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Event Notification Report for December 3, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/02/2004 - 12/03/2004

** EVENT NUMBERS **


41230 41236 41239 41240

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General Information or Other Event Number: 41230
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: NORTH SHORE MEDICAL CENTER
Region: 1
City: SALEM State: MA
County:
License #: 44-0161
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/29/2004
Notification Time: 14:07 [ET]
Event Date: 09/25/2001
Event Time: 17:00 [EST]
Last Update Date: 11/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
LINDA GERSEY (NMSS)

Event Text

MEDICAL MISADMINISTRATION DUE TO IMPROPER POSITIONING OF IMPLANT DEVICE

"Abstract - Female patient undergoing vaginal implant therapy on September 25, 2001. 'T-bomb' applicator loaded with 3 Cs-137 sources, each 19.73 mg RaEq [milligram Radium Equivalent] (49.92 mCi each, total activity 149.75 mCi). Implant performed 8:30 AM on 9/25/01. Status of implant placement made by nurse at 10:42 AM, and again at 2:10 PM. When physician checked patient at 5:00 PM on 9/25/01, implant was found outside of patient adjacent to her vaginal area. Physician did not report incident to Radiation Safety Officer, thus Licensee did not report incident to State. Estimate of total absorbed dose to the surface of the affected area was 7.55 Gy [Gray], this includes a dose of 0.74 Gy that comes from the normal implant itself.

"Consequence of exposure - Tissue necrosis in affected area."

The cause of the misadministration is still under investigation. A contributing factor was the failure to periodically check the implant placement. The patient was informed.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 41236
Rep Org: CHRIST HOSPITAL
Licensee: CHRIST HOSPITAL
Region: 1
City: JERSEY CITY State: NJ
County:
License #: 29-126-6401
Agreement: N
Docket:
NRC Notified By: LINDA BELDKAMP
HQ OPS Officer: BILL GOTT
Notification Date: 12/02/2004
Notification Time: 13:46 [ET]
Event Date: 12/01/2004
Event Time: 11:00 [EST]
Last Update Date: 12/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1)
TOM ESSIG (NMSS)

Event Text

MEDICAL EVENT - GREATER THAN PERSCRIBED DOSE TO AN ORGAN

At 1100 EST on 12/01/04 a patient was to receive 4.5 milliCuries Thallium - 201 (Tl-201) and then 3 millicuries Technitium-99M (Tc-99M). The first dose was administered but instead of administering the technetium, a second dose of Thallium was administered. The patient and physician were informed. No adverse affects are expected. The hospital is conducting an investigation as to the cause of the improper administration.

* * * RETRACTION FROM L BELDCAMP TO W GOTT AT 1640 ON 12/02/04 * * *

After consulting with NRC Region 1, the licensee determined that this is not a reportable event because Thallium is not an NRC regulated isotope.

Notified R1DO (Trapp) and NMSS (Janosko).

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Power Reactor Event Number: 41239
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KEN HIGGINBOTHAM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/02/2004
Notification Time: 20:10 [ET]
Event Date: 12/02/2004
Event Time: 17:30 [CST]
Last Update Date: 12/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
DAVID GRAVES (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 77 Power Operation

Event Text

TECHNICAL SPECIFICATION SHUTDOWN DUE TO LOSS OF THE DIVISION 2 125 VDC BATTERY CHARGER

"On December 2, 2004, at 17:30 p.m. CST, River Bend Station commenced a plant shutdown required by Technical Specifications. This action was made necessary by the loss of the Division 2 safety-related 125 volt battery charger. The cause of the failure has not been determined. Actions are ongoing to restore the charger to service.

"The pertinent Technical Specification action statement was entered at 1236 CST on 12/02/2004, and requires the plant to be in Mode 3 by 0036 CST on 12/03/2004 and Mode 4 by 0036 CST on 12/04/2004. This event is being report in accordance with 10CFR50.72(b)(2)(i)."

The licensee added that the Division 1 electrical system is available and fully capable of supporting all reactor safety-related protective functions. The licensee is still trouble shooting the cause of the charger malfunction.

The licensee has notified the NRC Senior Resident Inspector.

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Power Reactor Event Number: 41240
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL ABBOTT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/02/2004
Notification Time: 21:39 [ET]
Event Date: 12/02/2004
Event Time: 19:30 [EST]
Last Update Date: 12/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES TRAPP (R1)
JOSE CALVO (NRR)
ELIOT BRENNER (PAO)

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

Event Text

PRESS RELEASE CONCERNING THE PLANNED SHUTDOWN OF THE SALEM UNITS DUE TO AN OIL SPILL

"PSEG Nuclear announced, via a press release, that based on Delaware River conditions and the potential for oil from the Athos I oil tanker spill to reach the plant circulating and service water intake structures, it has been decided to take both units at the Salem Nuclear Generating Station offline. Hope Creek Generating Station is currently offline in a refueling outage. PSEG Nuclear currently plans to begin reducing power on both Salem Units on Friday December 3, 2004. PSEG Nuclear is continually monitoring river conditions and tracking the progress of the oil spill. Today, PSEG Nuclear began placing booms around the water intake structures at both Salem and Hope Creek nuclear generating stations. The boom is a barrier placed approximately 18 inches deep in the water and is relatively effective in controlling the spread of oil that is on top or close to the surface. However, since the oil spilled in the Delaware River was crude oil, it is expected that the heavier oil might be suspended in the river at varying depths, increasing the potential that oil could reach the plant intake structures. Since the potential exists to adversely impact the plant cooling systems if oil was entrained in the plant cooling water, both Salem 1 and 2 are going to be shutdown.

"This report is being made due to the press release and the possibility that this release will generate public interest. No power reduction has been started at this time. At this time there has been no adverse impact noted on either Salem Unit 1 or 2 due to the oil spill. No injuries have resulted from this condition."

The licensee will notify the NRC Resident Inspector, LAC Township, and representatives of the states of NJ and Delaware.

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