Event Notification Report for February 21, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/20/2003 - 02/21/2003
EVENT NUMBERS
39612396083960939610
Hospital
Event Number: 39612
Rep Org: FAIRFAX HOSPITAL
Licensee: FAIRFAX HOSPITAL
Region: 2
City: FALLS CHURCH State: VA
County: FAIRFAX
License #: 4517128-01
Agreement: N
Docket:
NRC Notified By: GARY TALKINGTON
HQ OPS Officer: YAMIR DIAZ
Licensee: FAIRFAX HOSPITAL
Region: 2
City: FALLS CHURCH State: VA
County: FAIRFAX
License #: 4517128-01
Agreement: N
Docket:
NRC Notified By: GARY TALKINGTON
HQ OPS Officer: YAMIR DIAZ
Notification Date: 02/24/2003
Notification Time: 07:45 [ET]
Event Date: 02/21/2003
Event Time: 12:15 [EST]
Last Update Date: 02/24/2003
Notification Time: 07:45 [ET]
Event Date: 02/21/2003
Event Time: 12:15 [EST]
Last Update Date: 02/24/2003
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):
CHARLES R. OGLE (R2)
FRED BROWN (NMSS)
CHARLES R. OGLE (R2)
FRED BROWN (NMSS)
LOST RADIOPHARMACEUTICAL DEVICE CONTAINING TECHNETIUM-99
On 2/21/03 at approximately 1030 EST, the radio-pharmacy in the Nuclear Medicine Department of the Fairfax Hospital received a shipment of radio pharmaceuticals. As they were preparing to administer a dose to a patient, they discovered that one syringe containing 10 millicuries of Technetium-99M Mag-3 was missing. The licensee stated that the dose was listed on the in-processing documents as received. The licensee's current assumption is that either the dose was not actually shipped or that it was misplaced within the laboratory. The licensee plans on continuing to investigate the whereabouts of the device.
On 2/21/03 at approximately 1030 EST, the radio-pharmacy in the Nuclear Medicine Department of the Fairfax Hospital received a shipment of radio pharmaceuticals. As they were preparing to administer a dose to a patient, they discovered that one syringe containing 10 millicuries of Technetium-99M Mag-3 was missing. The licensee stated that the dose was listed on the in-processing documents as received. The licensee's current assumption is that either the dose was not actually shipped or that it was misplaced within the laboratory. The licensee plans on continuing to investigate the whereabouts of the device.
Power Reactor
Event Number: 39608
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: ENGLAND
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: ENGLAND
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/21/2003
Notification Time: 02:30 [ET]
Event Date: 02/21/2003
Event Time: 00:25 [EST]
Last Update Date: 02/21/2003
Notification Time: 02:30 [ET]
Event Date: 02/21/2003
Event Time: 00:25 [EST]
Last Update Date: 02/21/2003
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):
CLIFFORD ANDERSON (R1)
CLIFFORD ANDERSON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 70 | Power Operation |
REACTOR IS BEING SHUT DOWN DUE TO ONE RECIRCULATION LOOP BEING INOPERABLE
"On 2/20/03 @ 0525 PNPS experienced a trip/lockout of 1 of their 2 Recirc MG sets. This caused Reactor Power to decrease to 70% of rated. All other safety and nonsafety plant equipment functioned normally after the Recirc
MG trip. Due to our Facility Operating Licenses PNPS entered an Active LCO for One Recirculation Loop Inoperable. The License states, 'The Reactor shall not be operated with one recirculation loop out of service for more than 24 hours. With the reactor operating, the plant shall be placed in a hot shutdown condition within 24 hours unless the loop is sooner returned to service.'
"After extensive trouble shooting activities PNPS decided that the loop will not be returned to service in the required time frame and has commenced a normal shutdown to hot shutdown condition on 2/21/03 @ 0025. Reactor
Power at the time of commencement of shutdown was 37%."
The licensee believes the cause was due to a field lead breaking off the slip rings. Estimated down time is 5 to 8 days.
The NRC Resident Inspector was notified and the licensee may notify the media.
"On 2/20/03 @ 0525 PNPS experienced a trip/lockout of 1 of their 2 Recirc MG sets. This caused Reactor Power to decrease to 70% of rated. All other safety and nonsafety plant equipment functioned normally after the Recirc
MG trip. Due to our Facility Operating Licenses PNPS entered an Active LCO for One Recirculation Loop Inoperable. The License states, 'The Reactor shall not be operated with one recirculation loop out of service for more than 24 hours. With the reactor operating, the plant shall be placed in a hot shutdown condition within 24 hours unless the loop is sooner returned to service.'
"After extensive trouble shooting activities PNPS decided that the loop will not be returned to service in the required time frame and has commenced a normal shutdown to hot shutdown condition on 2/21/03 @ 0025. Reactor
Power at the time of commencement of shutdown was 37%."
