Event Notification Report for August 16, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/15/2000 - 08/16/2000
** EVENT NUMBERS **
37225 37226 37227 37228 37229
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|Power Reactor |Event Number: 37225 |
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| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 08/15/2000|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 01:45[EDT]|
| RXTYPE: [1] GE-2 |EVENT DATE: 08/15/2000|
+------------------------------------------------+EVENT TIME: 01:40[EDT]|
| NRC NOTIFIED BY: JERE FREEMAN |LAST UPDATE DATE: 08/15/2000|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 86 Power Operation |78 Power Operation |
| | |
| | |
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EVENT TEXT
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| TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF SECONDARY |
| CONTAINMENT |
| |
| Two reactor building isolation valves (V-28-21 and V-28-22) are not |
| performing their isolation function. The plant is required to be in the |
| shutdown mode by 0704 EDT on 8/15/00 and cold shutdown mode by 0904 EDT on |
| 8/15/00. The valves were discovered at 0304 EDT on 8/14/00 and the licensee |
| has been working on restoring their function. The licensee is continuing to |
| try to restore their function and qualify other valves to perform their |
| function. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| * * * UPDATE ON 08/15/00 AT 1241 ET BY WRONKA TAKEN BY MACKINNON * * * |
| |
| Correction: This event notification corrects the above reported Oyster |
| Creek Notification. The plant was required to be in shutdown mode by 0704 ET |
| today, 08/15/00. A loss of Secondary Containment Integrity was discovered |
| at 0304 ET on 08/14/00. Subsequent troubleshooting determined at 1120 ET on |
| 08/14/00 that V-28-21 and V-28-22, Reactor Building Exhaust Valves, leak by |
| when closed. A 30 hour LCO, Cold Shutdown, was in effect at the time of the |
| initial notification which was determined to be not applicable and was |
| exited at 0438 ET on 08/15/00. R1DO (Cliff Anderson) notified. |
| |
| The NRC Resident Inspector was notified of this update by the licensee. |
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|General Information or Other |Event Number: 37226 |
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| REP ORG: TENNESSEE DIV OF RAD HEALTH |NOTIFICATION DATE: 08/15/2000|
|LICENSEE: CUMBERLAND MEDICAL CENTER |NOTIFICATION TIME: 14:03[EDT]|
| CITY: CROSSVILLE REGION: 2 |EVENT DATE: 08/14/2000|
| COUNTY: STATE: TN |EVENT TIME: 12:00[EDT]|
|LICENSE#: R-18002 AGREEMENT: Y |LAST UPDATE DATE: 08/15/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE BOLAND R2 |
| |BRIAN SMITH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DEBRA SHULTS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Hospital |Event Number: 37227 |
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| REP ORG: UNIVERSITY OF PITTSBURGH |NOTIFICATION DATE: 08/15/2000|
|LICENSEE: UNIVERSITY OF PITTSBURGH |NOTIFICATION TIME: 16:20[EDT]|
| CITY: PITTSBURGH REGION: 1 |EVENT DATE: 08/15/2000|
| COUNTY: STATE: PA |EVENT TIME: 14:00[EDT]|
|LICENSE#: 37-00245-02 AGREEMENT: N |LAST UPDATE DATE: 08/15/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLIFFORD ANDERSON R1 |
| |PHILIP TING NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: M SHEETZ | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
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| | |
| | |
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EVENT TEXT
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| POSSIBLE MEDICAL MISADMINISTRATION INVOLVING YTTRIUM-90 (Y-90). |
| |
| This event occurred at the University of Pittsburgh Presbyterian Hospital |
| located at 200 Lothrop St, Pittsburgh, PA. |
| |
| A patient was to have received 80 millicuries of Y-90 for cancer treatment. |
| The Y-90 was contained in glass microspheres which were to be transferred to |
| the patient cancer site via a catheter. The Thera Sphere delivery device |
| made by Nordion did not delivery most of the microspheres to the patient and |
| at this time it is unknown how much of the 80 millicuries of Y-90 is still |
| in the catheter. The caller, a Health Physicist, did not know what caused |
| the Nordion Thera Sphere delivery device to fail. No one was contaminated |
| or overexposed by this incident. The patients physician was notified of the |
| potential Medical Misadministration. NRC Region 1 Jim Dwyer was notified of |
| this event by the licensee. Half Life of Y-90 is 64 hours. |
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|General Information or Other |Event Number: 37228 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 08/15/2000|
|LICENSEE: SAIC, INC. |NOTIFICATION TIME: 17:12[EDT]|
| CITY: SAN DIEGO REGION: 4 |EVENT DATE: 08/14/2000|
| COUNTY: STATE: CA |EVENT TIME: 18:00[PDT]|
|LICENSE#: 2290-037 AGREEMENT: Y |LAST UPDATE DATE: 08/15/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHUCK PAULK R4 |
| |PHILIP TING NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: D. BUNN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 37229 |
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| FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 08/16/2000|
| UNIT: [1] [] [] STATE: GA |NOTIFICATION TIME: 02:15[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 08/16/2000|
+------------------------------------------------+EVENT TIME: 00:30[EDT]|
| NRC NOTIFIED BY: PAUL UNDERWOOD |LAST UPDATE DATE: 08/16/2000|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |PAUL FREDRICKSON R2 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
|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 |
| | |
| | |
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EVENT TEXT
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| UNIT 1 DECLARED HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE DUE TO A |
| FAILURE DURING SURVEILLANCE TESTING |
| |
| "While performing weekly exercise per Operating Order 00-01-0200S, High |
| Pressure Coolant Injection turbine stop valve failed to close when trip |
| solenoid pushbutton was depressed. |
| |
| "High Pressure Coolant Injection was declared inoperable. |
| |
| "Cause of turbine stop valve failure to close is under investigation." |
| |
| With HPCI inoperable, Unit 1 entered a 14 day LCO Action Statement. Both |
| Maintenance and Engineering are evaluating corrective actions. The licensee |
| will inform the NRC Resident Inspector. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021