Event Notification Report for January 18, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/17/2005 - 01/18/2005
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 41346
Facility: LIMERICK
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK CRIM
HQ OPS Officer: JOHN MacKINNON
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK CRIM
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/19/2005
Notification Time: 11:08 [ET]
Event Date: 01/18/2005
Event Time: 12:55 [EST]
Last Update Date: 02/16/2005
Notification Time: 11:08 [ET]
Event Date: 01/18/2005
Event Time: 12:55 [EST]
Last Update Date: 02/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1)
HAROLD GRAY (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 |
24-HOUR CONDITION OF LICENSE REPORT FOR POTENTIAL NON-COMPLIANCE OF THE FIRE PROTECTION PROGRAM
"The notification is being made pursuant to Unit 2 Operating License for potential non-compliance of the Fire Protection Program.
"At 12:55 on January 18, 2005 following the review of Operating Experience for Wolf Creek (ENS 41327), it was discovered that the pilot lines to the manual pneumatic actuator pilot lines on the Halon bottles for the Halon System for the Auxiliary Equipment Room were incorrectly piped. In accordance with TRM 3.7.6.4 a continuous fire watch was established in the area.
"This event resulted in a condition that could have rendered the Halon System for the Unit 2 Auxiliary Equipment Room inoperable during a fire. The Unit 1 Auxiliary Equipment Room Halon System was not affected and remained operable.
"At this time the cause of this condition is not currently known, and an investigation is ongoing."
NRC Resident Inspector was notified of this event by the licensee.
HOO NOTE: See Ens # 41326 and 41327 for similar reports.
* * * UPDATE AT 1059 ON 02/16/05 FROM MARK CRIM TO W. GOTT * * *
"The notification is being made to retract the ENS 41346 Rev 0 reported on 1/19/05 pursuant to Unit 2 Operating License for a potential noncompliance of the Fire Protection Program.
"At 12:55 on January 18, 2005 following the review of Operating Experience for Wolf Crook (ENS 41327), it was discovered that the pilot lines to the manual pneumatic actuator on the main and reserve Halon cylinders for the Unit 2 Auxiliary Equipment Room Under Floor Halon System were incorrectly piped. In accordance with TRM 3.7.6.4, a continuous fire watch was established in the area.. Immediately following the event, it was believed that the condition could have rendered the Unit 2 Auxiliary Equipment Room Under Floor Halon System inoperable during a fire. On January 19, 2005 Limerick corrected the piping to meet the vendor design for the manual-pneumatic actuators associated with the Unit 2 Auxiliary Equipment Room Under Floor Halon System.
"On January 26, 2005 Chemetron performed a functional test of the Halon System for Callaway with the incorrect pilot line piping and discovered that Halon injected properly with a 2 second delay (See IEN 2005-001). Callaway had a similar Halon system configuration as Limerick Unit 2 Auxiliary Equipment Room Under Floor Halon System (same make and model number manual-pneumatic actuators and cylinder heads). An evaluation of the test report concluded that the Limerick Unit 2 Auxiliary Equipment Room Under Floor Halon System would have actuated in the event of a fire.
"In conclusion, despite the pilot line piping error, the Unit 2 Auxiliary Equipment Room Under Floor Halon System would have remained operable and would have completed it's suppression function during a fire. Therefore, there was no violation of the Unit 2 Operating License Section 2.C.(3) for the Fire Protection."
The licensee will notify the NRC Resident Inspector.
Notified R1DO (E. Coby).
"The notification is being made pursuant to Unit 2 Operating License for potential non-compliance of the Fire Protection Program.
"At 12:55 on January 18, 2005 following the review of Operating Experience for Wolf Creek (ENS 41327), it was discovered that the pilot lines to the manual pneumatic actuator pilot lines on the Halon bottles for the Halon System for the Auxiliary Equipment Room were incorrectly piped. In accordance with TRM 3.7.6.4 a continuous fire watch was established in the area.
"This event resulted in a condition that could have rendered the Halon System for the Unit 2 Auxiliary Equipment Room inoperable during a fire. The Unit 1 Auxiliary Equipment Room Halon System was not affected and remained operable.
"At this time the cause of this condition is not currently known, and an investigation is ongoing."
