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
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|General Information or Other |Event Number: 39096 |
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| 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 |
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| NRC NOTIFIED BY: P. V. EGIDI | |
| HQ OPS OFFICER: FANGIE JONES | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| 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). |
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|Hospital |Event Number: 39110 |
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| 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 |
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| NRC NOTIFIED BY: KARI CANN | |
| HQ OPS OFFICER: FANGIE JONES | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33 MED MISADMINISTRATION | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 39111 |
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| 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 | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 94 Power Operation |94 Power Operation |
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EVENT TEXT
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| 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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