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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!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 155�F. |
| |
| 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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