Event Notification Report for August 30, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/29/2001 - 08/30/2001
EVENT NUMBERS
38258382553825138253
General Information or Other
Event Number: 38258
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ATSER CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L04741
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS (FACSIMILE)
HQ OPS Officer: BOB STRANSKY
Licensee: ATSER CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L04741
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS (FACSIMILE)
HQ OPS Officer: BOB STRANSKY
Notification Date: 08/31/2001
Notification Time: 17:15 [ET]
Event Date: 08/30/2001
Event Time: 12:15 [CDT]
Last Update Date: 08/31/2001
Notification Time: 17:15 [ET]
Event Date: 08/30/2001
Event Time: 12:15 [CDT]
Last Update Date: 08/31/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GAIL GOOD (R4)
GAIL GOOD (R4)
AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGE FOUND
"A yellow box with a Yellow II label was found and Hazmat responded to the scene. The box was found abandoned in a dumpster at an apartment building. Hazmat's radiation survey meters indicated the presence of radioactive material. However, the radiation levels indicated were inconsistent with readings expected from a gauge. It was later determined the Hazmat team had confused µR with mR and the readings were much lower than earlier believed.
"The city requested assistance to identify the owner of the gauge and possibly to take possession of the gauge. Because Houston was recently flooded, the city's basement area (with a lead lined vault was severely damaged and could not be used to temporarily secure the gauge.
"It was determined that the gauge belonged to ATSER Corporation (L04741). A former employee reported carrying it in his vehicle and it was stolen along with the vehicle. The company is still investigating. The gauge is a Humboldt, s/n 3612. The source serial number of the Cs-137 source is 9842GQ and the Am-241/Be source is NJ03905."
"A yellow box with a Yellow II label was found and Hazmat responded to the scene. The box was found abandoned in a dumpster at an apartment building. Hazmat's radiation survey meters indicated the presence of radioactive material. However, the radiation levels indicated were inconsistent with readings expected from a gauge. It was later determined the Hazmat team had confused µR with mR and the readings were much lower than earlier believed.
"The city requested assistance to identify the owner of the gauge and possibly to take possession of the gauge. Because Houston was recently flooded, the city's basement area (with a lead lined vault was severely damaged and could not be used to temporarily secure the gauge.
"It was determined that the gauge belonged to ATSER Corporation (L04741). A former employee reported carrying it in his vehicle and it was stolen along with the vehicle. The company is still investigating. The gauge is a Humboldt, s/n 3612. The source serial number of the Cs-137 source is 9842GQ and the Am-241/Be source is NJ03905."
Hospital
Event Number: 38255
Rep Org: MAYO CLINIC
Licensee: SAINT MARYS HOSPITAL
Region: 3
City: ROCHESTER State: MN
County:
License #: 22-26031-01
Agreement: N
Docket:
NRC Notified By: CLASSIC
HQ OPS Officer: CHAUNCEY GOULD
Licensee: SAINT MARYS HOSPITAL
Region: 3
City: ROCHESTER State: MN
County:
License #: 22-26031-01
Agreement: N
Docket:
NRC Notified By: CLASSIC
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/31/2001
Notification Time: 09:19 [ET]
Event Date: 08/30/2001
Event Time: 08:55 [CDT]
Last Update Date: 08/31/2001
Notification Time: 09:19 [ET]
Event Date: 08/30/2001
Event Time: 08:55 [CDT]
Last Update Date: 08/31/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
JOHN MADERA (R3)
JOHN HICKEY (NMSS)
JOHN MADERA (R3)
JOHN HICKEY (NMSS)
MEDICAL MISADMINISTRATION DURING THE USE OF A GAMMA STEREO TACTIC UNIT
A CANCER PATIENT WAS UNDERGOING THERAPEUTIC TREATMENTS AND RECEIVED A COBALT-60 DOSE GREATER THAN 39% OF THE PRESCRIBED DOSE. THE PRESCRIBED DOSE WAS 20 GRAYS AND THE ACTUAL DOSE WAS 27.8 GRAYS. CAUSE OF THE MISADMINISTRATION WAS DUE TO THE TIME OF TREATMENT BEING INCORRECTLY ENTERED IN THE TREATMENT UNIT. THE PATIENT AND PHYSICIAN WERE NOTIFIED.
