Event Notification Report for December 17, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
12/14/2001 - 12/17/2001
** EVENT NUMBERS **
38513 38562 38563 38564 38565 38566 38567 38568 38569 38570 38571 38572
38573 38574 38575 38576
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38513 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/23/2001|
| UNIT: [1] [] [] STATE: FL |NOTIFICATION TIME: 12:30[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 11/23/2001|
+------------------------------------------------+EVENT TIME: 12:10[EST]|
| NRC NOTIFIED BY: CHARLIE PIKE |LAST UPDATE DATE: 12/15/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CAUDLE JULIAN R2 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO FLORIDA STATE INVOLVING RECOVERED SEA TURTLE
FROM |
| UNIT 1 INTAKE STRUCTURE |
| |
| "A sea turtle with no external injuries but appearing to be distressed was |
| recovered from the Unit 1 Intake Structure. The State Stranding Coordinator |
| for sea turtles has been contacted." |
| |
| * * * UPDATE 11/23/01 AT 1255EST FROM CHARLIE PIKE TO S. SANDIN * * * |
| |
| "Turtle has died." |
| |
| The licensee informed both the State of Florida and the NRC Resident |
| Inspector. |
| |
| * * * UPDATE 1413EST ON 12/3/01 FROM JACK BREEN TO FANGIE JONES * * * |
| |
| At approximately 1215 EST on 12/3/01, a report was made to the Florida |
| Department of Fish and Wildlife concerning the recovery of an injured sea |
| turtle from the plant's intake canal. The turtle was a green sea turtle in |
| the intake canal that appeared distressed and looked to have a wound from a |
| boat motor on its back. It will be transferred to the State for |
| rehabilitation. |
| |
| The licensee plans to notify the NRC resident inspector. Notified |
| R2DO(MacAlpine). |
| |
| * * * UPDATE 1333EST ON 12/15/01 FROM JACK BREEN TO JOHN MACKINNON * * * |
| |
| At approximately 1215 EST on 12/15/01, a report was made to the Florida |
| Department of Fish and Wildlife Conservation Commission to pick up a Green |
| Turtle for rehabilitation. The Green Turtle was taken from the plant's |
| intake canal, and the turtle appears to have shark bites. |
| |
| The licensee plans to notify the NRC resident inspector. Notified R2DO |
| (Chuck Ogle). |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38562 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 12/14/2001|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 08:57[EST]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 12/14/2001|
+------------------------------------------------+EVENT TIME: 06:45[CST]|
| NRC NOTIFIED BY: KEVIN HUJET |LAST UPDATE DATE: 12/14/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE MARIE STONE R3 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 95 Power Operation |95 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT COMPUTER AND SAFETY PARAMETERS DISPLAY SYSTEM INOPERABLE
|
| |
| The unit suffered a failure of the plant computer at 1452 CST on 12/13/01 |
| and repairs are ongoing. The plant computer is expected to be down greater |
| than 24 hours. The plant computer feeds the Safety Parameter Display System |
| (SPDS), which is inoperable also. The licensee has made a decision to make |
| this report under a major loss of emergency assessment capabilities per 10 |
| CFR 50.72(b)(3)(xiii) as a conservative measure. The control board |
| indicators are operable and are used by the operators normally in an |
| emergency. The Shift Technical Advisor will perform a manual review of |
| safety parameters in the case of an emergency, using the control board |
| indications. |
| |
| The licensee notified the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38563 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ELKHART HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: ELKHART HOSPITAL |NOTIFICATION TIME: 12:17[EST]|
| CITY: ELKHART REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: 00:00[CST]|
|LICENSE#: 13-18879-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GARETH WILLIAMS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATIONS: UNDERDOSES OF SAMARIUM-153 |
| |
| Elkhart Hospital was notified today by the RSO for Spectrum Pharmaceuticals |
| that Sa-153 quadramet doses total activity shipped to them was incorrectly |
| calibrated. Spectrum Pharmaceuticals informed the Hospital that they had |
| made an error in the attenuation calculation for the beta factor in the |
| samarium-153 total activity and that this error may have been made more than |
| 6 months ago. Spectrum Pharmaceuticals believes that the Sa-153 total |
