Event Notification Report for August 14, 2000
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/13/2000 - 08/14/2000
EVENT NUMBERS
37226372233722437228
General Information or Other
Event Number: 37226
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: CUMBERLAND MEDICAL CENTER
Region: 2
City: CROSSVILLE State: TN
County:
License #: R-18002
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: JOHN MacKINNON
Licensee: CUMBERLAND MEDICAL CENTER
Region: 2
City: CROSSVILLE State: TN
County:
License #: R-18002
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/15/2000
Notification Time: 14:03 [ET]
Event Date: 08/14/2000
Event Time: 12:00 [EDT]
Last Update Date: 08/15/2000
Notification Time: 14:03 [ET]
Event Date: 08/14/2000
Event Time: 12:00 [EDT]
Last Update Date: 08/15/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE BOLAND (R2)
BRIAN SMITH (NMSS)
ANNE BOLAND (R2)
BRIAN SMITH (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION
On 08/14/00, the Medical Physicist at Cumberland Medical Center called to report a therapy misadministration. Two patients were treated for prostate cancer with I-125 implants. The pre-plan called for patient 1 to be treated with 78 seeds containing 0.326 millicurie per seed. The pre-plan called for patient 2 to be treated with 123 seeds containing 0.229 millicurie per seed. During the post plan review, it was discovered that an error had occurred when ordering the seeds. Patient 1 was treated with seeds containing 0.414 mCi/seed and Patient 2 was treated with seeds containing 0.291 mCi/seed. The physicist has implemented measures to prevent reoccurrence. The licensee will submit a written report within 15 days.
Tennessee event Report No. is TN-00-122.
On 08/14/00, the Medical Physicist at Cumberland Medical Center called to report a therapy misadministration. Two patients were treated for prostate cancer with I-125 implants. The pre-plan called for patient 1 to be treated with 78 seeds containing 0.326 millicurie per seed. The pre-plan called for patient 2 to be treated with 123 seeds containing 0.229 millicurie per seed. During the post plan review, it was discovered that an error had occurred when ordering the seeds. Patient 1 was treated with seeds containing 0.414 mCi/seed and Patient 2 was treated with seeds containing 0.291 mCi/seed. The physicist has implemented measures to prevent reoccurrence. The licensee will submit a written report within 15 days.
Tennessee event Report No. is TN-00-122.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 37223
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WESLEY HILL
HQ OPS Officer: FANGIE JONES
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WESLEY HILL
HQ OPS Officer: FANGIE JONES
Notification Date: 08/14/2000
Notification Time: 07:42 [ET]
Event Date: 08/14/2000
Event Time: 06:58 [EDT]
Last Update Date: 08/16/2000
Notification Time: 07:42 [ET]
Event Date: 08/14/2000
Event Time: 06:58 [EDT]
Last Update Date: 08/16/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(ii)(B) - OUTSIDE DESIGN BASIS
10 CFR Section:
50.72(b)(1)(ii)(B) - OUTSIDE DESIGN BASIS
Person (Organization):
ANNE BOLAND (R2)
ANNE BOLAND (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
BOTH TRAINS OF HIGH PRESSURE INJECTION DECLARED INOPERABLE
The licensee, in the process of a routine train swap between the 1B nuclear volume control (NV) pump and the 1A NV pump, the 1B discharge check valve did not fully seat. Flow from the 1A NV pump was being returned through the 1B NV pump to the suction header. This could have affected the capability of both of the NV pumps to perform their required actions in the event that high head injection to the reactor coolant system was needed. Both pumps were declared inoperable at 0658 EDT which made the high head injection system inoperable. The discharge valve on the 1B NV pump was shut at 0710 EDT to restore the 1A NV pump to operable.
The method to be used to restore the 1B NV pump to operable is being considered.
The licensee intends to notify the NRC Resident Inspector.
* * * RETRACTION ON 08/16/00 AT 1711 ET BY T. HEAFNER TAKEN BY MACKINNON * * *
"Subsequent to the report, further evaluation determined that the calculated back flow through the 1B NV pump would not have prevented proper starting and operation of that pump. Consequently, that pump was capable of performing it's safety function. With one NV pump operable, there is sufficient injection flow capacity to the reactor coolant system during the event. In addition, for the short time that the 1A NV pump was inoperable, it was not required to assume a single failure of the 1B NV pump during an event. Consequently, McGuire Nuclear Station was not outside it's design basis and Event Report 37223 is retracted." NRC R2DO (Paul Fredrickson) notified.
The NRC Resident Inspector was notified of this event retraction by the licensee.