THERE IS NO ANTICIPATION OF ANY ADVERSE AFFECT.
A CANCER PATIENT WAS UNDERGOING THERAPEUTIC TREATMENTS AND RECEIVED A COBALT-60 DOSE GREATER THAN 39% OF THE PRESCRIBED DOSE. THE PRESCRIBED DOSE WAS 20 GRAYS AND THE ACTUAL DOSE WAS 27.8 GRAYS. CAUSE OF THE MISADMINISTRATION WAS DUE TO THE TIME OF TREATMENT BEING INCORRECTLY ENTERED IN THE TREATMENT UNIT. THE PATIENT AND PHYSICIAN WERE NOTIFIED.
THERE IS NO ANTICIPATION OF ANY ADVERSE AFFECT.
Power Reactor
Event Number: 38251
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: PFEFFER
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: PFEFFER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/30/2001
Notification Time: 11:50 [ET]
Event Date: 08/30/2001
Event Time: 09:58 [CDT]
Last Update Date: 08/30/2001
Notification Time: 11:50 [ET]
Event Date: 08/30/2001
Event Time: 09:58 [CDT]
Last Update Date: 08/30/2001
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):
JOHN MADERA (R3)
JOHN MADERA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF OFFSITE RESPONSE CAPABILITY
The loss of the Public Prompt Notification System(PANS) was discovered during the performance of a surveillance test.
The Wright County Civil Defense was notified and is standing by to perform route alert if necessary.
The NRC Resident Inspector will be notified along with state and local agencies.
The loss of the Public Prompt Notification System(PANS) was discovered during the performance of a surveillance test.
The Wright County Civil Defense was notified and is standing by to perform route alert if necessary.
The NRC Resident Inspector will be notified along with state and local agencies.
Power Reactor
Event Number: 38253
Facility: COOK
Region: 3 State: MI
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: COBB
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: MI
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: COBB
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/30/2001
Notification Time: 14:09 [ET]
Event Date: 08/30/2001
Event Time: 12:48 [EDT]
Last Update Date: 08/30/2001
Notification Time: 14:09 [ET]
Event Date: 08/30/2001
Event Time: 12:48 [EDT]
Last Update Date: 08/30/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JOHN MADERA (R3)
JOHN MADERA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 3 | Startup | 0 | Hot Standby |
INDIVIDUAL ROD POSITION INDICATORS(IRPI) BECAME UNRELIABLE AND INOPERABLE
As the unit was shutting down per management direction from problems encountered with the ESW system (Refer to event #38249 for additional information.), several Individual Rod Position Indicators became unreliable and inoperable as a result of changing RCS temperatures. At 1248 on 8/30/01, more than one IRPI per group became inoperable which is beyond Cook TS 3.1.3.2. Action statement. This would require entry into TS 3.0.3 which requires initiating action within one hour to place the unit in a mode in which the specification does not apply. At that time Unit 2 was in mode 2@3.3% power and was expected to enter mode 3 at which time 3.1.3.2 would no longer be applicable. At 1347 the unit was shut down in mode 3 and exited both TS 3.1.3.2 and 3.0.3.
The NRC Resident Inspector was notified.
As the unit was shutting down per management direction from problems encountered with the ESW system (Refer to event #38249 for additional information.), several Individual Rod Position Indicators became unreliable and inoperable as a result of changing RCS temperatures. At 1248 on 8/30/01, more than one IRPI per group became inoperable which is beyond Cook TS 3.1.3.2. Action statement. This would require entry into TS 3.0.3 which requires initiating action within one hour to place the unit in a mode in which the specification does not apply. At that time Unit 2 was in mode 2@3.3% power and was expected to enter mode 3 at which time 3.1.3.2 would no longer be applicable. At 1347 the unit was shut down in mode 3 and exited both TS 3.1.3.2 and 3.0.3.
The NRC Resident Inspector was notified.