Event Notification Report for August 15, 2000
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/14/2000 - 08/15/2000
Hospital
Event Number: 37227
Rep Org: UNIVERSITY OF PITTSBURGH
Licensee: UNIVERSITY OF PITTSBURGH
Region: 1
City: PITTSBURGH State: PA
County:
License #: 37-00245-02
Agreement: N
Docket:
NRC Notified By: M SHEETZ
HQ OPS Officer: JOHN MacKINNON
Licensee: UNIVERSITY OF PITTSBURGH
Region: 1
City: PITTSBURGH State: PA
County:
License #: 37-00245-02
Agreement: N
Docket:
NRC Notified By: M SHEETZ
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/15/2000
Notification Time: 16:20 [ET]
Event Date: 08/15/2000
Event Time: 14:00 [EDT]
Last Update Date: 08/15/2000
Notification Time: 16:20 [ET]
Event Date: 08/15/2000
Event Time: 14:00 [EDT]
Last Update Date: 08/15/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
CLIFFORD ANDERSON (R1)
PHILIP TING (NMSS)
CLIFFORD ANDERSON (R1)
PHILIP TING (NMSS)
POSSIBLE MEDICAL MISADMINISTRATION INVOLVING YTTRIUM-90 (Y-90).
This event occurred at the University of Pittsburgh Presbyterian Hospital located at 200 Lothrop St, Pittsburgh, PA.
A patient was to have received 80 millicuries of Y-90 for cancer treatment. The Y-90 was contained in glass microspheres which were to be transferred to the patient cancer site via a catheter. The Thera Sphere delivery device made by Nordion did not delivery most of the microspheres to the patient and at this time it is unknown how much of the 80 millicuries of Y-90 is still in the catheter. The caller, a Health Physicist, did not know what caused the Nordion Thera Sphere delivery device to fail. No one was contaminated or overexposed by this incident. The patients physician was notified of the potential Medical Misadministration. NRC Region 1 Jim Dwyer was notified of this event by the licensee. Half Life of Y-90 is 64 hours.
This event occurred at the University of Pittsburgh Presbyterian Hospital located at 200 Lothrop St, Pittsburgh, PA.
A patient was to have received 80 millicuries of Y-90 for cancer treatment. The Y-90 was contained in glass microspheres which were to be transferred to the patient cancer site via a catheter. The Thera Sphere delivery device made by Nordion did not delivery most of the microspheres to the patient and at this time it is unknown how much of the 80 millicuries of Y-90 is still in the catheter. The caller, a Health Physicist, did not know what caused the Nordion Thera Sphere delivery device to fail. No one was contaminated or overexposed by this incident. The patients physician was notified of the potential Medical Misadministration. NRC Region 1 Jim Dwyer was notified of this event by the licensee. Half Life of Y-90 is 64 hours.
Power Reactor
Event Number: 37225
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: JERE FREEMAN
HQ OPS Officer: FANGIE JONES
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: JERE FREEMAN
HQ OPS Officer: FANGIE JONES
Notification Date: 08/15/2000
Notification Time: 01:45 [ET]
Event Date: 08/15/2000
Event Time: 01:40 [EDT]
Last Update Date: 08/15/2000
Notification Time: 01:45 [ET]
Event Date: 08/15/2000
Event Time: 01:40 [EDT]
Last Update Date: 08/15/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(i)(A) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(1)(i)(A) - PLANT S/D REQD BY TS
Person (Organization):
CLIFFORD ANDERSON (R1)
CLIFFORD ANDERSON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 86 | Power Operation | 78 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF SECONDARY CONTAINMENT
Two reactor building isolation valves (V-28-21 and V-28-22) are not performing their isolation function. The plant is required to be in the shutdown mode by 0704 EDT on 8/15/00 and cold shutdown mode by 0904 EDT on 8/15/00. The valves were discovered at 0304 EDT on 8/14/00 and the licensee has been working on restoring their function. The licensee is continuing to try to restore their function and qualify other valves to perform their function.
