Event Notification Report for November 24, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/23/2003 - 11/24/2003
Power Reactor
Event Number: 40351
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: JEFF ROTTON
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/24/2003
Notification Time: 12:21 [ET]
Event Date: 11/24/2003
Event Time: 03:22 [CST]
Last Update Date: 11/24/2003
Notification Time: 12:21 [ET]
Event Date: 11/24/2003
Event Time: 03:22 [CST]
Last Update Date: 11/24/2003
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):
BLAIR SPITZBERG (R4)
BLAIR SPITZBERG (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
INABILITY TO INITIATE EMERGENCY SIRENS FROM EMERGENCY OPERATIONS FACILITY
"At 0322 CST, on 11/24/2003, an alarm was received on the Alert Notification System. The system alarm is not necessarily indicative of a system fault. Normal procedure is to check the system at the start of the normal work day. When the system was tested at 0615 CST it was discovered that the emergency sirens could not be sounded from the Emergency Operations Facility (EOF).
"Troubleshooting efforts were begun. The repair crew discovered that the sirens are able to be sounded by their normal stations (the counties). The sirens were also able to be sounded by a remote unmanned alternate location [owned by the utility located in downtown Omaha]. However, the EOF could not have verified which sirens had sounded. Verification of siren actuation was possible from the unmanned alternate location. Troubleshooting continues."
The licensee has informed the NRC Resident Inspector.
"At 0322 CST, on 11/24/2003, an alarm was received on the Alert Notification System. The system alarm is not necessarily indicative of a system fault. Normal procedure is to check the system at the start of the normal work day. When the system was tested at 0615 CST it was discovered that the emergency sirens could not be sounded from the Emergency Operations Facility (EOF).
"Troubleshooting efforts were begun. The repair crew discovered that the sirens are able to be sounded by their normal stations (the counties). The sirens were also able to be sounded by a remote unmanned alternate location [owned by the utility located in downtown Omaha]. However, the EOF could not have verified which sirens had sounded. Verification of siren actuation was possible from the unmanned alternate location. Troubleshooting continues."
The licensee has informed the NRC Resident Inspector.
General Information or Other
Event Number: 40352
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee:
Region: 3
City: State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: GERRY WAIG
Licensee:
Region: 3
City: State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: GERRY WAIG
Notification Date: 11/25/2003
Notification Time: 11:32 [ET]
Event Date: 11/24/2003
Event Time: 14:15 [CST]
Last Update Date: 11/25/2003
Notification Time: 11:32 [ET]
Event Date: 11/24/2003
Event Time: 14:15 [CST]
Last Update Date: 11/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SONIA BURGESS (R3)
JOHN GREEVES (NMSS)
SONIA BURGESS (R3)
JOHN GREEVES (NMSS)
AGREEMENT STATE REPORT - DOSE TO PATIENT OUTSIDE INTENDED TREATMENT SITE
"[Radiation Safety Officer (RSO)] for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy [IVB] procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.
" The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area.
"The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days."
Illinois Event Report ID: IL030078, License Number: IL -01152-01
Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies
"[Radiation Safety Officer (RSO)] for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy [IVB] procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.
" The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area.
"The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days."
Illinois Event Report ID: IL030078, License Number: IL -01152-01
Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies
General Information or Other
Event Number: 40387
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: LEXINGTON CLINIC
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-016-26
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: MIKE RIPLEY
Licensee: LEXINGTON CLINIC
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-016-26
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/11/2003
Notification Time: 14:06 [ET]
Event Date: 11/24/2003
Event Time: 00:00 [CST]
Last Update Date: 12/11/2003
Notification Time: 14:06 [ET]
Event Date: 11/24/2003
Event Time: 00:00 [CST]
Last Update Date: 12/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANIELLO DELLA GRECA (R1)
TOM ESSIG (NMSS)
ANIELLO DELLA GRECA (R1)
TOM ESSIG (NMSS)
KENTUCKY AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
On 11/24/03 a patient was administered a thyroid uptake dose of 0.98 millicuries. The prescribed dose was 0.015 millicuries. The misadministration apparently occurred due to the prescription order being made incorrectly with no subsequent verification. The patient and the patient's physician were notified on 11/26/03. No adverse effect to the patient occurred as a result of the misadministration.
On 11/24/03 a patient was administered a thyroid uptake dose of 0.98 millicuries. The prescribed dose was 0.015 millicuries. The misadministration apparently occurred due to the prescription order being made incorrectly with no subsequent verification. The patient and the patient's physician were notified on 11/26/03. No adverse effect to the patient occurred as a result of the misadministration.