Event Notification Report for October 18, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/17/2002 - 10/18/2002
Hospital
Event Number: 39307
Rep Org: SOUTHERN INDIANA RADIOLOGICAL ASSOC
Licensee: SOUTHERN INDIANA RADIOLOGICAL ASSOC
Region: 3
City: BLOOMINGTON State: IN
County: MONROE
License #: 13-24646-02
Agreement: N
Docket:
NRC Notified By: BILL HEADLEY
HQ OPS Officer: MIKE RIPLEY
Licensee: SOUTHERN INDIANA RADIOLOGICAL ASSOC
Region: 3
City: BLOOMINGTON State: IN
County: MONROE
License #: 13-24646-02
Agreement: N
Docket:
NRC Notified By: BILL HEADLEY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/21/2002
Notification Time: 16:27 [ET]
Event Date: 10/18/2002
Event Time: 14:00 [CST]
Last Update Date: 10/21/2002
Notification Time: 16:27 [ET]
Event Date: 10/18/2002
Event Time: 14:00 [CST]
Last Update Date: 10/21/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
CHRISTINE LIPA (R3)
M. WAYNE HODGES (NMSS)
CHRISTINE LIPA (R3)
M. WAYNE HODGES (NMSS)
MEDICAL MISADMINISTRATION
A radiological laboratory technician inadvertently administered the incorrect dose of Tc-99M to a patient. A bone dose was desired and a lung dose was actually administered. The laboratory stated that the absorbed dose to the patient was insignificant. The cause of the misadministration was a failure by the technician to properly identify the syringe. The corrective action to prevent recurrence was to counsel the technician.
The laboratory notified the patient's physician and will file a written report to NRC Region 3.
A radiological laboratory technician inadvertently administered the incorrect dose of Tc-99M to a patient. A bone dose was desired and a lung dose was actually administered. The laboratory stated that the absorbed dose to the patient was insignificant. The cause of the misadministration was a failure by the technician to properly identify the syringe. The corrective action to prevent recurrence was to counsel the technician.
The laboratory notified the patient's physician and will file a written report to NRC Region 3.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 39303
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JOHN LECHMAIER
HQ OPS Officer: MIKE NORRIS
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JOHN LECHMAIER
HQ OPS Officer: MIKE NORRIS
Notification Date: 10/19/2002
Notification Time: 05:27 [ET]
Event Date: 10/18/2002
Event Time: 21:30 [CDT]
Last Update Date: 12/13/2002
Notification Time: 05:27 [ET]
Event Date: 10/18/2002
Event Time: 21:30 [CDT]
Last Update Date: 12/13/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS KOZAK (R3)
THOMAS KOZAK (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
RCIC HIGH STEAM FLOW ISOLATION INSTRUMENTATION INOPERABLE DUE TO BEING OUT OF TOLERANCE
"At 2130 hours CDT on 10/18/2002, the U1 RCIC High Steam Flow Isolation Instrumentation was determined to have been inoperable. Both U1 RCIC High Steam Flow switches were found to be outside their Technical Specification Allowable Value during a calibration surveillance. Both U1 RCIC High Steam Flow switches were subsequently recalibrated back to within their Technical Specification Allowable Value.
"This notification is being made in accordance with 10CFR50.72(b)(3)."
The NRC Resident Inspector has been notified.
* * * UPDATE 1145EST ON 12/13/02 FROM RON RUSTICK TO S. SANDIN * * *
The licensee is retracting this report based on the following:
"The purpose of this notification is to retract the ENS report made on 10/19/2002 at 05:27 EDT (Event #39303). The initial report concerned the Reactor Core Isolation Cooling (RCIC) system high steam flow isolation function. On 10/18/2002, both required high steam flow isolation instruments were found to be outside of their Technical Specifications Allowable Value (AV); therefore, a notification was made under 10CFR50.72(b)(3)(V)(D). However, a subsequent review of this event has determined that only one of the two required channels actually exceeded the AV and thus one channel was OPERABLE and capable of initiating the isolation function (i.e., there was no loss of safety function). For this reason, Quad Cities Station has concluded that the RCIC high steam flow isolation function was preserved."
The licensee informed the NRC resident inspector. Notified R3DO(Hiland).
"At 2130 hours CDT on 10/18/2002, the U1 RCIC High Steam Flow Isolation Instrumentation was determined to have been inoperable. Both U1 RCIC High Steam Flow switches were found to be outside their Technical Specification Allowable Value during a calibration surveillance. Both U1 RCIC High Steam Flow switches were subsequently recalibrated back to within their Technical Specification Allowable Value.
"This notification is being made in accordance with 10CFR50.72(b)(3)."
The NRC Resident Inspector has been notified.
