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Event Notification Report for July 3, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/02/2001 - 07/03/2001

                              ** EVENT NUMBERS **

38005  38112  38113  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38005       |
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| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 05/17/2001|
|    UNIT:  [] [3] []                 STATE:  NY |NOTIFICATION TIME: 14:46[EDT]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        05/08/2001|
+------------------------------------------------+EVENT TIME:        02:10[EDT]|
| NRC NOTIFIED BY:  FIRTH                        |LAST UPDATE DATE:  07/02/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JOHN ROGGE           R1      |
|10 CFR SECTION:                                 |JOHN TAPPERT         NRR     |
|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|3     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| INTERRUPTION OF THE COOLING FUNCTION PERFORMED BY THE PRIMARY LOOP OF THE    |
| BACKUP SPENT FUEL POOL COOLING SYSTEM OCCURRED FOR 20 MINS.                  |
|                                                                              |
| "On May 8, 2001 P3 was in RO-11, and the reactor was de-fueled with all      |
| discharged fuel in the Spent Fuel Pool (SFP).  SFP cooling was provided by   |
| the Backup Spent Fuel Pool Cooling system (B/U SFPCS) because the normal     |
| Spent Fuel Cooling system was out of service for maintenance.   At           |
| approximately 0210 hours on May 8, 2001, the water supply to the secondary   |
| loop of the B/U SFPCS was interrupted due to a loss of power involving IP3's |
| demineralized water source.  This water interruption subsequently caused a   |
| low differential pressure trip of the primary loop pump of the B/U SFPCS.    |
| Operator response re-gained the dernineralized water supply to the secondary |
| loop.   SFP cooling from this system was restored.   The cooling function    |
| performed by the primary loop of the B/U SFPCS was interrupted for           |
| approximately 20 minutes total.   A Root Cause Team investigation was        |
| commenced the morning of May 8, 2001 to review this event.  This event is    |
| being considered potentially reportable under 10 CFR 50.72 (b)(3)(v)(B).     |
| Investigation into the cause and reportability of this event is ongoing and  |
| this ENS report is being made at this time due to the continuing             |
| investigation of reportability."                                             |
|                                                                              |
| Temperature increased from 151 to 155F.                                     |
|                                                                              |
| The NRC Resident Inspector was notified along with state and local agencies. |
| Their US Congressman was also notified.                                      |
|                                                                              |
| * * * RETRACTION 0912 7/2/2001 FROM PRUSSMAN TAKEN BY STRANSKY * * *         |
|                                                                              |
| "On May 17, 2001, Entergy notified the Operations Center that a loss of      |
| Back-up Spent Fuel Pool Cooling System (BUSFPCS) was potentially reportable  |
| (ENS 38005). Reporting was under 10 CFR 50.72(b)(3)(v)(B) 'any event or      |
| condition that at the time of discovery could have prevented the fulfillment |
| of the safety function of structures or systems that are needed to... (B)    |
| remove residual heat.' Entergy is hereby retracting that notification. The   |
| event was subsequently determined to be not reportable. Section 3.2.7 of     |
| NUREG-1022, Revision 2 (NRC guidance for reporting), says the 'intent of     |
| these criteria is to capture events that would have been a failure of a      |
| safety system to properly complete a safety function, regardless of whether  |
| there was an actual demand.' The NUREG goes on to say that the 'definition   |
| of the systems included in the scope of these criteria is provided in the    |
| rules themselves. It includes systems required by the TS to be operable to   |
| perform one of the four functions (A) through (D) specified in the rule.'    |
| Examples 1 and 2 in NUREG 1022, Section 3.2.7 illustrate that events or      |
| conditions associated with a system not in the TS are not reportable because |
| of that fact. Example 2 states 'If such systems are required by Technical    |
| Specifications to be operational and the system is needed to fulfill one of  |
| the safety functions identified in this section of the rule then system      |
| level failures are reportable. If the system is not covered by Technical     |
| Specifications and is not required to meet the single failure criterion,     |
| then failures of the system are not reportable under this criterion.' Based  |
| on the statements contained in NUREG 1022, Revision 2, Entergy concluded     |
| that the event was not reportable. The BUSFPCS and SFPCS are not in IP3 TS   |
| and the only TS parameter associated with this event was the pool level. The |
| pool level was maintained within limits at all times."                       |
|                                                                              |
| The NRC resident inspector has been informed of this retraction. Notified    |
| R1DO (Barkley).                                                              |
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|General Information or Other                     |Event Number:   38112       |
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| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 07/02/2001|
|LICENSEE:  FLOWERS HOSPITAL                     |NOTIFICATION TIME: 20:00[EDT]|
|    CITY:  DOTHAN                   REGION:  2  |EVENT DATE:        06/05/2001|
|  COUNTY:                            STATE:  AL |EVENT TIME:             [CDT]|
|LICENSE#:  549                   AGREEMENT:  Y  |LAST UPDATE DATE:  07/02/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |THOMAS DECKER        R2      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+ANTON VEGEL          R3      |
