Event Notification Report for May 8, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/07/2001 - 05/08/2001
** EVENT NUMBERS **
37966 37969 37970 37971
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|Other Nuclear Material |Event Number: 37966 |
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| REP ORG: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION DATE: 05/05/2001|
|LICENSEE: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION TIME: 11:51[EDT]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 05/04/2001|
| COUNTY: PHILADELPHIA STATE: PA |EVENT TIME: 16:30[EDT]|
|LICENSE#: 37-00118-07 AGREEMENT: N |LAST UPDATE DATE: 05/07/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |HAROLD GRAY R1 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT FORREST | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| DISCOVERY OF A BRACYTHERAPY MISADMINISTRATION INVOLVING A LEAKING IODINE-125 |
| SOURCE AT THE UNIVERSITY OF PENNSYLVANIA IN PHILADELPHIA |
| |
| At approximately 1000 on 05/04/01, the licensee administered a prostate |
| implant involving the 94 iodine-125 seeds on the order of about 1/2 |
| millicurie per seed. (It is currently believed that the intended dosage for |
| the patient was approximately 47 millicuries. The licensee reported that |
| the intended dose is received from decay of the seeds which remain in the |
| patient after treatment.) |
| |
| Surveys were performed after the administration, and one of the implant |
| needles had readings that were higher than expected. At that time, it was |
| assumed that a source was stuck in the applicable needle (a more likely |
| scenario). However, at approximately 1630, removable contamination (due to |
| a leaking source) was discovered on the applicable needle. It is currently |
| believed that one of the seeds may have been damaged during the needle |
| loading process, and that the damaged seed was implanted into the patient |
| during treatment administration. |
| |
| At this time, there is only [one]complication that is expected as a result |
| of the leaking iodine-125 source. It was reported that the activity from |
| the leaking source could get into the blood stream and that the thyroid |
| would filter the radio-iodine. Therefore, the patient may receive an |
| unintended thyroid dose. |
| |
| The authorized user was notified, and the patient was informed. The patient |
| was also prescribed Lugols solution (a potassium iodide solution) to |
| minimize the unintended iodine-125 thyroid uptake from the leaking seed. |
| Initial estimates indicate a thyroid activity measurement of 73 nanocuries. |
| [Based on normal thyroid turnover, a dose of about 320 millirem is |
| calculated to the thyroid.] |
| |
| The licensee plans to notify the referring physician. |
| (Call the NRC operations officer for a licensee contact telephone number.) |
| |
| * * * UPDATE ON 5/7/01 @ 1059 FROM FORREST TO GOULD * * * |
| |
| This update was to make the event clear. The changes appear in the |
| brackets[ ]. |
| Notified Reg 1 RDO(Cook) and NMSS EO(Frant) |
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|Power Reactor |Event Number: 37969 |
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| FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 05/07/2001|
| UNIT: [] [2] [] STATE: CT |NOTIFICATION TIME: 15:23[EDT]|
| RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 05/07/2001|
+------------------------------------------------+EVENT TIME: 14:43[EDT]|
| NRC NOTIFIED BY: STEPHEN BAKER |LAST UPDATE DATE: 05/07/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |WILLIAM COOK R1 |
|10 CFR SECTION: | |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 97 Power Operation |0 Hot Standby |
| | |
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EVENT TEXT
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| MANUAL REACTOR TRIP - LOSS OF CIRCULATING WATER PUMP |
| |
| Operators manually inserted a reactor trip when a circulating water pump |
| tripped. The "A" pump was out for maintenance with divers in the water bay. |
| As a precaution for the safety of the divers, the travelling screens on the |
| "B" water bay were stopped and tagged. Kelp started building up on the "B" |
| traveling screens and the licensee pulled the divers from the water and |
| restarted the "B" screens. As the screens started to move an increase in |
| pressure across the screens and led to the pump trip. |
| |
| The plant response to the trip was normal all control rods fully inserted. |
| The plant is stable in mode three. Reactor coolant pumps are running and |
| decay is being removed by dumping steam to the main condenser (two |
| circulating water pumps are still running). |
| |
| The licensee notified the NRC resident inspector, the State DEP and the town |
| of Waterford. A press release is planned. |
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|Other Nuclear Material |Event Number: 37970 |
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| REP ORG: NEB DIV OF RADIOACTIVE MATERIALS |NOTIFICATION DATE: 05/07/2001|
|LICENSEE: NEB PUBLIC POWER DISTRICT |NOTIFICATION TIME: 16:22[EDT]|
| CITY: SUTHERLAND REGION: 4 |EVENT DATE: 05/01/2001|
| COUNTY: STATE: NE |EVENT TIME: [CDT]|
|LICENSE#: NE-10-03-03 AGREEMENT: Y |LAST UPDATE DATE: 05/07/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JEFF SHACKELFORD R4 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+SUSAN FRANT NMSS |
| NRC NOTIFIED BY: JOHN FASSELL | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT |
| |
| The event took place at a coal plant where a nuclear gauge is installed on a |
| coal chute. Not following established maintenance procedures led to workers |
| entering the chute with the source exposed. A field of approximately 450 |
| mr/hr was created. Whole body exposure was calculated based on a five hour |
| stay time resulting in an estimate of 2.25 Rem for the most exposed |
| individual. Two other individuals were involved with lower total exposure. |
| |
| |
| The source involved is believed to be Cs-137 with an activity between 100 |
| and 200 mCi. |
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|Power Reactor |Event Number: 37971 |
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| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 05/08/2001|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 01:52[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 00:09[EDT]|
| NRC NOTIFIED BY: VEITCH |LAST UPDATE DATE: 05/08/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 22 Power Operation |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| REACTOR WAS MANUALLY SCRAMMED FROM 22% POWER DUE TO FAILURE OF RECIRC PUMP |
| TO RESTART |
| |
| A manual scram was inserted at 0009 on 5/8/01. The scram was conducted in |
| accordance with plant procedures, IOI-8 "Manual Scram," due to a failure of |
| the reactor recirculation pump "A" to restart during a downshift from fast |
| to slow speed operation. Plant response to the manual scram was as |
| anticipated, all rods fully inserted, no ECCS actuations occurred and no |
| SRVs opened. Reactor vessel water level reached Level 3 (177.7 inches) and |
| operators entered the Plant Emergency Instructions. At 0016 the Plant |
| Emergency Instructions were exited. The cause of the "A" recirculation pump |
| failure to restart is being investigated. |
| |
| The NRC Resident Inspector was notified. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021