Event Notification Report for October 08, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/07/2003 - 10/08/2003
EVENT NUMBERS
4023640231402324023340332
General Information or Other
Event Number: 40236
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SACRED HEART MEDICAL CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: WN-M031-1
Agreement: Y
Docket:
NRC Notified By: TERRY C. FRAZEE
HQ OPS Officer: STEVE SANDIN
Licensee: SACRED HEART MEDICAL CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: WN-M031-1
Agreement: Y
Docket:
NRC Notified By: TERRY C. FRAZEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/09/2003
Notification Time: 14:32 [ET]
Event Date: 10/08/2003
Event Time: 00:00 [PDT]
Last Update Date: 10/09/2003
Notification Time: 14:32 [ET]
Event Date: 10/08/2003
Event Time: 00:00 [PDT]
Last Update Date: 10/09/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
DOUG BROADDUS (NMSS)
WILLIAM JOHNSON (R4)
DOUG BROADDUS (NMSS)
AGREEMENT STATE REPORT INVOLVING POTENTIAL LEAKING SOURCE
"This is notification of an event in Washington state as reported to the WA Department of Health, Division of Radiation Protection.
"STATUS:
"New (this is an preliminary notification due to the lack of required information at this point in time).
"Licensee: Sacred Heart Medical Center
"City and state: Spokane, Washington
"License number: WN-M031-1
"Type of license: Medical
"Date of event: 8 October 2003
"Location of Event: on campus (OR)
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)
"The licensee was implanting a source train of I-125 seeds for a lung cancer treatment and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped a source rather than the space between the sources.
"What is the notification or reporting criteria involved? Leaking source, possibly. If not, no notification is required, if so, then a possible overexposure to the patient (thyroid).
"Activity and Isotope(s) involved: Iodine-125 therapy seed(s).
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient.
"Lost, Stolen or Damaged? (mfg., model, serial number): This was an Iodine-125 seed, part of a source train of such seeds which was damaged when the licensee attempted to shorten the train but cut through a seed instead of the interstice desired.
"Disposition/recovery: No loss of seeds.
"Leak test? Licensee is performing one ASAP but as of this writing there are no results.
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number): N/A
"Release of activity? Unknown at this time, if the seed is not leaking, then 'no'. If the seed is in fact leaking then the potential exists for release of material inside the patient.
"Activity and pharmaceutical compound intended: N/A, the proper nuclide and activity was delivered to the intended treatment site.
"Misadministered activity and/or compound received: N/A, this was not a misadministration.
Device (HDR, etc.) Mfg., Model; computer program: N/A, no device involved.
Exposure (intended/actual); consequences: No unplanned exposure, unless the source turns out to be leaking.
Was patient or responsible relative notified? Unknown at this time.
"Was written report provided? Not yet, but it will be.
"Was referring physician notified? Yes, referring MD notified by oncologist.
"Consultant used? No."
This is WA Event Report # WA-03-043.
* * * UPDATE 1830 EDT ON 10/9/03 FROM ARDEN C. SCROGGS VIA EMAIL * * *
"New (this is an updated notification).
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)
"The licensee was implanting a source train of 31 [Iodine-125] seeds for a lung cancer treatment along the lining of the pleura and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped two source(s) rather than the space between the sources.
"The licensee administered large quantities of SSKI within one hour of breaching the seeds. The current plan is to continue administration of SSKI in amounts of at least 0.5ml daily for at least the next two weeks.
"What is the notification or reporting criteria involved? MISADMINISTRATION via leaking source.
"Activity and Isotope(s) involved: Iodine-125 therapy seed(s). A total of two seeds with an activity of 0.729mCi each according to the licensee.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient. The primary handler has received thyroid bioassay with negative results. The licensee is expecting results of the pleural fluid sample taken from the patient soon, and will attempt thyroid bioassay of the patient at the 72-hour exposure interval.
"Lost, Stolen or Damaged? (mfg., model, serial number): These are Iodine-125 seeds, part of a source train of such seeds which were damaged when the licensee attempted to shorten the train but cut through two seeds instead of the interstice desired. The manufacturer is MPI, the model is the 'Oncoseed' 'Rapid Strand'. The licensee will include an enlarged version of the product insert with their written report.