NRC Resident Inspector was notified of this event by the licensee.
HOO NOTE: See Ens # 41326 and 41327 for similar reports.
* * * UPDATE AT 1059 ON 02/16/05 FROM MARK CRIM TO W. GOTT * * *
"The notification is being made to retract the ENS 41346 Rev 0 reported on 1/19/05 pursuant to Unit 2 Operating License for a potential noncompliance of the Fire Protection Program.
"At 12:55 on January 18, 2005 following the review of Operating Experience for Wolf Crook (ENS 41327), it was discovered that the pilot lines to the manual pneumatic actuator on the main and reserve Halon cylinders for the Unit 2 Auxiliary Equipment Room Under Floor Halon System were incorrectly piped. In accordance with TRM 3.7.6.4, a continuous fire watch was established in the area.. Immediately following the event, it was believed that the condition could have rendered the Unit 2 Auxiliary Equipment Room Under Floor Halon System inoperable during a fire. On January 19, 2005 Limerick corrected the piping to meet the vendor design for the manual-pneumatic actuators associated with the Unit 2 Auxiliary Equipment Room Under Floor Halon System.
"On January 26, 2005 Chemetron performed a functional test of the Halon System for Callaway with the incorrect pilot line piping and discovered that Halon injected properly with a 2 second delay (See IEN 2005-001). Callaway had a similar Halon system configuration as Limerick Unit 2 Auxiliary Equipment Room Under Floor Halon System (same make and model number manual-pneumatic actuators and cylinder heads). An evaluation of the test report concluded that the Limerick Unit 2 Auxiliary Equipment Room Under Floor Halon System would have actuated in the event of a fire.
"In conclusion, despite the pilot line piping error, the Unit 2 Auxiliary Equipment Room Under Floor Halon System would have remained operable and would have completed it's suppression function during a fire. Therefore, there was no violation of the Unit 2 Operating License Section 2.C.(3) for the Fire Protection."
The licensee will notify the NRC Resident Inspector.
Notified R1DO (E. Coby).
General Information or Other
Event Number: 41399
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: RICK HORKY
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF LOUISVILLE
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: RICK HORKY
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/10/2005
Notification Time: 15:53 [ET]
Event Date: 01/18/2005
Event Time: 00:00 [CST]
Last Update Date: 02/10/2005
Notification Time: 15:53 [ET]
Event Date: 01/18/2005
Event Time: 00:00 [CST]
Last Update Date: 02/10/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
EUGENE COBEY (R1)
C.W. (BILL) REAMER (NMSS)
EUGENE COBEY (R1)
C.W. (BILL) REAMER (NMSS)
AGREEMENT STATE REPORT INVOLVING LESS THAN PLANNED DOSE FRACTION FOR CERVICAL CANCER
The following is excerpted from a transmittal sent by the licensee and received on 2/3 by the State of KY concerning a medical event:
"1. Licensee's name: Brown Cancer Center, University of Louisville Hospital
"2. Prescribing physician's name: [Attending Physician]
"3. A brief description of the event: On Tuesday, January 18, 2005 a patient was scheduled to undergo a vaginal cylinder HDR procedure using a 3.0 cm cylinder. The catheter was placed in position [under the supervision of the Attending Physician]. When the setup was complete, and upon leaving the room [the Resident Physician] noticed that the catheter was 'draped' around the patient's foot as it ran from the cylinder to the HDR machine. [The Resident Physician] 'undraped' the catheter from her foot, then all staff left the room. The treatment then ran for it's scheduled 5.5 minutes.
"After the treatment was completed, the Medical Physicist removed the catheter. He noticed that the catheter appeared to not be fully inserted into the cylinder as required and estimates that it may have been withdrawn from the desired location by approximately 15 cm. He promptly informed [the Attending and Resident Physicians] and together informed [the] Chairman of Radiation Oncology.
"4. Effect on the individual: This treatment was the second of three treatments prescribed. The patient is being monitored and no adverse effects to the patient are expected nor did any occur.
"5. Why the event occurred: The event occurred due to the lack of a positive mechanical 'lock' of the HDR catheter to metal guide insert tube. The system uses a moveable nylon collar surrounding the catheter, which is slid into position once the catheter is placed into the metal guide insert tube. A nut is then screwed over the nylon collar forming a 'compression' fitting much like that used for compression fittings on copper-tubing.
