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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    |
+------------------------------------------------+                             |
| 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     |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|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  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37518       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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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