Event Notification Report for May 23, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/22/2003 - 05/23/2003
General Information or Other
Event Number: 39883
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GUIDANT CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L05178-000
Agreement: Y
Docket:
NRC Notified By: OGDEN
HQ OPS Officer: CHAUNCEY GOULD
Licensee: GUIDANT CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: L05178-000
Agreement: Y
Docket:
NRC Notified By: OGDEN
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/27/2003
Notification Time: 10:17 [ET]
Event Date: 05/23/2003
Event Time: 15:50 [CDT]
Last Update Date: 05/27/2003
Notification Time: 10:17 [ET]
Event Date: 05/23/2003
Event Time: 15:50 [CDT]
Last Update Date: 05/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE DOERFLEIN (R1)
TOM ESSIG (NMSS)
WILLIAM JONES (R4)
LAWRENCE DOERFLEIN (R1)
TOM ESSIG (NMSS)
MALFUNCTION OF A HIGH DOSE RATE AFTERLOADER
During a heart procedure at the Union Memorial Hospital in Maryland with a Galileo III (HDR - High dose rate afterloader) device using a Phosphorus - 32 source wire, of up to 600 millicuries, a malfunction occurred with the active wire in place in the patient's heart. When the source was to be retracted the source would not retract. The physician utilized the machine interrupt to try to get the source to move to the shielded position and it failed. The physician then pushed the system STOP button to get the source to retract and it also failed to perform the retraction. The physician then moved to the hand-wheel to retract the source, but this function also malfunctioned. At this point the physician pulled the entire catheter and dropped it to the Operating Room floor. The power cord was then removed from the wall receptacle depriving the machine of power and then the source retracted to the fully shielded position. The licensee was informed that this would constitute a Therapy Event within the State of Texas and the state would need a complete report and an emergency read of all badged personnel in the OR during the procedure. The Licensee responded that the machine was not within the State of Texas. A report to the state of Texas is still required by License Condition # 16 due to failure of the drive mechanism of the GALILEO III to retract the source to safe storage until the fourth emergency procedure was performed.
During a heart procedure at the Union Memorial Hospital in Maryland with a Galileo III (HDR - High dose rate afterloader) device using a Phosphorus - 32 source wire, of up to 600 millicuries, a malfunction occurred with the active wire in place in the patient's heart. When the source was to be retracted the source would not retract. The physician utilized the machine interrupt to try to get the source to move to the shielded position and it failed. The physician then pushed the system STOP button to get the source to retract and it also failed to perform the retraction. The physician then moved to the hand-wheel to retract the source, but this function also malfunctioned. At this point the physician pulled the entire catheter and dropped it to the Operating Room floor. The power cord was then removed from the wall receptacle depriving the machine of power and then the source retracted to the fully shielded position. The licensee was informed that this would constitute a Therapy Event within the State of Texas and the state would need a complete report and an emergency read of all badged personnel in the OR during the procedure. The Licensee responded that the machine was not within the State of Texas. A report to the state of Texas is still required by License Condition # 16 due to failure of the drive mechanism of the GALILEO III to retract the source to safe storage until the fourth emergency procedure was performed.
General Information or Other
Event Number: 39884
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: SPECTRATEK SERVICES
Region: 4
City: ALBUQUERQUE State: NM
County:
License #: TA-172-21
Agreement: Y
Docket:
NRC Notified By: WILLIAM FLOYD
HQ OPS Officer: ERIC THOMAS
Licensee: SPECTRATEK SERVICES
Region: 4
City: ALBUQUERQUE State: NM
County:
License #: TA-172-21
Agreement: Y
Docket:
NRC Notified By: WILLIAM FLOYD
HQ OPS Officer: ERIC THOMAS
Notification Date: 05/27/2003
Notification Time: 12:49 [ET]
Event Date: 05/23/2003
Event Time: 16:30 [MDT]
Last Update Date: 05/27/2003
Notification Time: 12:49 [ET]
Event Date: 05/23/2003
Event Time: 16:30 [MDT]
Last Update Date: 05/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
DOUG BROADDUS (NMSS)
CAUDLE JULIAN (R2)
WILLIAM JONES (R4)
DOUG BROADDUS (NMSS)
CAUDLE JULIAN (R2)
AGREEMENT STATE REPORT
On 5/22/2003, the licensee sent a shipment of radioactive material to Elite Airfreight in Houston, TX. On 5/23/2003 at approximately 1630 MDT, Elite Airfreight contacted the licensee to inform them that only 2 of the 3 boxes of radioactive material in the shipment had arrived in Houston. The licensee contacted Federal Express, who tracked the missing package to the Fedex facility in Memphis, TN. Fedex planned to send the missing package to Houston on 5/24/2003. As of 5/27/2003, the package still had not arrived in Houston. The licensee contacted Fedex again, and was told the package was still in Memphis, and would be shipped to Houston today (5/27/2003).
