Event Notification Report for January 16, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/15/2003 - 01/16/2003
** EVENT NUMBERS **
39509 39510 39512 39513 39514
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|Hospital |Event Number: 39509 |
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| REP ORG: ALLEGHENY GENERAL HOSPITAL |NOTIFICATION DATE: 01/15/2003|
|LICENSEE: ALLEGHENY GENERAL HOSPITAL |NOTIFICATION TIME: 13:08[EST]|
| CITY: PITTSBURGH REGION: 1 |EVENT DATE: 01/14/2003|
| COUNTY: STATE: PA |EVENT TIME: 15:00[EST]|
|LICENSE#: 37-01317-01 AGREEMENT: N |LAST UPDATE DATE: 01/15/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOE OCH | |
| HQ OPS OFFICER: MIKE NORRIS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BOV2 20.2202(b)(1) PERS OVEREXPOSURE/TEDE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| ESTIMATED OVEREXPOSURE TO SKIN OR EXTREMITIES > 50 REM |
| |
| An employee at the hospital was found to have an estimated 6 microcuries of |
| I-131 contamination on his right index finger. It is suspected that he |
| received the contamination while working in the hot lab. Decontamination |
| efforts are in progress at this time. There is no spread of contamination |
| in the hot lab and an investigation is in progress. The estimated exposure |
| to the finger is > 50 Rem. |
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|Hospital |Event Number: 39510 |
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| REP ORG: PENNSYLVANIA HOSPITAL |NOTIFICATION DATE: 01/15/2003|
|LICENSEE: PENNSYLVANIA HOSPITAL |NOTIFICATION TIME: 13:49[EST]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 01/13/2003|
| COUNTY: STATE: PA |EVENT TIME: 12:00[EST]|
|LICENSE#: 37-06864-06 AGREEMENT: N |LAST UPDATE DATE: 01/15/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DR. LEONARD SHABASON | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| DAMAGED IODINE-125 SEED RESULTS IN DOSE THAT DIFFERS FROM PRESCRIBED DOSE BY |
| >20 % |
| |
| "On Monday January 13, 2003 a prostate implant was performed on [DELETED]. |
| The seeds that were used were Amersham's Echoseed. Each seed had an |
| activity of 0.472 [millicurie] apparent activity (NIST 1999) on the day of |
| the implant. The actual activity is 1.78 times the apparent activity which |
| results in an actual activity of 0.84 [millicurie]. |
| |
| "During the implant there was difficulty in removing a cartridge. Once the |
| cartridge was removed, there was some activity that registered in the Mick |
| gun. A blood clot that registered radioactivity was expelled from the gun |
| and was isolated and the implant proceeded. This involved the last seed in |
| a Mick disposable cartridge. |
| |
| "Once the implant was completed, the blood clot was examined and was found |
| to contain a fragment of a seed. The entire operating room was checked |
| carefully to see if the other portion of the seed was anywhere on the |
| operating room. There was no contamination found in any of the instruments |
| or in any of the used cartridges with the GM probe. No seeds or any |
| activity was discovered during cystography or in any of the trash in the |
| operating room. The feet of all the individuals involved in the procedure |
| were checked in case a seed adhered to a shoe covering. It was assumed that |
| the remainder of the seed was placed in the patient's prostate. The |
| radiation oncologist ordered that the patient be given a blocking dose of |
| iodine in the form of Lugol's solution. The radiation oncologist informed |
| the patient that he was being placed on this medication because of the |
| possibility that a leaking seed was implanted." |
| |
| The prescribing physician has informed the patient. |
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|General Information or Other |Event Number: 39512 |
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| REP ORG: ROCKBESTOS-SUPRENANT CABLE CORP. |NOTIFICATION DATE: 01/15/2003|
|LICENSEE: ROCKBESTOS-SUPRENANT CABLE CORP. |NOTIFICATION TIME: 16:42[EST]|
| CITY: EAST GRANBY REGION: 1 |EVENT DATE: 01/14/2003|
| COUNTY: STATE: CT |EVENT TIME: [EST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 01/15/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| |THOMAS DECKER R2 |
+------------------------------------------------+DAVID HILLS R3 |
| NRC NOTIFIED BY: RICHARD C. BROWN |GARY SANBORN R4 |
| HQ OPS OFFICER: HOWIE CROUCH |JACK FOSTER NRR |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INITIAL NOTIFICATION OF 10 CFR PART 21 DEFECT/FAILURE TO COMPLY |
| |
| "The following information is supplied in accordance with the requirements |
| of 10 CFR 21. |
| "I. Name and address of individual informing the Commission: |
| |
| [Deleted] |
| |
| "II. Identification of the basic component supplied which fails to comply or |
| contains a defect: |
| |
| "The KXL 760D insulation system (chemically crosslinked only) provided in |
| some of the Firewall III cables manufactured from January 1992 thru June |
| 1995 may include an alternate resin which was not part of the baseline |
| qualification testing. |
| |
| "III. Identification of the firm supplying the basic component which fails |
| to comply or contains a defect: |
| |
| "The Rockbestos-Surprenant Cable Corp., East Granby, CT facility. |
| |
| "IV. Nature of the defect or failure to comply and the safety hazard which |
| is created: |
| |
| "Nature of Defect: An alternate resin material may have been substituted in |
| the insulation system for Firewall III cables (chemically crosslinked cables |
| only). |
| Potential Hazard: The chemically cured insulation system utilizing KXL 760D |
| for cables manufactured from January 1992 thru June 1995 may not be |
| enveloped by qualification report QR5804. |
| |
| "V. The date on which the information of such defect or failure to comply |
| was obtained: |
| |
| "On the basis of our evaluation it was determined on January 14, 2003 that a |
| defect or failure to comply as defined by 10 CFR 21 existed. |
| |
| "VI. The number and location of all basic components which contain a defect |
| or falls to comply: |
| |
