Event Notification Report for April 8, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/07/1999 - 04/08/1999
** EVENT NUMBERS **
35552 35553 35554 35555
+------------------------------------------------------------------------------+
|Hospital |Event Number: 35552 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: BARNES-JUDISH HOSPITAL |NOTIFICATION DATE: 04/07/1999|
|LICENSEE: WASHINGTON UNIVERSITY, MO |NOTIFICATION TIME: 09:10[EDT]|
| CITY: St. Louis REGION: 3 |EVENT DATE: 03/09/1999|
| COUNTY: STATE: MO |EVENT TIME: 15:00[CDT]|
|LICENSE#: 24-00167-11 AGREEMENT: N |LAST UPDATE DATE: 04/07/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE BURGESS R3 |
| |FRED COMBS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOHN EICHLING | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| Description of the material |
| |
| On March 9, 1999, during preparation of preloaded needles for a permanent |
| interstitial prostate implant, a single I-125 radioactive seed was lost. |
| The seed was model 6711 manufactured by Medi-Physics, Inc., Amersham |
| Healthcare, Arlington Heights, IL 60005. The seed originated from either lot |
| number E3254 or E3256. The seed is 4.5 mm in length and 0.8 mm in diameter. |
| Radioactive material is absorbed on a silver core and encapsulated in a |
| titanium shell. The apparent activity of the seed on March 9, 1999 was 0.37 |
| mCi. As of today the apparent activity is 0.26 mCi. |
| |
| Description of the event |
| |
| As stated above, the source was lost on March 9, 1999, at approximately 3 |
| p.m., during preparation of needles for a permanent prostate implant. The |
| needle preparation procedure involves placement of seeds and spacers into |
| needles under sterile conditions. At the time of the event, needle |
| preparation was performed in a large operating room, which was also used to |
| store surgical equipment. Needle tips are plugged with wax. During the |
| course of the procedure there was a need to reload one of the needles. After |
| extracting seeds from the needle, two of the seeds were stuck in wax. The |
| technologist attempted to separate the two seeds using tweezers. One of the |
| seeds slipped from the tweezers and was ejected somewhere into the operating |
| room. |
| |
| Actions taken to recover material |
| |
| Immediately, the technologist attempted to locate the lost seed using a |
| Geiger detector. She and another technologist spent 45 minutes looking for |
| the seed. After an unsuccessful search, they contacted a physicist. The |
| physicist performed a careful search also using a Geiger detector, which |
| included a survey of the entire operating room and hallway, and the |
| technologist's shoes, clothing, and hair. At this time, it was decided to |
| lock the room and return in the morning. The following day, two physicists |
| attempted to locate the lost seed using a NI and Geiger detectors. This |
| search also proved unsuccessful. The following two days, members of the |
| radiation safety team performed two additional searches, which were also |
| unsuccessful. |
| |
| |
| Probable disposition of the material |
| |
| Approximately in the center of the operating room (6 feet away from the area |
| where the radioactive seeds were located) is a large drain. It is possible |
| that the seed reached the drain and that it was lost in the drain. |
| |
| Possible exposure to individuals in unrestricted areas |
| |
| The specific operating room is being used only for storage and it is |
| estimated that no individual spends more than 0.5 hours/week in that room. |
| The radiation levels in the room are at the background level. If the seed |
| was lost in the drain, there would be no exposure to any member of the |
| public due to the extremely low average energy of the source (28 kEv). The |
| risk to individuals is further reduced due to relatively short half-life of |
| I-125 (59.6 days). |
| |
| Procedures or actions to prevent a recurrence |
| |
| The licensee relocated the needle preparation procedure and equipment to a |
| much smaller room (approximately 4x8 square feet). Should a seed be lost |
| again it will be much easier to locate it in a small area. |
| |
| Other pertinent information |
| |
| The licensee has performed over 120 prostate implants that involved |
| approximately 14,000 seeds. During this time, the licensee has lost only |
| this one seed. This indicates that the system is well organized and that |
| proper precautions are in place. However, to further improve the process we |
| will prepare needles in the small room. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35553 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 04/07/1999|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 13:50[EDT]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 04/07/1999|
+------------------------------------------------+EVENT TIME: 12:13[CDT]|
| NRC NOTIFIED BY: TODD GRANLUND |LAST UPDATE DATE: 04/07/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE BURGESS R3 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(1)(ii) DEGRAD COND DURING OP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 99 Power Operation |99 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - A single failure could cause both trains of the switchgear heat removal |
| system to be inoperable - |
