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Event Notification Report for November 21, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/20/2003 - 11/21/2003

** EVENT NUMBERS **


40334 40337 40342 40343 40344 40345

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General Information or Other Event Number: 40334
Rep Org: NV DIV OF RAD HEALTH
Licensee: NV DEPARTMENT OF TRANSPORTATION
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-14-0404-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHALL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/18/2003
Notification Time: 14:13 [ET]
Event Date: 11/15/2003
Event Time: [PST]
Last Update Date: 11/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
ROBERTO TORRES (NMSS)

Event Text

NEVADA STATE LICENSEE REPORTED A STOLEN TROXLER GAUGE

The Nevada Department of Transportation notified the Nevada Division of Rad Health on 11/17/03 that on 11/15/03 a Troxler 4640B, s/n 2361 was stolen out of a field lab trailer. The gauge was secured in the trailer, but the thief was able to defeat the locks and barriers. The gauge contained 8 millicuries of Cs-137. Notifications were made to the local police, the FBI and other states of the stolen gauge.

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General Information or Other Event Number: 40337
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/18/2003
Notification Time: 17:59 [ET]
Event Date: 11/17/2003
Event Time: [PST]
Last Update Date: 11/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KRISS KENNEDY (R4)
JOHN GREEVES (NMSS)

Event Text

PATIENT RECEIVED AN OVERDOSE DURING A BRACHYTHERAPY PROCEDURE

The licensee's RSO reported on 18 November 2003, that a patient, at Swedish Medical Center, Providence Campus, was scheduled to receive an intravascular Brachytherapy procedure that involved the use of a NOVOSTE Bata-Cath device. The device, Serial Number ZB638, employed a total activity of 2907 Megabecquerels (78.56 millicuries) of Strontium 90/Yttrium 90, in a sealed source-train, Serial Number 91837. The cardiologist was unable to insert the source-train for the treatment because, as reported by the RSO, it was into a small artery and the routing did not follow a direct path. This resulted in a 143 second, 13.78 Gray (1378 Rad), exposure to healthy patient tissue.

The source-train was partially inserted into the patient when the cardiologist experienced difficulty. A 143 second exposure time elapsed before the cardiologist withdrew the source-train even though medical center procedure requires the sources to immediately be withdrawn once a problem is understood. The delay apparently occurred as the cardiologist first worked to fully insert the source-train and then discussed correcting the problem with the oncologist.

The cause of the exposure was failure to follow established procedures. The cardiologist has been suspended from further licensed activities until the details of the event are fully understood. It is anticipated that no health affects to the patient will be realized as a result of the exposure. A DOH staff health physicist will pursue additional details of the event. There is no media attention at this time.

Patient and referring physician were notified.

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Other Nuclear Material Event Number: 40342
Rep Org: CROW BUTTE RESOURCES, INC
Licensee: CROW BUTTE RESOURCES, INC
Region: 4
City: CRAWFORD State: NE
County:
License #: SUA-1534
Agreement: Y
Docket:
NRC Notified By: MIKE GRIFFIN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/20/2003
Notification Time: 10:16 [ET]
Event Date: 11/19/2003
Event Time: 14:00 [CST]
Last Update Date: 11/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
KRISS KENNEDY (R4)
ROBERTO TORRES (NMSS)

Event Text

MEDICAL TREATMENT INVOLVING CONTAMINATION

On 11/19/03, a contract worker at the licensee's facility fell from a ladder breaking his shoulder while working in a contaminated area. The worker was transported to the hospital with the licensee's RSO while wearing his protective clothing. The protective clothing had removable contamination measured at 1380 dpm/100 cm2 (disintegrations per minute per 100 square-centimeters). The employee was released from the hospital and the contaminated clothing was recovered by the licensee.

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Power Reactor Event Number: 40343
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW WISNIEWSKI
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/20/2003
Notification Time: 11:19 [ET]
Event Date: 11/20/2003
Event Time: 09:25 [EST]
Last Update Date: 11/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRIAN MCDERMOTT (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DECLARED INOPERABLE

At 0925, while performing the HPCI time to rated flow surveillance, operators discovered the HPCI flow controller to be operating sluggishly in the automatic mode. The surveillance was stopped and HPCI was declared inoperable.

The licensee entered a 24-hour LCO per Technical Specification 3.5.5.2 due to Torus Cooling being in service on RHR loop "A". The licensee is now in a 14-day LCO as a result of securing Torus Cooling and restoring RHR LPCI loop "A". Troubleshooting was performed with I&C prior to securing HPCI. I&C is pursuing controller restoration to operability.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40344
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID M EPPERSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/20/2003
Notification Time: 12:11 [ET]
Event Date: 11/20/2003
Event Time: 10:20 [CST]
Last Update Date: 11/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
KRISS KENNEDY (R4)
JACK FOSTER (NRR)
WILLIAM RULAND (NRR)
BRIAN MCDERMOTT (R1)
DAVID AYRES (R2)
CHRISTINE LIPA (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

Event Text

LOW VOLTAGE CIRCUIT BREAKER DEFECT AND NONCOMPLIANCE REPORT

Deviation related to upper stud assemblies for General Electric Nuclear AKR-30 low voltage circuit breakers. The deviation is specific to upper stud assemblies supplied under part number Q139C4632G1 and consist of an incorrect angle between the stud and pivot. Of the fifteen assemblies supplied with possible deviations to AmerenUE, five were returned and ten had been installed in Callaway Plant. The deviation will not prevent the circuit breakers from performing their design basis function at the Callaway Plant, however, the capability of the assemblies is indeterminate for severe faulted conditions. A circuit breaker could fail if an upper stud assembly with identified deviation was installed and the circuit breaker was called upon to interrupt a severe fault.

"Callaway has concluded that this deviation does not constitute a "defect" as defined in 10CFR Part 21 because the breakers would still perform their design basis requirements and would not create a substantial safety hazard. However, Callaway can not determine if the potential for a significant safety hazard or exceeding of a technical specification safety limit could exist at another nuclear power plant."

Received written documentation that the licensee has notified the NRC resident inspector.

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Power Reactor Event Number: 40345
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID SEENEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/20/2003
Notification Time: 18:43 [ET]
Event Date: 11/20/2003
Event Time: 17:00 [CST]
Last Update Date: 11/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KRISS KENNEDY (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF SPDS FOR GREATER THAN 8 HOURS

"During the performance of the control room logs CKL ZL-003 the updating of the SPDS [Safety Parameter Display System] program on the Nuclear Plant Information System (NPIS) computer system was noted to have not changed state. With the recent restoration of the condenser off gas monitor GE RE-092 the computer log had not updated and indicated that the computer was not updating. A review of the computer services backlogs indicates the program has not updated since 11/14/2003 @ 10:29 [CST].

"This condition is being reported as a Loss of Emergency Preparedness under 10CFR50.72(b)(3)(xiii). The loss of NPIS affects Safety Parameter Display System (SPDS). SPDS is considered a significant portion of the WCGS emergency assessment capability. Because SPDS has been lost for longer than a short period OF time, Wolf Creek Nuclear Operating Corporation is making this notification pursuant to 10CFR50.72(b)(3)(xiii). There is no other loss of normal procedures and are taking local readings of equipment normally monitored by the NPIS computer. Current plant status is still Mode 5, 0%."

The licensee notified the NRC resident inspector.

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