern that conditions

would worsen.

Later investigations revealed that the

potential for a more serious situation

existed if there had been a small break

loss-of-coolant accident, which is the

design basis for the HPI system, prior to

this event. If such an accident had

occurred, all three of the HPI pumps

would have automatically started and

become inoperable very quickly. In

addition, the pumps may have become

air bound and unavailable when the

pump suction was transferred to the

Borated Water Storage Tank to inject

into the RCS. This would have

significantly complicated recovery from

the accident, but would have been

within the Emergency Operating

Procedure guidance and training

provided to the operators. It would,

however, increase the probability of

core damage. The length of time that

Unit 3 was in this degraded status could

not be accurately determined, but the

condition may have existed since startup in March 1997, when plant

conditions required that the HPI system

be operable.

Cause or Causes—Loss of the HPI

pumps occurred when all of the water

was inadvertently pumped from the

LDST because of faulty level indication.

The erroneous level indication was

caused by the loss of approximately

one-half of the water in the level

detector reference leg because of a slight

leak in the instrument fitting. This loss

of the reference leg water caused the

tank level instrument to indicate a water

level higher than the actual level, a

condition that may have existed since

February 1997, the last time the

reference leg was verified to be full. It

also caused the loss of the low-level

alarm. As a result of these conditions,

the operators did not provide makeup

water to the tank when it was needed,

resulting in the HPI pump continuing to

run until the tank was empty. The LDST

level detection system consists of two

level instruments connected to a

common reference leg. Thus, the

condition affected both level detectors

equally.

In addition, the control room

operators did not properly monitor and

detect the inaccurate LDST level

indications. They did not notice that for

a short period of time the indicated

level stopped decreasing and

continuously showed the tank to be

approximately half-full at the same time

water was being pumped from the tank.

Actions Taken to Prevent Recurrence

Licensee—Corrective actions included

(1) the addition of a second reference leg

to the LDST to provide separate level

indications, (2) enhanced operator

training and procedures, and (3) the

performance of an HPI System

Reliability Study that is to be completed

by December 31, 1997.
Federal Register / Vol. 63, No. 90 / Monday, May 11, 1998 / Notices 25881

NRC—Escalated enforcement, which

incorporated this issue, resulted in the

determination that a Severity Level II

violation existed, and the licensee was

assessed a $330,000 civil penalty.

Information Notice 97–38, ‘‘LevelSensing System Initiates Common-Mode

Failure of High-Pressure-Injection

Pumps,’’ was issued on June 24, 1997,

to alert other licensees to this event.

This event is closed for the purpose

of this report.

* * * * *

Other NRC Licensees—(Industrial

Radiographers, Medical Institutions,

Industrial Users, etc.)

97–2 Overexposure of a Worker at

Mallinckrodt, Inc., in Maryland Heights,

Missouri

One of the AO criteria notes that any

unintended radiation exposure to an

adult (any individual 18 years of age or

older) resulting in an annual shallowdose equivalent to the skin or

extremities of 2500 mSv (250 rem) or

more will be considered for reporting as

an AO.

Date and Place—May 14–15, 1997;

Mallinckrodt, Inc.; Maryland Heights,

Missouri.

Nature and Probable Consequences—

On May 14, 1997, an employee was

removing radioactive waste from the hot

cell where rhenium-186 (Re-186) was

used. The employee was performing this

task manually, using gloves, instead of

remotely. When he left the area, he

attempted to perform a personal

contamination survey but the survey

meter immediately went off the scale.

He assumed that the high count rate was

due to background radiation from an

adjacent radioactive material transport

cart and, subsequently, forgot to

resurvey himself in a low background

area before he left the facility that

evening. Upon arrival at work the next

day, he was told that his urine sample,

which he had submitted before going

home the previous night, indicated

iodine-131 (I-131) radiation

contamination and that he was

restricted from working with radioactive

material. At that time, he performed a

personal contamination survey and

detected significant levels of

contamination on his left thumb which

subsequently was identified as Re-186.

The I-131 contamination level did not

exceed the AO criteria for exposure to

radiation from licensed material.

The licensee estimates that the

individual received a shallow-dose

equivalent of 6090 millisievert (609

rem) to an area of about 0.75 square

centimeters (0.12 square inches) on the

palm side of the thumb of his left hand.

