Event Notification Report for November 28, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/27/2001 - 11/28/2001
EVENT NUMBERS
38523385283852038521
General Information or Other
Event Number: 38523
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ROMAGOSA ONCOLOGY
Region: 4
City: NEW IBERIA State: LA
County:
License #: LA-0978-L01
Agreement: Y
Docket:
NRC Notified By: BLACKWELL (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: ROMAGOSA ONCOLOGY
Region: 4
City: NEW IBERIA State: LA
County:
License #: LA-0978-L01
Agreement: Y
Docket:
NRC Notified By: BLACKWELL (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/29/2001
Notification Time: 16:45 [ET]
Event Date: 11/28/2001
Event Time: 00:00 [CST]
Last Update Date: 11/29/2001
Notification Time: 16:45 [ET]
Event Date: 11/28/2001
Event Time: 00:00 [CST]
Last Update Date: 11/29/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
LARRY CAMPER (NMSS)
WILLIAM JOHNSON (R4)
LARRY CAMPER (NMSS)
STATE LICENSEE REPORTED A MEDICAL MISADMINISTRATION
A patient was being treated with a brachytherapy dose of Ir-192. The Ir-192 was 6.6 Ci. The facility was performing multiple fractions. Each fraction was supposed to be 440 centigray. Fraction 5 of 6 was 269 centigray, which is more than a 20% difference. The individual making the notification stated that another directive would be written for the sixth fraction so that the patient receives the full 2640 centigray dose.
A patient was being treated with a brachytherapy dose of Ir-192. The Ir-192 was 6.6 Ci. The facility was performing multiple fractions. Each fraction was supposed to be 440 centigray. Fraction 5 of 6 was 269 centigray, which is more than a 20% difference. The individual making the notification stated that another directive would be written for the sixth fraction so that the patient receives the full 2640 centigray dose.
General Information or Other
Event Number: 38528
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA AT SAN DIEGO
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: FANGIE JONES
Licensee: UNIVERSITY OF CALIFORNIA AT SAN DIEGO
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: FANGIE JONES
Notification Date: 11/30/2001
Notification Time: 12:48 [ET]
Event Date: 11/28/2001
Event Time: 11:00 [PST]
Last Update Date: 11/30/2001
Notification Time: 12:48 [ET]
Event Date: 11/28/2001
Event Time: 11:00 [PST]
Last Update Date: 11/30/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
FRED BROWN (NMSS)
WILLIAM JOHNSON (R4)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT - LOST SOURCE
A patient receiving palliative treatment for lung cancer had six seeds implanted in the lungs. Each seed contained 0.4 mCi of I-125. After about 2 hours, an x-ray of the lungs was performed to verify positioning of the seeds and 3 of the seeds were missing. A search/survey of the area did not find the missing seeds. It is unknown where the seeds are, it is possible the patient coughed up the seeds and swallowed them. The patient was released later that day. There is minimal threat to any member of the public.
California Radiation Control Program office contacted NRC State Programs (Pat Larkin).
A patient receiving palliative treatment for lung cancer had six seeds implanted in the lungs. Each seed contained 0.4 mCi of I-125. After about 2 hours, an x-ray of the lungs was performed to verify positioning of the seeds and 3 of the seeds were missing. A search/survey of the area did not find the missing seeds. It is unknown where the seeds are, it is possible the patient coughed up the seeds and swallowed them. The patient was released later that day. There is minimal threat to any member of the public.
California Radiation Control Program office contacted NRC State Programs (Pat Larkin).
General Information or Other
Event Number: 38520
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: TRI-STATE TESTING AND DRILLING, INC.
Region: 2
City: CHATTANOOGA State: TN
County:
License #: R-33105
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS (fax)
HQ OPS Officer: LEIGH TROCINE
Licensee: TRI-STATE TESTING AND DRILLING, INC.
Region: 2
City: CHATTANOOGA State: TN
County:
License #: R-33105
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS (fax)
HQ OPS Officer: LEIGH TROCINE
Notification Date: 11/28/2001
Notification Time: 11:50 [ET]
Event Date: 11/28/2001
Event Time: 06:00 [EST]
Last Update Date: 11/28/2001
Notification Time: 11:50 [ET]
Event Date: 11/28/2001
Event Time: 06:00 [EST]
Last Update Date: 11/28/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
EDWARD MCALPINE (R2)
FRED BROWN (NMSS)
EDWARD MCALPINE (R2)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT REGARDING A TRI-STATE TESTING AND DRILLING, INC. TROXLER MOISTURE DENSITY GAUGE STOLEN IN CHATTANOOGA, TENNESSEE
The following text is a portion of a facsimile received from the State of Tennessee, Department of Environment and Conservation, Division of Radiological Health:
"Event Report ID No.: TN-01-217"
"License Number: R-33105"
"Licensee: Tri-State Testing and Drilling, Inc."