The missing package is a 12X12X12 inch fiberboard box containing 40 millicuries of Antimony-124, and has a Transportation Index of 4. This event is state of New Mexico event number NM03-02.
On 5/22/2003, the licensee sent a shipment of radioactive material to Elite Airfreight in Houston, TX. On 5/23/2003 at approximately 1630 MDT, Elite Airfreight contacted the licensee to inform them that only 2 of the 3 boxes of radioactive material in the shipment had arrived in Houston. The licensee contacted Federal Express, who tracked the missing package to the Fedex facility in Memphis, TN. Fedex planned to send the missing package to Houston on 5/24/2003. As of 5/27/2003, the package still had not arrived in Houston. The licensee contacted Fedex again, and was told the package was still in Memphis, and would be shipped to Houston today (5/27/2003).
The missing package is a 12X12X12 inch fiberboard box containing 40 millicuries of Antimony-124, and has a Transportation Index of 4. This event is state of New Mexico event number NM03-02.
Power Reactor
Event Number: 39991
Facility: SURRY
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BARRY GARBER
HQ OPS Officer: MIKE RIPLEY
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BARRY GARBER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/11/2003
Notification Time: 13:30 [ET]
Event Date: 05/23/2003
Event Time: 17:55 [EDT]
Last Update Date: 07/11/2003
Notification Time: 13:30 [ET]
Event Date: 05/23/2003
Event Time: 17:55 [EDT]
Last Update Date: 07/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
THOMAS DECKER (R2)
THOMAS DECKER (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling Shutdown | 0 | Refueling Shutdown |
INVALID EMERGENCY DIESEL START SIGNAL
"The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not considered a licensee Event Report.
"With the unit in refueling shutdown and defueled, a loss of the 1B DC Electrical Bus occurred during maintenance activities associated with the 1B Main Station Battery performance test. The DC Bus voltage went to zero as a result of the 1B-1 battery charger not assuming the load after the current sharing parallel charger 1B-2 was placed in stand-by.
"The Unit 1J Emergency AC Bus degraded and undervoltage protection relays, powered from the 1B DC Bus, deenergized and provided a start signal for the #3 Emergency Diesel Generator (EDG). The #3 EDG started, however, it did not load on the Unit 1J AC Bus due to the loss of control power to Unit 1J AC Bus circuit breakers. The signal to start the #3 EDG on the emergency AC electrical power system was considered invalid because the Unit 1 Emergency AC Bus did not experience an actual degraded/undervoltage condition.
"Operations personnel stripped the 1B DC Bus in accordance with abnormal procedures and restored the vital busses via manual transfer switches. Aligning the 1B-2 battery charger to the stripped bus reenergized the 1B DC Bus.
"The direct cause of the loss of the 1B DC Bus was the failure of the 1B-1 battery charger to pick up the load on the 1B DC Bus. A root cause evaluation is being performed."
The licensee notified the NRC Resident Inspector.
"The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not considered a licensee Event Report.
"With the unit in refueling shutdown and defueled, a loss of the 1B DC Electrical Bus occurred during maintenance activities associated with the 1B Main Station Battery performance test. The DC Bus voltage went to zero as a result of the 1B-1 battery charger not assuming the load after the current sharing parallel charger 1B-2 was placed in stand-by.
"The Unit 1J Emergency AC Bus degraded and undervoltage protection relays, powered from the 1B DC Bus, deenergized and provided a start signal for the #3 Emergency Diesel Generator (EDG). The #3 EDG started, however, it did not load on the Unit 1J AC Bus due to the loss of control power to Unit 1J AC Bus circuit breakers. The signal to start the #3 EDG on the emergency AC electrical power system was considered invalid because the Unit 1 Emergency AC Bus did not experience an actual degraded/undervoltage condition.
"Operations personnel stripped the 1B DC Bus in accordance with abnormal procedures and restored the vital busses via manual transfer switches. Aligning the 1B-2 battery charger to the stripped bus reenergized the 1B DC Bus.
"The direct cause of the loss of the 1B DC Bus was the failure of the 1B-1 battery charger to pick up the load on the 1B DC Bus. A root cause evaluation is being performed."
The licensee notified the NRC Resident Inspector.