Event Notification Report for February 9, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/08/1999 - 02/09/1999
** EVENT NUMBERS **
35324 35352 35353 35354 35355
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 35324 |
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| FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 01/29/1999|
| UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 09:48[EST]|
| RXTYPE: [3] CE |EVENT DATE: 01/29/1999|
+------------------------------------------------+EVENT TIME: 07:57[CST]|
| NRC NOTIFIED BY: VICTOR COLLINS |LAST UPDATE DATE: 02/08/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES MARSCHALL R4 |
|10 CFR SECTION: | |
|DDDD 73.71 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3 N Y 94 Power Operation |94 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| SECURITY REPORT - |
| |
| UNACCOUNTED FOR PERSONNEL DOOR LOCK PULLER. COMPENSATORY MEASURES |
| IMMEDIATELY TAKEN UPON DISCOVERY. THE LICENSEE NOTIFIED THE NRC RESIDENT |
| INSPECTOR. REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. |
| |
| * * * RETRACTION AT 1541 EST ON 2/8/99 FROM GREGORY SCOTT TO S.SANDIN * * * |
| |
| The licensee is retracting this event. Contact the Headquarters Operations |
| Officer for details. The licensee will inform the NRC Resident Inspector. |
| Notified R4DO(Pellet) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35352 |
+------------------------------------------------------------------------------+
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| FACILITY: GRAND GULF REGION: 4 |NOTIFICATION DATE: 02/08/1999|
| UNIT: [1] [] [] STATE: MS |NOTIFICATION TIME: 00:34[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 02/07/1999|
+------------------------------------------------+EVENT TIME: 22:38[CST]|
| NRC NOTIFIED BY: HANKS |LAST UPDATE DATE: 02/08/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JEFF SHACKELFORD R4 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| THE LICENSEE DECLARED RCIC INOPERABLE AND ENTERED A 14 DAY LCO ACTION |
| STATEMENT. |
| |
| RCIC WAS DECLARED INOPERABLE WHEN A DIVISION II ISOLATION OCCURRED DUE TO AN |
| INVALID SIGNAL DURING THE PERFORMANCE OF A SURVEILLANCE. THE CAUSE IS BEING |
| INVESTIGATED. HPCS WAS VERIFIED OPERABLE WITHIN ONE HOUR , AS REQUIRED BY |
| THE LCO ACTION STATEMENT, AT 2310 CST. RCIC IS REQUIRED TO BE RETURNED TO |
| SERVICE WITHIN 14 DAYS. THE ISOLATION SIGNAL HAS BEEN RESET, BUT THE VALVES |
| ARE STILL CLOSED AND WILL NOT BE REOPENED UNTIL THE CAUSE OF THE ISOLATION |
| HAS BEEN DETERMINED. |
| |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED. |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35353 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 02/08/1999|
| UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 13:43[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 02/08/1999|
+------------------------------------------------+EVENT TIME: 09:58[CST]|
| NRC NOTIFIED BY: JIM GILMORE |LAST UPDATE DATE: 02/08/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN PELLET R4 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - OFFSITE NOTIFICATION REGARDING A CHEMICAL SPILL INTO THE WOLF CREEK |
| COOLING LAKE - |
| |
| AT 0958 CST ON 02/08/1999, THE LICENSEE NOTIFIED THE STATE OF KANSAS THAT |
| APPROXIMATELY 2000 GALLONS OF WATER CONTAINING AT MOST 50 GALLONS OF SODIUM |
| HYPOCHLORITE AND 13 GALLONS OF SODIUM BROMIDE HAD SPILLED INTO THE WOLF |
| CREEK COOLING LAKE. A CHEMICAL INJECTION PUMP MECHANICAL SEAL FAILED AND |
| CAUSED THE CHEMICAL SPILL AT THE PLANT INTAKE STRUCTURE. THE CONCENTRATIONS |
| OF THE CHEMICAL SPILL EXCEEDED THE ALLOWABLE KANSAS STATE PERMIT LIMITS. |
| THE LICENSEE STOPPED THE SPILL, PLACED ABSORBENT MATERIAL ON THE GROUND |
| SURROUNDING THE SPILL AND REMOVED THE ABSORBENT MATERIAL. |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. |
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|General Information or Other |Event Number: 35354 |
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| REP ORG: WA DEPARTMENT OF HEALTH |NOTIFICATION DATE: 02/08/1999|
|LICENSEE: PROVIDENCE MEDICAL CENTER |NOTIFICATION TIME: 11:45[EST]|
| CITY: SEATTLE REGION: 4 |EVENT DATE: 12/16/1998|
| COUNTY: STATE: WA |EVENT TIME: 12:00[PST]|