"Event date and time: November 28, 2001, approx. 0600 EST"
"Event location: Chattanooga, TN"
"Event type: Stolen moisture density gauge"
"Notifications: Tennessee Emergency Management Agency, USNRC Region II, Alabama Office of Radiation Control, Georgia Radioactive Materials Program, Chattanooga Police Department"
"Media interest: None at this time. A press release is being issued by TDEC."
"Event description: Tri-State Testing and Drilling, Inc. reported a Troxler moisture density gauge, Model 3440, SN 17252, containing 8 millicuries of Cesium-137 and 40 millicuries of Americium-241:Beryllium, was stolen from the bed of a pickup truck early this morning. The gauge was chained in the back of the truck parked at an employees residence. Thieves cut the chain and removed the locked container. State DRH inspectors are onsite investigating at this time."
(Call the NRC operations officer for contact information.)
The following text is a portion of a facsimile received from the State of Tennessee, Department of Environment and Conservation, Division of Radiological Health:
"Event Report ID No.: TN-01-217"
"License Number: R-33105"
"Licensee: Tri-State Testing and Drilling, Inc."
"Event date and time: November 28, 2001, approx. 0600 EST"
"Event location: Chattanooga, TN"
"Event type: Stolen moisture density gauge"
"Notifications: Tennessee Emergency Management Agency, USNRC Region II, Alabama Office of Radiation Control, Georgia Radioactive Materials Program, Chattanooga Police Department"
"Media interest: None at this time. A press release is being issued by TDEC."
"Event description: Tri-State Testing and Drilling, Inc. reported a Troxler moisture density gauge, Model 3440, SN 17252, containing 8 millicuries of Cesium-137 and 40 millicuries of Americium-241:Beryllium, was stolen from the bed of a pickup truck early this morning. The gauge was chained in the back of the truck parked at an employees residence. Thieves cut the chain and removed the locked container. State DRH inspectors are onsite investigating at this time."
(Call the NRC operations officer for contact information.)
Power Reactor
Event Number: 38521
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: KARL EHRHARDT
HQ OPS Officer: LEIGH TROCINE
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: KARL EHRHARDT
HQ OPS Officer: LEIGH TROCINE
Notification Date: 11/28/2001
Notification Time: 20:00 [ET]
Event Date: 11/28/2001
Event Time: 18:20 [CST]
Last Update Date: 11/28/2001
Notification Time: 20:00 [ET]
Event Date: 11/28/2001
Event Time: 18:20 [CST]
Last Update Date: 11/28/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
JOSE CALVO (NRR)
WILLIAM JOHNSON (R4)
JOSE CALVO (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONFIRMATION OF A LOOSE PART IN THE REACTOR SYSTEM (DISCOVERY OF AN OBSTRUCTION IN A JET PUMP NOZZLE)
During a daily jet pump surveillance test at approximately 1800 CST on 11/27/01, the licensee discovered that the flow through reactor recirculation jet pump #13 was reduced. Although one of three surveillance criteria was not met, the jet pump and recirculation system remained operable because at least two of the three criteria were met. The surveillance criteria that was not met involved a deviation of jet pump flows from one jet pump to the other jet pumps (i.e., flow not being within 10% of an established pattern).
The licensee reported that the loose parts detection system was not working and was undergoing a review for potential removal. However, further analysis today (11/28/01) confirmed that one nozzle of jet pump #13 is obstructed by a loose part. The obstruction size and type have not yet been determined. Additional investigations are ongoing.
The licensee stated that confirmation of a loose part in the reactor system constitutes a 1-hour reportable event in accordance with procedure 01S065. This was also reported to be a commitment in the Final Safety Analysis Report.
The licensee contacted General Electric and the NRC resident inspector.
During a daily jet pump surveillance test at approximately 1800 CST on 11/27/01, the licensee discovered that the flow through reactor recirculation jet pump #13 was reduced. Although one of three surveillance criteria was not met, the jet pump and recirculation system remained operable because at least two of the three criteria were met. The surveillance criteria that was not met involved a deviation of jet pump flows from one jet pump to the other jet pumps (i.e., flow not being within 10% of an established pattern).
The licensee reported that the loose parts detection system was not working and was undergoing a review for potential removal. However, further analysis today (11/28/01) confirmed that one nozzle of jet pump #13 is obstructed by a loose part. The obstruction size and type have not yet been determined. Additional investigations are ongoing.
The licensee stated that confirmation of a loose part in the reactor system constitutes a 1-hour reportable event in accordance with procedure 01S065. This was also reported to be a commitment in the Final Safety Analysis Report.
The licensee contacted General Electric and the NRC resident inspector.