Event Notification Report for March 25, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/24/2004 - 03/25/2004
General Information or Other
Event Number: 40610
Rep Org: FAIRBANKS MORSE ENGINE
Licensee: FAIRBANKS MORSE ENGINE
Region: 3
City: BELOIT State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TODD COLLINS (FAX)
HQ OPS Officer: STEVE SANDIN
Licensee: FAIRBANKS MORSE ENGINE
Region: 3
City: BELOIT State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TODD COLLINS (FAX)
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/25/2004
Notification Time: 17:56 [ET]
Event Date: 03/25/2004
Event Time: 00:00 [CST]
Last Update Date: 03/25/2004
Notification Time: 17:56 [ET]
Event Date: 03/25/2004
Event Time: 00:00 [CST]
Last Update Date: 03/25/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN MADERA (R3)
RONALD BELLAMY (R1)
DAVID GRAVES (R4)
VERN HODGE (NRR)
JACK FOSTER (NRR)
JOHN MADERA (R3)
RONALD BELLAMY (R1)
DAVID GRAVES (R4)
VERN HODGE (NRR)
JACK FOSTER (NRR)
PART 21 NOTIFICATION INVOLVING POTENTIAL SAFETY HAZARD FOR BLOWERS ON OP ENGINES
"Subject:Roots Blower on OP Engines
"On March 23, 2004, Fairbanks Morse Engine evaluation determined a potential safety hazard exists for blowers (P/N 16609294) on OP engines. It is possible that the aluminum rotors can slip on the steel shaft and cause rotor-to-rotor or rotor-to-housing contact which could cause blower failure and inability of engine to perform its safety function.
"The defect was caused by improper cleaning of the shaft prior to casting the rotor onto the shaft. This causes an inadequate bond and allows the aluminum rotor to move axially on the steel shaft. Sample testing of rotors has found this condition to exist to varying degrees on approximately 75% of rotors produced between 1998 and 2003.
"(4) blowers were shipped to nuclear utilities that may be affected:
"Utility Site Blower S/N
"Exelon Limerick (RB813A, RB3871, RB816)
"Entergy ANO-2 (RB814)
"To date, no engine failures have been experienced as a result of this problem. However, the potential exists. All slipped rotors have been found during routine maintenance inspections. This condition has been found to manifest itself within a low number of hours of operation. Therefore, the longer the rotors run and maintain proper clearance, the less likely they are to be affected by this condition.
"The affected utilities will be notified to evaluate inspection results and replace as necessary."
"Subject:Roots Blower on OP Engines
"On March 23, 2004, Fairbanks Morse Engine evaluation determined a potential safety hazard exists for blowers (P/N 16609294) on OP engines. It is possible that the aluminum rotors can slip on the steel shaft and cause rotor-to-rotor or rotor-to-housing contact which could cause blower failure and inability of engine to perform its safety function.
"The defect was caused by improper cleaning of the shaft prior to casting the rotor onto the shaft. This causes an inadequate bond and allows the aluminum rotor to move axially on the steel shaft. Sample testing of rotors has found this condition to exist to varying degrees on approximately 75% of rotors produced between 1998 and 2003.
"(4) blowers were shipped to nuclear utilities that may be affected:
"Utility Site Blower S/N
"Exelon Limerick (RB813A, RB3871, RB816)
"Entergy ANO-2 (RB814)
"To date, no engine failures have been experienced as a result of this problem. However, the potential exists. All slipped rotors have been found during routine maintenance inspections. This condition has been found to manifest itself within a low number of hours of operation. Therefore, the longer the rotors run and maintain proper clearance, the less likely they are to be affected by this condition.
"The affected utilities will be notified to evaluate inspection results and replace as necessary."
General Information or Other
Event Number: 40611
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: SAINT FRANCIS HOSPITAL
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79104
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: STEVE SANDIN
Licensee: SAINT FRANCIS HOSPITAL
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79104
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/26/2004
Notification Time: 14:53 [ET]
Event Date: 03/25/2004
Event Time: 08:45 [EST]
Last Update Date: 03/26/2004
Notification Time: 14:53 [ET]
Event Date: 03/25/2004
Event Time: 08:45 [EST]
Last Update Date: 03/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1)
ROBERTO TORRES (NMSS)
RONALD BELLAMY (R1)
ROBERTO TORRES (NMSS)
AGREEMENT STATE REPORT INVOLVING A MISADMINSTRATION DURING EYE TREATMENT
"Event description: A pterygium patient was scheduled to receive a 42.5 second treatment utilizing a 100 millicurie Srontium-90 sealed source manufactured by 3M Company, model number 6D1A. The dosimetrist programmed the manual timer for 4 minutes and 25 seconds. During the treatment, the physician questioned the treatment time and it was terminated after 2 minutes and 30 seconds. The prescribed dose was 20 Gy. The patient received 70.59 Gy. The patient and the physician were notified of the misadministration. The licensee notified the Division the same day of the event. The licensee will submit a written report within 15 days. This incident is reportable under 1200-2-5-.32 (79) (e) (4) of 'State Regulations for Protection Against Radiation.'"
TN Event Report ID No.: TN-04-035
"Event description: A pterygium patient was scheduled to receive a 42.5 second treatment utilizing a 100 millicurie Srontium-90 sealed source manufactured by 3M Company, model number 6D1A. The dosimetrist programmed the manual timer for 4 minutes and 25 seconds. During the treatment, the physician questioned the treatment time and it was terminated after 2 minutes and 30 seconds. The prescribed dose was 20 Gy. The patient received 70.59 Gy. The patient and the physician were notified of the misadministration. The licensee notified the Division the same day of the event. The licensee will submit a written report within 15 days. This incident is reportable under 1200-2-5-.32 (79) (e) (4) of 'State Regulations for Protection Against Radiation.'"
TN Event Report ID No.: TN-04-035