Event Notification Report for June 05, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/04/2001 - 06/05/2001
Power Reactor
Event Number: 38052
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: BRADLY McMAHON
HQ OPS Officer: FANGIE JONES
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: BRADLY McMAHON
HQ OPS Officer: FANGIE JONES
Notification Date: 06/05/2001
Notification Time: 04:59 [ET]
Event Date: 06/05/2001
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2001
Notification Time: 04:59 [ET]
Event Date: 06/05/2001
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRENT CLAYTON (R3)
BRENT CLAYTON (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
LOSS OF PROCESS COMPUTER WITH LINK TO SAFETY PARAMETERS DISPLAY SYSTEM
The plant process computer system failed. This system provides a link to the Safety Parameter Display System (SPDS). Immediate actions were taken to restore the computer and SPDS to no avail. The plant computer group representative has been called in to address the computer problem. Work continues to try and restore the computer to operation. Also, the availability of the Emergency Response Data System (ERDS) availability is questionable.
The licensee notified the NRC Resident Inspector.
The plant process computer system failed. This system provides a link to the Safety Parameter Display System (SPDS). Immediate actions were taken to restore the computer and SPDS to no avail. The plant computer group representative has been called in to address the computer problem. Work continues to try and restore the computer to operation. Also, the availability of the Emergency Response Data System (ERDS) availability is questionable.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 38053
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: C. MARPLE
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: C. MARPLE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/05/2001
Notification Time: 13:24 [ET]
Event Date: 06/05/2001
Event Time: 10:48 [EDT]
Last Update Date: 06/05/2001
Notification Time: 13:24 [ET]
Event Date: 06/05/2001
Event Time: 10:48 [EDT]
Last Update Date: 06/05/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
BRIAN BONSER (R2)
BRIAN BONSER (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 |
UNEXPECTED TRIP OF THE "1A2" REACTOR COOLANT PUMP CAUSED A TURBINE TRIP/REACTOR TRIP.
On 06/05/01 at 1048ET St. Lucie Unit 1 experienced an unexpected trip of the "1A2" Reactor Coolant Pump. This was immediately followed by an automatic reactor trip from the Reactor Protection System on reactor coolant low flow and subsequent turbine trip. All rods fully inserted into the core. Approximately one minute later the "1B" Main Feedwater pump tripped and then the Auxiliary Feedwater System actuated, "B" Electric Driven Auxiliary Feedwater Pump and the Turbine Driven Auxiliary Feedwater Pump, to the "1B" Steam Generator. The Reactor Coolant System is stable in Mode 3, Hot Standby, with the secondary steaming via the steam bypass control system and feedwater from the "1A" Main Feedwater Pump. The causes of the Reactor Coolant Pump trip and the Main Feedwater pump trip are currently under investigation. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable if needed.
Steam generator safety valves opened/closed. No leaking steam generator tubes.
"1A" Component Cooling Water Heat Exchanger and the "1A" Reactor Vessel Level Monitoring System were inoperable during the reactor trip.
The NRC Resident Inspector was notified of this event by the licensee.
On 06/05/01 at 1048ET St. Lucie Unit 1 experienced an unexpected trip of the "1A2" Reactor Coolant Pump. This was immediately followed by an automatic reactor trip from the Reactor Protection System on reactor coolant low flow and subsequent turbine trip. All rods fully inserted into the core. Approximately one minute later the "1B" Main Feedwater pump tripped and then the Auxiliary Feedwater System actuated, "B" Electric Driven Auxiliary Feedwater Pump and the Turbine Driven Auxiliary Feedwater Pump, to the "1B" Steam Generator. The Reactor Coolant System is stable in Mode 3, Hot Standby, with the secondary steaming via the steam bypass control system and feedwater from the "1A" Main Feedwater Pump. The causes of the Reactor Coolant Pump trip and the Main Feedwater pump trip are currently under investigation. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable if needed.
Steam generator safety valves opened/closed. No leaking steam generator tubes.
"1A" Component Cooling Water Heat Exchanger and the "1A" Reactor Vessel Level Monitoring System were inoperable during the reactor trip.
The NRC Resident Inspector was notified of this event by the licensee.