The licensee believes the cause was due to a field lead breaking off the slip rings. Estimated down time is 5 to 8 days.
The NRC Resident Inspector was notified and the licensee may notify the media.
Power Reactor
Event Number: 39609
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: ENGLAND
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: ENGLAND
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/21/2003
Notification Time: 08:10 [ET]
Event Date: 02/21/2003
Event Time: 04:24 [EST]
Last Update Date: 02/21/2003
Notification Time: 08:10 [ET]
Event Date: 02/21/2003
Event Time: 04:24 [EST]
Last Update Date: 02/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CLIFFORD ANDERSON (R1)
CLIFFORD ANDERSON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 27 | Power Operation | 0 | Hot Shutdown |
REACTOR WAS MANUALLY SCRAMMED FROM 27% POWER
On 2/21/03 @ 0424 PNPS was making preparations to scram using an approved Shut Down procedure and experienced a Recirc Pump Runback of the only Recirc MG set in service. Computer generated Core Flow indicated approximately 17 Mlbm/Hr and 25% Reactor Power. The Operator at the Controls calculated Reactor Power and Flow using the PNPS Power to Flow (P/F) Map. Indications on the P/F Map showed a value in the OPERATION PROHIBITED REGION (17% Reactor Power and 14 Mlbm/Hr Flow). Per PNPS procedures, intentional operation in this area is prohibited and you must immediately restore to within the analyzed operation area. This area is not part of the Reactor Instability Region. These discrepancies were noted by the Shift Manager who directed the Reactor to be Scrammed. All other safety and nonsafety plant equipment functioned normally after the Reactor Scram. All rods fully inserted, no ECCS actuated and no relief valves lifted.
The NRC Resident Inspector was notified.
On 2/21/03 @ 0424 PNPS was making preparations to scram using an approved Shut Down procedure and experienced a Recirc Pump Runback of the only Recirc MG set in service. Computer generated Core Flow indicated approximately 17 Mlbm/Hr and 25% Reactor Power. The Operator at the Controls calculated Reactor Power and Flow using the PNPS Power to Flow (P/F) Map. Indications on the P/F Map showed a value in the OPERATION PROHIBITED REGION (17% Reactor Power and 14 Mlbm/Hr Flow). Per PNPS procedures, intentional operation in this area is prohibited and you must immediately restore to within the analyzed operation area. This area is not part of the Reactor Instability Region. These discrepancies were noted by the Shift Manager who directed the Reactor to be Scrammed. All other safety and nonsafety plant equipment functioned normally after the Reactor Scram. All rods fully inserted, no ECCS actuated and no relief valves lifted.
The NRC Resident Inspector was notified.
Hospital
Event Number: 39610
Rep Org: U.S. DEPT OF VETERANS AFFAIRS
Licensee: VA MEDICAL CENTER, DENVER, CO
Region: 4
City: Denver State: CO
County:
License #: 05-01401-02
Agreement: Y
Docket:
NRC Notified By: DR. EDWIN LEIDHOLDT
HQ OPS Officer: ERIC THOMAS
Licensee: VA MEDICAL CENTER, DENVER, CO
Region: 4
City: Denver State: CO
County:
License #: 05-01401-02
Agreement: Y
Docket:
NRC Notified By: DR. EDWIN LEIDHOLDT
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/21/2003
Notification Time: 17:27 [ET]
Event Date: 02/21/2003
Event Time: 09:00 [MST]
Last Update Date: 02/21/2003
Notification Time: 17:27 [ET]
Event Date: 02/21/2003
Event Time: 09:00 [MST]
Last Update Date: 02/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
KRISS KENNEDY (R4)
ROBERT PIERSON (NMSS)
KRISS KENNEDY (R4)
ROBERT PIERSON (NMSS)
POSSIBLE MEDICAL EVENT
During an intravascular brachiotherapy procedure, several Strontium-90 sources (approx. 60 millicuries) were used. The sources were deployed from the transfer device and were not seen at the desired treatment on the patient. The sources were withdrawn back into the transfer device. The physician does not believe that the sources entered the patient on this initial attempt, but there was a possible dose at a location other than the treatment site in excess of the limits in 10 CFR 30.3045(a)(iii).
After retraction, the sources were successfully deployed into the patient and verified by the physician via a fluoroscope. Adverse effects on the patient are not expected.
During an intravascular brachiotherapy procedure, several Strontium-90 sources (approx. 60 millicuries) were used. The sources were deployed from the transfer device and were not seen at the desired treatment on the patient. The sources were withdrawn back into the transfer device. The physician does not believe that the sources entered the patient on this initial attempt, but there was a possible dose at a location other than the treatment site in excess of the limits in 10 CFR 30.3045(a)(iii).
After retraction, the sources were successfully deployed into the patient and verified by the physician via a fluoroscope. Adverse effects on the patient are not expected.