The licensee, in the process of a routine train swap between the 1B nuclear volume control (NV) pump and the 1A NV pump, the 1B discharge check valve did not fully seat. Flow from the 1A NV pump was being returned through the 1B NV pump to the suction header. This could have affected the capability of both of the NV pumps to perform their required actions in the event that high head injection to the reactor coolant system was needed. Both pumps were declared inoperable at 0658 EDT which made the high head injection system inoperable. The discharge valve on the 1B NV pump was shut at 0710 EDT to restore the 1A NV pump to operable.
The method to be used to restore the 1B NV pump to operable is being considered.
The licensee intends to notify the NRC Resident Inspector.
* * * RETRACTION ON 08/16/00 AT 1711 ET BY T. HEAFNER TAKEN BY MACKINNON * * *
"Subsequent to the report, further evaluation determined that the calculated back flow through the 1B NV pump would not have prevented proper starting and operation of that pump. Consequently, that pump was capable of performing it's safety function. With one NV pump operable, there is sufficient injection flow capacity to the reactor coolant system during the event. In addition, for the short time that the 1A NV pump was inoperable, it was not required to assume a single failure of the 1B NV pump during an event. Consequently, McGuire Nuclear Station was not outside it's design basis and Event Report 37223 is retracted." NRC R2DO (Paul Fredrickson) notified.
The NRC Resident Inspector was notified of this event retraction by the licensee.
General Information or Other
Event Number: 37224
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TERA - MAR, INC.
Region: 4
City: FORT WORTH State: TX
County:
License #: L03157-008
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: JOHN MacKINNON
Licensee: TERA - MAR, INC.
Region: 4
City: FORT WORTH State: TX
County:
License #: L03157-008
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/14/2000
Notification Time: 16:55 [ET]
Event Date: 08/14/2000
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2000
Notification Time: 16:55 [ET]
Event Date: 08/14/2000
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHUCK PAULK (R4)
C.W. (BILL) REAMER (NMSS)
CHUCK PAULK (R4)
C.W. (BILL) REAMER (NMSS)
AGREEMENT STATE REPORT INVOLVING STOLEN HUMBOLT MODEL 51001 GAUGE
"Gauge was stolen from the back of a Company truck while the operator was in a FINA Station at 2910 Loop 12, Dallas, Texas. The driver had not chained the gauge in the truck and had noted the presence of "unsavory" persons that seemed to be following him and were present at the station when he exited his vehicle. When he returned to his vehicle the gauge was missing. He had the keys and the equipment with which to secure the gauge.
"The missing gauge is a Humbolt Model 51001, Serial No.: 2692 with 10 millicurie Cs-137 source, Serial No.: 6604GQ and 40 millicurie Am-241 Be source, Serial No.: NJ02854.
"The operator has been counseled by the RSO.
"Texas License L03157-008. Licensee is located in Fort Worth, Texas."
"Gauge was stolen from the back of a Company truck while the operator was in a FINA Station at 2910 Loop 12, Dallas, Texas. The driver had not chained the gauge in the truck and had noted the presence of "unsavory" persons that seemed to be following him and were present at the station when he exited his vehicle. When he returned to his vehicle the gauge was missing. He had the keys and the equipment with which to secure the gauge.
"The missing gauge is a Humbolt Model 51001, Serial No.: 2692 with 10 millicurie Cs-137 source, Serial No.: 6604GQ and 40 millicurie Am-241 Be source, Serial No.: NJ02854.
"The operator has been counseled by the RSO.
"Texas License L03157-008. Licensee is located in Fort Worth, Texas."
General Information or Other
Event Number: 37228
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAIC, INC.
Region: 4
City: SAN DIEGO State: CA
County:
License #: 2290-037
Agreement: Y
Docket:
NRC Notified By: D. BUNN
HQ OPS Officer: JOHN MacKINNON
Licensee: SAIC, INC.
Region: 4
City: SAN DIEGO State: CA
County:
License #: 2290-037
Agreement: Y
Docket:
NRC Notified By: D. BUNN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/15/2000
Notification Time: 17:12 [ET]
Event Date: 08/14/2000
Event Time: 18:00 [PDT]
Last Update Date: 08/15/2000
Notification Time: 17:12 [ET]
Event Date: 08/14/2000
Event Time: 18:00 [PDT]
Last Update Date: 08/15/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHUCK PAULK (R4)
PHILIP TING (NMSS)
CHUCK PAULK (R4)
PHILIP TING (NMSS)
AGREEMENT STATE REPORT CONCERNING MISSING AMERICIUM-241 CALIBRATION SOURCE.
State of California Department of Health was notified today by SAIC, Inc., located in San Diego, that a 14 millicurie Americium-241 calibration source has been missing since yesterday evening. The lab in which the calibration source was located has been surveyed and now other rooms are being surveyed to locate the missing source.
State of California Department of Health was notified today by SAIC, Inc., located in San Diego, that a 14 millicurie Americium-241 calibration source has been missing since yesterday evening. The lab in which the calibration source was located has been surveyed and now other rooms are being surveyed to locate the missing source.