Event Notification Report for July 12, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/11/2001 - 07/12/2001
EVENT NUMBERS
3814038133381343813538136
Hospital
Event Number: 38140
Rep Org: WILLIAM BEAUMONT HOSPITAL
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: SHERYL SCHULTZ
HQ OPS Officer: BOB STRANSKY
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: SHERYL SCHULTZ
HQ OPS Officer: BOB STRANSKY
Notification Date: 07/13/2001
Notification Time: 15:12 [ET]
Event Date: 07/12/2001
Event Time: 19:00 [EDT]
Last Update Date: 07/13/2001
Notification Time: 15:12 [ET]
Event Date: 07/12/2001
Event Time: 19:00 [EDT]
Last Update Date: 07/13/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
DAVID HILLS (R3)
DONALD COOL (NMSS)
DAVID HILLS (R3)
DONALD COOL (NMSS)
MEDICAL MISADMINISTRATION
An individual prescribed a dose of 2.8 - 3.46 GBq (75.6 - 93.5 mCi) of Y-90 only received 1.1 GBq (29.7 mCi) due to a procedural error. The Y-90 was in the form of insoluble glass microspheres and was being injected into the liver in a saline solution. The procedure was being performed under an FDA approved humanitarian device exemption. During the treatment, the seal on the vial containing the microspheres was not properly pierced, causing backpressure to develop in the delivery lines and forcing some of the microspheres to back up into the treatment device. The licensee is implementing additional controls to prevent recurrence of this type of event. In addition, the device vendor (MDS Nordion) will continue with onsite proctoring of dose administrations until all treatment staff are fully trained.
An individual prescribed a dose of 2.8 - 3.46 GBq (75.6 - 93.5 mCi) of Y-90 only received 1.1 GBq (29.7 mCi) due to a procedural error. The Y-90 was in the form of insoluble glass microspheres and was being injected into the liver in a saline solution. The procedure was being performed under an FDA approved humanitarian device exemption. During the treatment, the seal on the vial containing the microspheres was not properly pierced, causing backpressure to develop in the delivery lines and forcing some of the microspheres to back up into the treatment device. The licensee is implementing additional controls to prevent recurrence of this type of event. In addition, the device vendor (MDS Nordion) will continue with onsite proctoring of dose administrations until all treatment staff are fully trained.
Power Reactor
Event Number: 38133
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: CRAIG MOWREY
HQ OPS Officer: BOB STRANSKY
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: CRAIG MOWREY
HQ OPS Officer: BOB STRANSKY
Notification Date: 07/12/2001
Notification Time: 14:21 [ET]
Event Date: 07/12/2001
Event Time: 10:45 [EDT]
Last Update Date: 07/12/2001
Notification Time: 14:21 [ET]
Event Date: 07/12/2001
Event Time: 10:45 [EDT]
Last Update Date: 07/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PAUL FREDRICKSON (R2)
PAUL FREDRICKSON (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 4 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNITS IN POTENTIALLY UNANALYZED CONDITION
"On July 12, 2001, Turkey Point determined that a previous failed surveillance may have constituted an unanalyzed condition that significantly degraded plant safety. On June 8, 2001, flow damper D-21 was discovered mispositioned. Damper D-21 controls the amount of recirculation flow in the Control Room Ventilation System (CRVS), when the system is in the emergency (recirculation) mode.
"The CRVS is designed such that when it shifts to recirculation mode, the Train B emergency supply fan starts. It draws in a nominal 250 cfm of outside intake air flow, and a nominal 750 cfm of recirculation air flow, for a total of 1000 cfm of flow through the HEPA and charcoal filters. If the Train B fan does not start, the resulting low recirculation flow (less than or equal to 100 cfm) will cause the Train A fan to start.
"During the surveillance it was found that, with the damper open too far, the recirculation flow stayed so high (about 250 cfm), that even with no supply fan running, the Train A fan did not receive a low flow start signal. The recirculation flow came from the three running Air Handling Units. As a result, a single failure of the Train B emergency supply fan could have caused a loss of emergency supply air forced flow.
"As a result of no forced flow, the outside intake air flow would be reduced, and the recirculation flow from the Air Handling Units would stay at about 250 cfm, as measured. By itself, this situation does not significantly degrade plant safety. If there were no outside air drawn in, the dose to the Control Room operators would be minimal. However, with no filtered outside intake air, Turkey Point cannot assure that the Control Room envelope would be pressurized, the unfiltered inleakage of outside air may be sufficient to increase the dose to operators."
The NRC resident inspector has been informed of this notification by the licensee.
"On July 12, 2001, Turkey Point determined that a previous failed surveillance may have constituted an unanalyzed condition that significantly degraded plant safety. On June 8, 2001, flow damper D-21 was discovered mispositioned. Damper D-21 controls the amount of recirculation flow in the Control Room Ventilation System (CRVS), when the system is in the emergency (recirculation) mode.
"The CRVS is designed such that when it shifts to recirculation mode, the Train B emergency supply fan starts. It draws in a nominal 250 cfm of outside intake air flow, and a nominal 750 cfm of recirculation air flow, for a total of 1000 cfm of flow through the HEPA and charcoal filters. If the Train B fan does not start, the resulting low recirculation flow (less than or equal to 100 cfm) will cause the Train A fan to start.
"During the surveillance it was found that, with the damper open too far, the recirculation flow stayed so high (about 250 cfm), that even with no supply fan running, the Train A fan did not receive a low flow start signal. The recirculation flow came from the three running Air Handling Units. As a result, a single failure of the Train B emergency supply fan could have caused a loss of emergency supply air forced flow.
