Event Notification Report for October 22, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/21/2002 - 10/22/2002
EVENT NUMBERS
39310393123932739470
Power Reactor
Event Number: 39310
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOE BENNETT
HQ OPS Officer: GERRY WAIG
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOE BENNETT
HQ OPS Officer: GERRY WAIG
Notification Date: 10/22/2002
Notification Time: 17:34 [ET]
Event Date: 10/22/2002
Event Time: 12:52 [CDT]
Last Update Date: 10/22/2002
Notification Time: 17:34 [ET]
Event Date: 10/22/2002
Event Time: 12:52 [CDT]
Last Update Date: 10/22/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION 50.72(b)(3)(v)(B) - POT RHR INOP
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION 50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
ROBERT HAAG (R2)
ROBERT HAAG (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 |
LOSS OF HIGH PRESSURE COOLANT INJECTION SYSTEM
"At 1252 [CDT] on 10/22/02, during troubleshooting activities, a loss of the Unit 3 Division II ECCS inverter occurred. This resulted in a loss of the High Pressure Coolant Injection system (HPCI) due to a loss of power to the flow indicating controller. This event is reportable within 8 hours per 10CFR 50.72(b)(3)(v) and requires a 60 day written report per 10CFR 50.73(a)(2)(v)."
The licensee has notified the NRC Resident Inspector.
"At 1252 [CDT] on 10/22/02, during troubleshooting activities, a loss of the Unit 3 Division II ECCS inverter occurred. This resulted in a loss of the High Pressure Coolant Injection system (HPCI) due to a loss of power to the flow indicating controller. This event is reportable within 8 hours per 10CFR 50.72(b)(3)(v) and requires a 60 day written report per 10CFR 50.73(a)(2)(v)."
The licensee has notified the NRC Resident Inspector.
Hospital
Event Number: 39312
Rep Org: TENET HEALTH SYSTEMS GRADUATE
Licensee: TENET HEALTH SYSTEMS GRADUATE
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-28359-01
Agreement: N
Docket:
NRC Notified By: KENT LAMBERT
HQ OPS Officer: GERRY WAIG
Licensee: TENET HEALTH SYSTEMS GRADUATE
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-28359-01
Agreement: N
Docket:
NRC Notified By: KENT LAMBERT
HQ OPS Officer: GERRY WAIG
Notification Date: 10/23/2002
Notification Time: 16:38 [ET]
Event Date: 10/22/2002
Event Time: 10:00 [EDT]
Last Update Date: 10/23/2002
Notification Time: 16:38 [ET]
Event Date: 10/22/2002
Event Time: 10:00 [EDT]
Last Update Date: 10/23/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
FRANK COSTELLO (R1)
MELVYN LEACH (NMSS)
FRANK COSTELLO (R1)
MELVYN LEACH (NMSS)
MEDICAL MISADMINISTRATION-SOURCE RUPTURE DURING REMOVAL
A 830 microcurie Iodine 125 brachytherapy source ruptured while it was being withdrawn from a patient's bladder during a prostate implant. The seed was removed and the patient's bladder was flushed. The flush solution measured 0.2 microcuries. Follow-up actions include evaluation of possible patient thyroid uptake and investigation to determine why the retrieval mechanism ruptured the source. The patient and prescribing physician have been informed of this event. The licensee also notified NRC Region 1 of the event.
A 830 microcurie Iodine 125 brachytherapy source ruptured while it was being withdrawn from a patient's bladder during a prostate implant. The seed was removed and the patient's bladder was flushed. The flush solution measured 0.2 microcuries. Follow-up actions include evaluation of possible patient thyroid uptake and investigation to determine why the retrieval mechanism ruptured the source. The patient and prescribing physician have been informed of this event. The licensee also notified NRC Region 1 of the event.
