Event Notification Report for March 7, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/06/2001 - 03/07/2001
** EVENT NUMBERS **
37807 37810
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|Hospital |Event Number: 37807 |
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| REP ORG: SAINT LUKE'S HOSPITAL |NOTIFICATION DATE: 03/05/2001|
|LICENSEE: SAINT LUKE'S HOSPITAL |NOTIFICATION TIME: 15:13[EST]|
| CITY: KANSAS CITY REGION: 3 |EVENT DATE: 02/23/2001|
| COUNTY: STATE: MO |EVENT TIME: 11:15[CST]|
|LICENSE#: 24-00889-01 AGREEMENT: N |LAST UPDATE DATE: 03/06/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN MADERA R3 |
| |BRIAN SMITH NMSS |
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| NRC NOTIFIED BY: SCOTT SORENSEN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
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|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| POSSIBLE MEDICAL MISADMINISTRATION |
| |
| A remote afterloader device failed to function as it was intended during a |
| random FDA trial. The remote afterloader was in automatic, and it was |
| supposed to insert an intravascular, brachytherapy, 93-mCi, P-32, wire |
| source into a patient. The remote afterloader device did not operate |
| properly, and it inserted and withdrew the wire source 4 times. No dwell |
| time was recorded by the afterloader since the wire source inserted less |
| than 5 seconds each time before the wire source was automatically withdrawn. |
| The patient was supposed to have received a total dose of 20 grays. The |
| patient received a dose much less than intended. The FDA was notified of |
| this event by the licensee. |
| |
| ***** UPDATE AT 0958 EST ON 03/06/01 FROM SCOTT SORENSEN TO LEIGH TROCINE |
| ***** |
| |
| The licensee called the NRC Operation Center to clarify that the trial |
| afterloader device was under the operator's control and that the device's |
| internal safety checks and sensors caused the source to be removed and would |
| not allow the dose to be delivered as intended. The following text is a |
| portion of a clarification received from the licensee via an E-mail at 1024 |
| EST on 03/06/01: |
| |
| "Radiation therapy was not delivered as prescribed during [an] FDA-approved |
| clinical trial for Intravascular Brachytherapy. A 93-mCi P-32 wire was to |
| be placed across a coronary artery lesion for approximately 5 |
| minutes of dwell time. Multiple attempts were made to place the source at |
| the treatment position. However, an internal safety trigger in the |
| afterloader caused the source wire to be withdrawn from the patient |
| immediately upon source arrival at the targeted treatment site. The |
| licensee extended the active wire a total of 4 times into the patient, |
| followed by immediate, automatic withdrawal by the afterloader. No dwell |
| time was recorded at the treatment location, and transit time through the |
| patient's arteries was approximately 5 seconds each way. The procedure was |
| abandoned without the patient receiving the intended 20 Gray dose. The |
| event was under direct supervision of [an] NRC-approved Radiation Oncologist |
| and the institution's Radiation Safety Officer. The FDA was notified of the |
| study protocol deviation by the licensee." |
| |
| (Call the NRC operations officer for licensee contact information.) |
| |
| The NRC operations officer notified the R3DO (Madera) and NMSS EO (Sturz). |
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|Power Reactor |Event Number: 37810 |
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| FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 03/06/2001|
| UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 00:24[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 03/05/2001|
+------------------------------------------------+EVENT TIME: 23:24[EST]|
| NRC NOTIFIED BY: JIM CROWLEY |LAST UPDATE DATE: 03/06/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |RICHARD CONTE R1 |
|10 CFR SECTION: |BILL BATEMAN NRR |
|*AEC 50.72(a) (1) (i) EMERGENCY DECLARED |CHARLES MILLER IRO |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|CHARLIE BAGWELL FEMA |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| DISCRETIONARY UNUSUAL EVENT DECLARED DUE TO A MOMENTARY LOSS OF OFFSITE |
| POWER DURING AN ONGOING SEVERE WINTER STORM AND SUBSEQUENT AUTOMATIC REACTOR |
| TRIP DUE TO GRID INSTABILITY |
| |
| During an ongoing severe winter storm, the 345-kV breakers tripped open and |
| re-closed resulting in a momentary loss of offsite power. An automatic |
| reactor trip also occurred at 2324 on 03/05/01 due to electrical grid |
| instability. (The exact cause of the reactor trip is currently under |
| investigation because there was no first out indication.) All rods fully |
| inserted. The reactor coolant pumps tripped as expected, and one has been |
| placed back in service. Both emergency diesel generators automatically |
| started but did not load. Availability of the condenser was also lost due |
| to the loss of power, and operators closed the main steam isolation valves. |
| There were no radiation releases, and there were no reactor coolant system |
| or steam generator tube leaks. All systems functioned as required with one |
| exception. The steam-driven emergency feedwater pump failed to |
| automatically actuate. |
| |
| At this time, the unit is in Mode 3. Normal charging and letdown, |
| pressurizer heaters and sprays, and one reactor coolant pump are being |
| utilized for primary system level, pressure, and transport control. Water |
| is being supplied to the steam generators via an electric-driven emergency |
| feedwater pump, and the atmospheric dumps are being utilized as the heat |
| sink. Containment parameters are normal. The grid is currently available |
| for offsite power, and the emergency diesel generators are still running. |
| |
| Based on a discretionary shift management call, the licensee declared an |
| Unusual Event at 2336 on 03/05/01. The licensee stated that a |
