Event Notification Report for March 20, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/19/2002 - 03/20/2002
** EVENT NUMBERS **
38680 38781 38782 38783 38784
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 38680 |
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| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 02/07/2002|
| UNIT: [] [3] [] STATE: NY |NOTIFICATION TIME: 16:52[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 02/07/2002|
+------------------------------------------------+EVENT TIME: 16:00[EST]|
| NRC NOTIFIED BY: ROGER YOUNG |LAST UPDATE DATE: 03/19/2002|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LAWRENCE DOERFLEIN R1 |
|10 CFR SECTION: |RICHARD ROSANO IAT |
|DDDD 73.71 UNSPECIFIED PARAGRAPH |SUSIE BLACK NRR |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| 1-HOUR SECURITY REPORT INVOLVING THE POTENTIAL LOSS OF SAFEGUARDS
|
| INFORMATION |
| |
| Discovery of loss of classified document/safeguards information. No |
| compensatory measures available. Licensee notified the NRC Resident |
| Inspector. Contact the Headquarters Operations Center for additional |
| details. |
| |
| ***RETRACTED ON 3/19/02 AT 1110 EST FROM BRIAN ROKES TO RICH LAURA*** |
| |
| The licensee is retracting this event after completing their investigation. |
| The licensee informed the Resident Inspector. Notified the RIDO (R. Conte). |
| Contact the HOO for details. |
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|General Information or Other |Event Number: 38781 |
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| REP ORG: ABB INC |NOTIFICATION DATE: 03/19/2002|
|LICENSEE: ABB INC |NOTIFICATION TIME: 12:53[EST]|
| CITY: CORAL SPRING REGION: 2 |EVENT DATE: 03/18/2002|
| COUNTY: STATE: FL |EVENT TIME: [EST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAY HENSON R2 |
| |VERN HODGE NRR |
+------------------------------------------------+RICHARD CONTE R1 |
| NRC NOTIFIED BY: R. GONNAM/M. RUIZ |PATRICK HILAND R3 |
| HQ OPS OFFICER: GERRY WAIG |DALE POWERS R4 |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INITIAL NOTIFICATION OF POTENTIAL DEFECT CLASS 1E TYPE CV-2 AND CV-22 |
| RELAYS |
| |
| "This letter is the initial notification of a deviation concerning our Class |
| 1E type CV-2 and CV-22 relays. |
| |
| "One of our customers notified us that several of the CV-2 relays they had |
| recently received did not have a particular assembly on the moving disc |
| which other CV-2 relays on the same order did have. Discussions with this |
| customer concluded they were speaking of a weight assembly that is used in |
| balancing the moving disc and is required as a part of the completed relay. |
| |
| "Upon visual examination of the CV-2 relays returned to us for corrective |
| action this deviation was confirmed. A preliminary investigation showed that |
| our manufacturing system allowed for the potential for this deviation to |
| occur. |
| |
| "Details will be provided in our written notification forthcoming within the |
| next thirty days." |
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|Power Reactor |Event Number: 38782 |
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| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 03/19/2002|
| UNIT: [] [2] [] STATE: WI |NOTIFICATION TIME: 14:15[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 03/19/2002|
+------------------------------------------------+EVENT TIME: 10:56[CST]|
| NRC NOTIFIED BY: MIKE MEYER |LAST UPDATE DATE: 03/19/2002|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MONTE PHILLIPS R3 |
|10 CFR SECTION: | |
|ADEG 50.72(b)(3)(ii)(A) DEGRADED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |98 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| LOSS OF SPDS DEGRADES COMMUNICATION/ASSESSMENT/RESPONSE CAPABILITY
|
| |
| "During the performance of a software update to the Primary Plant Process |
| Computer System (PPCS) the Unit 2 PPCS servers failed rendering Reactor |
| Thermal Output and Safety Parameter Display functions for Unit 2 inoperable. |
| At the time of the failure the software update was only being performed on |
| Unit 2. Unit 1 PPCS was verified operable and was not affected because the |
| software update was only being applied to the Unit 2 Servers. |
| |
| "Abnormal Operating Procedure AOP-21, PPCS Malfunction was entered and |