The event may have occurred when [the Resident Physician] 'undraped' the catheter which was 'draped' around the patient's foot. The nylon collar-nut compression fitting may have allowed the catheter to be pulled partially out of the metal guide tube.
"6. What improvements are needed to prevent recurrence The manufacturer also offers a different type of collar-nut compression fitting utilizing a stainless steel collar that is glued onto the catheter at the appropriate distance. This constitutes a 'positive' mechanically locked position for the catheter. This alternate system is being readied for use henceforth.
"7. Action taken to prevent recurrence: The catheter is now length/position marked and is checked by both the physician and the physicist prior to leaving and upon re-entering the HDR suite. A soon as the parts are assembled for the stainless steel type of collar, the HDR catheters will be switched over to the new equipment. This will provide a 'positive' lock on catheter length into the metal guide tube assembly.
"8. If licensee informed the individual or individual's responsible relative or guardian, and if not, why: The patient and referring physician were informed of the situation by [the Attending Physician].
"9. Information provided to the individual or individual's responsible relative or guardian: The patient was informed that she may have received a dose lower than that prescribed to the area of intended treatment. She was informed that the treatment would not be repeated (this was the second of three treatments planned) as it was not absolutely clear if an under dose occurred. She was told that she would be carefully monitored for progress."
A followup transmittal from the licensee received on 2/9 by the state of KY provided estimated dose data:
"As the report described, during the treatment the source for the HDR may have been withdrawn from the desired treatment site by 15 cm. The dose desired for the 5.5 minute treatment was seven hundred and fifty (750) cGy to the site of interest. With the source offset by 15 cm, the delivered dose would have been four (4) cGy. Assuming that the source was in fact approximately 2 cm exterior to the vagina, the dose at the labia would have been one hundred (100) cGy."
The following is excerpted from a transmittal sent by the licensee and received on 2/3 by the State of KY concerning a medical event:
"1. Licensee's name: Brown Cancer Center, University of Louisville Hospital
"2. Prescribing physician's name: [Attending Physician]
"3. A brief description of the event: On Tuesday, January 18, 2005 a patient was scheduled to undergo a vaginal cylinder HDR procedure using a 3.0 cm cylinder. The catheter was placed in position [under the supervision of the Attending Physician]. When the setup was complete, and upon leaving the room [the Resident Physician] noticed that the catheter was 'draped' around the patient's foot as it ran from the cylinder to the HDR machine. [The Resident Physician] 'undraped' the catheter from her foot, then all staff left the room. The treatment then ran for it's scheduled 5.5 minutes.
"After the treatment was completed, the Medical Physicist removed the catheter. He noticed that the catheter appeared to not be fully inserted into the cylinder as required and estimates that it may have been withdrawn from the desired location by approximately 15 cm. He promptly informed [the Attending and Resident Physicians] and together informed [the] Chairman of Radiation Oncology.
"4. Effect on the individual: This treatment was the second of three treatments prescribed. The patient is being monitored and no adverse effects to the patient are expected nor did any occur.
"5. Why the event occurred: The event occurred due to the lack of a positive mechanical 'lock' of the HDR catheter to metal guide insert tube. The system uses a moveable nylon collar surrounding the catheter, which is slid into position once the catheter is placed into the metal guide insert tube. A nut is then screwed over the nylon collar forming a 'compression' fitting much like that used for compression fittings on copper-tubing.
The event may have occurred when [the Resident Physician] 'undraped' the catheter which was 'draped' around the patient's foot. The nylon collar-nut compression fitting may have allowed the catheter to be pulled partially out of the metal guide tube.
"6. What improvements are needed to prevent recurrence The manufacturer also offers a different type of collar-nut compression fitting utilizing a stainless steel collar that is glued onto the catheter at the appropriate distance. This constitutes a 'positive' mechanically locked position for the catheter. This alternate system is being readied for use henceforth.
"7. Action taken to prevent recurrence: The catheter is now length/position marked and is checked by both the physician and the physicist prior to leaving and upon re-entering the HDR suite. A soon as the parts are assembled for the stainless steel type of collar, the HDR catheters will be switched over to the new equipment. This will provide a 'positive' lock on catheter length into the metal guide tube assembly.
