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Event Notification Report for July 24, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/23/2002 - 07/24/2002
** EVENT NUMBERS **
39068 39072 39073 39085
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|General Information or Other |Event Number: 39068 |
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| REP ORG: KENTUCKY DEPT OF RADIATION CONTROL |NOTIFICATION DATE:
07/18/2002|
|LICENSEE: MONROE COUNTY MEDICAL CENTER |NOTIFICATION TIME: 11:40[EDT]|
| CITY: TOMPKINSVILLE REGION: 2 |EVENT DATE: 07/12/2002|
| COUNTY: STATE: KY |EVENT TIME: 16:00[CDT]|
|LICENSE#: 202-247-24 AGREEMENT: Y |LAST UPDATE DATE: 07/18/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLIE PAYNE R2 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOHN A. VOLPE | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION |
| |
| "The Technologist (S.H) received a request to perform a Bone Scan on an |
| inpatient. She selected an MDP Dose (25.1 mCi) and proceeded to the room |
| listed on requisition. She approached the patient stated the name. The |
| patient acknowledged the name. The technologist explained the procedure |
| and injected the patient. When the patient presented to the Nuclear |
| Medicine Department with hospital chart it was discovered that the |
| misadministration had occurred. The technologist notified the authorized |
| user, the referring physician [and] the Radiation Safety officer. The |
| referring physician agreed to notify the patient. The Technologist was |
| reinstructed to check the hospital chart for a written order and verify the |
| patients identity by checking the hospital ORM board." |
| |
| Used Tc-99m MDP Bone. |
| |
| *****RETRACTED ON 7/18/02 AT 15:27 EDT FROM VOLPE TO LAURA***** |
| |
| The licensee determined the event was NOT reportable since the dose was |
| below the threshold (greater than 5 REM whole body or greater than 50 REM |
| for organs) for reportability. |
| |
| Notified R2DO (C. PAYNE) and NMSS (F. Brown). |
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|General Information or Other |Event Number: 39072 |
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| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE:
07/19/2002|
|LICENSEE: ARIZONA HEART HOSPITAL |NOTIFICATION TIME: 11:30[EDT]|
| CITY: PHOENIX REGION: 4 |EVENT DATE: 07/17/2002|
| COUNTY: STATE: AZ |EVENT TIME: 14:30[MST]|
|LICENSE#: 07-443 AGREEMENT: Y |LAST UPDATE DATE: 07/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LINDA HOWELL R4 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: AUBREY V. GODWIN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT: EQUIPMENT FAILURE |
| |
| |
| "On July 17, 2002, the Arizona Radiation Regulatory Agency was notified by |
| the Licensee that a Novoste Beta-Cath system utilizing 55mCi (2.04GBq) of |
| Strontium-90 had failed to retract after completing treatment of a patient. |
| Within seconds of determining that a failure had occurred, the Licensee |
| implemented emergency withdrawal procedures and successfully removed the |
| source without causing a misadministration. The patient was surveyed and |
| confirmed that all treatment radioactive material had been removed. |
| |
| "Initial examination by the Licensee did not determine a probable cause of |
| the failure of the return of the source to the shielded condition. The |
| entire system is being returned to the manufacturer for evaluation. Georgia |
| is aware of this event. |
| |
| "Agency continues to investigate this event. |
| "No press coverage is occurring or expected for this event. |
| |
| "First Notice: 02-9 |
| |
| "The State of Georgia and the U.S. NRC, is being notified of this event." |
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|General Information or Other |Event Number: 39073 |
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| REP ORG: IOWA RADIATION PROTECTION |NOTIFICATION DATE: 07/19/2002|
|LICENSEE: STORK-TWIN CITY TESTING CORPORATION |NOTIFICATION TIME:
12:03[EDT]|
| CITY: OSCEOLA REGION: 3 |EVENT DATE: 07/17/2002|
| COUNTY: STATE: IA |EVENT TIME: 09:00[CDT]|
|LICENSE#: 0282-2-77-IR1 AGREEMENT: Y |LAST UPDATE DATE: 07/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MONTE PHILLIPS R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GEORGE JOHNS | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| BROKEN RADIOGRAPHER CAMERA |
| |
| "As a result of one of our cameras had a source jammed because the camera |
| fell from a ladder it was sitting on during an exposure, we are submitting |
