Event Notification Report for January 18, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/17/2002 - 01/18/2002
** EVENT NUMBERS **
38518 38596 38618 38631 38633 38634 38635 38636 38637
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38518 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 11/26/2001|
| UNIT: [1] [2] [] STATE: WI |NOTIFICATION TIME: 13:37[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 11/26/2001|
+------------------------------------------------+EVENT TIME: 12:32[CST]|
| NRC NOTIFIED BY: ROBERT ADAMS |LAST UPDATE DATE: 01/17/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| ERDS INOPERABLE DUE TO PLANNED OUTAGE OF THE PLANT PROCESS COMPUTER
SYSTEM |
| (PPCS) |
| |
| AT 1232 CT, the Point Beach Nuclear Plant ERDS became inoperable as a result |
| of modifications to change out the plant process computer system (PPCS). |
| This is a planned evolution. ERDS will remain inoperable until |
| approximately, December 18, 2001. |
| |
| This information was verbally provided to a representative of NRR during the |
| week of 10/15/2001. The senior resident inspector has also been briefed on |
| the modifications and schedule. NMC to NRC letter (NRC 01-0080) dated |
| 11/21/2001 stated we would be submitting this Non-Emergency report. |
| |
| ***** UPDATE FROM RICK ROBBINS TO LEIGH TROCINE AT 2006 EST ON 11/27/01 |
| ***** |
| |
| The following additional information is a portion of a facsimile received |
| from the licensee: |
| |
| "As part of the PPCS modification, several inputs to the SPDS monitor were |
| also made unavailable. Any out-of-service indications on the SPDS can be |
| obtained by control room control board indications." |
| |
| The licensee notified the NRC resident inspector. The NRC operations center |
| notified the R3DO (Bruce Jorgensen). |
| |
| * * * UPDATE 1259EST ON 12/22/01 FROM RYAN RODE TO S. SANDIN * * * |
| |
| The licensee provided the following information as an update: |
| |
| "On 11/26/01 at 12:32, the PBNP ERDS and SPDS were declared out of service |
| for the PPCS upgrade project. EN #38518 indicated to the NRC that the |
| systems would remain unavailable until approximately December 18, 2001. Due |
| to reliability issues with the newly installed PPCS, that expected date has |
| been delayed to approximately January 3, 2002." |
| |
| The licensee informed the NRC Resident Inspector. Notified R3DO(Phillips). |
| |
| * * * UPDATE ON 01/03/02 @1430 BY MEYER TO GOULD * * * |
| |
| During the installation of the new PPCS, issues were identified which need |
| to be resolved to allow SPDS and ERDS to be placed back in service fully. |
| Currently, the new PPCS is only partially operable. Work is continuing on |
| the new PPCS to allow full operability. The current estimate for return to |
| service of SPDS and ERDS is 01/19/02. This date may need to be extended |
| again due to parts availability. |
| |
| The NRC Resident Inspector was notified. |
| |
| Notified Reg 3 RDO(Shear) |
| |
| * * * UPDATE ON 1/17/02 @ 1855 BY HARRSCH TO GOULD * * * |
| |
| Update to 1/3/02 update (see below). Work continues on the Plant Process |
| Computer System (PPCS) to allow full operability. The Safety Parameter |
| Display System (SPDS) is still out of service, however the Emergency |
| Response Data System (ERDS) is now available. As mentioned in the 1/3/02 |
| update, parts availability has been a problem and the date for returning |
| SPDS to service is now estimated to be 2/16/02. |
| |
| The NRC Resident Inspector was notified. |
| |
| Reg 3 RDO(Vegel) was informed |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38596 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 12/26/2001|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 15:39[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 12/21/2001|
+------------------------------------------------+EVENT TIME: 20:25[EST]|
| NRC NOTIFIED BY: VEITCH |LAST UPDATE DATE: 01/17/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 85 Power Operation |85 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| INDETERMINATE IF HIGH PRESSURE CORE SPRAY (HPCS) EMERGENCY DIESEL
GENERATOR |
| (DG) COULD FULFILL ITS REQUIRED SAFETY FUNCTION. |
| |