"8. If licensee informed the individual or individual's responsible relative or guardian, and if not, why: The patient and referring physician were informed of the situation by [the Attending Physician].
"9. Information provided to the individual or individual's responsible relative or guardian: The patient was informed that she may have received a dose lower than that prescribed to the area of intended treatment. She was informed that the treatment would not be repeated (this was the second of three treatments planned) as it was not absolutely clear if an under dose occurred. She was told that she would be carefully monitored for progress."
A followup transmittal from the licensee received on 2/9 by the state of KY provided estimated dose data:
"As the report described, during the treatment the source for the HDR may have been withdrawn from the desired treatment site by 15 cm. The dose desired for the 5.5 minute treatment was seven hundred and fifty (750) cGy to the site of interest. With the source offset by 15 cm, the delivered dose would have been four (4) cGy. Assuming that the source was in fact approximately 2 cm exterior to the vagina, the dose at the labia would have been one hundred (100) cGy."
General Information or Other
Event Number: 41554
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS
Region: 4
City: PASADENA State: TX
County:
License #: L04322
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: FUGRO CONSULTANTS
Region: 4
City: PASADENA State: TX
County:
License #: L04322
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/31/2005
Notification Time: 16:21 [ET]
Event Date: 01/18/2005
Event Time: 00:00 [CST]
Last Update Date: 03/31/2005
Notification Time: 16:21 [ET]
Event Date: 01/18/2005
Event Time: 00:00 [CST]
Last Update Date: 03/31/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)
AGREEMENT STATE - OVEREXPOSURE
The following information was provided by the Texas Department of State Health Services via E-mail (state text in quotes):
"Radiography was conducted at both field and fixed locations during the December [2004] monitoring period. The badge of [the radiographer trainee] was the only high badge for the Licensee during the monitoring period. The Radiography Trainer claims that his pocket dosimeter and alarming rate meter showed no unusual activity during the monitoring period. All exposure devices were leak tested December 30, 2004, with no leakage in excess of applicable limits being exceeded - no leakage. The Radiographer Trainer was on two crews during the monitoring period. Both other crew members had normal exposures for the monitoring period. No explanation for a possible source of exposure to the badge was offered by the Licensee or the wearer of the badge. The Licensee was cited for violating the Deep dose annual exposure limits for calendar year 2004."
The trainee was seen by a physician however, the blood work results are not yet available. As corrective action, the licensee has notified all radiographers to carefully monitor their pocket dosimeters and alarming rate meters, and to keep their personal monitoring badges away from sources of radiation.
The four cameras used contained Ir-192 (72.4 Ci, 81.5 Ci, 34.1 Ci, and 39.4 Ci). Total dose received by the radiographer trainee was 11.885 REM DDE for December 2004 and 12.771 REM DDE for the annual monitoring period.
Texas Incident # I-8199.
The following information was provided by the Texas Department of State Health Services via E-mail (state text in quotes):
"Radiography was conducted at both field and fixed locations during the December [2004] monitoring period. The badge of [the radiographer trainee] was the only high badge for the Licensee during the monitoring period. The Radiography Trainer claims that his pocket dosimeter and alarming rate meter showed no unusual activity during the monitoring period. All exposure devices were leak tested December 30, 2004, with no leakage in excess of applicable limits being exceeded - no leakage. The Radiographer Trainer was on two crews during the monitoring period. Both other crew members had normal exposures for the monitoring period. No explanation for a possible source of exposure to the badge was offered by the Licensee or the wearer of the badge. The Licensee was cited for violating the Deep dose annual exposure limits for calendar year 2004."
The trainee was seen by a physician however, the blood work results are not yet available. As corrective action, the licensee has notified all radiographers to carefully monitor their pocket dosimeters and alarming rate meters, and to keep their personal monitoring badges away from sources of radiation.
The four cameras used contained Ir-192 (72.4 Ci, 81.5 Ci, 34.1 Ci, and 39.4 Ci). Total dose received by the radiographer trainee was 11.885 REM DDE for December 2004 and 12.771 REM DDE for the annual monitoring period.
Texas Incident # I-8199.