| activity is actually less by 20 to 30%. At this time, Elkhart Hospital does |
| not know how many patients have received an underdose of Sa-153. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38564 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: GOSHEN GENERAL HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: GOSHEN GENERAL HOSPITAL |NOTIFICATION TIME: 12:18[EST]|
| CITY: GOSHEN REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: 00:00[CST]|
|LICENSE#: 13-18845-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: Dr. SHEPERD | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATIONS: UNDERDOSES OF SAMARIUM-153 |
| |
| Goshen General Hospital was notified today by the RSO for Spectrum |
| Pharmaceuticals that Sa-153 quadramet, used for pain relief in bone cancer |
| patients, beta attenuation were incorrectly calculated. This attenuation |
| calculation error made by Spectrum Pharmaceuticals has resulted in patient's |
| given Sa-153 at Goshen General Hospital being underdosed between 20 to 30%. |
| The attenuation error may have existed for greater than 6 months. Three |
| patients have been given a possible underdose of Sa-153. |
| |
| NRC Region 3 personnel have been notified of this event by the licensee. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38565 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: HOME HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: HOME HOSPITAL |NOTIFICATION TIME: 13:17[EST]|
| CITY: LAFAYETTE REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: [CST]|
|LICENSE#: 13-09788-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DUNSEATH | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION: UNDERDOSE OF SAMARIUM-153 |
| |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30% |
| less than labeled due to an error in the attenuation calculation for the |
| beta factor in the Sa-153 total activity calculation. This calculation |
| error may have existed for greater than 6 months. The licensee is aware of |
| one patient who was treated during this period and is reviewing treatment |
| records to determine whether any others may be affected. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38566 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. JOSEPH'S REGIONAL MEDICAL CENTR |NOTIFICATION DATE:
12/14/2001|
|LICENSEE: ST. JOSEPH'S REGIONAL MEDICAL CENTR. |NOTIFICATION TIME:
14:13[EST]|
| CITY: SOUTH BEND REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: [CST]|
|LICENSE#: 13-02650-02 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: Dr. JOHN SCHEU | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATIONS: UNDERDOSES OF SAMARIUM-153
|
| |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30% |
| less than labeled due to an error in the attenuation calculation for the |
| beta factor in the Sa-153 total activity calculation. This calculation |
| error may have existed greater than 6 months. The licensee is aware of two |
| patients who were treated during this period. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38567 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 12/14/2001|
| UNIT: [1] [2] [] STATE: MI |NOTIFICATION TIME: 14:30[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/14/2001|
+------------------------------------------------+EVENT TIME: 11:27[EST]|
| NRC NOTIFIED BY: STEVE COSAR |LAST UPDATE DATE: 12/14/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE MARIE STONE R3 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY REPORT |
| |
| A contract supervisor tested positive for illegal drug use during a random |
| test. The individual did not have access to vital areas, and his site access |
| has been terminated. The NRC resident inspector has been informed of this |
| event by the licensee. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38568 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: BORGESS MEDICAL CENTER |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: BORGESS MEDICAL CENTER |NOTIFICATION TIME: 14:44[EST]|
| CITY: KALAMAZOO REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: MI |EVENT TIME: [EST]|
|LICENSE#: 21-12275-02 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ERIC RAMSAY | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION: UNDERDOSE OF SAMARIUM-153 |
| |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30% |
| less than labeled due to an error in the attenuation calculation for the |
| beta factor in the Sa-153 total activity calculation. This calculation |
| error may have existed for greater than 6 months. The licensee does not |
| know how many patients have been treated and is looking through records to |
