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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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT SORENSEN               |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|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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