| "The number and location of all basic components which may contain a defect |
| or fail to comply is yet to be determined. |
| |
| "VII. The corrective action which has been, is being, or will be taken; the |
| name of the individual or organization responsible for the action; and the |
| length of time that has been or will be taken to complete the action: |
| |
| "Based on testing and analysis, both resin suppliers indicated that both |
| resins were quite similar and they were not able to distinguish or identify |
| one resin from the other. Documented evidence of their conclusion has been |
| requested. Rockbestos-Surprenant has instituted a similarity analysis |
| program on both resins that is expected to be completed by March 14, 2003. |
| Preliminary test results indicate that the two resins are indistinguishable. |
| A full report will be available upon completion of the similarity analysis |
| program. |
| |
| " VIII. Any advice related to the defect or failure to comply about the |
| basic component that has been, is being, or will be given to purchasers: |
| |
| "Purchasers will be advised not to install any Firewall III cables that |
| employ the chemically cured insulation material that were manufactured from |
| January 1992 thru June 1995 until the results of the similarity program are |
| known. Further advice will be provided at that time." |
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|Power Reactor |Event Number: 39513 |
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| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 01/15/2003|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 21:01[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 01/15/2003|
+------------------------------------------------+EVENT TIME: 20:10[EST]|
| NRC NOTIFIED BY: JOE GALLAGHER |LAST UPDATE DATE: 01/15/2003|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |DAVID HILLS R3 |
|10 CFR SECTION: |TAD MARSH NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |NADER MAMISH IRO |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|BUTCH DUNDRIFF FEMA |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| UNUSUAL EVENT DECLARED DUE TO FIRE IN THE MAIN TRANSFORMER >15 MIN. |
| |
| Unusual event declared at 2025 EST due to fire in the Unit 1 main |
| transformer caused main turbine trip, resulting in a reactor trip. All |
| control rods fully inserted, all reactor coolant pumps are running with |
| offsite power available. Cause of fire is unknown at this time. Fire was out |
| at 2045 EST. Off-site fire assistance was called but fire was out prior to |
| their arrival. One person transported off-site for minor injury due to |
| fall. Environmental issues due to transformer oil and fire suppression. |
| Environmental personnel are on-site. Clean-up is in progress. |
| |
| NRC Resident Inspector has been informed. |
| |
| ***Update 1/15/03 2238 Dan Malone to Howie Crouch*** |
| |
| Unusual Event terminated at 2220 EST. |
| |
| NRC Resident Inspector has been notified. Notified R3DO (Hill), NRREO |
| (Marsh) and FEMA. |
| |
| ***Update 1/15/03 2339 EST Brian Bates to Howie Crouch*** |
| |
| "At 2010 on 1/5103, a fault occurred in the Unit 1 Main Transformer, |
| resulting in a fire. The fault caused an automatic main generator trip and |
| an immediate turbine trip and reactor trip. The fire was originally |
| extinguished at 2035, with one minor reflash that was promptly controlled by |
| the fire brigade. The Emergency Plan was activated at the Unusual Event |
| level due to a fire within the protected area not being extinguished within |
| fifteen minutes. All applicable notifications were made for the Emergency |
| Plan declaration, including a one-hour report to the NRC at 2100 (event |
| notification # 39513). There was one minor personnel injury involved which |
| required off-site medical attention, due to an individual suffering a fall |
| and smoke inhalation. Offsite notifications were made to the National |
| Response Center, Michigan Emergency Alert System, and the Local Emergency |
| Planning Commission regarding the spilled transformer oil, which is |
| currently being cleaned up. The auxiliary feedwater system actuated due to |
| low steam generator levels after the reactor trip, as expected. There were |
| no significant complications in the plant response to the reactor trip, and |
| the unit is stable in Mode 3. The Unusual Event was exited at 2220." |
| |
| The Licensee notified the NRC Resident Inspector of this update. |
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|Power Reactor |Event Number: 39514 |
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| FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 01/15/2003|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 22:12[EST]|
| RXTYPE: [1] CE |EVENT DATE: 01/15/2003|
+------------------------------------------------+EVENT TIME: 21:15[EST]|
| NRC NOTIFIED BY: DAVID VANDEWALLE |LAST UPDATE DATE: 01/15/2003|
| HQ OPS OFFICER: JASON FLEMMING +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID HILLS R3 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
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| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |95 Power Operation |
| | |
| | |
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EVENT TEXT
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| TECHNICAL SPECIFICATION SHUTDOWN DUE TO STEAM GENERATOR CHANNELS DECLARED |
| INOPERABLE |
| |
| "On January 15, 2003 at 2115 hours a Technical Specification required |
| shutdown was initiated in accordance with the Technical Specification 3.0.3. |
| Technical Specification 3.0.3 had been entered due to all four steam |
| generator low-level channels in each steam generator being declared |
| inoperable when the low-level trip setpoints were determined to be set below |
| the allowable value specified in Technical Specification 3.3.1, 'Reactor |
| Protection System Instrumentation', and Technical Specification 3.3.3. ' |
| Engineered Safety Features Instrumentation'." |
| |
| NRC Resident Inspector has been informed. |
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