Lower levels of contamination were

found on the back of his right hand and

fingers. On May 15, 1997, the employee

had undergone decontamination to the

extent that only approximately 4

percent of the activity remained.

The licensee surveyed the offsite

locations where the employee had been

after leaving work on May 14, 1997.

Low levels of Re-186 contamination

were found on three locations inside the

employee’s vehicle and on various items

in the bathroom and kitchen of his

home. The employee’s vehicle and

home were decontaminated. The

employee was examined by a physician

who identified no immediate health

effects. However, according to a report

from an NRC consultant, a small

possibility exists for skin cancer to

develop in the exposed area of the

thumb.

Cause or Causes—The cause of the

event was a procedural deficiency in

handling waste from the Re-186 hot cell.

Normally, radioactive waste in other hot

cells at the facility was handled with

remote tools. However, in this case,

procedural controls did not require

remote handling of the waste. Once the

employee completed the work, poor

radiation work practices were exhibited

as he cross-contaminated his hands

when he removed his gloves. In

addition, the worker did not investigate

the detection of high count rates during

his first attempt to perform a

contamination survey.

Actions Taken to Prevent Recurrence

Licensee—The staff was instructed on

the importance of conducting proper

personal contamination surveys and the

proper use of protective clothing. The

use of Re-186 was suspended until

improvements to existing waste disposal

procedures could be evaluated and

implemented. Plans were made (1) to

compile all existing contamination

protection procedures into one

contamination protection procedure, (2)

to evaluate the use of a portal type

monitoring system, and (3) to post

personal-monitoring reminder signs at

all laboratory exits.

NRC—NRC conducted a special safety

inspection, proposed a $55,000 civil

penalty on December 17, 1997, and the

licensee paid the civil penalty on

January 20, 1998.

This event is closed for the purpose

of this report.

* * * * *

Agreement State Licensees

AS 97–1 Multiple Transuranic

Overexposures to a Worker at Isotope

Products Laboratories in Burbank,

California

One of the AO criteria notes that any

unintended radiation exposure to an

adult (any individual 18 years of age or

older) resulting in an annual total

effective dose equivalent (TEDE) of 250

millisievert (mSv) (25 rem) or more; or

an annual sum of the deep dose

equivalent (DDE) (external dose) and

committed dose equivalent (CDE)

(intake of radioactive material) to any

individual organ or tissue other than the

lens of the eye, bone marrow, and the

gonads of 2500 mSv (250 rem) or more

will be considered for reporting as an

AO. In addition, another AO criterion

states that a serious deficiency in

management or procedural controls in

major areas will be considered for

reporting as an AO.

Date and Place—Between January 1

and December 31, 1995; Isotope

Products Laboratories; Burbank,

California.

Nature and Probable Consequences—

A radiochemist was assigned to make

transuranic and other types of sources.

The transuranics utilized included the

isotopes of plutonium-238 (Pu-238), Pu239, Pu-240, americium-241 (Am-241),

and curium-244 (Cm-244). During

January 1995, while making a Cm-244

source, it was discovered that the

exhaust fan of the fume hood where the

source was being fabricated was not

working. An analysis of room air

samples confirmed the loss of Cm-244

into the working area.

Bioassay results disclosed that the

fecal and urine samples provided by the

radiochemist contained Cm-244 and

Am-241. The licensee hired dosimetry

and radiation protection consultants as

directed by the State Agency. Careful

analysis of the bioassay data by these

consultants, which included dose

summation and retrospective time

correction for various intakes, suggested

that during 1995 the radiochemist

received a TEDE of 383.20 mSv (38.32

rem) and a CDE of 6900 mSv (690 rem)

to the bone surfaces. The specific

exposures were as follows: (1)

committed effective dose equivalent

(CEDE) of 271.8 mSv (27.18 rem) from

Cm-244, (2) CEDE of 80 mSv (8 rem)

from Am-241, (3) CEDE of 4.4 mSv (0.44

rem) from Pu-238, Pu-239, and Pu-240,

and (4) DDE of 27.0 mSv (2.70 rem) from

external radiation.