| "On 12/21/01, Condition Report 01-4350 was initiated to document the failure |
| of Div . 3 DG to pass SVI-E22-T1319. Specifically, the DG did not come up to |
| frequency/voltage within the required 13 seconds (TS 3.8.1.7.b.2). The DG |
| was declared inoperable and an immediate investigation was requested. The |
| immediate investigation indicated that the cause of the SVI failure was due |
| to the DG governor control switch not being properly set during shutdown on |
| the DG on 12/16/01. In analyzing the shutdown data from the 12/21/01 DG |
| surveillance testing, it was determined that the situation had been |
| corrected, and that the next DG start, the DG would satisfy the TS SR. The |
| DG was started on 12/22/01 and satisfied the SR. The DG was then declared |
| operable. |
| |
| "During this time, it is indeterminate if the HPCS DG could fulfill its |
| required safety function. The immediate investigation infers that an |
| operator error occurred when shutting down the DG on 12/16/01. This error, |
| the mis-operation of the DG governor control switch, prevented the DG from |
| properly coming up to the required frequency/voltage within 13 seconds as |
| identified on 12/21/01. Hence, it is conservative to assume that the |
| capability to perform the safety function was not maintained. This |
| condition is an 8-hour report pursuant to 50.72(b)(3)(v) and (vi). It |
| should be noted that HPCS is a single train system and there are no |
| redundant features within the same system to perform the safety function." |
| |
| The NRC resident inspector will be notified of this event by the licensee. |
| |
| * * * UPDATE ON 1/17/02 @ 1204 BY RUSSELL TO GOULD * * * RETRACTION |
| |
| On 12/26/01, a report was made per 10CFR50.72(b)(3)(v)(D) for the Loss of |
| Safety Function of the High Pressure Core Spray pump, a single train safety |
| system. The cause of the loss of the HPCS pump was the failure of the |
| DIVISION 3 diesel generator to achieve the required frequency. |
| Subsequently, it was determined by further engineering evaluation that the |
| HPCS pump and its supporting systems had sufficient margins available to |
| perform the required safety functions at the reduced frequency. Therefore, |
| no loss of safety function occurred and therefore event notification 38596 |
| is retracted accordingly. |
| |
| The NRC Resident Inspector was notified. The Region 3 RDO (Vegel) was |
| notified. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38618 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 01/08/2002|
| UNIT: [1] [2] [] STATE: WI |NOTIFICATION TIME: 17:25[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 01/08/2002|
+------------------------------------------------+EVENT TIME: 09:08[CST]|
| NRC NOTIFIED BY: RICK ROBBINS |LAST UPDATE DATE: 01/17/2002|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID HILLS R3 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| DISCOVERY OF A POTENTIAL UNANALYZED CONDITION INVOLVING AN APPENDIX R
SAFE |
| SHUTDOWN FIRE ANALYSIS |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "While investigating fire risk scenarios associated with the auxiliary |
| feedwater system (see EN #38541), a potential unanalyzed condition involving |
| an Appendix R safe shutdown fire analysis was discovered. The problem |
| involves the availability of sufficient AFW flow capacity for a fire in the |
| Central 26' and 46' areas of the Primary Auxiliary Building (Fire Area |
| A01-B/Fire Zones 187 [and] 237)." |
| |
| "Cables and equipment associated with all [four] AFW pumps (both turbine- |
| and motor-driven pumps) are located in this fire area. A fire in this area |
| could potentially cause a loss of normal Steam Generator instrumentation for |
| both units. This would require shutdown of both units. An alternate cable |
| routing is available for only the Red channel of instrumentation. This |
| channel is only available for the 'B' train steam generators. Therefore, |
| the present Appendix R Safe Shutdown Analysis assumes this shutdown would be |
| accomplished using the 'B' steam generators for each unit and the P38B |
| motor-driven AFW pump, which feeds the 'B' steam generator in each unit, |
