United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2002

Event Notification Report for December 12, 2002


                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           12/11/2002 - 12/12/2002

                              ** EVENT NUMBERS **

39426  39437  39438  39439  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39426       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 12/06/2002|
|LICENSEE:  NORTHWEST COMMUNITY HOSPITAL         |NOTIFICATION TIME: 13:13[EST]|
|    CITY:  ARLINGTON HEIGHTS        REGION:  3  |EVENT DATE:        12/05/2002|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CST]|
|LICENSE#:  IL-01094-01           AGREEMENT:  Y  |LAST UPDATE DATE:  12/06/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KENNETH RIEMER       R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOE KLINGER                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL EVENT, DOSE GREATER THAN 20% LARGER THAN    |
| PRESCRIBED                                                                   |
|                                                                              |
| "On December 5, 2002, the RSO at Northwest Community Hospital, Arlington     |
| Heights IL, notified the department of a 'reportable'  (misadministration)   |
| event that occurred involving Intravascular Brachytherapy.   The treatment   |
| was for a 52 mm lesion using 85 mCi [millicuries] of  P-32 (GDT source) in a |
| Guidant Corporation Galileo device.  The prescribed dose was 20 gray.  Using |
| a three step automated system, as  the 1st step was completed, the           |
| authorized user intervened and repositioned the markers for the system to    |
| intentionally deliver an  additional dose to this area of the lesion.  After |
| completing the treatment. The calculated dose to the lesion was determined   |
| to be 24.6  gray.  This is greater than 20% over the prescribed dose for     |
| this treatment and thus a reportable event. The RSO reported that the        |
| clinical  range for this treatment is 15-26 gray so no adverse health        |
| effects are anticipated with this event.  The RSO stated that a written      |
| report would be filed with the department within the required 15 day         |
| period.                                                                      |
|                                                                              |
| "Event Date  12/05/2002  License No:  IL-01094-01 Licensee: Northwest        |
| Community Hospital                                                           |
| City: Arlington Heights    State: IL  Event Class:  MD2 - MEDICAL EVENT      |
| Medical Event Information:  Patient Number: 1                                |
| % Overexposed: 23                                                            |
| Procedure:  BRACHY, REMOTE AFTERLOADER,                                      |
| Dose in RAD:  2460  Organ:  HEART   Study:  CARDIOVASCULAR SYSTEM            |
| Radionuclide:  P-32                                                          |
| Administered By:  PHYSICIAN  Keywords:  INTRAVASCULAR BRACHYTHERAPY"         |
|                                                                              |
| Item Number:  IL020074                                                       |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39437       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 12/11/2002|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 02:41[EST]|
|   RXTYPE: [1] GE-2                             |EVENT DATE:        12/11/2002|
+------------------------------------------------+EVENT TIME:        02:30[EST]|
| NRC NOTIFIED BY:  STEVE FULLER                 |LAST UPDATE DATE:  12/11/2002|
|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MICHELE EVANS        R1      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO FAA                                                  |
|                                                                              |
| Licensee made an offsite notification to FAA due to loss of power to plant   |
| stack lighting.  FAA assigned notification number MIV-212/061-RG.  FAA was   |
| again notified at 0230 EST that the stack lights were returned to service,   |
|                                                                              |
| Licensee notified NRC resident.                                              |
|                                                                              |
| RETRACTION BY FRANK CIGANIK TO ERIC THOMAS ON 12/11/02 AT 1736               |
|                                                                              |
| "Reason for retraction: As per written guidance in NUREG-1022 (Event         |
| Reporting Guidelines) Section 3.2.12,  the NRC doesn't need to be informed   |
| of problems with plant stack or water tower lighting"                        |
|                                                                              |
| Licensee notified the NRC Resident Inspector.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39438       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 12/11/2002|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 11:20[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        12/11/2002|
+------------------------------------------------+EVENT TIME:        11:20[EST]|
| NRC NOTIFIED BY:  ROBERT BOESCH                |LAST UPDATE DATE:  12/11/2002|
|  HQ OPS OFFICER:  JASON FLEMMING               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID LEW            R1      |
|10 CFR SECTION:                                 |PETER BIRMINGHAM     IAT     |
|DDDD 73.71(b)(1)         SAFEGUARDS REPORTS     |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNAUTHORIZED ENTRY INTO A VITAL PLANT AREA BY CONTRACT PERSONNEL             |
|                                                                              |
| An unauthorized entry into a vital area occurred by a contract employee.     |
| Immediate compensatory measures were taken upon discovery.  The licensee     |
| notified the NRC Resident Inspector. Contact the HOO for additional details. |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39439       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 12/12/2002|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 00:20[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        12/11/2002|
+------------------------------------------------+EVENT TIME:        18:13[EST]|
| NRC NOTIFIED BY:  Jim Case                     |LAST UPDATE DATE:  12/12/2002|
|  HQ OPS OFFICER:  JASON FLEMMING               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |PATRICK HILAND       R3      |
|10 CFR SECTION:                                 |                             |
|AINC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RHR B MINIMUM CONTROL FLOW VALVE INOPERABLE                                  |
|                                                                              |
| "Scheduled maintenance activities were being performed on RHR B minimum flow |
| valve IE12-F064B which is a containment isolation valve. When the E12-F064 B |
| power supply was energized the Control Room indication for the valve         |
| indicated intermediate.   Local indication for the valve indicated the valve |
| was closed.  When the valve control switch was taken to closed the valve was |
| observed to move 1/16 of an inch and the control room indication changed to  |
| full close. The valve was closed and verified down powered on 12/09/02 to    |
| comply with Tech Spec 3.6.1.3 Primary Containment Isolation Valves.          |
| Maintenance test equipment was installed however no maintenance had been     |
| performed."                                                                  |
|                                                                              |
| Licensee informed NRC resident inspector.                                    |
+------------------------------------------------------------------------------+