The State Agency discovered this

incident during a routine inspection on

December 5, 1995, and was initially

reported to NRC in January 1996. During
25882 Federal Register / Vol. 63, No. 90 / Monday, May 11, 1998 / Notices

a follow-up inspection, the State Agency

learned that another Cm-244 incident

took place and was significant. The

State Agency also learned of other

exposure incidents that indicated the

licensee had a deficient contamination

control program, an inability to conduct

internal dose assessments, and

inadequate management oversight. The

State provided additional information

on these events to NRC in 1997.

Cause or Causes—The licensee’s

radiation protection program was

inadequate and lacked important

elements needed to ensure the radiation

safety of its workers. Some of these

inadequacies were the lack of (1) work

permits, (2) glove boxes for certain types

of work, and (3) radiation procedural

controls.

Actions Taken To Prevent Recurrence

Licensee—After the licensee’s

consultants conducted their review and

comprehensive audit of the existing

radiation protection program, they made

recommendations to ensure future

compliance with the license and

regulations. The licensee hired a

competent radiation safety officer, and

the radiochemist was assigned duties

that did not involve the handling or

processing of radioactive materials.

State Agency—The State Agency

completed its investigation and is

committed to closely tracking the

licensee’s radiation protection program

to ensure continued compliance.

This event is closed for the purpose

of this report.

* * * * *

AS 97–2 Overexposure of a

Radiographer and an Untrained

Technician at Wolf Creek Mine in

Walker County, Alabama

One of the AO criteria notes that any

unintended radiation exposure to an

adult (any individual 18 years of age or

older) resulting in an annual total

effective dose equivalent (TEDE) of 250

millisievert (mSv) (25 rem) or more; or

an annual sum of the deep dose

equivalent (DDE) (external dose) and

committed dose equivalent (CDE)

(intake of radioactive material) to any

individual organ or tissue other than the

lens of the eye, bone marrow, and the

gonads of 2500 mSv (250 rem) or more

will be considered for reporting as an

AO. In addition, another AO criterion

states that a serious deficiency in

management or procedural controls in

major areas will be considered for

reporting as an AO.

Date and Place—July 1, 1996; Wolf

Creek Mine, Walker County, Alabama.

Nature and Probable Consequences—

A radiographer, employed by Certified

Testing and Inspection of Cottondale,

Alabama, and a technician, employed

by Ultron, Inc., of Mt. Vernon, Illinois,

were performing industrial radiography

at the Wolf Creek Mine in Walker

County, Alabama, when they became so

distracted by problems with excessively

exposed film that they forgot they had

an exposure in progress and entered the

high radiation area without making a

survey and changed the film with the

source in the unshielded exposed

position. The radiographer had received

prior radiation safety training, however,

the technician, an employee of Ultron,

Inc., had not received prior radiation

safety training. The radiography film

and the device used to support the

source and the film during exposures

were being supplied to the radiographer

by Ultron, Inc.

Consequently, both individuals

received unintended radiation exposure.

The State Agency estimated that the

radiographer received a dose of 530

millisievert (mSv) (53 rem) to his head

and 48 mSv (4.8 rem) to the center of

his body and the Ultron, Inc., technician

received a dose of 110 mSv (11 rem) to

his head and 28 mSv (2.8 rem) to the

center of his body. Neither individual

reported any acute radiation symptoms.

The radiography film supplied by

Ultron, Inc., had faster and different

exposure characteristics than the film

usually used by Certified Testing and

thus was being overexposed during

processing in the darkroom. The

darkroom, which was supplied by

Certified Testing, utilized a homemade

‘‘safe light,’’ which had been made a

safe light by the application of red spray

paint. The radiographer did not realize

beforehand that the light would not be

‘‘safe’’ for the film supplied by Ultron,

Inc.

Cause or Causes—The radiographer

entered a designated high radiation area

with his alarm ratemeter turned off and

without following his normal practice of

cranking in the source and surveying

the guide tube and camera. The

radiographer interpreted the silence

from the alarm ratemeter as an

indication of safe conditions.

Unfortunately, when turned off, the

alarm ratemeter gives the same

indication as it does when indicating

safe conditions. In addition, the

radiographer did not utilize a collimator

to reduce the exposure to himself and

the Ultron, Inc., technician.

Actions Taken To Prevent Recurrence

Licensee—The licensee stated that the

radiographer did not develop any

symptom of acute radiation exposure

and that its personnel were reinstructed

in the importance of performing surveys

and using a collimator. The licensee

committed to the State Agency to verify

the training of all technicians, including

those of the company that hires the

licensee to perform radiography.