| along with the use of manual actions to mitigate the fire damage to cables |
| associated with valves and instruments. The nominal capacity of this AFW |
| pump is 200 GPM." |
| |
| "An Appendix R calculation shows that approximately 200 gal/min is required |
| during the initial start-up of AFW flow to maintain sufficient heat removal |
| capability for one unit. Under the current conditions with procedural |
| controls, only the one motor-driven AFW pump is made available, [and] there |
| may not be enough capacity to provide adequate decay heat removal for both |
| units. Without sufficient AFW flow, the Appendix R performance requirement |
| of 10 CFR [Part] 50, Appendix R III.G.L.2.c, which requires the reactor heat |
| removal function shall be capable of achieving and maintaining decay heat |
| removal, may not be met. This condition is potentially an unanalyzed |
| Appendix R situation." |
| |
| "As a compensatory measure, fire rounds are being conducted in the fire |
| areas affected." |
| |
| The licensee notified the NRC resident inspector. |
| |
| * * * UPDATE @ 1349 ON 1/17/02 BY RODE TO GOULD * * * RETRACTION |
| |
| At 1625 CST on January 8, 2002, ENS Event Notification #38618 was made in |
| accordance with 10 CFR 50.72(b)(3)(ii)(B) for identification of a potential |
| unanalyzed condition involving the Appendix R safe shutdown fire analysis. |
| The notification involved a concern with the availability of sufficient |
| auxiliary feedwater (AFW) flow capacity for a fire in the Central 26' and |
| 46' areas of the Primary Auxiliary Building (Fire Area A01 -B/ Fire Zones |
| 187 & 237). The information documented in the SSAMS (Safe Shutdown Analysis |
| Management System) database, indicated that the Appendix R fire scenario for |
| Fire Area A01-B relies on the use of a single motor driven AFW pump (P-038B) |
| to provide RCS decay heat removal for both units. The design capacity of |
| P-038B is approximately 200 gpm @ 1,300 psi. An Appendix R Calculation |
| demonstrates that approximately 200 gal/min is initially required during |
| fire safe shutdown to maintain sufficient heat removal capability for each |
| Unit. Therefore, P-038B, alone, does not provide sufficient decay heat |
| removal capacity for both units. |
| |
| Upon closer examination of the analyses and documentation supporting the |
| SSAMS, we have identified that this was not an unanalyzed condition but was |
| due to a SSAMS documentation error. A PBNP Manual Action Feasibility |
| Report (FPTE-012) had evaluated the feasibility of the use of two separate |
| sets of aux. feed water pumps for fires in different areas of Fire Area |
| A01-B. That report documented the capability for manually operating the |
| steam supply valves to start the turbine driven pumps (each with a capacity |
| in excess of 400 gpm which can be aligned to the unit's B' steam generators) |
| for a fire in Fire Zones 187-199. For the fire in Fire Zone 237, the |
| electric driven pumps can be manually aligned to the 'B' steam generators |
| using the available cross-connect (i.e., opening valves AF-30 and AF-43). |
| The two electric pumps provide a total capacity of 400 gpm, which is |
| sufficient decay heat removal capacity for both units. This information was |
| inadvertently omitted from the SSAMS database. Based on this more complete |
| information, we have concluded that an unanalyzed condition did not exist |
| and are retracting our event notification. |
| |
| The NRC Resident Inspector was notified. |
| |
| Region 3 RDO (Vegel) was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 38631 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: STORA ENSO NORTH AMERICA CORP. |NOTIFICATION DATE: 01/16/2002|
|LICENSEE: STORA ENSO NORTH AMERICA CORP. |NOTIFICATION TIME: 09:56[EST]|
| CITY: WISCONSIN RAPIDS REGION: 3 |EVENT DATE: 01/15/2002|
| COUNTY: WOOD STATE: WI |EVENT TIME: 15:00[CST]|
|LICENSE#: 48-01117-01 AGREEMENT: N |LAST UPDATE DATE: 01/17/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANTON VEGEL R3 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHARLES CHAPMAN | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DISCOVERY OF A MISSING CESIUM-137 SOURCE AT A PAPER MILL (STORA ENSO
NORTH |
