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Event Notification Report for November 28, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2003 - 11/28/2003

** EVENT NUMBERS **


40352 40357 40358 40359

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General Information or Other Event Number: 40352
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee:
Region: 3
City:  State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: GERRY WAIG
Notification Date: 11/25/2003
Notification Time: 11:32 [ET]
Event Date: 11/24/2003
Event Time: 14:15 [CST]
Last Update Date: 11/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
JOHN GREEVES (NMSS)

Event Text

AGREEMENT STATE REPORT - DOSE TO PATIENT OUTSIDE INTENDED TREATMENT SITE

"[Radiation Safety Officer (RSO)] for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy [IVB] procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.

" The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area.

"The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days."

Illinois Event Report ID: IL030078, License Number: IL -01152-01

Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies

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Power Reactor Event Number: 40357
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: TODD GRANLUND
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/27/2003
Notification Time: 03:24 [ET]
Event Date: 11/27/2003
Event Time: 00:52 [CST]
Last Update Date: 11/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
SONIA BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 23 Power Operation 0 Hot Shutdown

Event Text

REACTOR MANUALLY SCRAMMED FROM 23% DUE TO DECREASING REACTOR VESSEL WATER LEVEL

A manual reactor scram was initiated due to a decreasing reactor vessel water level. The decreasing water level occurred during a feedwater transient while performing a power reduction in preparation for taking the main generator off line for maintenance. The licensee is investigating the cause of the feedwater transient, but it occurred while one turbine driven reactor feed pump was being taken off line. All rods fully inserted following the scram and no ECCS or safety relief valves actuated. Residual heat is being rejected to the condenser.

The licensee notified NRC Resident Inspector.

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Power Reactor Event Number: 40358
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BRUCE FERGUSON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/27/2003
Notification Time: 06:51 [ET]
Event Date: 11/27/2003
Event Time: 06:29 [EST]
Last Update Date: 11/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ANTHONY DIMITRIADIS (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 20 Power Operation 0 Hot Standby

Event Text

PLANT HAD A MANUAL REACTOR TRIP FROM 23% POWER DUE TO TURBINE VIBRATION

While rolling the turbine when at 20% power they experienced an over speed turbine trip. During a second attempt when at 23% power, the turbine had high vibration so they manually tripped the reactor. Cause for the vibration is being investigated since a new rotor had just been installed in the turbine. All rods fully inserted during the reactor trip and no ECCS injection occurred or primary relief valves lifted.


The licensee notified the NRC Resident, the State of Connecticut and Local agencies

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Power Reactor Event Number: 40359
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMIE MCCONNELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/28/2003
Notification Time: 01:55 [ET]
Event Date: 11/27/2003
Event Time: 22:55 [EST]
Last Update Date: 11/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEPHEN CAHILL (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling Shutdown 0 Refueling Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

COMPONENT COOLING SYSTEM SURGE TANK SUPPORTS MAY FAIL DURING A SEISMIC EVENT

During an ISI inspection of the component cooling system, it was discovered that several of the surge tank support stiffener plates were missing due to a design change that was never fully implemented. This condition creates a question as to the adequacy of the tanks to withstand a seismic event. This deficiency affects both trains of component cooling on Units 1 and 2. The problem will be corrected on Unit 1 while it is in its refueling outage. Work on the Unit 2 "A" train is currently ongoing, making that train of the component cooling system inoperable, therefore, putting the plant in a 72 hour LCO. When work on the "A" train is completed, they will exit the LCO, but re-enter it when work begins on the "B" train.


Licensee will notify the NRC Resident Inspector, the State and local agencies

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Friday, March 30, 2012