"Disposition/recovery: No loss of seeds although remains of the two leaking sources are properly stored awaiting decay/disposal.
"Leak test? Leak test results from the soak test (four hours in plain water) showed 'significant leakage' according to the licensee, and they are assuming a worst-case scenario basis of one entire seed leaking and one-half the second seed leaking.
"Release of activity? Yes, it is assumed on a worst-case basis that the entire contents of one seed and fifty percent of the second seed has or will leak.
"Misadministered activity and/or compound received: This was a misadministration by definition because the sources are determined to have leaked.
"Exposure (intended/actual); consequences: Exposure is limited to the patient only. The licensee will attempt to quantify through both calculation and bioassay the extent of patient/thyroid exposure. Physicians involved expect little or no adverse effects at this point, assuming the SSKI works as expected.
"Was patient or responsible relative notified? Yes.
"Rev 1. 1530 hrs, 9 October 2003"
Notified R4DO(Bill Johnson) and NMSS(Holonich).
"This is notification of an event in Washington state as reported to the WA Department of Health, Division of Radiation Protection.
"STATUS:
"New (this is an preliminary notification due to the lack of required information at this point in time).
"Licensee: Sacred Heart Medical Center
"City and state: Spokane, Washington
"License number: WN-M031-1
"Type of license: Medical
"Date of event: 8 October 2003
"Location of Event: on campus (OR)
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)
"The licensee was implanting a source train of I-125 seeds for a lung cancer treatment and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped a source rather than the space between the sources.
"What is the notification or reporting criteria involved? Leaking source, possibly. If not, no notification is required, if so, then a possible overexposure to the patient (thyroid).
"Activity and Isotope(s) involved: Iodine-125 therapy seed(s).
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient.
"Lost, Stolen or Damaged? (mfg., model, serial number): This was an Iodine-125 seed, part of a source train of such seeds which was damaged when the licensee attempted to shorten the train but cut through a seed instead of the interstice desired.
"Disposition/recovery: No loss of seeds.
"Leak test? Licensee is performing one ASAP but as of this writing there are no results.
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number): N/A
"Release of activity? Unknown at this time, if the seed is not leaking, then 'no'. If the seed is in fact leaking then the potential exists for release of material inside the patient.
"Activity and pharmaceutical compound intended: N/A, the proper nuclide and activity was delivered to the intended treatment site.
"Misadministered activity and/or compound received: N/A, this was not a misadministration.
Device (HDR, etc.) Mfg., Model; computer program: N/A, no device involved.
Exposure (intended/actual); consequences: No unplanned exposure, unless the source turns out to be leaking.
Was patient or responsible relative notified? Unknown at this time.
"Was written report provided? Not yet, but it will be.
"Was referring physician notified? Yes, referring MD notified by oncologist.
"Consultant used? No."
This is WA Event Report # WA-03-043.
* * * UPDATE 1830 EDT ON 10/9/03 FROM ARDEN C. SCROGGS VIA EMAIL * * *
"New (this is an updated notification).
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)
"The licensee was implanting a source train of 31 [Iodine-125] seeds for a lung cancer treatment along the lining of the pleura and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped two source(s) rather than the space between the sources.
"The licensee administered large quantities of SSKI within one hour of breaching the seeds. The current plan is to continue administration of SSKI in amounts of at least 0.5ml daily for at least the next two weeks.
"What is the notification or reporting criteria involved? MISADMINISTRATION via leaking source.
"Activity and Isotope(s) involved: Iodine-125 therapy seed(s). A total of two seeds with an activity of 0.729mCi each according to the licensee.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient. The primary handler has received thyroid bioassay with negative results. The licensee is expecting results of the pleural fluid sample taken from the patient soon, and will attempt thyroid bioassay of the patient at the 72-hour exposure interval.
