Event Notification Report for February 23, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/22/2004 - 02/23/2004
Power Reactor
Event Number: 40539
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: MARK SHAFFER
HQ OPS Officer: MIKE RIPLEY
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: MARK SHAFFER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 02/23/2004
Notification Time: 07:32 [ET]
Event Date: 02/23/2004
Event Time: 01:52 [EST]
Last Update Date: 02/23/2004
Notification Time: 07:32 [ET]
Event Date: 02/23/2004
Event Time: 01:52 [EST]
Last Update Date: 02/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAMELA HENDERSON (R1)
PAMELA HENDERSON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 94 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN STARTED DUE TO GRASS INTRUSION
"At 0152 on February 23rd the station service water system at Hope Creek experienced elevated differential pressure due to grass intrusion. At the time of the grass intrusion the `C' Service Water Traveling Screen was removed from service for an inspection. The grass intrusion resulted in the `A' Service Water strainer breaker tripping open de-energizing the strainer. Differential pressure on this strainer was pegged high and flow was reduced to 1900 gallons per minute [17,000 normal; 15,500 minimum]. The combination of these conditions resulted in inadequate cooling water flow to the `A' Station Auxiliaries Cooling Water system, and consequently inadequate cooling for the `A' Control Room Emergency Filtration [CREF] unit. With the `B' CREF fan already inoperable for a scheduled maintenance window, this resulted in entry into Technical Specification 3.0.3.
"This report is to document starting a unit shutdown to comply with Technical Specifications 3.0.3. Power reduction for Unit shutdown was commenced at 0407 [ET]. Unit shutdown was terminated at 0424 when `C' Service water pump was returned to service restoring cooling water to `A' SACS loop, restoring it to an OPERABLE status. This event is reportable under 10CFR50.72(b)(2)(i) as a four hour report.
"The Control Room Ventilation System provides heating, cooling, ventilation, and environmental control for the control room and adjacent areas. Under accident conditions, the Control Room Emergency Filtration Unit (CREF) ensures that the control room will remain habitable during and following all design basis accidents. Because the CREF system is required to automatically respond in the event of a design basis accident, having both trains of CREF inoperable at the same time impacted the ability to mitigate the consequences of an accident. Therefore, this event is also being reported in accordance with 10CFR50.72(b)(3)(v)(D) to comply with the requirements of an 8 hour report.
"At the time of the event the following Tech Spec related equipment was inoperable. `C' Service Water for screen inspection and `B' CREF for chiller maintenance work. Currently all safety related equipment is operable with the exception of the `A' Service Water Loop."
The licensee notified the NRC Resident Inspector.
"At 0152 on February 23rd the station service water system at Hope Creek experienced elevated differential pressure due to grass intrusion. At the time of the grass intrusion the `C' Service Water Traveling Screen was removed from service for an inspection. The grass intrusion resulted in the `A' Service Water strainer breaker tripping open de-energizing the strainer. Differential pressure on this strainer was pegged high and flow was reduced to 1900 gallons per minute [17,000 normal; 15,500 minimum]. The combination of these conditions resulted in inadequate cooling water flow to the `A' Station Auxiliaries Cooling Water system, and consequently inadequate cooling for the `A' Control Room Emergency Filtration [CREF] unit. With the `B' CREF fan already inoperable for a scheduled maintenance window, this resulted in entry into Technical Specification 3.0.3.
"This report is to document starting a unit shutdown to comply with Technical Specifications 3.0.3. Power reduction for Unit shutdown was commenced at 0407 [ET]. Unit shutdown was terminated at 0424 when `C' Service water pump was returned to service restoring cooling water to `A' SACS loop, restoring it to an OPERABLE status. This event is reportable under 10CFR50.72(b)(2)(i) as a four hour report.
"The Control Room Ventilation System provides heating, cooling, ventilation, and environmental control for the control room and adjacent areas. Under accident conditions, the Control Room Emergency Filtration Unit (CREF) ensures that the control room will remain habitable during and following all design basis accidents. Because the CREF system is required to automatically respond in the event of a design basis accident, having both trains of CREF inoperable at the same time impacted the ability to mitigate the consequences of an accident. Therefore, this event is also being reported in accordance with 10CFR50.72(b)(3)(v)(D) to comply with the requirements of an 8 hour report.
"At the time of the event the following Tech Spec related equipment was inoperable. `C' Service Water for screen inspection and `B' CREF for chiller maintenance work. Currently all safety related equipment is operable with the exception of the `A' Service Water Loop."
The licensee notified the NRC Resident Inspector.