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 08/15/00 AT 1241 ET BY WRONKA TAKEN BY MACKINNON * * *
Correction: This event notification corrects the above reported Oyster Creek Notification. The plant was required to be in shutdown mode by 0704 ET today, 08/15/00. A loss of Secondary Containment Integrity was discovered at 0304 ET on 08/14/00. Subsequent troubleshooting determined at 1120 ET on 08/14/00 that V-28-21 and V-28-22, Reactor Building Exhaust Valves, leak by when closed. A 30 hour LCO, Cold Shutdown, was in effect at the time of the initial notification which was determined to be not applicable and was exited at 0438 ET on 08/15/00. R1DO (Cliff Anderson) notified.
The NRC Resident Inspector was notified of this update by the licensee.
Two reactor building isolation valves (V-28-21 and V-28-22) are not performing their isolation function. The plant is required to be in the shutdown mode by 0704 EDT on 8/15/00 and cold shutdown mode by 0904 EDT on 8/15/00. The valves were discovered at 0304 EDT on 8/14/00 and the licensee has been working on restoring their function. The licensee is continuing to try to restore their function and qualify other valves to perform their function.
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 08/15/00 AT 1241 ET BY WRONKA TAKEN BY MACKINNON * * *
Correction: This event notification corrects the above reported Oyster Creek Notification. The plant was required to be in shutdown mode by 0704 ET today, 08/15/00. A loss of Secondary Containment Integrity was discovered at 0304 ET on 08/14/00. Subsequent troubleshooting determined at 1120 ET on 08/14/00 that V-28-21 and V-28-22, Reactor Building Exhaust Valves, leak by when closed. A 30 hour LCO, Cold Shutdown, was in effect at the time of the initial notification which was determined to be not applicable and was exited at 0438 ET on 08/15/00. R1DO (Cliff Anderson) notified.
The NRC Resident Inspector was notified of this update by the licensee.
General Information or Other
Event Number: 37329
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AGILENT TECHNOLOGIES, INC.
Region: 4
City: NEWARK State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN MacKINNON
Licensee: AGILENT TECHNOLOGIES, INC.
Region: 4
City: NEWARK State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/15/2000
Notification Time: 17:04 [ET]
Event Date: 08/15/2000
Event Time: 00:00 [PDT]
Last Update Date: 09/15/2000
Notification Time: 17:04 [ET]
Event Date: 08/15/2000
Event Time: 00:00 [PDT]
Last Update Date: 09/15/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
LARRY CAMPER (NMSS)
GARY SANBORN (R4)
LARRY CAMPER (NMSS)
187 MICROCURIE PROMETHIUM-147 SOURCE LOST
Promethium-147 is held under a General License. State of California event # CA-09-15-00
Agilent Technologies, Inc. located in Newark, CA was preparing to ship a 187 microcurie Promethium-147 source back to Hewlett Packard located in San Jose, CA. The source was taken out of its container and placed on a desk in a cubicle located in an Agilent Technology, Inc. building. When the person came back to get the source it was missing. Employees in the area were asked if they had seen or taken the small source and a survey of the area was performed to find the source. The source was not found. The original activity of the source, November 1994, was 900 microcuries. The half life of Promethium-147 is 2.62 years. The missing Promethium-147 was used in a Betascope which is used to measure the thickness of silicon wafers.
Agilent Technologies, Inc. notified the State of California regarding the missing source on 08/17/00
Promethium-147 is held under a General License. State of California event # CA-09-15-00
Agilent Technologies, Inc. located in Newark, CA was preparing to ship a 187 microcurie Promethium-147 source back to Hewlett Packard located in San Jose, CA. The source was taken out of its container and placed on a desk in a cubicle located in an Agilent Technology, Inc. building. When the person came back to get the source it was missing. Employees in the area were asked if they had seen or taken the small source and a survey of the area was performed to find the source. The source was not found. The original activity of the source, November 1994, was 900 microcuries. The half life of Promethium-147 is 2.62 years. The missing Promethium-147 was used in a Betascope which is used to measure the thickness of silicon wafers.
Agilent Technologies, Inc. notified the State of California regarding the missing source on 08/17/00