Event Notification Report for January 17, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/16/2001 - 01/17/2001
General Information or Other
Event Number: 37669
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ST. JOSEPH'S HOSPITAL, INC.
Region: 2
City: SAVANNAH State: GA
County:
License #: GA 48-1
Agreement: Y
Docket:
NRC Notified By: ELIZABETH DRINNON
HQ OPS Officer: DOUG WEAVER
Licensee: ST. JOSEPH'S HOSPITAL, INC.
Region: 2
City: SAVANNAH State: GA
County:
License #: GA 48-1
Agreement: Y
Docket:
NRC Notified By: ELIZABETH DRINNON
HQ OPS Officer: DOUG WEAVER
Notification Date: 01/18/2001
Notification Time: 15:59 [ET]
Event Date: 01/17/2001
Event Time: 12:00 [EST]
Last Update Date: 01/18/2001
Notification Time: 15:59 [ET]
Event Date: 01/17/2001
Event Time: 12:00 [EST]
Last Update Date: 01/18/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WALTER RODGERS (R2)
ERIC LEEDS (NMSS)
WALTER RODGERS (R2)
ERIC LEEDS (NMSS)
AGREEMENT STATE REPORT
"Novoste Beta-Cath System, A1000 Series, device ejected the source train just prior to treating a patient. The shielded bailout box was used and most of the sources went immediately into the bailout box. All remaining sources were located and placed in the bailout box. The patient was removed from the room when the incident occurred. No misadministration occurred as patient treatment had been completed and no sources remained in the patient. The incident occurred on the 25th use of the device (device has a built in counter). Licensee contacted the manufacturer of the device on the day of the incident. Physicist and Radiologist were present during incident. Isotope: Strontium 90 Amount of Activity: < 300 millicuries"
"Novoste Beta-Cath System, A1000 Series, device ejected the source train just prior to treating a patient. The shielded bailout box was used and most of the sources went immediately into the bailout box. All remaining sources were located and placed in the bailout box. The patient was removed from the room when the incident occurred. No misadministration occurred as patient treatment had been completed and no sources remained in the patient. The incident occurred on the 25th use of the device (device has a built in counter). Licensee contacted the manufacturer of the device on the day of the incident. Physicist and Radiologist were present during incident. Isotope: Strontium 90 Amount of Activity: < 300 millicuries"
Power Reactor
Event Number: 37667
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON BRADLEY
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON BRADLEY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/17/2001
Notification Time: 19:12 [ET]
Event Date: 01/17/2001
Event Time: 16:20 [EST]
Last Update Date: 01/17/2001
Notification Time: 19:12 [ET]
Event Date: 01/17/2001
Event Time: 16:20 [EST]
Last Update Date: 01/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
WALTER RODGERS (R2)
WALTER RODGERS (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
TURBINE TRIP/REACTOR TRIP DURING TURBINE CONTROL TESTING.
Reactor Trip due to Turbine Generator trip greater than 69% power. All rods fully inserted into the core. Feedwater isolation due to reactor trip with Tave less than 564 degrees F (this is a design feature and was expected). Both Motor Driven Auxiliary Feedwater pumps automatically started as expected due to the Feedwater Isolation. As far as the licensee knew at the time of the call no Primary or Secondary PORVs or Code Safety Valves opened. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable. "1A" Nuclear Service Water pump is out of service for planned maintenance (currently being returned to service) and the "1A" Auxiliary Building Ventilation is also inoperable for planned maintenance.
Currently the cause of the turbine trip is unknown. Turbine Control Testing was in progress at the time of the trip.
The licensee will notify North & South Carolina and surrounding counties of the reactor trip.
The NRC Resident Inspector was notified of this event by the licensee.
Reactor Trip due to Turbine Generator trip greater than 69% power. All rods fully inserted into the core. Feedwater isolation due to reactor trip with Tave less than 564 degrees F (this is a design feature and was expected). Both Motor Driven Auxiliary Feedwater pumps automatically started as expected due to the Feedwater Isolation. As far as the licensee knew at the time of the call no Primary or Secondary PORVs or Code Safety Valves opened. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable. "1A" Nuclear Service Water pump is out of service for planned maintenance (currently being returned to service) and the "1A" Auxiliary Building Ventilation is also inoperable for planned maintenance.
Currently the cause of the turbine trip is unknown. Turbine Control Testing was in progress at the time of the trip.
The licensee will notify North & South Carolina and surrounding counties of the reactor trip.
The NRC Resident Inspector was notified of this event by the licensee.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 37672
Rep Org: FROEDTERT MEMORIAL LUTHERAN HOSP
Licensee: FROEDTERT MEMORIAL LUTHERAN HOSP
Region: 3
City: MILWAUKEE State: WI
County:
License #: 48-04193
Agreement: N
Docket:
NRC Notified By: MARCUM MARTZ
HQ OPS Officer: DOUG WEAVER
Licensee: FROEDTERT MEMORIAL LUTHERAN HOSP
Region: 3
City: MILWAUKEE State: WI
County:
License #: 48-04193
Agreement: N
Docket:
NRC Notified By: MARCUM MARTZ
HQ OPS Officer: DOUG WEAVER
Notification Date: 01/19/2001
Notification Time: 16:59 [ET]
Event Date: 01/17/2001
Event Time: 18:30 [CST]
Last Update Date: 04/11/2001
Notification Time: 16:59 [ET]
Event Date: 01/17/2001
Event Time: 18:30 [CST]
Last Update Date: 04/11/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
ROGER LANKSBURY (R3)
ERIC LEEDS (NMSS)
ROGER LANKSBURY (R3)
ERIC LEEDS (NMSS)
POTENTIAL MEDICAL MISADMINISTRATION
A patient being treated with a Leksell gamma system model 23004 type B received a treatment to the wrong site. The intended dose or dose delivered were not available. The dose was delivered to the wrong location because the head frame had been installed in the wrong position. The correct site was subsequently treated. The hospital is in the process of informing the patient and the referring physician. The attending physician did not believe the mistake would pose a problem to the patient.
***** UPDATE AT 1439 EDT ON 04/11/01 FROM MARCUM MARTZ TO LEIGH TROCINE *****
After discussions with the NRC Region 3 staff (Bob Gattone), it was determined that this event did not involve a medical misadministration. Therefore, the licensee is retracting this event notification.
The NRC operations officer notified the R3DO (Wright) and NMSS EO (Smith).
Call the NRC operations officer for a licensee contact telephone number.
A patient being treated with a Leksell gamma system model 23004 type B received a treatment to the wrong site. The intended dose or dose delivered were not available. The dose was delivered to the wrong location because the head frame had been installed in the wrong position. The correct site was subsequently treated. The hospital is in the process of informing the patient and the referring physician. The attending physician did not believe the mistake would pose a problem to the patient.
***** UPDATE AT 1439 EDT ON 04/11/01 FROM MARCUM MARTZ TO LEIGH TROCINE *****
After discussions with the NRC Region 3 staff (Bob Gattone), it was determined that this event did not involve a medical misadministration. Therefore, the licensee is retracting this event notification.
The NRC operations officer notified the R3DO (Wright) and NMSS EO (Smith).
Call the NRC operations officer for a licensee contact telephone number.