| AMERICA CORP.) LOCATED IN WISCONSIN RAPIDS, WISCONSIN |
| |
| During performance of a quarterly inventory on 01/15/02, the licensee |
| discovered that a 200-millicurie cesium-137 source was missing. It was used |
| as part of a fixed volume/density gauge which was mounted on a pipe. |
| Apparently, the unit had been stored in the locked position on the pipe. |
| The licensee reported that a paper machine dismantling project was ongoing |
| near the previous location of the unit. It is currently believed that the |
| unit may either have been moved or dismantled and shipped somewhere. The |
| licensee's investigation is still in progress. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
| |
| |
| * * * UPDATE ON 1/17/02 @ 1711 BY CHAPMAN TO GOULD * * * |
| |
| After further investigation the licensee has determined the source may have |
| been stolen from the site. The licensee has notified the police and Region |
| 3. The device manufacturer will be notified. |
| Notified RDO 3 (Vegel), NMSS EO(Frant) |
| |
| * * * UPDATE ON 1/17/02 @ 1843 BY BREWSTER TO GOULD * * * |
| |
| The licensee reported that they had been advised that an individual working |
| for a contractor took the missing device. They are further investigating |
| the incident. |
| |
| Notified RDO 3 (Vegel), NMSS EO(Frant) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Research Reactor |Event Number: 38633 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WASHINGTON STATE UNIVERSITY |NOTIFICATION DATE: 01/17/2002|
| RXTYPE: 1000 KW TRIGA (CONVERSION) |NOTIFICATION TIME: 12:22[EST]|
| COMMENTS: |EVENT DATE: 01/17/2002|
| |EVENT TIME: [PST]|
| |LAST UPDATE DATE: 01/17/2002|
| CITY: PULLMAN REGION: 4 +-----------------------------+
| COUNTY: WHITMAN STATE: WA |PERSON ORGANIZATION |
|LICENSE#: R-76 AGREEMENT: Y |DALE POWERS R4 |
| DOCKET: 05000027 |NADER MAMISH IRO |
+------------------------------------------------+CHRIS GRIMES NRR |
| NRC NOTIFIED BY: SHARP |MARVIN MENDOCA NRR |
| HQ OPS OFFICER: CHAUNCEY GOULD |JOE HOLONICH IRO |
+------------------------------------------------+BAGWELL FEMA |
|EMERGENCY CLASS: ALERT | |
|10 CFR SECTION: | |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| WASHINGTON STATE UNIVERSITY REPORTED AN ALERT CONDITION AT THEIR
REACTOR |
| |
| The university reported they had a rod stuck 2" out of the core but the |
| reactor is well shut down and they expect no radiological problems. They |
| did evacuate the building and notified their emergency organization, but did |
| not require the police or fire departments. They will troubleshoot to |
| determine the cause of the problem. |
| |
| |
| * * * UPDATE ON 1/17/02 @ 1747 BY TRIPARD TO GOULD * * * |
| |
| Alert terminated at 1449 PST due to the rod being fully inserted and the |
| reactor being in a safe and stable condition. They will make an inspection |
| to determine the problem. |
| |
| Notified Mendonca(NRR), Lyons(EO), Powers(Reg 4 RDO), Sweetser(FEMA) OTHER |
| AGENCIES by fax |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38634 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 01/17/2002|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 13:07[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 01/17/2002|
+------------------------------------------------+EVENT TIME: 11:45[EST]|
| NRC NOTIFIED BY: KELLY KORTH |LAST UPDATE DATE: 01/17/2002|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ROBERT HAAG 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 |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION INVOLVING RECOVERED SEA TURTLE FROM INTAKE CANAL
|
| |
| At approximately 1130 EST on 01/17/02, a green sea turtle was retrieved from |
| the intake canal and a determination was made that it was in need of |
| rehabilitation. As required by the Plant's Sea Turtle Permit, the Florida |
| Fish and Wildlife Conservation Commission (FFWCC) was notified at 1145 EST. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| See EN #38513 for 2001 occurrences. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 38635 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: STORA ENSO NORTH AMERICA CORP |NOTIFICATION DATE: 01/17/2002|
|LICENSEE: STORA ENSO NORTH AMERICA CORP |NOTIFICATION TIME: 17:11[EST]|