State Agency—The State Agency cited

the Licensee for the following four

violations: (1) excessive exposure to a

radiation worker, (2) excessive exposure

to a member of the public (the Ultron,

Inc., technician representative), (3)

failure to prevent unauthorized entry

into the High Radiation Area, and (4)

failure to exercise ALARA by using a

collimator. A civil penalty was

considered but not imposed. The State

Agency recommended that both

individuals contact the State and seek

medical attention if any symptoms of

acute exposure should appear.

This event is closed for the purpose

of this report.

* * * * *

AS 97–3 Radiopharmaceutical

Misadministration at Mad River

Community Hospital in Arcata,

California

One of the AO criteria states that a

medical misadministration that results

in a dose that is equal to or greater than

10 gray (Gy) (1000 rad) to any organ

(other than a major portion of the bone

marrow, to the lens of the eye, or to the

gonads) and represents a dose or dosage

that is at least 50 percent greater than

that prescribed in a written directive

will be considered for reporting as an

AO.

Date and Place—February 28, 1996;

Mad River Community Hospital; Arcata,

California. The State initially reported

this event to NRC in December 1996.

Nature and Probable Consequences—

A patient was prescribed a dosage of 3.7

megabecquerel (MBq) (0.1 millicurie

[mCi]) of iodine-131 (I–131) for a

thyroid scan and uptake procedure.

However, the patient was administered

a dosage of 262.7 MBq (7.1 mCi) of I–

131. As a result, the patient’s thyroid

received a dose of about 9100 centigray

(cGy) (9100 rad), instead of the

prescribed dose of 130 cGy (130 rad).

The licensee stated that such a dose

may induce a hypothyroid state

requiring the patient to take thyroid

hormone.

Cause or Causes—The wrong dosage

was administered on the assumption

that the patient was prescribed a whole

body thyroid scan for a cancer

metastatic disease evaluation.

Actions Taken To Prevent Recurrence

Licensee—Procedures for scheduling

a whole body scan for thyroid cancer

metastases were revised to include a

detailed patient preparation and history.
Federal Register / Vol. 63, No. 90 / Monday, May 11, 1998 / Notices 25883

The revised procedures required that

the approving radiologist sign the I–131

administration policy before ordering a

radiopharmaceutical. In addition, the

nuclear medicine technologist attended

a continuing education program at San

Francisco General Hospital, which

included a segment on the effects of

studies involving therapy dosages.

State Agency—The State Agency

conducted numerous follow-up

inspections to ensure that the licensee’s

actions taken to prevent recurrence had

been implemented.

This event is closed for the purpose

of this report.

* * * * *

AS 97–4 Radiopharmaceutical

Misadministration at Tuomey Regional

Medical Center in Sumter, South

Carolina

One of the AO criteria notes that a

medical misadministration that results

in a dose that is equal to or greater than

10 gray (Gy) (1000 rad) to any organ

(other than a major portion of the bone

marrow, to the lens of the eye, or to the

gonads) and represents a dose or dosage

that is at least 50 percent greater than

that prescribed in a written directive

will be considered for reporting as an

AO.

Date and Place—December 11, 1996;

Tuomey Regional Medical Center;

Sumter, South Carolina.

Nature and Probable Consequences—

A patient was prescribed a dosage of 74

megabecquerel (MBq) (2.0 millicurie

[mCi]) of iodine-131 (I–131) for a

treatment of Graves disease. However,

the patient was administered a 388.5

MBq (10.5 mCi) dosage of I–131. As a

result, the patient’s thyroid received a

dose of 40,400 centigray (cGy) (40,400

rad) instead of the prescribed dose of

7700 cGy (7700 rad).

The licensee stated that the

administered dose of I–131 to the

patient’s thyroid is not expected to have

major health effects.

Cause or Causes—The wrong dosage

was administered to the patient because

the written order for the I–131

procedure was misread by the

administering technologist.

Actions Taken To Prevent Recurrence

Licensee—The licensee will have the

written order on hand before ordering

radiopharmaceuticals from the

pharmacy and will have a second

person verify the dosage before

administration to the patient.