"Lost, Stolen or Damaged? (mfg., model, serial number): These are Iodine-125 seeds, part of a source train of such seeds which were damaged when the licensee attempted to shorten the train but cut through two seeds instead of the interstice desired. The manufacturer is MPI, the model is the 'Oncoseed' 'Rapid Strand'. The licensee will include an enlarged version of the product insert with their written report.
"Disposition/recovery: No loss of seeds although remains of the two leaking sources are properly stored awaiting decay/disposal.
"Leak test? Leak test results from the soak test (four hours in plain water) showed 'significant leakage' according to the licensee, and they are assuming a worst-case scenario basis of one entire seed leaking and one-half the second seed leaking.
"Release of activity? Yes, it is assumed on a worst-case basis that the entire contents of one seed and fifty percent of the second seed has or will leak.
"Misadministered activity and/or compound received: This was a misadministration by definition because the sources are determined to have leaked.
"Exposure (intended/actual); consequences: Exposure is limited to the patient only. The licensee will attempt to quantify through both calculation and bioassay the extent of patient/thyroid exposure. Physicians involved expect little or no adverse effects at this point, assuming the SSKI works as expected.
"Was patient or responsible relative notified? Yes.
"Rev 1. 1530 hrs, 9 October 2003"
Notified R4DO(Bill Johnson) and NMSS(Holonich).
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 40231
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: PAT RYAN
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: PAT RYAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/08/2003
Notification Time: 12:20 [ET]
Event Date: 10/08/2003
Event Time: 11:24 [EDT]
Last Update Date: 10/10/2003
Notification Time: 12:20 [ET]
Event Date: 10/08/2003
Event Time: 11:24 [EDT]
Last Update Date: 10/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
RONALD BELLAMY (R1)
DONNA-MARIE PEREZ (TAS)
RONALD BELLAMY (R1)
DONNA-MARIE PEREZ (TAS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
SECURITY WEAPON AND HOLSTER LEFT UNATTENDED
Security weapon and holster left unattended. Immediate compensatory actions taken upon discovery. Contact the HOO for details.
The licensee will be notifying the NRC Resident Inspector and has notified the R1TAS (Greg Smith).
* * * UPDATE AT 1300 EDT ON 10/10/03 FROM STEVE MORRISSEY TO DICK JOLLIFFE * * *
The licensee is retracting this report based upon further review. Contact the HOO for details.
The licensee will inform the NRC Resident Inspector. Notified R1DO (Ron Bellamy).
Security weapon and holster left unattended. Immediate compensatory actions taken upon discovery. Contact the HOO for details.
The licensee will be notifying the NRC Resident Inspector and has notified the R1TAS (Greg Smith).
* * * UPDATE AT 1300 EDT ON 10/10/03 FROM STEVE MORRISSEY TO DICK JOLLIFFE * * *
The licensee is retracting this report based upon further review. Contact the HOO for details.
The licensee will inform the NRC Resident Inspector. Notified R1DO (Ron Bellamy).
Power Reactor
Event Number: 40232
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: LAURIE RAYLE
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: LAURIE RAYLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/08/2003
Notification Time: 13:45 [ET]
Event Date: 10/08/2003
Event Time: 10:30 [EDT]
Last Update Date: 10/08/2003
Notification Time: 13:45 [ET]
Event Date: 10/08/2003
Event Time: 10:30 [EDT]
Last Update Date: 10/08/2003
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):
RONALD BELLAMY (R1)
RONALD BELLAMY (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 96 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO PRIMARY COOLANT BOUNDARY LEAKAGE
"Nine Mile Point Unit 1 entered a Technical Specification (TS) required shutdown due to suspected unsatisfactory allowable leakage past Primary Coolant System Pressure Isolation Valves. At 10:30 EST, The Condition Monitoring group notified the Control Room that leakage past the Core Spray keep-fill check valves 40-22 and 40-23 exceeded the TS allowable leak rate. Preliminarily, leakage was quantified at 1.1 gpm (uncorrected). With these two valves declared inoperable, Technical Specification 3.2.7.1b required an orderly shutdown be initiated within 1 hour and the reactor in cold shutdown condition within 10 hours. The shutdown was initiated at 11:27 [hrs]. A surveillance test was performed to quantify leakage rate under test conditions. At 13:10 [hrs], it was determined that the leakage rate was 0.156 gpm (corrected to 1080 psid) and that the previous data received was not valid. The TS required shutdown was suspended and power recovery is planned."