Hospital
Event Number: 41532
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 3
City: SOUTH BEND State: IN
County:
License #: 13-02650-02
Agreement: N
Docket:
NRC Notified By: JOHN SCHEU
HQ OPS Officer: BILL GOTT
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 3
City: SOUTH BEND State: IN
County:
License #: 13-02650-02
Agreement: N
Docket:
NRC Notified By: JOHN SCHEU
HQ OPS Officer: BILL GOTT
Notification Date: 03/28/2005
Notification Time: 11:13 [ET]
Event Date: 02/23/2004
Event Time: 00:00 [CST]
Last Update Date: 04/05/2005
Notification Time: 11:13 [ET]
Event Date: 02/23/2004
Event Time: 00:00 [CST]
Last Update Date: 04/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
KENNETH RIEMER (R3)
TOM ESSIG (NMSS)
KENNETH RIEMER (R3)
TOM ESSIG (NMSS)
MEDICAL EVENT
The following information was supplied by the licensee:
"Two patients involved in what we now think to be reportable events.
1. A.M. 2-23-04 to 2-24-04
2. R.M. 3-01-04 to 3-02-04
"In both cases the patients were being treated for endometrial cancer with brachytherapy. A new Wang vaginal applicator was used. The tandem was loaded with incorrect size sources (of Cs-137) which then had the ability to slide out of the intended treatment position through the placement spring when the patient would sit in a more up-right position. With the sources out of position they would irradiate the patients inner thigh. The dose to the thigh had to be estimated based on estimated time the patient was in an up-right position and the effect seen on the skin.
"At the time these incidents took place it was not felt that reportable events had taken place because of the calculated exposure to the thigh, patient symptoms, and the interpretation of 35.3045 (a) (1)(2), (3).
"One of the patients (A.M.) returned recently (1/05) with an ulcer at the area of thigh exposure. This has caused the radiation therapy staff to reevaluate their dose estimation to the patients. After review, it is believed that reportable events my have occurred based on 35.3045 (A) (3).
"This conclusion was formulated on 3-25-05 after a staff meeting and 1 received the final letter from the physician today 3-28-05."
The tandem manufacturer recommends 3M seeds and the facility used Amersham seeds which resulted in the seeds shifting. A total of 5 patients were treated. The initial estimates determined that the exposure was less than the reportable limit. All the patients were notified of the exposure.
One of the two overexposed patients is responding well to treatment. The other patient may have received the higher dose. The remaining three patients appear to have received less than the reportable dose.
* * * UPDATE FROM JOHN SCHEU TO JEFF ROTTON ON 4/1/2005 AT 1608 * * *
Discussion between the licensee and NRC Region 3 inspectors determined that a third patient should be added to this event:
3. K.B. 3-19-04 to 3-22-04
Notified R3DO (Riemer) and NMSSEO (Collins).
* * * UPDATE FROM JOHN SCHEU TO HOWIE CROUCH ON 4/5/05 AT 1833 EDT * * *
Discussion between the licensee and NRC Region 3 inspectors determined that a fourth and fifth patient should be added to this event:
4. D. T. 1/26/04 to 1/27/04
5. M. S. 2/18/04 to 4/21/04
Notified R3DO (O'Brien) and NMSS EO (Leach).
The following information was supplied by the licensee:
"Two patients involved in what we now think to be reportable events.
1. A.M. 2-23-04 to 2-24-04
2. R.M. 3-01-04 to 3-02-04
"In both cases the patients were being treated for endometrial cancer with brachytherapy. A new Wang vaginal applicator was used. The tandem was loaded with incorrect size sources (of Cs-137) which then had the ability to slide out of the intended treatment position through the placement spring when the patient would sit in a more up-right position. With the sources out of position they would irradiate the patients inner thigh. The dose to the thigh had to be estimated based on estimated time the patient was in an up-right position and the effect seen on the skin.
"At the time these incidents took place it was not felt that reportable events had taken place because of the calculated exposure to the thigh, patient symptoms, and the interpretation of 35.3045 (a) (1)(2), (3).
"One of the patients (A.M.) returned recently (1/05) with an ulcer at the area of thigh exposure. This has caused the radiation therapy staff to reevaluate their dose estimation to the patients. After review, it is believed that reportable events my have occurred based on 35.3045 (A) (3).
"This conclusion was formulated on 3-25-05 after a staff meeting and 1 received the final letter from the physician today 3-28-05."
The tandem manufacturer recommends 3M seeds and the facility used Amersham seeds which resulted in the seeds shifting. A total of 5 patients were treated. The initial estimates determined that the exposure was less than the reportable limit. All the patients were notified of the exposure.
One of the two overexposed patients is responding well to treatment. The other patient may have received the higher dose. The remaining three patients appear to have received less than the reportable dose.
* * * UPDATE FROM JOHN SCHEU TO JEFF ROTTON ON 4/1/2005 AT 1608 * * *
Discussion between the licensee and NRC Region 3 inspectors determined that a third patient should be added to this event:
3. K.B. 3-19-04 to 3-22-04
Notified R3DO (Riemer) and NMSSEO (Collins).
* * * UPDATE FROM JOHN SCHEU TO HOWIE CROUCH ON 4/5/05 AT 1833 EDT * * *
Discussion between the licensee and NRC Region 3 inspectors determined that a fourth and fifth patient should be added to this event:
4. D. T. 1/26/04 to 1/27/04
5. M. S. 2/18/04 to 4/21/04
Notified R3DO (O'Brien) and NMSS EO (Leach).