State Agency—The State Agency

accepted the licensee’s report and

corrective action as appropriate. No

further action was requested.

This event is closed for the purpose

of this report.

* * * * *

Dated at Rockville, Maryland this 5th day

of May, 1998.

For the Nuclear Regulatory Commission.

John C. Hoyle,

Secretary of the Commission.

[FR Doc. 98–12390 Filed 5–8–98; 8:45 am]

BILLING CODE 7590–01–P

NUCLEAR REGULATORY

COMMISSION

[Docket Nos. 50–387 and 50–388]

Pennsylvania Power and Light

Company; Notice of Issuance of

Amendment to Facility Operating

License

The U.S. Nuclear Regulatory

Commission (Commission) has issued

Amendment No. 176 to Facility

Operating License No. NPF–14 and

Amendment No. 149 to Facility

Operating License No. NPF–22 issued to

Pennsylvania Power and Light Company

(PP&L, the licensee), which revised the

Technical Specifications (TSs) for

operation of the Susquehanna Steam

Electric Station, Units 1 and 2, located

in Luzerne County, Pennsylvania. The

amendment is effective as of the date of

issuance.

The amendment modified the TSs by

changing the Rod Block Monitor (RBM)

flow biased trip setpoints and also the

RBM channel calibration frequency and

allowed outage times.

The application for the amendment

complies with the standards and

requirements of the Atomic Energy Act

of 1954, as amended (the Act), and the

Commission’s rules and regulations.

The Commission has made appropriate

findings as required by the Act and the

Commission’s rules and regulations in

10 CFR Chapter I, which are set forth in

the license amendment.

Notice of Consideration of Issuance of

Amendment to Facility Operating

License and Opportunity for a Hearing

in connection with this action was

published in the Federal Register on

April 11, 1997 (62 FR 17885). No

request for a hearing or petition for

leave to intervene was filed following

this notice.

The Commission has prepared an

Environmental Assessment related to

the action and has determined not to

prepare an environmental impact

statement. Based upon the

environmental assessment, the

Commission has concluded that the

issuance of the amendment will not

have a significant effect on the quality

of the human environment (63 FR

24197).

For further details with respect to the

action see (1) the application for

amendment dated November 27, 1996,

and supplemented by letter dated

February 12, 1997, (2) Amendment

No.176 to License No. NPF–14, (3)

Amendment No. 149 to License No.

NPF–22, (4) the Commission’s related

Safety Evaluation, and (5) the

Commission’s Environmental

Assessment. All of these items are

available for public inspection at the

Commission’s Public Document Room,

the Gelman Building, 2120 L Street

NW., Washington, DC, and at the local

public document room located at the

Osterhout Free Library, Reference

Department, 71 South Franklin Street,

Wilkes Barre, PA 18701.

Dated at Rockville, Maryland, this 4th day

of May 1998.

For the Nuclear Regulatory Commission

Victor Nerses,

Senior Project Manager, Project Directorate

I–2, Division of Reactor Projects—I/II, Office

of Nuclear Reactor Regulation.

[FR Doc. 98–12391 Filed 5–8–98; 8:45 am]

BILLING CODE 7590–01–P

NUCLEAR REGULATORY

COMMISSION

Southern Nuclear Operating Company,

Inc., et al.; Notice of Consideration of

Issuance of Amendments to Facility

Operating Licenses, Proposed No

Significant Hazards Consideration

Determination, and Opportunity for a

Hearing

[Docket Nos. 50–424 and 50–425]

The U.S. Nuclear Regulatory

Commission (the Commission) is

considering issuance of amendments to

Facility Operating License Nos. NPF–68

and NPF–81, issued to Southern

Nuclear Operating Company, Inc., et al.

(the licensee), for operation of the

Vogtle Electric Generating Plant (VEGP),

Units 1 and 2, located in Burke County,

Georgia.

The proposed amendments would

revise the VEGP Technical

Specifications to authorize the licensee

to increase the storage capacity of the

VEGP Unit 1 spent fuel pool from the

present capacity of 288 fuel assemblies

to 1476 fuel assemblies. The change

would be accomplished by the

installation of high density fuel rack

modules. The racks would utilize a

neutron absorbing material between

cells to assure a subcritical

configuration.

The Commission had previously

issued a Notice of Consideration of