Event Notification Report for October 17, 2000
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/16/2000 - 10/17/2000
General Information or Other
Event Number: 37438
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: UNIVERSITY OF MARYLAND
Region: 1
City: State: MD
County:
License #: MD-0701401
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF MARYLAND
Region: 1
City: State: MD
County:
License #: MD-0701401
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/18/2000
Notification Time: 16:15 [ET]
Event Date: 10/17/2000
Event Time: 19:00 [EDT]
Last Update Date: 10/18/2000
Notification Time: 16:15 [ET]
Event Date: 10/17/2000
Event Time: 19:00 [EDT]
Last Update Date: 10/18/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM COOK (R1)
JOHN HICKEY (NMSS)
WILLIAM COOK (R1)
JOHN HICKEY (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION (UNDERDOSE)
AT 1650EDT ON 10/17/00, A 31 YEAR OLD MALE PATIENT UNDERGOING TREATMENT FOR LIVER CANCER RECEIVED 23.4% OF THE PRESCRIBED 150 GRAY DOSE USING YTTRIUM-90 GLASS SPHERES PRODUCED BY NORDION. THE LICENSEE HAS PERFORMED 10 SUCCESSFUL THERAPIES OF THIS TYPE IN THE PAST. THE MANUFACTURER IS EVALUATING THE ENTIRE DELIVERY SYSTEM IN ORDER TO DETERMINE ROOT CAUSE. THE LICENSEE'S PRELIMINARY EVALUATION INDICATES A DIFFICULTY IN THE DELIVERY RESULTING FROM AN AIR LEAK IN THE RUBBER CAP OF THE SOURCE VIAL AT THE SITE OF THE NEEDLE INSERTION. THE LICENSEE SUSPECTS THAT THE INLET NEEDLE AND THE OUTLET NEEDLE MAY HAVE BEEN INSERTED TOO CLOSE WHICH CAUSED THE RUBBER CAP TO LOSE ITS SELF-SEAL CAPABILITY. AT 1900EDT ON 10/18, THE LICENSEE DETERMINED THAT THE UNDERDOSE MET THE REPORTING REQUIREMENTS AS A MEDICAL MISADMINISTRATION.
THE STATE OF MARYLAND INTENDS TO CONDUCT AN INVESTIGATION OF THIS INCIDENT.
AT 1650EDT ON 10/17/00, A 31 YEAR OLD MALE PATIENT UNDERGOING TREATMENT FOR LIVER CANCER RECEIVED 23.4% OF THE PRESCRIBED 150 GRAY DOSE USING YTTRIUM-90 GLASS SPHERES PRODUCED BY NORDION. THE LICENSEE HAS PERFORMED 10 SUCCESSFUL THERAPIES OF THIS TYPE IN THE PAST. THE MANUFACTURER IS EVALUATING THE ENTIRE DELIVERY SYSTEM IN ORDER TO DETERMINE ROOT CAUSE. THE LICENSEE'S PRELIMINARY EVALUATION INDICATES A DIFFICULTY IN THE DELIVERY RESULTING FROM AN AIR LEAK IN THE RUBBER CAP OF THE SOURCE VIAL AT THE SITE OF THE NEEDLE INSERTION. THE LICENSEE SUSPECTS THAT THE INLET NEEDLE AND THE OUTLET NEEDLE MAY HAVE BEEN INSERTED TOO CLOSE WHICH CAUSED THE RUBBER CAP TO LOSE ITS SELF-SEAL CAPABILITY. AT 1900EDT ON 10/18, THE LICENSEE DETERMINED THAT THE UNDERDOSE MET THE REPORTING REQUIREMENTS AS A MEDICAL MISADMINISTRATION.
THE STATE OF MARYLAND INTENDS TO CONDUCT AN INVESTIGATION OF THIS INCIDENT.
Power Reactor
Event Number: 37434
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: BRUCE PROCTOR
HQ OPS Officer: STEVE SANDIN
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: BRUCE PROCTOR
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/17/2000
Notification Time: 22:15 [ET]
Event Date: 10/17/2000
Event Time: 19:53 [CDT]
Last Update Date: 10/17/2000
Notification Time: 22:15 [ET]
Event Date: 10/17/2000
Event Time: 19:53 [CDT]
Last Update Date: 10/17/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
Person (Organization):
JOHN PELLET (R4)
JOHN PELLET (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
INDICATION OF RCS PRESSURE BOUNDARY LEAKAGE DISCOVERED DURING INSPECTION OF PRESSURIZER HEATER SLEEVE
"A SMALL AMOUNT OF BORIC ACID WAS DISCOVERED IN THE AREA AROUND PRESSURIZER HEATER SLEEVE NUMBER F4 DURING A BARE METAL INSPECTION PERFORMED ON 10/17/00. THE BORIC ACID IS BELIEVED TO BE EVIDENCE OF PRIMARY STRESS CORROSION CRACKING OF THE INCONEL ALLOY 600 HEATER SLEEVE. THE BORIC ACID IS BELIEVED TO BE EVIDENCE OF REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY LEAKAGE, CONSTITUTING A DEGRADATION OF THE RCS PRESSURE BOUNDARY."
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.
"A SMALL AMOUNT OF BORIC ACID WAS DISCOVERED IN THE AREA AROUND PRESSURIZER HEATER SLEEVE NUMBER F4 DURING A BARE METAL INSPECTION PERFORMED ON 10/17/00. THE BORIC ACID IS BELIEVED TO BE EVIDENCE OF PRIMARY STRESS CORROSION CRACKING OF THE INCONEL ALLOY 600 HEATER SLEEVE. THE BORIC ACID IS BELIEVED TO BE EVIDENCE OF REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY LEAKAGE, CONSTITUTING A DEGRADATION OF THE RCS PRESSURE BOUNDARY."
THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.