The licensee has informed the NRC Resident Inspector.
"Nine Mile Point Unit 1 entered a Technical Specification (TS) required shutdown due to suspected unsatisfactory allowable leakage past Primary Coolant System Pressure Isolation Valves. At 10:30 EST, The Condition Monitoring group notified the Control Room that leakage past the Core Spray keep-fill check valves 40-22 and 40-23 exceeded the TS allowable leak rate. Preliminarily, leakage was quantified at 1.1 gpm (uncorrected). With these two valves declared inoperable, Technical Specification 3.2.7.1b required an orderly shutdown be initiated within 1 hour and the reactor in cold shutdown condition within 10 hours. The shutdown was initiated at 11:27 [hrs]. A surveillance test was performed to quantify leakage rate under test conditions. At 13:10 [hrs], it was determined that the leakage rate was 0.156 gpm (corrected to 1080 psid) and that the previous data received was not valid. The TS required shutdown was suspended and power recovery is planned."
The licensee has informed the NRC Resident Inspector.
Power Reactor
Event Number: 40233
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: JON BOWER
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: JON BOWER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/08/2003
Notification Time: 14:21 [ET]
Event Date: 10/08/2003
Event Time: 13:25 [EDT]
Last Update Date: 10/08/2003
Notification Time: 14:21 [ET]
Event Date: 10/08/2003
Event Time: 13:25 [EDT]
Last Update Date: 10/08/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (R1)
RONALD BELLAMY (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Decommissioned | 0 | Decommissioned |
OFFSITE NOTIFICATION DUE TO HYDRAULIC OIL SPILL
Offsite notification was due to a failure on a 100-ton mobile crane that resulted in a approximately 150 gallon hydraulic oil spill to the ground. The spill did not involve a pathway to surrounding bodies of water. Efforts are underway to remediate the affected area. The State of Connecticut Department of Environmental Protection as well as the National Response Center was notified.
The licensee will be notifying the NRC Resident Inspector.
Offsite notification was due to a failure on a 100-ton mobile crane that resulted in a approximately 150 gallon hydraulic oil spill to the ground. The spill did not involve a pathway to surrounding bodies of water. Efforts are underway to remediate the affected area. The State of Connecticut Department of Environmental Protection as well as the National Response Center was notified.
The licensee will be notifying the NRC Resident Inspector.
Power Reactor
Event Number: 40332
Facility: GINNA
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: RICHARD KAPP
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: RICHARD KAPP
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/18/2003
Notification Time: 14:02 [ET]
Event Date: 10/08/2003
Event Time: 02:16 [EST]
Last Update Date: 11/18/2003
Notification Time: 14:02 [ET]
Event Date: 10/08/2003
Event Time: 02:16 [EST]
Last Update Date: 11/18/2003
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):
JOHN ROGGE (R1)
JOHN ROGGE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
INVALID SAFETY INJECTION SIGNAL DURING SURVEILLANCE TESTING AT GINNA
"On October 8, 2003, at 0216 hours Eastern Daylight Savings Time, while in a refueling outage, R.E. Ginna Nuclear Station experienced an invalid "B" train Safety Injection (SI) signal. The invalid signal was the result of an error made while establishing pretest requirements during a 24 month surveillance. The invalid SI signal caused the "B" train Diesel Generator (DG) to actuate. The "B" DG started and functioned as designed, and all support systems functioned properly."
The licensee informed the NRC Resident Inspector.
"On October 8, 2003, at 0216 hours Eastern Daylight Savings Time, while in a refueling outage, R.E. Ginna Nuclear Station experienced an invalid "B" train Safety Injection (SI) signal. The invalid signal was the result of an error made while establishing pretest requirements during a 24 month surveillance. The invalid SI signal caused the "B" train Diesel Generator (DG) to actuate. The "B" DG started and functioned as designed, and all support systems functioned properly."
The licensee informed the NRC Resident Inspector.