Event Notification Report for April 17, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/16/2003 - 04/17/2003
EVENT NUMBERS
39766397673976842358
Power Reactor
Event Number: 39766
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JOHN KERRICK
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JOHN KERRICK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/17/2003
Notification Time: 13:21 [ET]
Event Date: 04/17/2003
Event Time: 12:10 [CDT]
Last Update Date: 04/17/2003
Notification Time: 13:21 [ET]
Event Date: 04/17/2003
Event Time: 12:10 [CDT]
Last Update Date: 04/17/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
THOMAS KOZAK (R3)
JOHN DAVIDSON (TAS)
THOMAS KOZAK (R3)
JOHN DAVIDSON (TAS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 0 | Startup | 0 | Startup |
SAFEGUARDS INFORMATION NOT PROPERLY CONTROLLED
Immediate compensatory measures taken upon discovery.
Contact the Headquarters Operations Officer for further details.
The NRC Resident Inspector was notified.
Immediate compensatory measures taken upon discovery.
Contact the Headquarters Operations Officer for further details.
The NRC Resident Inspector was notified.
Power Reactor
Event Number: 39767
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: KEVIN DAHM
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: KEVIN DAHM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/17/2003
Notification Time: 18:37 [ET]
Event Date: 04/17/2003
Event Time: 00:00 [EDT]
Last Update Date: 04/17/2003
Notification Time: 18:37 [ET]
Event Date: 04/17/2003
Event Time: 00:00 [EDT]
Last Update Date: 04/17/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
THOMAS KOZAK (R3)
THOMAS KOZAK (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
FITNESS FOR DUTY
A contract supervisor refused to provide a fitness-for-duty specimen after being randomly chosen for testing. The employee's access has been terminated. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector has been notified.
A contract supervisor refused to provide a fitness-for-duty specimen after being randomly chosen for testing. The employee's access has been terminated. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 39768
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN BAKER
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN BAKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/17/2003
Notification Time: 17:34 [ET]
Event Date: 04/17/2003
Event Time: 14:35 [EDT]
Last Update Date: 04/22/2003
Notification Time: 17:34 [ET]
Event Date: 04/17/2003
Event Time: 14:35 [EDT]
Last Update Date: 04/22/2003
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):
DAVID SILK (R1)
DAVID SILK (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
LOSS OF 9 OUT OF 16 EMERGENCY SIRENS IN ORANGE COUNTY
The following information was obtained from the Licensee via facsimile:
"On April 17, 2003, at 1435 hours, it was determined that 9 out of 16 emergency sirens in Orange County were out of service due to a transmission line failure. Unit 2 was at 100% power and Unit 3 was shutdown. This results in a degraded emergency siren notification system in one of the four counties covered by the emergency plan which is reportable under 10 CFR 50.72(b)(3)(xiii). The emergency plan had route alerting and public radio announcements available as necessary to notify the public in-lieu of the non-operational sirens. Restoration of the sirens occurred at 1709 hours. The county was notified."
The transmission line failure caused a loss of two substations which powered the affected sirens.
The NRC Resident Inspector will be notified by the Licensee.
***UPDATE ON 04/22/03 AT 1626 HOURS BY G. KELLER TAKEN BY MACKINNON***
At 1230 hours on April 22, 2003, during the review of the computer records for the loss of sirens previously reported on Thursday, April 17, 2003, it was determined that, at 1636 hours, two additional sirens in Putnam county could not be sounded. The loss of signal was not immediately evident and was due to the loss of power to repeater R-257 in Rockland county. This resulted in Putnam county having less than 90% of the sirens available.
At the time of the event this resulted in a degraded emergency siren notification system of an additional county covered by the emergency plan which is also reportable under 10 CFR 50.72(b)(3)(xiii). The emergency plan had route alerting and public radio announcements available as necessary to notify the public in lieu of the non-operational sirens. Restoration of the sirens occurred at 1659 hours. The State of New York and the county were notified. NRC R1DO (H. Gray) notified.
The NRC Resident Inspector was notified of this update by the licensee.
The following information was obtained from the Licensee via facsimile:
"On April 17, 2003, at 1435 hours, it was determined that 9 out of 16 emergency sirens in Orange County were out of service due to a transmission line failure. Unit 2 was at 100% power and Unit 3 was shutdown. This results in a degraded emergency siren notification system in one of the four counties covered by the emergency plan which is reportable under 10 CFR 50.72(b)(3)(xiii). The emergency plan had route alerting and public radio announcements available as necessary to notify the public in-lieu of the non-operational sirens. Restoration of the sirens occurred at 1709 hours. The county was notified."
The transmission line failure caused a loss of two substations which powered the affected sirens.
The NRC Resident Inspector will be notified by the Licensee.
***UPDATE ON 04/22/03 AT 1626 HOURS BY G. KELLER TAKEN BY MACKINNON***
At 1230 hours on April 22, 2003, during the review of the computer records for the loss of sirens previously reported on Thursday, April 17, 2003, it was determined that, at 1636 hours, two additional sirens in Putnam county could not be sounded. The loss of signal was not immediately evident and was due to the loss of power to repeater R-257 in Rockland county. This resulted in Putnam county having less than 90% of the sirens available.
