Event Notification Report for November 14, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/13/2000 - 11/14/2000
** EVENT NUMBERS **
37504 37512 37517 37518
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|General Information or Other |Event Number: 37504 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 11/08/2000|
|LICENSEE: AULTMAN HOSPITAL |NOTIFICATION TIME: 14:10[EST]|
| CITY: CANTON REGION: 3 |EVENT DATE: 11/04/2000|
| COUNTY: STATE: OH |EVENT TIME: 13:00[EST]|
|LICENSE#: 02120770003 AGREEMENT: Y |LAST UPDATE DATE: 11/13/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GEOFFREY WRIGHT R3 |
| |BRIAN SMITH NMSS |
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| NRC NOTIFIED BY: MARK LIGHT | |
| 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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| TWO PATIENTS GIVEN INCORRECT DELIVERED DOSE |
| |
| The Radiation Safety Officer from Aultman Hospital, on November 4, 2000, at |
| 1300 hours, notified the Ohio Department of Health, that two patients |
| received brachytherapy doses involving Ir-192 temporary implants in excess |
| of 20% of the prescribed dose. The misadministration were discovered during |
| an internal audit of the licensee's Quality Management Program on November |
| 3, 2000, by the Radiation Safety Officer and Radiation Protection Staff. |
| |
| One patient received two courses of brachytherapy treatments with Ir-192 |
| temporary implants. On September 18, 2000, the delivered dose was 3330 cGy, |
| while the prescribed dose was 2000 cGy. This represents a delivered dose |
| discrepancy of 67%. On October 9, 2000, the prescribed dose was 2250 cGy, |
| while the delivered dose was 3500 cGy. This represents a delivered dose |
| discrepancy of 56%. The patient also had external beam therapy treatment |
| from a linear accelerator that was not considered in this |
| misadministration. |
| |
| Another patient received two courses of brachytherapy treatments, with only |
| one brachytherapy treatment qualifying as a misadministration. On August |
| 22, 2000, the delivered dose from Ir-192 was 3500 cGy, while the prescribed |
| dose was 1980 cGy. This represents a delivered dose discrepancy of 78%. |
| The patient also had external beam therapy treatment from a linear |
| accelerator that was not considered in this misadministration. |
| |
| The primary notification from the licensee indicates that the |
| misadministrations are due to operator error in data entry of the source |
| strength in the treatment computer. The facility has recently acquired a |
| new computer, and the operator mistakenly entered the source strengths into |
| the computer as milligram-Radium equivalent (mg-Ra-eq) strengths instead of |
| units of millicuries. |
| |
| The licensee does not anticipate any adverse effects to the patients as a |
| result of the additional doses. One patient was notified of the |
| misadministration on November 3, 2000. The other patient will be notified |
| later this week by the radiation oncologist, as the referring physician was |
| not immediately available. |
| |
| The Licensee shall submit a written report to the Ohio Department of Health, |
| Bureau of Radiation Protection, within 15 days after discovery of the |
| misadministration, as delineated in 10 CFR 35.33(2). |
| |
| * * * UPDATE AT 1430 EST ON 11/13/00 BY MARK LIGHT TO FANGIE JONES * * * |
| |
| After review of procedures performed by the hospital, two additional |
| overexposures have been determined to have occurred on October 23, 2000 and |
| October 30, 2000. The hospital notified the Ohio Department of Health, |
| Bureau of Radiation Protection on November 13, 2000 at 0910 EST. |
| |
| The third patient received one course of brachytherapy treatment with Ir-192 |
| temporary implants. On October 30, 2000, the delivered dose was 3240 cGy, |
| while the prescribed dose was 1890 cGy. This represents a delivered dose |
| discrepancy of 71%. The patient also had external beam therapy treatment |
| from a linear accelerator that was not considered in this |
| misadministration. |
| |
| The fourth patient received two courses of brachytherapy treatments with |
| Ir-192 temporary implants. On October 23, 2000, the delivered dose was 3150 |
| cGy, while the prescribed dose was 2025 cGy. This represents a delivered |
| dose discrepancy of 56 %. On November 6, 2000, the second prescribed dose |
| was 1400 cGy, which was delivered correctly. The patient also had external |
| beam therapy treatment from a linear accelerator that was not considered in |
| this misadministration. |
| |
| The notification of the third and fourth patient is pending. The licensee |
| reports that the clinical treatment of all patients has not been affected by |
| the misadministration. |
| |
| As soon as the licensee's management determined that a reportable event had |
| occurred, the licensee took action to provide additional training to staff |
| involved in brachytherapy procedures. The licensee is reviewing their |
