United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > July 18

Event Notification Report for July 18, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           07/17/2003 - 07/18/2003



                              ** EVENT NUMBERS **



39986  40001  40004  



!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!

+------------------------------------------------------------------------------+

|Hospital                                         |Event Number:   39986       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  UNIVERSITY OF WISCONSIN - MADISON    |NOTIFICATION DATE: 07/09/2003|

|LICENSEE:  UNIVERSITY OF WISCONSIN              |NOTIFICATION TIME: 18:07[EDT]|

|    CITY:  Madison                  REGION:  3  |EVENT DATE:        07/09/2003|

|  COUNTY:  Dane                      STATE:  WI |EVENT TIME:        13:00[CDT]|

|LICENSE#:  48-09843-18           AGREEMENT:  N  |LAST UPDATE DATE:  07/17/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |CHRIS MILLER         R3      |

|                                                |SUSAN FRANT          NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  RONALD BRESELL               |                             |

|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| MEDICAL EVENT                                                                |

|                                                                              |

| At 1300 CDT on 7/9/03, an underadministration of Yttrium-90 (Y-90) occurred  |

| at the University of Wisconsin Hospital in Madison, WI.  A patient being     |

| treated for secondary liver cancer was to receive a dose of approximately 50 |

| millicuries of Y-90.  The dose was delivered using a SIRTECH (Selective      |

| Radiation Implantation) to pulse microspheres of Y-90 from a vial into the   |

| liver via a needle and catheter.                                             |

|                                                                              |

| During the procedure, the SIRTECH did not develop enough pressure to deliver |

| the entire dose to the patient, and only about 8 percent of the Y-90 was     |

| delivered to the patient (between 3-4 millicuries).  The remainder of the    |

| Y-90 microspheres were contained within the vial.                            |

|                                                                              |

| There was no adverse affect on the patient due to this underadministration,  |

| and the licensee is still investigating how to prevent a re-currence.  The   |

| patient was notified of the underadministration.                             |

|                                                                              |

| * * * RETRACTION AT 0615 EDT ON 07/17/03 FROM BRESELL TO GOTT * * *          |

|                                                                              |

| The licensee determined that the technician had misinterpreted the           |

| measurement of the Y-90 administered to the patient and determined that the  |

| correct amount of Y-90 was administered.  Because the correct amount of Y-90 |

| was administered, the licensee is retracting the event.  The licensee        |

| discussed this with Deborah Piskura, NRC Region III.                         |

|                                                                              |

| Notified R3DO (Riemer) and NMSS EO (Pierson)                                 |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Power Reactor                                    |Event Number:   40001       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| FACILITY: WOLF CREEK               REGION:  4  |NOTIFICATION DATE: 07/17/2003|

|    UNIT:  [1] [] []                 STATE:  KS |NOTIFICATION TIME: 06:57[EDT]|

|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        07/16/2003|

+------------------------------------------------+EVENT TIME:        22:08[CDT]|

| NRC NOTIFIED BY:  STEVEN HENRY                 |LAST UPDATE DATE:  07/17/2003|

|  HQ OPS OFFICER:  BILL GOTT                    +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |LINDA SMITH          R4      |

|10 CFR SECTION:                                 |TERRYREIS            NRR     |

|NINF                     INFORMATION ONLY       |TIM MCGINTY          IRO     |

|                                                |MATT HAHN            NSIR    |

|                                                |AL TARDIFF           NSIR    |

|                                                |                             |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|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                                   

+------------------------------------------------------------------------------+

| UNDECLARED UNUSUAL EVENT                                                     |

|                                                                              |

| At 0501 CDT on 07/17/03 the shift manager determined that a condition        |

| existed for 10 minutes the previous evening  which met the emergency plan    |

| criteria but no emergency was declared.  The basis for the emergency class   |

| no longer existed at the time of discovery.  Upon discovery he notified the  |

| NRC Operations Center and the NRC Resident Inspector.                        |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Fuel Cycle Facility                              |Event Number:   40004       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION    |NOTIFICATION DATE: 07/17/2003|

|   RXTYPE: URANIUM FUEL FABRICATION             |NOTIFICATION TIME: 16:00[EDT]|

| COMMENTS: LEU CONVERSION (UF6 to UO2)          |EVENT DATE:        07/17/2003|

|           COMMERCIAL LWR FUEL                  |EVENT TIME:        03:35[EDT]|

|                                                |LAST UPDATE DATE:  07/17/2003|

|    CITY:  COLUMBIA                 REGION:  2  +-----------------------------+

|  COUNTY:  RICHLAND                  STATE:  SC |PERSON          ORGANIZATION |

|LICENSE#:  SNM-1107              AGREEMENT:  Y  |JOHN PELCHAT         R2      |

|  DOCKET:  07001151                             |CHARLIE MILLER       NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  CARL SYNDER                  |                             |

|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NBNL                     RESPONSE-BULLETIN      |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| 24-HOUR NRC 91-01 BULLETIN NOTIFICATION INVOLVING LOSS OF CRITICALITY        |

| CONTROL                                                                      |

|                                                                              |

| The following is a portion of text from a fax submitted by the licensee:     |

|                                                                              |

| "Pump-Out to UNBSS Without Sample Results.                                   |

| "Reason for Notification:   An operator pumped out a batch from the clean    |

| dissolver to the uranyl nitrate bulk storage tank prior to receiving the     |

| required sample results for grams U-235 per liter, percent free acid, and    |

| pH.                                                                          |

|                                                                              |

| "Double Contingency Protection:  Double contingency protection for the bulk  |

| storage tank is based on concentration control. Concentration control is     |

| based upon maintaining uranyl nitrate that is pumped to the tanks at less    |

| than 5 grams U-235/liter. The pH is maintained at a value of less than 2 to  |

| ensure that the uranyl nitrate stays in solution. The percent free acid is   |

| maintained at greater than 4 percent to ensure that the uranyl nitrate stays |

| in solution and depresses the freezing temperature of the solution to        |

| prevent concentration by freezing.                                           |

|                                                                              |

| "It has been determined that less than previously documented double          |

| contingency protection remained for the system and that greater than a safe  |

| mass was involved., but a sufficient number of controls that were lost were  |

| restored within 4 hours. In accordance with Westinghouse Operating License   |

| (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a  |

| 24-hour notification.                                                        |

|                                                                              |

| "As Found Condition:  See 'Reason for Notification' above.                   |

|                                                                              |

| "Summary of Activity:  (1)  Pump outs to the bulk storage tanks were         |

| stopped, (2) Samples for grams U-235/liter, pH, and %free acid were taken to |

| ensure the tanks were in specification,  (3)  Before the end of the shift,   |

| sample results for grants U-235/liter, pH, and %free acid were determined to |

| be acceptable.                                                               |

|                                                                              |

| "Conclusions:  (1)  Loss of double contingency protection occurred, (2)      |

| Greater than a safe mass was involved, (3)  At no time was the health or     |

| safety to any employee or member of the public in jeopardy. No exposure to   |

| hazardous material was involved, (4)  The Incident Review Committee (IRC)    |

| determined that this is a safety significant incident in accordance with     |

| governing procedures, (5)  Notification was the result of an event, not a    |

| deficient NCS analysis, (6)  A causal analysis will be performed."           |

|                                                                              |

| The licensee attributes the cause of this incident to personnel error.  The  |

| licensee will inform both NRC Region 2 and the NRC Headquarters PM.          |

+------------------------------------------------------------------------------+