| determine number of patients treated with Sa-153. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38569 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: BRONSON METHODIST HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: BRONSON METHODIST HOSPITAL |NOTIFICATION TIME: 14:48[EST]|
| CITY: KALAMAZOO REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: MI |EVENT TIME: [EST]|
|LICENSE#: 21-13125-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARK WATTS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION: UNDERDOSE OF SAMARIUM-153 |
| |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30% |
| less than labeled due to an error in the attenuation calculation for the |
| beta factor in the Sa-153 total activity calculation. This calculation |
| error may have existed for greater than 6 months. The licensee is aware of |
| one patient treated in the last year. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38570 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. LUKES HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: ST. LUKES HOSPITAL |NOTIFICATION TIME: 15:07[EST]|
| CITY: BETHLAHAM REGION: 1 |EVENT DATE: 12/12/2001|
| COUNTY: STATE: PA |EVENT TIME: 07:00[EST]|
|LICENSE#: 37-07939-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CLIFFORD ANDERSON R1 |
| |PAUL BONNETT R1 |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KATHY SANDERS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAA1 20.1906(d)(1) SURFACE CONTAM LEVELS | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SURFACE CONTAMINATION |
| |
| IBA out of New Jersey delivered a metal case, ammo case, which contained |
| less than 21 millicuries of fluorine-18, to St. Lukes North outpatient |
| facility on 12/12/01 before 0700 hours. Swipes taken of the outside and |
| inside of the ammo case found technetium-99m contamination. Outside and |
| inside swipes both indicated contamination level around 6800 cpm. The ammo |
| case was decontaminated and placed in St. Lukes Hot Lab. St. Lukes |
| contacted IBA and informed them of the contamination. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38571 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: BAYOU TESTERS |NOTIFICATION TIME: 15:20[EST]|
| CITY: REGION: 4 |EVENT DATE: 12/12/2001|
| COUNTY: STATE: LA |EVENT TIME: 00:00[CST]|
|LICENSE#: LA-7112-L01 AGREEMENT: Y |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BILL JONES R4 |
| |FED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SCOTT BLACKWELL | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| EXCESSIVE EXPOSURE |
| |
| "The monthly personnel badges showed an excessive exposure for three |
| employees. [One individual] had 5136 mRem, [another individual] had 5095 |
| mRem, and [a third individual] had 5200 mRem for the year as of November 10, |
| 2001. Once the facility received the badge report, the facility notified |
| [the] DEQ. The facility is also sending a written report to [the] DEQ. |
| These three individuals have been removed from radiation work." |
| |
| Event Report No.: LA010017 |
| |
| (Call the NRC operation officer for contact information and for the names of |
| the individuals involved.) |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38572 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. JOSEPH'S HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: ST. JOSEPH'S HOSPITAL |NOTIFICATION TIME: 15:27[EST]|
| CITY: KOKOMO REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: 00:00[CST]|
|LICENSE#: 13-11385-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TODD REYBURN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION: UNDERDOSE OF SAMARIUM-153 |
| |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30% |
| less than labeled due to an error in the attenuation calculation for the |
| beta factor in the Sa-153 total activity calculation. This condition may |
| have existed for greater than 1 year. The licensee found one patient who |
| was treated with Sa-153 and that was on 10/05/00. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38573 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: MEMORIAL HOSPITAL |NOTIFICATION DATE: 12/14/2001|
|LICENSEE: MEMORIAL HOSPITAL |NOTIFICATION TIME: 15:43[EST]|
| CITY: SOUTH BEND REGION: 3 |EVENT DATE: 12/14/2001|
| COUNTY: STATE: IN |EVENT TIME: 00:00[CST]|
|LICENSE#: 13-18881-01 AGREEMENT: N |LAST UPDATE DATE: 12/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RICHARD SELLE | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATIONS: UNDERDOSES OF SAMARIUM-153
|
| |
| The licensee was notified today by the RSO of Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet does may be approximately 20-30% less |