| CITY: WISCONSIN RAPIDS REGION: 3 |EVENT DATE: 01/15/2002|
| COUNTY: STATE: WI |EVENT TIME: 15:00[CST]|
|LICENSE#: 48-01117-01 AGREEMENT: N |LAST UPDATE DATE: 01/17/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANTON VEGEL R3 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHAPMAN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING EXIT SIGN |
| |
| The licensee reported that during inventory check a Evanlite model LE exit |
| sign that was installed in their facility was missing. They believed the |
| sign, with a 20,000 millicurie H-3 source, was removed during ongoing |
| remodeling. They are still searching for the sign. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38636 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 01/17/2002|
|LICENSEE: MILLS BIOPHARMACEUTICAL |NOTIFICATION TIME: 18:14[EST]|
| CITY: OKLAHOMA REGION: 4 |EVENT DATE: 01/13/2002|
| COUNTY: STATE: OK |EVENT TIME: [CST]|
|LICENSE#: OK27502-01 AGREEMENT: Y |LAST UPDATE DATE: 01/17/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ROBERT HAAG R2 |
| NRC NOTIFIED BY: BISHOP | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OKLAHOMA LICENSEE REPORTED A MISSING SHIPMENT IODINE-125
BRACHYTHERAPY |
| SEEDS |
| |
| Mills Biopharmaceutical Co reported that a shipment which left 1/11 via |
| FedEx did not reach its destination, the Palisades Medical Center in New |
| Jersey, on the expected date 1/14/02. The shipment consisted of |
| brachytherapy seeds containing 13.3 millicuries of I-125. The |
| biopharmaceutical company was notified by FedEx on 1/13 that the shipment |
| had experienced a processing delay in Memphis, TN. and now FedEx can not |
| locate the shipment. FedEx is currently looking for it. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38637 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 01/17/2002|
|LICENSEE: LITTLETON RADIATION ONCOLOGY |NOTIFICATION TIME: 18:23[EST]|
| CITY: DENVER REGION: 4 |EVENT DATE: 08/03/2001|
| COUNTY: STATE: CO |EVENT TIME: [MST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 01/17/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BONZER (fax) | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OCCUPATIONAL EXPOSURE INCIDENT |
| |
| |
| On August 3, 2001, Littleton Radiation Oncology called to report error codes |
| 4 and 20. Upon inspection, the Field Service Engineer (FSE) identified a |
| loop in the source cable at the top of the source drum. The FSE removed the |
| loop in the cable; however, the source motor would not drive the source out. |
| The source exchange tool was connected to the service port of the emergency |
| container and the source was driven out manually. The emergency container |
| was used to house the source instead of the source shipping pig since the |
| motor would not drive the source. Per the FSE, the lead technologist was |
| informed of the source status within the room and that the source would need |
| to be moved to a secure storage area. |
| The FSE then left the treatment room to discuss the situation with the |
| physician when the lead technologist interrupted indicating that the source |
| had been pulled out of the container. The FSE secured the source in the |
| emergency container. Parts to make the appropriate repairs were sent |
| immediately and the afterloader was restored to proper working condition. |
| In order to identify the problem, secure the source, and make repairs, the |
| FSE handled a partially shielded to unshielded source on three occasions: i. |
| manually driving the source into the emergency container, ii. securing the |
| source back into the emergency container after it been pulled out by |
| ancillary staff, iii. moving the source from the emergency container to the |
| shipping pig. |
| |
| The FSE wore a self-reading dosimeter along with body and extremity badges |
| provided by Landauer. The occupational exposure reported by Landauer for |
| the period during which the exposure incident occurred is as follows: |
| |
| Deep Dose (DDE) 447 mrem |
| Extremity (SDE) 760 mrem |
| The year to date (1/15/01-8/14/01) total for the individual is 487 mrem |
| (DDE). |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021