Event Notification Report for February 20, 2002
*** NOT FOR PUBLIC DISTRIBUTION ***
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/19/2002 - 02/20/2002
** EVENT NUMBERS **
38707 38708 38709
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38707 |
+------------------------------------------------------------------------------+
*** NOT FOR PUBLIC DISTRIBUTION ***
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 02/19/2002|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 01:27[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 02/18/2002|
+------------------------------------------------+EVENT TIME: 18:15[EST]|
| NRC NOTIFIED BY: JAMES WITTER |LAST UPDATE DATE: 02/19/2002|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAMES TRAPP R1 |
|10 CFR SECTION: | |
|AINA 50.72(b)(3)(v)(A) POT UNABLE TO SAFE SD | |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH EMERGENCY DIESEL GENERATORS INADVERTENTLY MADE INOPERABLE |
| |
| "On 02/18/02, at 1815 hours, the licensee discovered that the Beaver Valley |
| Unit 2 #1 Emergency Diesel Generator had been rendered inoperable |
| inadvertently, by the posting of a clearance at 1408 hours on 2/14/02. The |
| #2 Emergency Diesel Generator had previously been removed from service for |
| maintenance activities. Upon discovery that the #1 Emergency Diesel |
| Generator was inoperable, action was immediately initiated to restore the #1 |
| Emergency Diesel Generator to Operable status. These actions were completed |
| and the #1 Emergency Diesel Generator was restored to Operable status at |
| 1830 hrs on 02/18/02. |
| |
| "The #1 Diesel Generator was rendered inoperable at 1406 hrs on 02/14/02. |
| During the period of inoperability, the licensee conducted core alterations |
| including core reload during the ongoing ninth refueling outage. During the |
| affected period, there were no challenges to the offsite power sources, and |
| core cooling was maintained. Investigation into this event is ongoing. |
| |
| "This event is being reported under 10CFR50.72(v)(A) and 10CFR50.72(v)(B) as |
| a loss of Safe Shutdown Capability, and RHR Capability, respectively. There |
| were no radiological releases associated with this event," |
| |
| The licensee intends to notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38708 |
+------------------------------------------------------------------------------+
*** NOT FOR PUBLIC DISTRIBUTION ***
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF WISCONSIN AT MADISON |NOTIFICATION DATE: 02/19/2002|
|LICENSEE: UNIVERSITY OF WISCONSIN AT MADISON |NOTIFICATION TIME: 08:12[EST]|
| CITY: MADISON REGION: 3 |EVENT DATE: 02/15/2002|
| COUNTY: STATE: WI |EVENT TIME: [CST]|
|LICENSE#: 4809843-18 AGREEMENT: N |LAST UPDATE DATE: 02/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANTON VEGEL R3 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BEN-ZIKRI | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION DUE TO AN EQUIPMENT MALFUNCTION |
| |
| A BetaCath Systems device containing strontium-90 produced by Novoste was |
| being used to treat a patient. On sending the active sources to the target |
| area, a fluid leak occurred which slowed the movement of the seeds into the |
| target vessel/position (Left Anterior Descending Artery). Not able to see |
| the active seeds on the fluoroscopy monitors, a decision to have the active |
| seeds returned to the holding device was made. A total time of 17 seconds |
| elapsed from the time of delivery until the active seeds were returned to |
| the holding device. |
| |
| On close inspection of the treatment catheter/device, one of the sealing |
| O-rings was found to be ruptured. This was the ultimate cause of the fluid |
| leak and consequently the slow movement of the active seeds to the target |
| position. |
| |
| With a dose rate of 0.095 Gy/s at 2 mm, the artery wall along the |
| approximately 1 m track over which the source traveled out and back for its |
| 17 sec would be calculated as: |
| |
| Speed equals 2 * (100 cm)/17 s = 11.8 cm/s |
| |
| Time wall was exposed to the 4 cm source = 4 cm / 11.8 cm/s = 0.34 s, but |
| this time is doubled since it is exposed coming and going, to 0.68 s. |
| |
| Dose to the wall = 0.68 s * 0.095 Gy/s = 0.0646 Gy = 6.5 rads. |
| |
| The normal dose to the wall (assuming an 8 s round trip) would be 3.0 rads. |
| |
| A new catheter was tested with the non-active device and the treatment was |
| continued. The treatment was timed, checked for the return of the active |
| sources and surveyed the patient/room post treatment. No problems were |
| encountered with the new treatment catheter. |
| |
| * * * UPDATE 1745EST ON 2/19/02 FROM ABDUL BEN-ZIKRI TO S. SANDIN VIA E-MAIL |
| * * * |
| |
| The following is a portion of an e-mail received at hoo1@nrc.gov: |
| |
| "I am retracting my event report (Event # 38708). I took a conservative |
| action and reported this event based on preliminary written information. |
| |
| "Our Hospital staff followed all standard operating & emergency procedures, |
| and retracted the source when they realized that they did not arrive to the |
| area of clinical interest as indicated in the report below. Based on the |
| investigation analysis, we conclude that there was no misadministration to |
| report." |
| |
| Notified R3DO(Jorgensen) and NMSS(Brach). |
| . |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 38709 |
+------------------------------------------------------------------------------+
*** NOT FOR PUBLIC DISTRIBUTION ***
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: PRINCETON UNIVERSITY |NOTIFICATION DATE: 02/19/2002|
|LICENSEE: PRINCETON UNIVERSITY |NOTIFICATION TIME: 11:35[EST]|
| CITY: PRINCETON REGION: 1 |EVENT DATE: 01/23/2002|
| COUNTY: STATE: NJ |EVENT TIME: [EST]|
|LICENSE#: 290518524 AGREEMENT: N |LAST UPDATE DATE: 02/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MICHAEL MODES R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SUE DUPRE | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING RAT CARCASSES CONTAMINATED WITH TRITIUM |
| |
| On 1/23/02 the Radiation Safety Officer was informed that 15 rat carcasses |
| contaminated with 14 mCi of tritium were missing from the freezer. This was |
| discovered on 1/21/02 when a scheduled pickup for disposal was made and the |
| 2 bags of rat carcasses were not located. A thorough search of the |
| laboratories and freezers was made. It is believed that the 2 bags were |
| mistakenly picked up on 11/7/01 when a scheduled pickup for disposal of |
| non-contaminated rat carcasses was made. The 2 bags were last seen in |
| October when the bags were placed in the freezer. |
| |
| New procedures have been put in place to prevent this event from being |
| repeated. A written report will be submitted within 30 days. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021