At the time of the event this resulted in a degraded emergency siren notification system of an additional county covered by the emergency plan which is also reportable under 10 CFR 50.72(b)(3)(xiii). The emergency plan had route alerting and public radio announcements available as necessary to notify the public in lieu of the non-operational sirens. Restoration of the sirens occurred at 1659 hours. The State of New York and the county were notified. NRC R1DO (H. Gray) notified.
The NRC Resident Inspector was notified of this update by the licensee.
General Information or Other
Event Number: 42358
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 04/17/2003
Event Time: 00:00 [EST]
Last Update Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 04/17/2003
Event Time: 00:00 [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)
AGREEMENT STATE REPORT INVOLVING A RADIOPHARMACEUTICAL MISADMINISTRATION
The following information was received via facsimile:
"NY-06-001
"Radiopharmaceutical Misadministration. (NYS DOH Internal Tracking No. 86)
"New York law prohibits the release of any identities in cases of medical, events. Therefore the facility name, etc., is not contained in this report.
"Date of occurrence 4/17/2003
"The patient was prescribed 300mCi of I-131 NaI for thyroid carcinoma but received only 233 mCi.
"Licensee received two vials from the radiopharmacy as ordered, one with 200 mCi and the other with 100 mCi. The vials were, as per Licensee's protocol, left in the outer plastic sleeve during assay, and the assays were within acceptable limits. Upon completion of administration to the patient, the vials were again assayed to access the residual activity in the vials. Nothing unusual was noted for the 100 mCi vial, however about 90 mCi remained in the 200 mCi vial. Water was added to that vial and the patient was administered that liquid portion. The vial was again assayed and about 70 mCi remained. The licensee asked the pharmacy for additional I-131 but was told that the additional dosage would not be available until the next day. Consequently the patient was released with only having received 233 of the 300 mCi prescribed. The patient and referring MD were notified.
"The RSO/licensee staff investigated. They noted that there was some liquid between the glass vial and its outer plastic sleeve. Upon close examination of the vial it appears that the seal between the vial and septum was flawed allowing material to 'leak' from the vial. Additional surveys of packaging and area were performed. The need for bioassays of those involved in the administration was addressed.
"We received copies of reports from both the medical licensee and radiopharmacy. It appears that the seal on the vial was compromised thus allowing material to move outside the vial but remain contained within the outer plastic vial. Thus it had appeared that the vial was okay for use. Bioassay and survey measurements were performed with negative results. Actions to prevent repeat of such an event were included in both reports.
"The licensee followed up in regard to the patient. The treating physician stated that the dose was within the therapeutic range by existing standards. The patient was subsequently retreated with 300 mCi of I-131 in August of 2004. This post-treatment scan was positive and he was advised to return again in 6 - 9 months for re-evaluation. He did not, citing difficulties relating to employment etc. However, some time later he agreed to come in for further follow-up."
The following information was received via facsimile:
"NY-06-001
"Radiopharmaceutical Misadministration. (NYS DOH Internal Tracking No. 86)
"New York law prohibits the release of any identities in cases of medical, events. Therefore the facility name, etc., is not contained in this report.
"Date of occurrence 4/17/2003
"The patient was prescribed 300mCi of I-131 NaI for thyroid carcinoma but received only 233 mCi.
"Licensee received two vials from the radiopharmacy as ordered, one with 200 mCi and the other with 100 mCi. The vials were, as per Licensee's protocol, left in the outer plastic sleeve during assay, and the assays were within acceptable limits. Upon completion of administration to the patient, the vials were again assayed to access the residual activity in the vials. Nothing unusual was noted for the 100 mCi vial, however about 90 mCi remained in the 200 mCi vial. Water was added to that vial and the patient was administered that liquid portion. The vial was again assayed and about 70 mCi remained. The licensee asked the pharmacy for additional I-131 but was told that the additional dosage would not be available until the next day. Consequently the patient was released with only having received 233 of the 300 mCi prescribed. The patient and referring MD were notified.
"The RSO/licensee staff investigated. They noted that there was some liquid between the glass vial and its outer plastic sleeve. Upon close examination of the vial it appears that the seal between the vial and septum was flawed allowing material to 'leak' from the vial. Additional surveys of packaging and area were performed. The need for bioassays of those involved in the administration was addressed.
"We received copies of reports from both the medical licensee and radiopharmacy. It appears that the seal on the vial was compromised thus allowing material to move outside the vial but remain contained within the outer plastic vial. Thus it had appeared that the vial was okay for use. Bioassay and survey measurements were performed with negative results. Actions to prevent repeat of such an event were included in both reports.
"The licensee followed up in regard to the patient. The treating physician stated that the dose was within the therapeutic range by existing standards. The patient was subsequently retreated with 300 mCi of I-131 in August of 2004. This post-treatment scan was positive and he was advised to return again in 6 - 9 months for re-evaluation. He did not, citing difficulties relating to employment etc. However, some time later he agreed to come in for further follow-up."