* * * UPDATE 1145EST ON 12/13/02 FROM RON RUSTICK TO S. SANDIN * * *
The licensee is retracting this report based on the following:
"The purpose of this notification is to retract the ENS report made on 10/19/2002 at 05:27 EDT (Event #39303). The initial report concerned the Reactor Core Isolation Cooling (RCIC) system high steam flow isolation function. On 10/18/2002, both required high steam flow isolation instruments were found to be outside of their Technical Specifications Allowable Value (AV); therefore, a notification was made under 10CFR50.72(b)(3)(V)(D). However, a subsequent review of this event has determined that only one of the two required channels actually exceeded the AV and thus one channel was OPERABLE and capable of initiating the isolation function (i.e., there was no loss of safety function). For this reason, Quad Cities Station has concluded that the RCIC high steam flow isolation function was preserved."
The licensee informed the NRC resident inspector. Notified R3DO(Hiland).
General Information or Other
Event Number: 39366
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HUNTINGTON TESTING AND TECHNOLOGY INC.
Region: 2
City: GHENT State: KY
County:
License #: 201-551-05
Agreement: Y
Docket:
NRC Notified By: BOB JOHNSON
HQ OPS Officer: RICH LAURA
Licensee: HUNTINGTON TESTING AND TECHNOLOGY INC.
Region: 2
City: GHENT State: KY
County:
License #: 201-551-05
Agreement: Y
Docket:
NRC Notified By: BOB JOHNSON
HQ OPS Officer: RICH LAURA
Notification Date: 11/12/2002
Notification Time: 16:30 [ET]
Event Date: 10/18/2002
Event Time: 07:30 [CST]
Last Update Date: 11/12/2002
Notification Time: 16:30 [ET]
Event Date: 10/18/2002
Event Time: 07:30 [CST]
Last Update Date: 11/12/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LEONARD WERT (R2)
FRED BROWN (NMSS)
LEONARD WERT (R2)
FRED BROWN (NMSS)
KY AGREEMENT STATE REPORT INVOLVING AN OVER EXPOSURE OF A RADIOGRAPHER
"This letter is notification of an overexposure incident that occurred on October 8, 2002 in Ghent, Kentucky. The licensee involved was Huntington Testing & Technology Inc.. Kentucky Radioactive Material License Number 201-551-05. The incident occurred while performing radiography at Kentucky Utilities. The radiography source was 103 Ci [Curies] of Ir-192 [Iridium], housed in a 660 B Camera, S/N B2954. The licensee's interpretation of the reporting criteria resulted in late notification thirty (30) days after the incident. That information was not only delayed, but also incomplete requiring further development before the State of Kentucky could forward this report.
"At approximately 7:00 a.m., on October 18, 2002, when reeling in the radiography source after an exposure, it was not fully retracted, nor recognized for approximately three (3) minutes by the radiographer who had entered the area. Upon realization that the source was not fully retracted, the radiographer immediately left the area, extended the source and then retracted it to the housed position. The RSO [Radiation Safety Officer] was contacted and the radiographer removed from any radiological work.
"The radiographer's dosimetry was immediately sent to Landauer for processing. The result of his exposure was 4.86 Rem whole body, in addition to his year-to-date exposure of 1.4 Rem, for total yearly whole body exposure of 6.26 Rem. These numbers appear to be close estimates, ending further evaluation of the radiographer's position in relation to the exposed source. Initial reports indicate a survey instrument failure, and failure of the radiographer to monitor the instrumentation and position indicator to ensure retraction of the radiography source.
"Further evaluation of the cause of this incident and final dose estimates will be forwarded ending further investigation."
"This letter is notification of an overexposure incident that occurred on October 8, 2002 in Ghent, Kentucky. The licensee involved was Huntington Testing & Technology Inc.. Kentucky Radioactive Material License Number 201-551-05. The incident occurred while performing radiography at Kentucky Utilities. The radiography source was 103 Ci [Curies] of Ir-192 [Iridium], housed in a 660 B Camera, S/N B2954. The licensee's interpretation of the reporting criteria resulted in late notification thirty (30) days after the incident. That information was not only delayed, but also incomplete requiring further development before the State of Kentucky could forward this report.
"At approximately 7:00 a.m., on October 18, 2002, when reeling in the radiography source after an exposure, it was not fully retracted, nor recognized for approximately three (3) minutes by the radiographer who had entered the area. Upon realization that the source was not fully retracted, the radiographer immediately left the area, extended the source and then retracted it to the housed position. The RSO [Radiation Safety Officer] was contacted and the radiographer removed from any radiological work.
"The radiographer's dosimetry was immediately sent to Landauer for processing. The result of his exposure was 4.86 Rem whole body, in addition to his year-to-date exposure of 1.4 Rem, for total yearly whole body exposure of 6.26 Rem. These numbers appear to be close estimates, ending further evaluation of the radiographer's position in relation to the exposed source. Initial reports indicate a survey instrument failure, and failure of the radiographer to monitor the instrumentation and position indicator to ensure retraction of the radiography source.
"Further evaluation of the cause of this incident and final dose estimates will be forwarded ending further investigation."