| the following response. |
| |
| |
| "Project Information: |
| |
| "Date: July 17, 2002 at approx. 9:00 A.M. |
| Rural water tower, south of Osceola, Iowa approx. 4 miles |
| Jobsite- down a dead-end road, in a field |
| Source S.N. 04016B 40.5 curies |
| Contractor: Phoenix Fabricators & Erectors, Inc. |
| |
| "Stork-Twin City Testing Corporation was at a temporary project site |
| performing radiographic testing when the camera fell off a ladder the camera |
| was sitting on (approx. 3 feet to the ground). The source would not crank |
| back into it's shielded position. I asked him, if they had resecured the |
| area and his response was that they had and that they had also informed the |
| contractor at the site of this incident. I told him, I was on my way and |
| arrived at the site approx. one hour later. I loaded my truck with lead |
| shielding and tools that might be needed to free up the source. Arriving at |
| the project site, I surveyed the guide tube from a distance and found that |
| the source was approx. 1 foot from the camera. They had the crank apart, so |
| you could pull on the cable, in which I had them do prior to my arrival, but |
| they said it would not move, I then tried this myself. I pushed on the cable |
| and then pulled it and the source went in the camera to it safe position. We |
| surveyed the camera and the guide tube and confirmed it was secured in the |
| camera. We then unconnected the control cable and checked the source end |
| with a nogo gauge and found it to be OK, we also cranked the cable out and |
| checked it for any bends or other damage and found it to be OK. We removed |
| the bent guide tube and replaced it with a good tube. We then cranked the |
| source out and made sure everything was functioning properly. |
| |
| "We then had an onsite safety meeting, which concluded that this would be |
| avoided in the future, by tying the camera to a stationary object so the |
| camera cannot fall to the ground and bend the guide tube. |
| |
| "There was no over exposure to the public (contractor's personnel) or to the |
| radiographers during this incident and the radiographers performed their |
| duties in a satisfactory manner, concerning the safety for all and the |
| following of our accident procedures." |
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|Power Reactor |Event Number: 39085 |
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| FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 07/23/2002|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 17:30[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 07/23/2002|
+------------------------------------------------+EVENT TIME: 16:32[EDT]|
| NRC NOTIFIED BY: BOB REINER |LAST UPDATE DATE: 07/23/2002|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RICHARD CONTE R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 100 Power Operation |0 Hot Shutdown |
| | |
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EVENT TEXT
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| MANUAL REACTOR SCRAM DUE TO THE LOSS OF CONDENSER VACUUM FOR
UNKNOWN |
| REASONS |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "Limerick Unit 2 was manually scrammed due to a loss of main condenser |
| vacuum. All systems functioned as expected during the scram. No [emergency |
| core cooling system injections] occurred. All rods fully inserted. No |
| [safety relief valves] lifted. The unit is currently stable in Mode 3. |
| Investigation into the loss of vacuum is continuing." |
| |
| The licensee stated that the main steam isolation valves remained open |
| during the event. There were no reactor core isolation cooling system |
| injections, and none were required. There were no related surveillance or |
| maintenance activities ongoing at the time of the reactor scram, and there |
| was nothing unusual or misunderstood with the exception of the cause for the |
| loss of condenser vacuum. |
| |
| The licensee also stated that reactor vessel level and pressure control are |
| currently being maintained via normal condensate and feedwater and via |
| normal turbine bypass, respectively. The main condenser is available as |
| the heat sink, and main condenser vacuum is being maintained via the steam |
| jet air ejectors. The mechanical vacuum pump had also been prepared and is |
| available to maintain condenser vacuum if needed. Containment parameters |
| were reported to be normal. |
| |
| The licensee notified the NRC resident inspector. |
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