| |
| A new potential single failure scenario has been identified on the |
| switchgear heat removal system, System VX. Damper #1(2)VX22Y is the System |
| VX exhaust air shaft isolation damper. This damper is a normally open, fail |
| open damper. This damper is closed if the System VX heat recovery fans are |
| running. If a single active failure were to occur, a short in the motor |
| would drive the damper closed. It is possible that the Division 2 and RPS |
| MG set rooms could pressurize. These rooms are adjacent to the control room |
| envelope. If these rooms pressurize, it is possible that the 1/8 inch |
| minimum positive differential pressure required between the VC/VE room and |
| the adjacent VX rooms may not be maintained. This would result in both |
| VC/VE room switchgear heat removal system trains being inoperable. |
| |
| Long term corrective actions are being determined. |
| |
| Damper #1(2)VX22Y is common to both Unit 1 and Unit 2. Unit 2 is currently |
| in Operational Condition 4 (Cold Shutdown) in a Refueling Outage. |
| |
| The licensee plans to notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35554 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 04/07/1999|
| UNIT: [1] [2] [] STATE: MI |NOTIFICATION TIME: 16:01[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/07/1999|
+------------------------------------------------+EVENT TIME: 13:15[EDT]|
| NRC NOTIFIED BY: MARY BETH DePUYDT |LAST UPDATE DATE: 04/07/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE BURGESS R3 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Cold Shutdown |0 Cold Shutdown |
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - Unit 1 and 2 EDG starting air system air compressors not safety related |
| seismic category 1 - |
| |
| This report is a four-hour notification in accordance 10CFR50.72(b)(2)(i), |
| of a condition which was found while both reactors were shutdown, which, had |
| it been found while the reactor was in operation, could have resulted in the |
| nuclear plant being in an unanalyzed condition. |
| |
| The Emergency Diesel Generator (EDG) system at Cook is comprised of four |
| EDGs, two per unit. The EDGs are designed to start automatically upon |
| receipt of a safety injection signal and/or a loss of offsite power signal |
| and be ready to accept loads within 10 seconds of receiving the start |
| signal. The starting air system supplies compressed air for starting the |
| EDGs, and each EDG has its own system consisting of two redundant starting |
| air trains. Each train has one receiver of sufficient volume for at least |
| two EDG start attempts when pressurized to 220 psig. The starting air |
| system also provides compressed air for the starting air supply valve |
| actuators, the diesel engine control system and the aftercooler cooling |
| water regulating valves. While the starting air receivers and piping are |
| safety related seismic category 1, the compressors are not safety related |
| nor are they seismically mounted. |
| |
| A potential deficiency in the design of the EDG starting air system has been |
| identified. If the starting air compressors were lost during a seismic |
| event, the ability of the starting air system could be impaired to the point |
| that the control air pressure necessary for the engine control system could |
| not be maintained. It is postulated that leakage from the system would |
| result in a loss of air receiver pressure of approximately 25 psi in a 12 |
| hour period. Based on preoperational test data, with a starting air |
| receiver pressure of 132 to 188 psig, the control air pressure could drop |
| below the critical value of 65 psig in less than two days. Therefore, it is |
| possible that the EDG would not be able to sustain long term operability |
| without the starting air compressors. |
| |
| Evaluation of this potential design deficiency is ongoing, as well as |
| research into the licensing/design basis of the starting air system. Both |
| units are in Mode 5 (Cold Shutdown) with all four EDGs declared inoperable, |
| but functional. The EDGs were already inoperable due to HFA relay concerns, |
| and will remain inoperable until this problem is resolved. With all four |
| EDGs inoperable, the plant has additional offsite power lines to back up |
| normal offsite power sources. This condition was discovered during an |
| extended plant system readiness review and has existed since initial plant |
| criticality. The Licensee informed the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35555 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 04/07/1999|
| UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 16:47[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 04/07/1999|
+------------------------------------------------+EVENT TIME: 14:52[EDT]|
| NRC NOTIFIED BY: GARY KILBY |LAST UPDATE DATE: 04/07/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |FRANK COSTELLO R1 |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
|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 N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| The licensee notified the National Marine Fisheries and the NRC Resident |
| Inspector that while cleaning the plant service water forebay, they |
| discovered a dead seal. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021