| Reactor Power was reduced approximately 2% and is currently being controlled |
| by Control Board Delta-T. The Safety Parameter Display System was also |
| rendered inoperable and is the bases for making this Notification. |
| |
| "Presently the Unit 2 PPCS servers are being re-booted, and it is expected |
| that PPCS will be available in about 2 hours. It is not known what the exact |
| failure mechanisms for Unit 2, only that it is either the software or the |
| procedure that caused the PPCS failure to unit 2." |
| |
| The licensee also notified the NRC Resident Inspector. |
| |
| * * * UPDATE ON 3/19/02 @1732 BY HARRSCH TO GOULD * * * |
| |
| As of 1534 CST, the PPCS system was returned to service for Unit 2. All |
| required functions were verified operable, including Reactor Thermal Output |
| (RTO) and the Safety Parameter Display System (SPDS). The initial failure |
| was related to the installation of a software upgrade and the problem has |
| been corrected. With the RTO function now Operable, Unit 2 will be |
| returning to full power from 98%. |
| |
| The NRC Resident Inspector was notified. |
| |
| Reg 3 RDO(Phillips) was informed |
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|Hospital |Event Number: 38783 |
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| REP ORG: ST FRANCIS HOSPITAL & HEALTH CTR |NOTIFICATION DATE: 03/19/2002|
|LICENSEE: ST FRANCIS HOSPITAL & HEALTH CTR |NOTIFICATION TIME: 17:31[EST]|
| CITY: BEECH GROVE REGION: 3 |EVENT DATE: 02/28/2002|
| COUNTY: MARION STATE: IN |EVENT TIME: [CST]|
|LICENSE#: 13-02128-03 AGREEMENT: N |LAST UPDATE DATE: 03/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MONTE PHILLIPS R3 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BERRY STEWART (RSO) | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION DURING STENT RESTENOSIS IRRADIATION |
| |
| "On 02/28/02, patient was scheduled for irradiation of an in stent |
| restenosis using the Novoste Beta-Cath system, specifically 30 mm serial |
| number 88746. |
| |
| "The cardiologist stated the reference vessel diameter was 2.7 mm |
| |
| "The standard dose for a reference diameter of 2.7 mm is 18.4 Gy delivered |
| in 3'22". |
| |
| "The patient was identified, and pre-procedure patient survey was performed. |
| The novoste unit was prepped, placed in sterile bag and catheter attached, |
| by the authorized user, system was pressurized to verify water flow through |
| the system. The sources were sent to the treatment position in the catheter |
| and verified visually by authorized user and medical physicist that the |
| sources were in the proper location within the catheter. The sources were |
| returned to the source holding area with a green light indicating they were |
| in the safe position. |
| |
| "The authorized user took the Novoste system to the patient and the |
| cardiologist inserted the treatment catheter through the arrow sheath |
| protector and forwarded the treatment catheter to the desired treatment |
| location, verified via fluoroscopy. |
| |
| "When the treatment catheter was in place, the cardiologist indicated the |
| location to be correct, the authorized user indicated he was ready to send |
| the sources, and upon acknowledgement the sources were sent to treatment |
| location under fluoroscopy. The distal marker was visualized but the |
| proximal marker wasn't seen. The cardiologist rotated the C-arm to change |
| the perspective of the image. The proximal marker still wasn't visualized. |
| |
| "The authorized user then attempted to return the sources to the safe |
| position in the Novoste device. There was no indication of the sources |
| returning to safe position. The catheter was immediately removed from the |
| patient and taken to the safety box. The medical physicist then attempted to |
| return the sources to the safe position and verify their location. This |
| attempt was unsuccessful. |
| |
| "The patient was surveyed and found to be at background. |
| |
| "Utilizing multiple wet gauze pads, the catheter was wiped clean in an |
| attempt to locate the sources visually. The sources were not seen. The |
| catheter was then passed over the survey meter, with the unit in the box to |
| determine if the sources were in the catheter. There were no sources in the |
| catheter, |
| |