General Information or Other
Event Number: 38112
Rep Org: ALABAMA RADIATION CONTROL
Licensee: FLOWERS HOSPITAL
Region: 2
City: DOTHAN State: AL
County:
License #: 549
Agreement: Y
Docket:
NRC Notified By: JAMES McNEES (fax)
HQ OPS Officer: LEIGH TROCINE
Licensee: FLOWERS HOSPITAL
Region: 2
City: DOTHAN State: AL
County:
License #: 549
Agreement: Y
Docket:
NRC Notified By: JAMES McNEES (fax)
HQ OPS Officer: LEIGH TROCINE
Notification Date: 07/02/2001
Notification Time: 20:00 [ET]
Event Date: 06/05/2001
Event Time: 00:00 [CDT]
Last Update Date: 07/02/2001
Notification Time: 20:00 [ET]
Event Date: 06/05/2001
Event Time: 00:00 [CDT]
Last Update Date: 07/02/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS DECKER (R2)
PATRICIA HOLAHAN (NMSS)
ANTON VEGEL (R3)
THOMAS DECKER (R2)
PATRICIA HOLAHAN (NMSS)
ANTON VEGEL (R3)
MISLABELED IODINE-125 SEEDS BY NYCOMED AMERSHAM IN ILLINOIS RESULTED IN AN APPARENT MEDICAL MISADMINISTRATION AT FLOWERS HOSPITAL IN DOTHAN, ALABAMA
The following text is a portion of a facsimile received from the Alabama Division of Radiation Control:
"Alabama Incident #01-11 - I-125 Prostate Seed Implant Misadministration"
"On the afternoon of June 29, 2001, the Alabama Office of Radiation Control was notified by [the] Illinois Department of Nuclear Safety that a possible misadministration of an iodine-125 prostate seed implant may have occurred at Flowers Hospital on June 5, 2001. Flowers Hospital is authorized to possess and use the radioactive material under Alabama Radioactive Material License No. 549."
"The details of the event are described by [the Illinois Department of Nuclear Safety] in the attached e-mail which was transmitted to this Agency."
"Representatives from the Alabama Office of Radiation Control telephoned the medical physicist for Flowers Hospital on the morning of July 2, 2001, to inquire about the possible misadministration. The medical physicist for Flowers Hospital confirmed that a possible misadministration did occur based on the information obtained from the manufacturer[,] but he was in the process of reviewing the records pertaining to the possible misadministration."
"The Alabama Office of Radiation Control is presently investigating the details of this apparent misadministration and will be conducting an onsite inspection of licensed activities at Flowers Hospital beginning on July 3, 2001."
The following text is a portion of a facsimile received from the Alabama Division of Radiation Control involving an e-mail they received from the Illinois Department of Nuclear Safety at 0421 on June 29, 2001:
"SUBJECT: Mislabeled Seeds by Nycomed Amersham Result in an Apparent Medical Misadministration in Alabama"
"[A] Nycomed Amersham, RAML No. IL-01044-0l, [representative] called this afternoon and reported the following concerning distribution of their Model 6711 I-125 seeds:"
"June 13, 2001 - Nycomed Amersham, while performing a review of their scrapping procedure and inventory of dispensed products noted a discrepancy in a lot consisting of .270 mCi I-125 seeds. The lot was short 110 seeds."
"June 14 - Continued review found a discrepancy with a lot consisting of .414 mCi I-125 seeds. This lot was 110 seeds over."
"They realized that there was a dispensing error and that 110 seeds of .270 mCi seeds were sent out as .414 mCi seeds."
"June 15 - Determined that the seeds in question were transferred to Flowers Hospital in Dothan, Alabama on [May 30, 2001]."
"June 16 - Contacted Flowers Hospital and informed the dosimetrist about the problem (Flowers Hospital medical physicist was on vacation until the 18th). The dosimetrist investigated and learned that the seeds had been assayed in a new dose calibrator at their facility and [that] the seeds were implanted in a patient undergoing prostate therapy on June 5, 2001. Apparently[,] the dose calibrator read slightly lower than expected but not enough to stop the use of the seeds in the therapy procedure."
"June 18 - Nycomed discussed with the medical physicist at Flowers Hospital. The medical physicist asked Nycomed to send a calibrated seed to his facility so he could check the calibration of the dose calibrator. Nycomed complied with the request."
"June 20 - Flowers Hospital medical physicist notified Nycomed that their dose calibrator did not obtain the expected reading using the calibrated seed. The medical physicist requested that Nycomed's physician contact Flowers Hospital attending physician to discuss the matter. The physicians discussed the matter and both concluded that the actual dose delivered from planned was approximately 30% less than that planned. It is believed that the patient also underwent external beam therapy in conjunction with the brachytherapy. The physicians also concluded that the effect on the patient was 'small.'"
[An Illinois Department of Nuclear Safety representative] asked if the Alabama program had been notified as this appears to be a misadministration event in Alabama. [The Nycomed Amersham representative] stated that he believed that they had been but did not know for sure as they depend on the licensee to make the necessary reports as they do not want to get in between the licensee and their regulator. [The Nycomed Amersham representative] also stated that the event had been reported to the Chicago District of FDA on a form entitled 'Medical Device Report of Removal.'"