| than labeled due to an error in the attenuation calculation for beta factor |
| in the Sa-153 total activity. The licensee believes that he has treated two |
| patients since 1998 with Sa-153. |
| |
| NRC Region 3 has been notified of this event. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38574 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 12/15/2001|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 23:00[EST]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 12/15/2001|
+------------------------------------------------+EVENT TIME: 19:00[EST]|
| NRC NOTIFIED BY: TOM RESTUCCIO |LAST UPDATE DATE: 12/15/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 60 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MANUAL REACTOR SCRAM FROM 60% POWER DUE TO UNIDENTIFIED LEAK RATE
EXCEEDING |
| 5 GPM |
| |
| At 0431 on December 15, 2001, Unit 2 noted a step increase in unidentified |
| drywell leakage from 0.2 gpm (normal) to 0.4 gpm. Coincident with this step |
| increase, containment atmosphere radiation levels rose and alarmed on the |
| particulate channels. Throughout the day, investigation continued into |
| possible causes, and the trend in leakage showed no appreciable increase. |
| At 1658, containment atmosphere radiation levels rose again, and a large |
| step increase in leakage was noted from approximately 0.5 gpm to 1.7 gpm. |
| The technical specification limit is less than 5 gpm unidentified leakage |
| and less than a 2-gpm rise in unidentified leakage during the previous the |
| 24 hours. At 1745, plant management ordered an orderly plant shutdown to |
| identify the source of leakage in the drywell. At 1900, a normal reactor |
| shutdown was commenced, original reactor power was 100%, in preparation for |
| repairing the leak in the drywell. At 1919, drywell unidentified leakage |
| rose to 2.27 gpm, and the technical specification action statement was |
| entered for greater than a 2-gpm rise in unidentified leakage during the |
| previous 24 hours. |
| |
| At 2040, the drywell unidentified leak rate exceeded 5 gpm (5.87 gpm), and |
| the decision was made to scram the plant. At 2046, the reactor mode switch |
| was placed in shutdown, all systems functioned as required, all rods fully |
| inserted into the core. The scram signal received was Average Power Range |
| Monitor (APRM) neutron upscale due to setpoint setdown with the mode switch |
| out of run. A secondary scram signal was received when reactor water level |
| dropped to less than 159.3" (Level 3) (expected due to level shrink on the |
| scram). Level 3 also provided a Primary Containment Isolation System (PCIS) |
| signal to group 4 (Residual Heat Removal System, [RHS] sampling valves) and |
| group 5 (RHS shutdown cooling valves). At the time of the signal, all group |
| 4 and 5 valves were closed. At 2043, technical specification action |
| statement associated with exceeding 5 gpm was exited. At 2149, technical |
| specification action statement associated with greater than 2 gpm rise over |
| the previous 24 hours was exited. |
| |
| At this time, drywell unidentified leakage 1.5 gpm and lowering, plant |
| pressure is being reduced. Reactor water level is being maintained with |
| condensate/feedwater. Reactor pressure control is being maintained via |
| turbine bypass valves with cooldown in progress. All Emergency Core Cooling |
| Systems and the Emergency Diesel Generator are fully operable, and the |
| electrical grid is stable. |
| |
| The NRC resident inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38575 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 12/16/2001|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 00:30[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 12/15/2001|
+------------------------------------------------+EVENT TIME: 22:28[EST]|
| NRC NOTIFIED BY: ALAN RABENOLD |LAST UPDATE DATE: 12/16/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE MARIE STONE R3 |
|10 CFR SECTION: | |
|ACCS 50.72(b)(2)(iv)(A) ECCS INJECTION | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE REACTOR RECIRCULATION PUMPS DOWN SHIFTED TO SLOW SPEED FOR
UNKNOWN |
| REASONS RESULTING IN AN AUTOMATIC REACTOR SCRAM, BALANCE-OF-PLANT
|
| ISOLATIONS, AND EMERGENCY CORE COOLING SYSTEM ACTUATIONS. |
| |
| At 2228 EST on 12/15/01, the reactor recirculation pumps down shifted to |
| slow speed for unknown reasons. This caused reactor pressure vessel (RPV) |
| water level to swell, and an automatic reactor scram from 100% power |
| occurred when Level 8 was reached. All control rods fully inserted. |