| NRC NOTIFIED BY:  JAMES McNEES (fax)           |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MISLABELED IODINE-125 SEEDS BY NYCOMED AMERSHAM IN ILLINOIS RESULTED IN AN   |
| APPARENT MEDICAL MISADMINISTRATION AT FLOWERS HOSPITAL IN DOTHAN, ALABAMA    |
|                                                                              |
| The following text is a portion of a facsimile received from the Alabama     |
| Division of Radiation Control:                                               |
|                                                                              |
| "Alabama Incident #01-11 - I-125 Prostate Seed Implant Misadministration"    |
|                                                                              |
| "On the afternoon of June 29, 2001, the Alabama Office of Radiation Control  |
| was notified by [the] Illinois Department of Nuclear Safety that a possible  |
| misadministration of an iodine-125 prostate seed implant may have occurred   |
| at Flowers Hospital on June 5, 2001.  Flowers Hospital is authorized to      |
| possess and use the radioactive material under Alabama Radioactive Material  |
| License No. 549."                                                            |
|                                                                              |
| "The details of the event are described by [the Illinois Department of       |
| Nuclear Safety] in the attached e-mail which was transmitted to this         |
| Agency."                                                                     |
|                                                                              |
| "Representatives from the Alabama Office of Radiation Control telephoned the |
| medical physicist for Flowers Hospital on the morning of July 2, 2001, to    |
| inquire about the possible misadministration.  The medical physicist for     |
| Flowers Hospital confirmed that a possible misadministration did occur based |
| on the information obtained from the manufacturer[,] but he was in the       |
| process of reviewing the records pertaining to the possible                  |
| misadministration."                                                          |
|                                                                              |
| "The Alabama Office of Radiation Control is presently investigating the      |
| details of this apparent misadministration and will be conducting an onsite  |
| inspection of licensed activities at Flowers Hospital beginning on July 3,   |
| 2001."                                                                       |
|                                                                              |
| The following text is a portion of a facsimile received from the Alabama     |
| Division of Radiation Control involving an e-mail they received from the     |
| Illinois Department of Nuclear Safety at 0421 on June 29, 2001:              |
|                                                                              |
| "SUBJECT:  Mislabeled Seeds by Nycomed Amersham Result in an Apparent        |
| Medical Misadministration in Alabama"                                        |
|                                                                              |
| "[A] Nycomed Amersham, RAML No. IL-01044-0l, [representative] called this    |
| afternoon and reported the following concerning distribution of their Model  |
| 6711 I-125 seeds:"                                                           |
|                                                                              |
| "June 13, 2001 - Nycomed Amersham, while performing a review of their        |
| scrapping procedure and inventory of dispensed products noted a discrepancy  |
| in a lot consisting of .270 mCi I-125 seeds.  The lot was short 110 seeds."  |
|                                                                              |
| "June 14 - Continued review found a discrepancy with a lot consisting of     |
| .414 mCi I-125 seeds.  This lot was 110 seeds over."                         |
|                                                                              |
| "They realized that there was a dispensing error and that 110 seeds of .270  |
| mCi seeds were sent out as .414 mCi seeds."                                  |
|                                                                              |
| "June 15 - Determined that the seeds in question were transferred to Flowers |
| Hospital in Dothan, Alabama on [May 30, 2001]."                              |
|                                                                              |
| "June 16 - Contacted Flowers Hospital and informed the dosimetrist about the |
| problem (Flowers Hospital medical physicist was on vacation until the 18th). |
| The dosimetrist investigated and learned that the seeds had been assayed in  |
| a new dose calibrator at their facility and [that] the seeds were implanted  |
| in a patient undergoing prostate therapy on June 5, 2001.  Apparently[,] the |
| dose calibrator read slightly lower than expected but not enough to stop the |
| use of the seeds in the therapy procedure."                                  |
|                                                                              |
| "June 18 - Nycomed discussed with the medical physicist at Flowers Hospital. |
| The medical physicist asked Nycomed to send a calibrated seed to his         |
| facility so he could check the calibration of the dose calibrator.  Nycomed  |
| complied with the request."                                                  |
|                                                                              |
| "June 20 - Flowers Hospital medical physicist notified Nycomed that their    |
| dose calibrator did not obtain the expected reading using the calibrated     |
| seed.  The medical physicist requested that Nycomed's physician contact      |
| Flowers Hospital attending physician to discuss the matter.  The physicians  |
| discussed the matter and both concluded that the actual dose delivered from  |
| planned was approximately 30% less than that planned.  It is believed that   |
| the patient also underwent external beam therapy in conjunction with the     |
| brachytherapy.  The physicians also concluded that the effect on the patient |
| was 'small.'"                                                                |