"[An Illinois Department of Nuclear Safety representative] then contacted the Alabama State Dept. of Public Health, Office of Radiation Control. [The Illinois Department of Nuclear Safety representative] provided the above information to Kirk Whatley and Jim McNees [of the Alabama Office of Radiation Control]. They stated that this was the first that they had heard about it and that they will follow up on the event. They will notify the NRC Ops Center if in fact a misadministration event actually occurred."
"[The Nycomed Amersham representative] will keep us posted on this matter."
(Please call the NRC operations center for the Illinois Department of Nuclear Safety and Nycomed Amersham contact names.)
The following text is a portion of a facsimile received from the Alabama Division of Radiation Control:
"Alabama Incident #01-11 - I-125 Prostate Seed Implant Misadministration"
"On the afternoon of June 29, 2001, the Alabama Office of Radiation Control was notified by [the] Illinois Department of Nuclear Safety that a possible misadministration of an iodine-125 prostate seed implant may have occurred at Flowers Hospital on June 5, 2001. Flowers Hospital is authorized to possess and use the radioactive material under Alabama Radioactive Material License No. 549."
"The details of the event are described by [the Illinois Department of Nuclear Safety] in the attached e-mail which was transmitted to this Agency."
"Representatives from the Alabama Office of Radiation Control telephoned the medical physicist for Flowers Hospital on the morning of July 2, 2001, to inquire about the possible misadministration. The medical physicist for Flowers Hospital confirmed that a possible misadministration did occur based on the information obtained from the manufacturer[,] but he was in the process of reviewing the records pertaining to the possible misadministration."
"The Alabama Office of Radiation Control is presently investigating the details of this apparent misadministration and will be conducting an onsite inspection of licensed activities at Flowers Hospital beginning on July 3, 2001."
The following text is a portion of a facsimile received from the Alabama Division of Radiation Control involving an e-mail they received from the Illinois Department of Nuclear Safety at 0421 on June 29, 2001:
"SUBJECT: Mislabeled Seeds by Nycomed Amersham Result in an Apparent Medical Misadministration in Alabama"
"[A] Nycomed Amersham, RAML No. IL-01044-0l, [representative] called this afternoon and reported the following concerning distribution of their Model 6711 I-125 seeds:"
"June 13, 2001 - Nycomed Amersham, while performing a review of their scrapping procedure and inventory of dispensed products noted a discrepancy in a lot consisting of .270 mCi I-125 seeds. The lot was short 110 seeds."
"June 14 - Continued review found a discrepancy with a lot consisting of .414 mCi I-125 seeds. This lot was 110 seeds over."
"They realized that there was a dispensing error and that 110 seeds of .270 mCi seeds were sent out as .414 mCi seeds."
"June 15 - Determined that the seeds in question were transferred to Flowers Hospital in Dothan, Alabama on [May 30, 2001]."
"June 16 - Contacted Flowers Hospital and informed the dosimetrist about the problem (Flowers Hospital medical physicist was on vacation until the 18th). The dosimetrist investigated and learned that the seeds had been assayed in a new dose calibrator at their facility and [that] the seeds were implanted in a patient undergoing prostate therapy on June 5, 2001. Apparently[,] the dose calibrator read slightly lower than expected but not enough to stop the use of the seeds in the therapy procedure."
"June 18 - Nycomed discussed with the medical physicist at Flowers Hospital. The medical physicist asked Nycomed to send a calibrated seed to his facility so he could check the calibration of the dose calibrator. Nycomed complied with the request."
"June 20 - Flowers Hospital medical physicist notified Nycomed that their dose calibrator did not obtain the expected reading using the calibrated seed. The medical physicist requested that Nycomed's physician contact Flowers Hospital attending physician to discuss the matter. The physicians discussed the matter and both concluded that the actual dose delivered from planned was approximately 30% less than that planned. It is believed that the patient also underwent external beam therapy in conjunction with the brachytherapy. The physicians also concluded that the effect on the patient was 'small.'"
[An Illinois Department of Nuclear Safety representative] asked if the Alabama program had been notified as this appears to be a misadministration event in Alabama. [The Nycomed Amersham representative] stated that he believed that they had been but did not know for sure as they depend on the licensee to make the necessary reports as they do not want to get in between the licensee and their regulator. [The Nycomed Amersham representative] also stated that the event had been reported to the Chicago District of FDA on a form entitled 'Medical Device Report of Removal.'"
"[An Illinois Department of Nuclear Safety representative] then contacted the Alabama State Dept. of Public Health, Office of Radiation Control. [The Illinois Department of Nuclear Safety representative] provided the above information to Kirk Whatley and Jim McNees [of the Alabama Office of Radiation Control]. They stated that this was the first that they had heard about it and that they will follow up on the event. They will notify the NRC Ops Center if in fact a misadministration event actually occurred."
"[The Nycomed Amersham representative] will keep us posted on this matter."
(Please call the NRC operations center for the Illinois Department of Nuclear Safety and Nycomed Amersham contact names.)