| "Discretionary Event" under item 18A refers to an event in progress (or has |
| occurred) that indicates a potential degradation of the level of safety of |
| the station. The licensee plans to notify the NRC when the Unusual Event |
| has terminated or if conditions degrade. |
| |
| A severe winter storm is currently ongoing. At the time of the event, the |
| unit was experiencing winds at a rate of approximately 50 miles per hour. |
| The licensee reported that these strong winds were ongoing and that only a |
| few inches of snow had fallen (although up to 2 feet is expected). |
| |
| The licensee notified the state at 2347 on 03/05/01 and plans to notify the |
| NRC resident inspector as well as applicable local officials. The licensee |
| also plans to issue a press release. |
| |
| ***** UPDATE AT 0222 ON 03/06/01 FROM JIM HILL TO LEIGH TROCINE ***** |
| |
| This update provides both clarifications/corrections to the original event |
| notification and additional information regarding licensee plans. |
| |
| CLARIFICATIONS/CORRECTIONS: Prior to the event, two of three offsite power |
| lines had been lost in close succession. The remaining offsite line was |
| subsequently lost, and its breaker re-closed within a short duration. This |
| resulted in the momentary loss of offsite power and subsequent plant |
| transient. This initial electrical imbalance was sufficient to result in |
| the automatic starting and loading of both emergency diesel generators. |
| |
| CURRENT STATUS: The unit remains in the Unusual Event, and winds are |
| currently sustained at a rate of approximately 40 miles per hour. All three |
| offsite power lines have been restored. Both emergency diesel generators |
| remain in operation and continue to provide power to both vital (emergency) |
| buses. The non-vital buses have been re-energized from offsite power. An |
| additional auxiliary pump (the startup feedwater pump) has also been started |
| to provide additional water to the steam generators. This pump is a |
| non-safety related housekeeping pump. |
| |
| PLANS: Within the next half hour, the licensee plans to commence a |
| discretionary plant cooldown and plans to place the unit in Mode 5 (Cold |
| Shutdown). At some point in time, the licensee also plans to secure the |
| electric-driven emergency feedwater pump and rely on the startup feedwater |
| pump to supply water to the steam generators. |
| |
| The licensee notified the NRC resident inspector and an onsite member of an |
| NRC residual heat removal inspection team. The NRC operations officer |
| notified the R1DO (Conte), NRR EO (Bateman), and IRO (Miller). |
| |
| ***** UPDATE AT 0438 ON 03/06/01 FROM JIM HILL TO LEIGH TROCINE ***** |
| |
| The licensee has commenced a plant cooldown and anticipates that it will |
| take approximately 6 hours for the unit to reach Cold Shutdown. Other than |
| commencement of the cooldown, there has been no change in plant conditions |
| or equipment status. |
| |
| The licensee stated that the criteria for exiting the Unusual Event have |
| been met. However, the licensee currently plans to remain in the Unusual |
| Event for a while longer because the high line insulators onsite are still |
| arcing and are suspect and because the in-house vital buses are still being |
| powered by the emergency diesel generators. |
| |
| The licensee notified an onsite member of an NRC residual heat removal |
| inspection team, who in turn notified the NRC resident inspector. The NRC |
| operations officer notified the R1DO (Conte), NRR EO (Bateman), and IRO |
| (Miller). |
| |
| ***** UPDATE AT 0800 ON 03/06/01 FROM JOHN LaVALLEY TO LEIGH TROCINE ***** |
| |
| The licensee called to provide the following status update: |
| |
| The unit remains in the Unusual Event. The reactor coolant system is |
| currently at 445 degrees F, and the cooldown is still in progress via |
| utilization of boration and the atmospheric steam dumps. The emergency |
| diesel generators are still supplying power to the vital buses. |
| |
| The licensee currently plans to place the unit in Mode 5 (Cold Shutdown) and |
| then to restore the secondary side of the plant (assuming that offsite power |
| supplies are stable). |
| |
| The NRC operations officer notified the R1DO (Conte) and NRR EO (Tappert). |
| |
| *** UPDATE AT 1509 ET ON 03/06/01 FROM JOHN LaVALLEY TO JOHN MACKINNON |
| ***** |
| |
| The licensee called to provide the following status update: |
| |
| The unit remains in the Unusual Event. The reactor coolant system is |
| currently 360 degrees F, and cooldown is still in progress. The licensee |
| will reduce reactor coolant system temperature to approximately 240 degrees |
| F. The emergency diesel generators are still supplying power to the vital |
| buses. The licensee is waiting for Load Dispatcher permission to take down |
| one 345kV line at a time to clean the lines bushing. After the bushings for |
| the 3 345kV lines have been cleaned and the grid is stable, the licensee |
| will make a determination whether to exit the Unusual Event. |
| Additional information: After the reactor trip the Turbine Driven Auxiliary |
| Feedwater pump failed to start. The licensee thinks that the pump tripped |
| on overspeed. Licensee is investigating this problem. |
| |
| The NRC operations officer notified the R1DO (Bellamy) and NRR EO (C. |
| Grimes) |
| |
| ****UPDATE AT 1619ET ON 03/06/01 FROM M KILEY TO JOHN MACKINNON***** |
| |
| The licensee called to provide the following clarification to event write |
| up: |
| |
| The exact cause of the reactor trip as indicated by the "First Out Light" |
| was "Power Range Negative Flux Rate Hi". Secondly, both Emergency Diesel |
| Generators automatically started and loaded all safety related loads |
| associated with Emergency Electrical Buses 5 and 6. |
| |
| The NRC operations officer notified the R1DO (Bellamy) and NRR EO (Tad |
| Marsh). |
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