|                                                                              |
| [An Illinois Department of Nuclear Safety representative] asked if the       |
| Alabama program had been notified as this appears to be a misadministration  |
| event in Alabama.  [The Nycomed Amersham representative] stated that he      |
| believed that they had been but did not know for sure as they depend on the  |
| licensee to make the necessary reports as they do not want to get in between |
| the licensee and their regulator.   [The Nycomed Amersham representative]    |
| also stated that the event had been reported to the Chicago District of FDA  |
| on a form entitled 'Medical Device Report of Removal.'"                      |
|                                                                              |
| "[An Illinois Department of Nuclear Safety representative] then contacted    |
| the Alabama State Dept. of Public Health, Office of Radiation Control.  [The |
| Illinois Department of Nuclear Safety representative] provided the above     |
| information to Kirk Whatley and Jim McNees [of the Alabama Office of         |
| Radiation Control].  They stated that this was the first that they had heard |
| about it and that they will follow up on the event.  They will notify the    |
| NRC Ops Center if in fact a misadministration event actually occurred."      |
|                                                                              |
| "[The Nycomed Amersham representative] will keep us posted on this matter."  |
|                                                                              |
| (Please call the NRC operations center for the Illinois Department of        |
| Nuclear Safety and Nycomed Amersham contact names.)                          |
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|Fuel Cycle Facility                              |Event Number:   38113       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 07/02/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 19:31[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        07/02/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        10:00[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/02/2001|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |ANTON VEGEL          R3      |
|  DOCKET:  0707001                              |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  W. F. CAGE                   |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01 RESPONSE - FAILURE TO MAINTAIN THE DOUBLE CONTINGENCY     |
| (24-Hour Report)                                                             |
|                                                                              |
| The following text is a portion of a facsimile received from  Paducah:       |
|                                                                              |
| "At 1000, on 07/02/01, the Plant Shift Superintendent (PSS) was notified     |
| that while approving a cylinder for wash on the C-400 Cylinder Wash stand,   |
| an incorrect cylinder number was both entered and independently verified on  |
| the UF6 Cylinder Wash Facility Data Sheet violating NCSA 400-002.  As a      |
| result of these actions, an unapproved cylinder was washed.  NCSA 400-002    |
| required the cylinder number be independently verified to be correct on the  |
| approval data sheet.  The cylinder number is used to prevent                 |
| misidentification of cylinders.   Since the cylinder washed had an           |
| unverified UF6 heel (mass control) and independent verification of the       |
| cylinder to be washed was incorrectly performed (assay control), double      |
| contingency was not maintained."                                             |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:  Independent verification required to ensure |
| the correct cylinder be washed was not performed correctly."                 |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW           |
| CRITICALITY COULD OCCUR:  In order for a criticality to be possible, a       |
| cylinder containing a critical mass of enriched uranium would need to be     |
| washed.  The cylinder incorrectly washed had an assay <1.0 WT %235U."        |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):    |
| [The] two process conditions relied on for double contingency for this       |
| scenario are assay and mass."                                                |
|                                                                              |
| "ESTIMATED AMOUNT ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):  The cylinder washed was <1.0 WT      |
| %235U."                                                                      |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES:  The first leg of double contingency is     |
| based on the assay not exceeding 2.0 WT %235U. The cylinder intended for     |
| wash and the cylinder actually washed were both 4BHX cylinders, which are    |
| limited to a maximum enrichment of 1.0%.  While the control was violated,    |
| the process condition was maintained."                                       |
|                                                                              |
| "The second leg of double contingency is based on the heel mass not          |
| exceeding 72 pounds.  The cylinder actually washed has an unverified heel    |
| weight.  Therefore, this control was violated, and this leg of double        |
| contingency was lost."                                                       |
|                                                                              |
| "Since the process parameter for mass was not independently verified prior   |
| to washing the cylinder, double contingency was not maintained."             |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| This condition was identified while reviewing completed cylinder work        |
| records.  There is no action that can be performed to resolve this condition |
| and bring the process back into compliance since the cylinder activity has   |
| been completed."                                                             |
|                                                                              |
| Paducah personnel notified the NRC resident inspector.                       |
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