Event Notification Report for August 6, 2002
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/05/2002 - 08/06/2002 ** EVENT NUMBERS ** 39096 39110 39111 . +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39096 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/26/2002| |LICENSEE: ST. MARY'S HOSPITAL |NOTIFICATION TIME: 19:30[EDT]| | CITY: GRAND JUNCTION REGION: 4 |EVENT DATE: 07/26/2002| | COUNTY: STATE: CO |EVENT TIME: 16:45[MDT]| |LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 08/05/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |BILL JONES R4 | | |MELVYN LEACH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: P. V. EGIDI | | | HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - MISSING I-125 SEEDS | | | | The following is from a facsimile report: | | | | "At approximately 4:45 PM Friday July 26, 2002, I [Colorado Department of | | Health and Environment] received a call from ..., RSO and Medical Physicist | | at St. Mary's Hospital in Grand Junction, Colorado. | | | | "[RSO] informed us he is missing 3, I-125 prostrate seeds (approx. 0.36 mCi | | [millicuries] each). He was made aware of the loss late this morning. | | Surveys were conducted in all suspect areas of the hospital to no avail. It | | is possible that either the seeds never arrived due to poor inventory | | control of the supplier, or that the seeds went to the trash, which left the | | hospital around 7:00 A.M. Since the seeds are shielded, they would probably | | not be detected at the landfill." | | | | * * * UPDATED AT 1800 EDT ON 8/5/02 BY TIME BONZER TO FANGIE JONES * * * | | | | The final report is that the seeds were not found, it is indeterminate | | whether the seeds actually made it to the hospital. The hospital will take | | additional steps to insure that they actually receive the seeds they are | | suppose to receive. | | | | The hospitals action plan is as follows: | | | | "We are revising our QA processes. We will return to performing our own | | source counts and not be dependent on others so we do not go looking for | | something we may have never received. We also will increase our needle-prep | | area monitoring to include a more thorough area survey Including removing | | the lead shielding" | | | | Notified the R4DO (Chuck Cain) and NMSS EO (E. William Brach). | +------------------------------------------------------------------------------+ . +------------------------------------------------------------------------------+ |Hospital |Event Number: 39110 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: BENEFIS HEALTH CARE |NOTIFICATION DATE: 08/05/2002| |LICENSEE: BENEFIS HEALTH CARE |NOTIFICATION TIME: 17:36[EDT]| | CITY: GREAT FALLS REGION: 4 |EVENT DATE: 08/05/2002| | COUNTY: STATE: MT |EVENT TIME: [MDT]| |LICENSE#: 25-12710-01 AGREEMENT: N |LAST UPDATE DATE: 08/05/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CHUCK CAIN R4 | | |E. WILLIAM BRACH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: KARI CANN | | | HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |LADM 35.33 MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION - DOSE GIVEN APPROXIMATELY 22% LESS THAN | | PRESCRIBED | | | | This report is made due to failure to provide test per NRC Notification | | Notice 2002-19. A review of the administration records indicate that 6 | | patients received palliative doses of samarium since 12/99 that were about | | 22% low. Benifis Health Care does not use unit dose vials, they receive | | multidose vials and withdraw a dose out into a plastic syringe. After | | receipt of a calibration source, the RSO determined that radiation readings | | for a dose in a plastic syringe was 21.6% higher than in a glass syringe. A | | correction factor has been put in place for plastic syringes to insure | | proper dosages in the future. The patients have been determined to have no | | adverse affects, they all had relief of pain even with the lower dose. The | | patients and attending physicians have not been informed at this time. | +------------------------------------------------------------------------------+ . +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39111 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 08/06/2002| | UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 04:34[EDT]| | RXTYPE: [1] GE-4 |EVENT DATE: 08/05/2002| +------------------------------------------------+EVENT TIME: 23:33[CDT]| | NRC NOTIFIED BY: BRIAN HUPKE |LAST UPDATE DATE: 08/06/2002| | HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 | |10 CFR SECTION: | | |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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 94 Power Operation |94 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF RESIDUAL HEAT REMOVAL (RHR) HEAT REMOVAL CAPABILITY. | | | | "At 23:33 on 8/5/02 both loops of RHRSW (Residual Heat Removal Service | | Water) were declared inoperable due to experiencing high differential | | pressure greater than 12 psid across the 'A' loop RHRSW strainer and the 'B' | | loop RHRSW strainer. | | | | "On 8/4/02 while running a surveillance for the 'B' RHRSW pump a high | | strainer differential pressure annunciator was received, which comes in a 6 | | psid. 'B' pump flow at the time was 2400 GPM. The in plant operator was | | sent locally to investigate the local differential pressure indication and | | discovered the instrument was pegged high at > (greater than ) 15 psid. The | | pump was secured and the corresponding Limiting Condition of Operation of 7 | | days was entered for the 'B' RHRSW loop. Maintenance was immediately | | planned and begun to clean the 'B' RHRSW strainer. At the time plans were | | also made to inspect the 'B' RHRSW/ESW (Emergency Service Water) pit and | | Stilling Basin. | | | | "On 8/5/02 after inspections of the Stilling basin found algae growth, plans | | were made to run the 'A' side RHRSW pumps to determine operability of the | | 'A' loop of RHRSW. At that time the Stilling basin cleaning also began. | | After the completion of stilling basin cleaning on 8/5/02, the 'A' RHRSW | | pump was started and strainer differential was between 2.5 - 4.5 psid at a | | pump flow of 2400 GPM which was held for 15 minutes. At this time the 'C' | | RHRSW pump was started and flow raised to 4100 GPM at which time strainer | | differential pressure was steady at 5.5 - 6.0 psid. As flow was raised to | | 5000 GPM Strainer differential pressure pegged high at > (greater than) 15 | | psid within 3 minutes. The 'A' RHRSW pump was then secured and flow lowered | | to 2100 GPM where strainer differential pressure remained at 10 - 12 psid | | and then pegged high at greater than 15 psid. The 'C' RHRSW pump was then | | secured and the 'A' RHRSW loop was declared inoperable at 23:33 on 8/5/02. | | The LCO for both loops of RHRSW inoperable was then entered at 23:33 on | | 8/5/02. | | | | "This report is being made under 50.72(b)(3)(v)(B) 'Any event or condition | | that at the time of discovery could have prevented the fulfillment of the | | safety function of structures or systems that are needed to remove residual | | heat.' " | | | | | | All other Emergency Core Cooling Systems are fully operable if needed. | | | | | | The NRC Resident Inspector was notified of this event by the licensee. | +------------------------------------------------------------------------------+
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Page Last Reviewed/Updated Thursday, March 25, 2021