Event Notification Report for October 31, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/30/2002 - 10/31/2002
General Information or Other
Event Number: 39335
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BAYFRONT MEDICAL CENTER
Region: 2
City: ST. PETERSBURG State: FL
County:
License #: 0023-2
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS(email)
HQ OPS Officer: ARLON COSTA
Licensee: BAYFRONT MEDICAL CENTER
Region: 2
City: ST. PETERSBURG State: FL
County:
License #: 0023-2
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS(email)
HQ OPS Officer: ARLON COSTA
Notification Date: 10/31/2002
Notification Time: 16:45 [ET]
Event Date: 10/31/2002
Event Time: 00:00 [EST]
Last Update Date: 11/05/2002
Notification Time: 16:45 [ET]
Event Date: 10/31/2002
Event Time: 00:00 [EST]
Last Update Date: 11/05/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KERRY LANDIS (R2)
PATRICIA HOLAHAN (NMSS)
KERRY LANDIS (R2)
PATRICIA HOLAHAN (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT
"Manufacturer's employee changed the Gamma Knife's printer on 2 Aug 02 and during the process the calibration parameters for the Gamma Knife instrument were reset from 3.52 c/gray (on 6-02) to 3.5 c/gray (on 1-99). Licensee was not aware of the change. Ten patients were treated with this instrument from 26 Aug-30 Oct 02. The area treated was the brain and the overexposure was as much as 60% above the prescribed dose of 12-24 grays. The physicians and patients involved are being notified. The error was discovered during a recalibration on 10-30-02. The instrument has been removed from service. Florida is investigating."
The isotope used by the Gamma Knife Model C S/N 4189C is Co-60 (Activity 5.72 Ci).
*** UPDATE AT 0800 11/5/2002 FROM CHARLIE ADAMS TO ERIC THOMAS ***
The above Co-60 activity was listed incorrectly in the original report. The correct value is 5720 Ci.
"Manufacturer's employee changed the Gamma Knife's printer on 2 Aug 02 and during the process the calibration parameters for the Gamma Knife instrument were reset from 3.52 c/gray (on 6-02) to 3.5 c/gray (on 1-99). Licensee was not aware of the change. Ten patients were treated with this instrument from 26 Aug-30 Oct 02. The area treated was the brain and the overexposure was as much as 60% above the prescribed dose of 12-24 grays. The physicians and patients involved are being notified. The error was discovered during a recalibration on 10-30-02. The instrument has been removed from service. Florida is investigating."
The isotope used by the Gamma Knife Model C S/N 4189C is Co-60 (Activity 5.72 Ci).
*** UPDATE AT 0800 11/5/2002 FROM CHARLIE ADAMS TO ERIC THOMAS ***
The above Co-60 activity was listed incorrectly in the original report. The correct value is 5720 Ci.
Power Reactor
Event Number: 39333
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DONALD STRAKA
HQ OPS Officer: MIKE RIPLEY
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DONALD STRAKA
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/31/2002
Notification Time: 11:04 [ET]
Event Date: 10/31/2002
Event Time: 05:45 [MST]
Last Update Date: 10/31/2002
Notification Time: 11:04 [ET]
Event Date: 10/31/2002
Event Time: 05:45 [MST]
Last Update Date: 10/31/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CLAUDE JOHNSON (R4)
TERRY REIS (NRR)
CLAUDE JOHNSON (R4)
TERRY REIS (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 19 | Power Operation | 0 | Hot Standby |
UNIT 1 MANUALLY TRIPPED DUE TO HIGH SULFATE CONCENTRATIONS IN THE STEAM GENERATORS
"On October 31 2002, at approximately 05:45 MST Palo Verde Unit 1 experienced a manual reactor trip from approximately 19% rated thermal power due to high sulfate concentrations in the steam generators. Unit 1 was at normal temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. This was an uncomplicated reactor trip. No ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event.
"Unit 1 is stable at normal operating temperature and pressure in Mode 3. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public."
The licensee stated that the trip was initiated at the recommendation of the Chemistry Manager. The licensee continues to investigate the reason for the high sulfate concentration and an estimated restart date was not given.
The licensee notified the NRC Resident Inspector.
"On October 31 2002, at approximately 05:45 MST Palo Verde Unit 1 experienced a manual reactor trip from approximately 19% rated thermal power due to high sulfate concentrations in the steam generators. Unit 1 was at normal temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. This was an uncomplicated reactor trip. No ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event.
"Unit 1 is stable at normal operating temperature and pressure in Mode 3. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public."
The licensee stated that the trip was initiated at the recommendation of the Chemistry Manager. The licensee continues to investigate the reason for the high sulfate concentration and an estimated restart date was not given.
The licensee notified the NRC Resident Inspector.
Other Nuclear Material
Event Number: 39394
Rep Org: UNITED STATES ARMY -ABERDEEN
Licensee: UNITED STATES ARMY
Region: 1
City: ABERDEEN State: MD
County:
License #: 91-30563-01
Agreement: Y
Docket:
NRC Notified By: JOYCE KUYKENDALL
HQ OPS Officer: JOHN MacKINNON
Licensee: UNITED STATES ARMY
Region: 1
City: ABERDEEN State: MD
County:
License #: 91-30563-01
Agreement: Y
Docket:
NRC Notified By: JOYCE KUYKENDALL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/22/2002
Notification Time: 15:31 [ET]
Event Date: 10/31/2002
Event Time: 00:00 [EST]
Last Update Date: 11/22/2002
Notification Time: 15:31 [ET]
Event Date: 10/31/2002
Event Time: 00:00 [EST]
Last Update Date: 11/22/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MOHAMED SHANBAKY (R1)
DAVID AYRES (R2)
FRED BROWN (NMSS)
MOHAMED SHANBAKY (R1)
DAVID AYRES (R2)
FRED BROWN (NMSS)
MISSING CHEMICAL AGENT DETECTOR CONTAINING 30 MILLICURIES OF NICKEL-63
During a conversation in a training exercise on October 31, 2002, the Radiation Safety Officer at Fort Bragg, NC learned that a Unit had lost a GID-3 Chemical Agent Detector, containing 30 millicuries of Nickel-63, during a training exercise back in Oct/Nov of 2001. The training area was searched and other Units were asked if they had possession of the missing Chemical Agent Detector. The detector was not found and is now it considered missing.
During a conversation in a training exercise on October 31, 2002, the Radiation Safety Officer at Fort Bragg, NC learned that a Unit had lost a GID-3 Chemical Agent Detector, containing 30 millicuries of Nickel-63, during a training exercise back in Oct/Nov of 2001. The training area was searched and other Units were asked if they had possession of the missing Chemical Agent Detector. The detector was not found and is now it considered missing.