|LICENSE#: WN-MO45-1 AGREEMENT: Y |LAST UPDATE DATE: 02/08/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN PELLET R4 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BOB VERELLEN | |
| HQ OPS OFFICER: DICK JOLLIFFE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| - AGREEMENT STATE REPORT REGARDING MEDICAL MISADMINISTRATION - |
| |
| The following information was received via Email in the NRC Operations |
| Center: |
| |
| Subject: Washington Incident Notification #WA-99-003 |
| |
| This is notification/update of an event in Washington state as reported to |
| or investigated by the WA Department of Health, Division of Radiation |
| Protection. |
| |
| Licensee: Providence Medical Center |
| City and state: Seattle, WA. |
| License number: WN-M045-1 |
| Type of License: Medical, Broad Type A |
| |
| Date of Event: 16 December 1998 |
| |
| Location of Event: Licensee's facility, Radiation Oncology Dept. |
| |
| ABSTRACT: |
| The licensee, a Broad Medical, had reviewed and approved the clinical trial |
| of the Guidant Intravascular Radiotherapy project. The project uses a |
| modified Nucletron high dose rate afterloader (HDR) and an Omnitron |
| International, Inc. Phosphorus-32 brachytherapy source model NC-P32-3N with |
| an activity of approximately 150 millicuries. The trial is to evaluate |
| local radiation for the prevention of restenosis after coronary |
| angioplasty. |
| |
| On 16 December 1998, the Guidant Clinical Research Coordinator introduced a |
| new type catheter, provided training for the licensee's personnel and |
| supervised the use of the new catheter system on a patient. The licensee |
| reported that the source was thought to have been seen at the proper |
| location for the planned treatment using fluoro and the inactive source |
| wire. The treatment was completed. |
| |
| On 11 January 1999, the Guidant Coordinator informed the licensee that the |
| new catheter required the use of a different connector on the front end of |
| the afterloader and that, if not used, the source would not be at the proper |
| treatment site and therefore the treatment on 16 Dec would not have been |
| correct. |
| |
| On 13 January 1999, the license performed some tests and confirmed that a |
| misadministration had occurred. Their review indicates that the source was |
| approximately 34 cm from the intended treatment site. In their second |
| written report to the state the licensee estimated dose to the vessel wall |
| to range from 108 Gy worst case, to 70 Gy as a most realistic dose. |
| |
| MAJOR ISSUES: |
| |
| 1. THE INABILITY TO CONFIRM THE LOCATION OF THE SOURCE USING FLUORO when |
| fluoro visualization is indicated in the project's description and |
| procedures as an essential verification for the use of this device. |
| |
| 2. THE INCOMPLETE TRAINING AND DIRECTION PROVIDED THE LICENSEE BY THE |
| GUIDANT PERSONNEL WHEN DEVICE EQUIPMENT CHANGES WERE MADE ON 16 DECEMBER |
| 1998. |
| |
| What is the notification or reporting criteria involved? WAC 246-240-050 |
| "NOTIFICATIONS, RECORDS, AND REPORTS OF THERAPY MISADMINISTRATIONS." |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35355 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 02/08/1999|
| UNIT: [2] [] [] STATE: PA |NOTIFICATION TIME: 17:45[EST]|
| RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 02/08/1999|
+------------------------------------------------+EVENT TIME: 17:00[EST]|
| NRC NOTIFIED BY: PAT NAVIN |LAST UPDATE DATE: 02/08/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LAURIE PELUSO R1 |
|10 CFR SECTION: | |
|AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE DUE TO A FAILED COMPUTER - |
| |
| DURING COMPUTER TESTING, THE UNIT 2 PLANT MONITORING SYSTEM COMPUTER FAILED, |
| RENDERING THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE. PLANT |
| TECHNICIANS ARE RESTORING THE FAILED COMPUTER. THE LICENSEE WILL INFORM THE |
| NRC RESIDENT INSPECTOR. |
| |
| * * * UPDATE AT 2213 ON 02/08/99 FROM JIM KOVALCHICK TO JOLLIFFE * * * |
| |
| AT 2157, THE LICENSEE RESTORED THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM TO |
| OPERABLE STATUS. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE NRC |
| OPERATIONS OFFICER NOTIFIED R1DO (LAURIE PELUSO). |
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