| Following the scram, RPV water level started to decrease because the |
| feedwater pumps also tripped (as designed) when Level 8 was reached. When |
| RPV water level dropped to Level 2 (130 inches), balance-of-plant isolations |
| occurred, and all of the applicable valves properly isolated. In addition, |
| the high pressure core spray (HPCS) and reactor core isolation cooling |
| (RCIC) systems automatically actuated when Level 2 was reached. The HPCS |
| and RCIC systems were utilized to restore RPV water level to the normal |
| range. |
| |
| The unit is currently stable in Mode 3 with RPV pressure at 900 psi and RPV |
| water level at 210 inches. Normal feedwater is being utilized to maintain |
| RPV water level within the proper band, and the HPCS and RCIC systems have |
| been secured. The main steam isolation valves remained open, and the |
| condenser is being utilized as the heat sink. Containment parameters are |
| currently normal, the electrical grid is stable, and the emergency diesel |
| generators are available. |
| |
| The licensee stated that all systems functioned as required and that there |
| was nothing unusual or misunderstood other than the cause of the initiating |
| event (the recirculation pumps down shifting to slow speed). The licensee's |
| investigation is underway. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38576 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 12/16/2001|
| UNIT: [] [3] [] STATE: PA |NOTIFICATION TIME: 21:39[EST]|
| RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 12/16/2001|
+------------------------------------------------+EVENT TIME: 16:45[EST]|
| NRC NOTIFIED BY: JOHN McCLINTOCK |LAST UPDATE DATE: 12/16/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: | |
|AINC 50.72(b)(3)(v)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH HIGH FLOW INSTRUMENTATION FOR REACTOR WATER CLEANUP (RWCU)
FOUND |
| INOPERABLE. |
| |
| During performance of routine surveillance testing on the PBAPS Unit 3 RWCU |
| system high flow isolation instrumentation, it was discovered that both |
| channels of isolation instrumentation were simultaneously inoperable. Both |
| affected instruments were returned to operable status by 1828 hours on |
| 12/16/01. |
| |
| The RWCU system is designed to automatically isolate upon detection of a |
| high flow condition. This isolation detection system utilizes two channels |
| of differential pressure instrumentation for high flow detection. An |
| isolation of the RWCU system can be accomplished by actuation of either |
| channel of the logic. A single channel trip would result in either an |
| inboard or outboard isolation. A failure of both channels would result in a |
| failure of the system to isolate as required. |
| |
| On 12/16/01 at 1111 hours, surveillance testing of the "A" channel high flow |
| instrument (DPIS 3-12-124A) determined that this instrument failed to trip |
| due to entrapped air in the sensing line. DPIS 3-12-124A was vented, |
| retested, and returned to operable status at 1536 on 12/16/01. |
| |
| At 1645 hours, surveillance testing of the "B" channel RWCU high flow |
| instrument (DPIS 3-12-124B) determined that this instrument failed to trip |
| due to entrapped air in the sensing line. DPIS 3-12-124B was vented, |
| retested, and returned to operable status at 1828 on 12/16/01. |
| |
| At 1645 on 12/16/01, it was determined that both channels of Unit 3 RWCU |
| system high flow isolation instrumentation were simultaneously inoperable |
| since the system had been placed in service during refueling outage 3R13. |
| Unit 3 entered Mode 2 on 10/08/01 at 2221 hours, requiring the Primary |
| Containment Isolation (PCIS) function to be operable. |
| |
| Based on the above, this event is reportable under 10 CFR |
| 50.72(b)(3)(v)(C). |
| |
| The systems affected were the RWCU system isolation logic instruments, DPIS |
| 3-12-124A and DPIS 3-12-124B. These instruments actuate on high system flow |
| of 125%. No plant effects or transient occurred as a result of this event. |
| The RWCU system isolation capability, on high system flow, was inoperable. |
| This isolation capability is required whenever the RWCU system is in service |
| with the reactor in Modes 1, 2, or 3. |
| |
| DPISs 3-12-124A and 3-12-124B were filled, vented, tested satisfactorily, |
| and returned to operable status. |
| |
| A station investigation to determine the cause of the air entrapment is in |
| progress. |
| |
| The NRC resident inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
.
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021