| current Quality Management Program. |
| |
| The Ohio Department of Health, Bureau of Radiation Protection will conduct |
| an on-site investigation to review the procedures and finding of the |
| licensee's Quality Management review and to confirm the adequacy of |
| corrective actions to prevent reoccurrence. |
| |
| The R3DO (Bruce Jorgennsen) and the NMSS EO (Wayne Hodges) have been |
| notified. |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 37512 |
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| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 11/10/2000|
| UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 09:52[EST]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 11/10/2000|
+------------------------------------------------+EVENT TIME: 06:10[CST]|
| NRC NOTIFIED BY: D. COVEYOU |LAST UPDATE DATE: 11/13/2000|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GEOFFREY WRIGHT R3 |
|10 CFR SECTION: | |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Shutdown |0 Hot Shutdown |
| | |
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EVENT TEXT
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| OFFGAS ISOLATION VALVE FAILED TO CLOSE UPON DEMAND |
| |
| "At 0610 on November 10, 2000, the offgas isolation valve to the station |
| ventilation stack (2N62-F057) failed to close when the main control room |
| control switch for the valve was placed in the 'close' position. The valve |
| subsequently closed approximately 20 minutes later without other action |
| taken. The valve is air operated and is designed to close upon receipt of a |
| high offgas release rate or via the control switch. There were no abnormal |
| radiological releases occurring at the time of the failure. The unit was in |
| the process of being shut down for a planned refueling outage. No other |
| problems occurred during the event. All systems operated as designed except |
| as described. A prompt investigation has been initiated to determine the |
| cause of the valve failure. Corrective actions will be taken to address the |
| cause." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
| |
| * * * RETRACTED AT 1526 EST ON 11/13/00 BY DAN COVEYOU TO FANGIE JONES * * |
| * |
| |
| This event has been retracted. "Further investigation has determined that |
| this valve serves no safety function. The investigation has determined that |
| while the design of this valve is to close upon a high radiation condition, |
| this is not an accident mitigation function. The equipment is not safety |
| related nor single failure proof; there are no safety design bases for this |
| valve." |
| |
| The licensee has notified the NRC Resident Inspector. The R3DO (Bruce |
| Jorgensen) has been notified. |
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|Power Reactor |Event Number: 37517 |
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| FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 11/13/2000|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 15:31[EST]|
| RXTYPE: [1] GE-4 |EVENT DATE: 11/13/2000|
+------------------------------------------------+EVENT TIME: 11:00[EST]|
| NRC NOTIFIED BY: MARK SHAFFER |LAST UPDATE DATE: 11/13/2000|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MICHELE EVANS R1 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| LICENSEE EMPLOYEE TESTED POSITIVE FOR ALCOHOL DURING A FOR-CAUSE |
| FITNESS-FOR-DUTY TEST (24-HOUR REPORT PER 10 CFR 26.73.a(2)(ii)) |
| |
| A non-licensed employee tested positive for alcohol during a for-cause |
| fitness-for-duty test conducted on 11/13/00. The individual's access |
| authorization has been suspended and badge deactivated. Plant safety has |
| not been affected by this event. |
| |
| (Call the NRC operations officer for additional information.) |
| |
| The licensee notified the NRC resident inspector. |
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|Power Reactor |Event Number: 37518 |
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| FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 11/13/2000|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 15:32[EST]|
| RXTYPE: [1] GE-4 |EVENT DATE: 11/13/2000|
+------------------------------------------------+EVENT TIME: 09:15[EST]|
| NRC NOTIFIED BY: MARK SHAFFER |LAST UPDATE DATE: 11/13/2000|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MICHELE EVANS R1 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| LICENSEE EMPLOYEE TESTED POSITIVE FOR ALCOHOL DURING A RANDOM |
| FITNESS-FOR-DUTY TEST (24-HOUR REPORT PER 10 CFR 26.73.a(2)(ii)) |
| |
| A non-licensed employee tested positive for alcohol during a random |
| fitness-for-duty test conducted on 06/07/00. The individual's access |
| authorization has been suspended and badge deactivated. Plant safety has |
| not been affected by this event. |
| |
| (Call the NRC operations officer for additional information.) |
| |
| The licensee notified the NRC resident inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021