General Information or Other
Event Number: 39327
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ROBERT BOISSONEAULT ONCOLOGY INSTITUTE
Region: 2
City: LACANTO State: FL
County:
License #: 2155-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MIKE RIPLEY
Licensee: ROBERT BOISSONEAULT ONCOLOGY INSTITUTE
Region: 2
City: LACANTO State: FL
County:
License #: 2155-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/29/2002
Notification Time: 13:04 [ET]
Event Date: 10/22/2002
Event Time: 00:00 [EDT]
Last Update Date: 10/29/2002
Notification Time: 13:04 [ET]
Event Date: 10/22/2002
Event Time: 00:00 [EDT]
Last Update Date: 10/29/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KERRY LANDIS (R2)
FRED BROWN (NMSS)
KERRY LANDIS (R2)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT
"On 10-22-02 the patient was undergoing the first of six fraction therapy using a HDR source in the cervix. The source was misplaced by approximately 2 centimeters. The dose received was 800 Rem instead of the prescribed dose of 500 Rem. On 10-28-02 the error was discovered during planning for the second fraction, and it was reported the same day. The patient and physician have been notified. No long term health effect is expected and the prescribed treatment is continuing. Licensee will submit a letter of explanation within 15 days. Florida is continuing it's investigation."
Florida Incident No. FL02-161
Isotope used was 9.961 Curies Ir-192.
"On 10-22-02 the patient was undergoing the first of six fraction therapy using a HDR source in the cervix. The source was misplaced by approximately 2 centimeters. The dose received was 800 Rem instead of the prescribed dose of 500 Rem. On 10-28-02 the error was discovered during planning for the second fraction, and it was reported the same day. The patient and physician have been notified. No long term health effect is expected and the prescribed treatment is continuing. Licensee will submit a letter of explanation within 15 days. Florida is continuing it's investigation."
Florida Incident No. FL02-161
Isotope used was 9.961 Curies Ir-192.
Hospital
Event Number: 39470
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA PUGET SOUND HEALTH CARE SYSTEM
Region: 4
City: SEATTLE State: WA
County:
License #: 46-00990-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL C. SIMMONS
HQ OPS Officer: MIKE RIPLEY
Licensee: VA PUGET SOUND HEALTH CARE SYSTEM
Region: 4
City: SEATTLE State: WA
County:
License #: 46-00990-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL C. SIMMONS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/23/2002
Notification Time: 16:04 [ET]
Event Date: 10/22/2002
Event Time: 00:00 [PST]
Last Update Date: 02/12/2003
Notification Time: 16:04 [ET]
Event Date: 10/22/2002
Event Time: 00:00 [PST]
Last Update Date: 02/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LINDA HOWELL (R4)
BOB PIERSON (NMSS)
LINDA HOWELL (R4)
BOB PIERSON (NMSS)
NICKEL-63 SOURCES INADVERTENTLY DISPOSED OF AS SCRAP
A gas chromatograph, Model HP 5880GLC, with two Ni-63 sources was inadvertently disposed of with other excess property as scrap metal from the Veterans Administration's Puget Sound Health Care System on 10/22/02 without notifying the RSO. The loss was discovered on 11/25/02 during a routine inventory. The two sealed sources were contained in an electron capture detector within the gas chromatograph. The two sources consist of 13.1 millicuries of Ni-63 each (as of 11/25/02). The source serial numbers are 89665 and 89474. The RSO and the Veterans Administration National Health Physics Program are investigating and will file a written report within 30 days.
* * * UPDATE ON 2/12/03 @ 1510 BY SIMMONS TO GOULD * * *
The licensee reported that the Ni-63 sources were licensed under a general license and should have been reported under 31.5.c.viii.
Notified R4 DO (Marschall) and NMSS EO (Holahan).
A gas chromatograph, Model HP 5880GLC, with two Ni-63 sources was inadvertently disposed of with other excess property as scrap metal from the Veterans Administration's Puget Sound Health Care System on 10/22/02 without notifying the RSO. The loss was discovered on 11/25/02 during a routine inventory. The two sealed sources were contained in an electron capture detector within the gas chromatograph. The two sources consist of 13.1 millicuries of Ni-63 each (as of 11/25/02). The source serial numbers are 89665 and 89474. The RSO and the Veterans Administration National Health Physics Program are investigating and will file a written report within 30 days.
* * * UPDATE ON 2/12/03 @ 1510 BY SIMMONS TO GOULD * * *
The licensee reported that the Ni-63 sources were licensed under a general license and should have been reported under 31.5.c.viii.
Notified R4 DO (Marschall) and NMSS EO (Holahan).