Event Notification Report for June 29, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/28/1999 - 06/29/1999
General Information or Other
Event Number: 35879
Rep Org: ABB COMBUSTION ENGINEERING
Licensee: ABB COMBUSTION ENGINEERING
Region: 1
City: WINDSOR State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: IAN RICKARD (VIA FAX)
HQ OPS Officer: BOB STRANSKY
Licensee: ABB COMBUSTION ENGINEERING
Region: 1
City: WINDSOR State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: IAN RICKARD (VIA FAX)
HQ OPS Officer: BOB STRANSKY
Notification Date: 06/29/1999
Notification Time: 16:28 [ET]
Event Date: 06/29/1999
Event Time: 00:00 [EDT]
Last Update Date: 06/29/1999
Notification Time: 16:28 [ET]
Event Date: 06/29/1999
Event Time: 00:00 [EDT]
Last Update Date: 06/29/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
LAWRENCE DOERFLEIN (R1)
JAMES CREED (R3)
LINDA SMITH (R4)
VERN HODGE (via fax) (NRR)
LAWRENCE DOERFLEIN (R1)
JAMES CREED (R3)
LINDA SMITH (R4)
VERN HODGE (via fax) (NRR)
10 CFR PART 21 REPORT DUE TO DEFECTIVE OSCILLATION POWER RANGE MONITORS
The following text has been excerpted from a letter submitted via facsimile from the vendor:
"The defect concerns the ABB Oscillation Power Range Monitor (OPRM) delivered to Susquehanna 1 & 2, Clinton, Hope Creek, WNP-2, Perry, LaSalle 1 & 2, Dresden 2 & 3 and Quad Cities 1 & 2. Specifically, the defect concerns the Slave OPRM module randomly resetting, potentially causing the OPRM trip channel to be out of service for a short period of time, typically under one minute. The defect could lead to non-conservative failure of detecting and suppressing thermo-hydraulic core oscillations during this time.
"None of the OPRM systems are presently being used to detect and suppress core oscillations. Installed OPRM systems are in the monitor mode with the trip contacts disabled."
The following text has been excerpted from a letter submitted via facsimile from the vendor:
"The defect concerns the ABB Oscillation Power Range Monitor (OPRM) delivered to Susquehanna 1 & 2, Clinton, Hope Creek, WNP-2, Perry, LaSalle 1 & 2, Dresden 2 & 3 and Quad Cities 1 & 2. Specifically, the defect concerns the Slave OPRM module randomly resetting, potentially causing the OPRM trip channel to be out of service for a short period of time, typically under one minute. The defect could lead to non-conservative failure of detecting and suppressing thermo-hydraulic core oscillations during this time.
"None of the OPRM systems are presently being used to detect and suppress core oscillations. Installed OPRM systems are in the monitor mode with the trip contacts disabled."
Hospital
Event Number: 35900
Rep Org: WAUKESHA MEMORIAL HOSPITAL
Licensee: WAUKESHA MEMORIAL HOSPITAL
Region: 3
City: WAUKESHA State: WI
County: WAUKESHA
License #: 48-06239-01
Agreement: N
Docket:
NRC Notified By: MARY WETZGER
HQ OPS Officer: JOHN MacKINNON
Licensee: WAUKESHA MEMORIAL HOSPITAL
Region: 3
City: WAUKESHA State: WI
County: WAUKESHA
License #: 48-06239-01
Agreement: N
Docket:
NRC Notified By: MARY WETZGER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/07/1999
Notification Time: 16:37 [ET]
Event Date: 06/29/1999
Event Time: 12:00 [CDT]
Last Update Date: 07/07/1999
Notification Time: 16:37 [ET]
Event Date: 06/29/1999
Event Time: 12:00 [CDT]
Last Update Date: 07/07/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
TONY VEGEL (R3)
JOHN SURMEIER (NMSS)
TONY VEGEL (R3)
JOHN SURMEIER (NMSS)
POST IMPLANT SURVEY OF A LOADING CART STERILE DRAPE DETECTED A RADIOACTIVE LEVEL OF 20MREM/HR..
Post implant survey in the operating room found radiation reading levels on the sterile drape of a cart used to hold Iodine-125 seeds which were implanted into a patients thyroid . A small piece of metal (less than 1 millimeter in length) on the carts sterile drape was found to have a radioactive level of 20mrem/hr at 3 centimeters. The small piece of metal was placed in a lead pig and is now stored in the Hospital isotope room. All the Iodine-125 seeds that were not used for implantation in the patient were accounted for and placed in lead containers. A bioassay will be performed on the patient within in the next few days to make sure the patient does not have any leaking iodine-125 seeds in their thyroid.
This event was discovered to be reportable yesterday evening ,7/6/99, after the Radiation Safety Officer discovered that leaking seeds is considered a Medical Misadministration
Post implant survey in the operating room found radiation reading levels on the sterile drape of a cart used to hold Iodine-125 seeds which were implanted into a patients thyroid . A small piece of metal (less than 1 millimeter in length) on the carts sterile drape was found to have a radioactive level of 20mrem/hr at 3 centimeters. The small piece of metal was placed in a lead pig and is now stored in the Hospital isotope room. All the Iodine-125 seeds that were not used for implantation in the patient were accounted for and placed in lead containers. A bioassay will be performed on the patient within in the next few days to make sure the patient does not have any leaking iodine-125 seeds in their thyroid.
This event was discovered to be reportable yesterday evening ,7/6/99, after the Radiation Safety Officer discovered that leaking seeds is considered a Medical Misadministration
Other Nuclear Material
Event Number: 36101
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: JEFF HAVENER
HQ OPS Officer: BOB STRANSKY
Licensee: US ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: JEFF HAVENER
HQ OPS Officer: BOB STRANSKY
Notification Date: 08/31/1999
Notification Time: 14:07 [ET]
Event Date: 06/29/1999
Event Time: 00:00 [CDT]
Last Update Date: 08/31/1999
Notification Time: 14:07 [ET]
Event Date: 06/29/1999
Event Time: 00:00 [CDT]
Last Update Date: 08/31/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DAVID HILLS (R3)
JOHN ROGGE (R1)
DON COOL (NMSS)
DAVID HILLS (R3)
JOHN ROGGE (R1)
DON COOL (NMSS)
MISSING M43A1 CHEMICAL AGENT DETECTORS
On 6/29/1999, B Company, 1/105 Infantry, New York National Guard reported that four M43A1 chemical agent detectors, each containing 250 µCi of Am-241, could not be found during a change of command inventory. The detectors were last inventoried before being shipped to OMS-14 (Staten Island, NY) for repairs. These detectors may have been reissued to another unit after repair.
On 6/29/1999, B Company, 1/105 Infantry, New York National Guard reported that four M43A1 chemical agent detectors, each containing 250 µCi of Am-241, could not be found during a change of command inventory. The detectors were last inventoried before being shipped to OMS-14 (Staten Island, NY) for repairs. These detectors may have been reissued to another unit after repair.