"As a result of no forced flow, the outside intake air flow would be reduced, and the recirculation flow from the Air Handling Units would stay at about 250 cfm, as measured. By itself, this situation does not significantly degrade plant safety. If there were no outside air drawn in, the dose to the Control Room operators would be minimal. However, with no filtered outside intake air, Turkey Point cannot assure that the Control Room envelope would be pressurized, the unfiltered inleakage of outside air may be sufficient to increase the dose to operators."
The NRC resident inspector has been informed of this notification by the licensee.
Power Reactor
Event Number: 38134
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DROWN
HQ OPS Officer: BOB STRANSKY
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DROWN
HQ OPS Officer: BOB STRANSKY
Notification Date: 07/12/2001
Notification Time: 16:17 [ET]
Event Date: 07/12/2001
Event Time: 16:17 [EDT]
Last Update Date: 07/12/2001
Notification Time: 16:17 [ET]
Event Date: 07/12/2001
Event Time: 16:17 [EDT]
Last Update Date: 07/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)
ANTHONY DIMITRIADIS (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION
The licensee will be notifying the Maryland Department of the Environment (MDE) regarding positive test results for coliform bacteria in drinking water samples taken from the educational center. The NRC resident inspector has been informed of this notification.
The licensee will be notifying the Maryland Department of the Environment (MDE) regarding positive test results for coliform bacteria in drinking water samples taken from the educational center. The NRC resident inspector has been informed of this notification.
General Information or Other
Event Number: 38135
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: KLB CONSTRUCTION
Region: 4
City: ISSAQUAH State: WA
County:
License #: ORE-90865
Agreement: Y
Docket:
NRC Notified By: KEVIN SEIBERT
HQ OPS Officer: BOB STRANSKY
Licensee: KLB CONSTRUCTION
Region: 4
City: ISSAQUAH State: WA
County:
License #: ORE-90865
Agreement: Y
Docket:
NRC Notified By: KEVIN SEIBERT
HQ OPS Officer: BOB STRANSKY
Notification Date: 07/12/2001
Notification Time: 17:58 [ET]
Event Date: 07/12/2001
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2001
Notification Time: 17:58 [ET]
Event Date: 07/12/2001
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHUCK CAIN (R4)
JOSEPHINE PICCONE (NMSS)
CHUCK CAIN (R4)
JOSEPHINE PICCONE (NMSS)
AGREEMENT STATE REPORT
A Troxler Model 3430 gauge (S/N 28872) was stolen from a storage building in Issaquah, WA. The gauge had been transported to a work site in WA and placed into a locked storage building. The local police department has been notified (Case #01-05791). The licensee is offering a reward for the return of the gauge.
[See related report 38136]
A Troxler Model 3430 gauge (S/N 28872) was stolen from a storage building in Issaquah, WA. The gauge had been transported to a work site in WA and placed into a locked storage building. The local police department has been notified (Case #01-05791). The licensee is offering a reward for the return of the gauge.
[See related report 38136]
General Information or Other
Event Number: 38136
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KLB CONSTRUCTION
Region: 4
City: ISSAQUAH State: WA
County:
License #: ORE-90865
Agreement: Y
Docket:
NRC Notified By: TERRY FRAZEE (EMAIL)
HQ OPS Officer: BOB STRANSKY
Licensee: KLB CONSTRUCTION
Region: 4
City: ISSAQUAH State: WA
County:
License #: ORE-90865
Agreement: Y
Docket:
NRC Notified By: TERRY FRAZEE (EMAIL)
HQ OPS Officer: BOB STRANSKY
Notification Date: 07/12/2001
Notification Time: 18:33 [ET]
Event Date: 07/12/2001
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2001
Notification Time: 18:33 [ET]
Event Date: 07/12/2001
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHUCK CAIN (R4)
JOSEPHINE PICCONE (NMSS)
CHUCK CAIN (R4)
JOSEPHINE PICCONE (NMSS)
AGREEMENT STATE REPORT
"The Oregon licensee reported that a Troxler model 3430 portable gauge, serial number 28872, containing 10 mCi of cesium-137 and 50 mCi of americium-241 was stolen from a locked cargotainer at a work site in Washington state. The Oregon Licensee had transported the portable gauge to the work site of a Washington licensee in order to complete a sales transaction. The licensee's employee arrived at approximately 5:30 PM on July 11. Since no one from the Washington licensee was available on site to take possession of the gauge, the licensee's employee locked it in a work site cargotainer. The yellow transport box was reported to be locked. When the licensee's employee came back around 7:00 AM on July 12, the locks had been broken and the gauge and several tools had been stolen. The theft was reported to the City of Issaquah Police. The Washington Radiation control Program has been in contact with the Oregon Radiation control Program to coordinate follow-up."
[See related report 38135]
"The Oregon licensee reported that a Troxler model 3430 portable gauge, serial number 28872, containing 10 mCi of cesium-137 and 50 mCi of americium-241 was stolen from a locked cargotainer at a work site in Washington state. The Oregon Licensee had transported the portable gauge to the work site of a Washington licensee in order to complete a sales transaction. The licensee's employee arrived at approximately 5:30 PM on July 11. Since no one from the Washington licensee was available on site to take possession of the gauge, the licensee's employee locked it in a work site cargotainer. The yellow transport box was reported to be locked. When the licensee's employee came back around 7:00 AM on July 12, the locks had been broken and the gauge and several tools had been stolen. The theft was reported to the City of Issaquah Police. The Washington Radiation control Program has been in contact with the Oregon Radiation control Program to coordinate follow-up."
[See related report 38135]