| "At this time, the cardiologist was asked if he wanted to change systems and |
| continue the treatment. The authorized user and cardiologist decided to |
| abort the procedure. The patient was notified of the decision by the |
| cardiologist at this time. |
| |
| "The Novoste system was removed from the Cath lab in the safety box. Under |
| visual inspection there appeared to be 6 source pellets and proximal marker |
| in the source holding area of the Novoste unit. The remaining 6 source |
| pellets and distal marker appeared to be in the base of the catheter that |
| fits into the Novoste unit. |
| |
| "All sources were visually accounted for, Novoste was called, and problem |
| reported. |
| |
| "Novoste representative arrived within 2 hours of notification, and was able |
| to return all sources to the safe location, with the unit indicating the |
| safe condition, |
| |
| "Upon inspection, there was some type of material (black) in the source |
| holding chamber. This material apparently restricted movement of the source |
| pellets out of the source holding chamber, |
| |
| "The Novoste unit was immediately removed from service and it and the |
| catheter was placed in the lead shield container to be returned to Novoste |
| for evaluation. |
| |
| "The time estimate for the time the distal marker was seen and the system |
| removed from patient was approximately 30 seconds. |
| |
| "The treatment was never actually started as the proximal marker was never |
| visualized and that is the indication to start the timer, thus starting the |
| treatment. |
| |
| "The only definite location of the sources is that the distal marker was at |
| the proper location in the catheter. |
| |
| "If one assumes the six pellets were behind the distal marker for 20 |
| seconds, then the dose would be approximately 1.8 Gy to a length of 0.5 - |
| 0.75 mm. |
| |
| "This would be a maximum dose estimate, as part of the time they were being |
| remove from the patient, and in vessels that were much large than 2.7 mm |
| diameter." |
| |
| The licensee stated that NRC Region 3 was notified of this event on 2/28/02. |
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|Power Reactor |Event Number: 38784 |
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 03/19/2002|
| UNIT: [1] [] [] STATE: AZ |NOTIFICATION TIME: 19:02[EST]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 03/15/2002|
+------------------------------------------------+EVENT TIME: 06:30[MST]|
| NRC NOTIFIED BY: DAN MARKS |LAST UPDATE DATE: 03/19/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DALE POWERS R4 |
|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
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| NON WORK RELATED FATALITY NOTIFICATION IN ACCORDANCE WITH 10CFR50.72
|
| |
| "At approximately 06:30 MST on March 15, 2002, a non-work related on-site |
| fatality occurred at the Palo Verde Nuclear Generating Station. The fatality |
| was not related to the health and safety of the public or onsite personnel. |
| Specifically, a contract carpenter was found by coworkers in the carpenter |
| shop before work hours with no pulse or life signs. The individual was |
| promptly attended by Palo Verde Emergency Medical Technicians (EMTs) and an |
| air evacuation was completed. The individual was pronounced dead upon |
| arrival at the hospital. |
| |
| "The individual was outside of the Radiological Controlled Area and no |
| radioactive material or contamination was involved. The work location was |
| outside of the Protected Area. |
| |
| "Palo Verde has not observed any heightened public, media or government |
| concern as a result of the fatality. Since the fatality is unrelated to Palo |
| Verde's industrial or radiological health and safety, no news release is |
| planned. |
| |
| "Since the fatality was not work-related, nor the result of an accident, no |
| notification to other government agencies was made at the time. However, |
| Palo Verde is now making a notification to the Arizona Department of |
| Occupational Safety and Health (ADOSH) due to a requirement to report any |
| cardiac arrest on-site. Thus this ENS notification is in response to a |
| notification to another government agency in accordance |
| with10CFR50.72(b)(2)(xi)." |
| |
| The licensee notified the NRC Resident Inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021