Event Notification Report for March 17, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/16/2005 - 03/17/2005
Power Reactor
Event Number: 41500
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN MANLY
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN MANLY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/17/2005
Notification Time: 21:45 [ET]
Event Date: 03/17/2005
Event Time: 17:55 [EST]
Last Update Date: 03/17/2005
Notification Time: 21:45 [ET]
Event Date: 03/17/2005
Event Time: 17:55 [EST]
Last Update Date: 03/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LAWRENCE DOERFLEIN (R1)
LAWRENCE DOERFLEIN (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OTHER UNSPECIFIED REQUIREMENT - LICENSE CONDITION 2.F
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"This notification is being made in accordance with License Condition 2.F for Nine Mile Point Unit 2 which states in part 'report any violations of the requirements contained in Section 2.C of this license in the following manner: initial notification shall be made within 24 hours to the NRC Operations Center via the Emergency Notification System, with written follow-up within 30 days in accordance with the procedures described in 10 CFR 50.73(b), (c), and (e).' License condition 2.C (2) states in part 'Nine Mile Point Nuclear Station, LLC shall operate the facility in accordance with the Technical Specifications.'
"Earlier this year Operations was notified by Engineering that a portion of the procedural guidance contained in the Operating Procedure for Standby Gas Treatment System (SGTS) would render an operating SGTS sub-system inoperable during certain evolutions (e.g. Primary Containment Purge). Specifically when the filter train's recirculation valves are taken out of the automatic mode of operation, the subsystem's ability to drawdown the Secondary Containment within the required time and maintain less than 1/4" W.C. vacuum cannot be assured.
"In accordance with the guidance provided in NUREG-1022, an extensive review of the operation of the SGTS system over the past 3 years was performed. This review identified two (2) instances where, if a SGTS subsystem(s) had been declared inoperable as required, one or more Technical Specifications would have been violated. For example: on 3/15/2002 one SGTS subsystem was being utilized for Primary Containment Purge evolutions (and as such inoperable) and the opposite Division's EDG was simultaneously inoperable for pre-planned maintenance for greater than 4 hours. Technical Specification 3.8.1 Condition B.2 requires declaring required feature(s), supported by the inoperable DG, inoperable when the redundant required feature(s) are inoperable (i.e. the non-running SGTS subsystem). This was not recognized and the requirement to initiate a plant shutdown per LCO 3.0.3 was not performed. The second instance occurred in November of 2002 and was similar to the first occurrence. Following the identification of these occurrences Engineering performed an analysis of actual plant data to confirm inoperability of SGTS.
"The example noted above and the others identified will be explained in detail in the follow-up LER that will be submitted as required by 10CFR 50.73(a)(2)(i)(B) - 'Any operation or condition which was prohibited by the plant's Technical Specifications.'"
The licensee has notified the NRC Resident Inspector.
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"This notification is being made in accordance with License Condition 2.F for Nine Mile Point Unit 2 which states in part 'report any violations of the requirements contained in Section 2.C of this license in the following manner: initial notification shall be made within 24 hours to the NRC Operations Center via the Emergency Notification System, with written follow-up within 30 days in accordance with the procedures described in 10 CFR 50.73(b), (c), and (e).' License condition 2.C (2) states in part 'Nine Mile Point Nuclear Station, LLC shall operate the facility in accordance with the Technical Specifications.'
"Earlier this year Operations was notified by Engineering that a portion of the procedural guidance contained in the Operating Procedure for Standby Gas Treatment System (SGTS) would render an operating SGTS sub-system inoperable during certain evolutions (e.g. Primary Containment Purge). Specifically when the filter train's recirculation valves are taken out of the automatic mode of operation, the subsystem's ability to drawdown the Secondary Containment within the required time and maintain less than 1/4" W.C. vacuum cannot be assured.
"In accordance with the guidance provided in NUREG-1022, an extensive review of the operation of the SGTS system over the past 3 years was performed. This review identified two (2) instances where, if a SGTS subsystem(s) had been declared inoperable as required, one or more Technical Specifications would have been violated. For example: on 3/15/2002 one SGTS subsystem was being utilized for Primary Containment Purge evolutions (and as such inoperable) and the opposite Division's EDG was simultaneously inoperable for pre-planned maintenance for greater than 4 hours. Technical Specification 3.8.1 Condition B.2 requires declaring required feature(s), supported by the inoperable DG, inoperable when the redundant required feature(s) are inoperable (i.e. the non-running SGTS subsystem). This was not recognized and the requirement to initiate a plant shutdown per LCO 3.0.3 was not performed. The second instance occurred in November of 2002 and was similar to the first occurrence. Following the identification of these occurrences Engineering performed an analysis of actual plant data to confirm inoperability of SGTS.
"The example noted above and the others identified will be explained in detail in the follow-up LER that will be submitted as required by 10CFR 50.73(a)(2)(i)(B) - 'Any operation or condition which was prohibited by the plant's Technical Specifications.'"
The licensee has notified the NRC Resident Inspector.
General Information or Other
Event Number: 41501
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: A. SCROGGS (E-MAIL)
HQ OPS Officer: BILL HUFFMAN
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: A. SCROGGS (E-MAIL)
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/18/2005
Notification Time: 11:30 [ET]
Event Date: 03/17/2005
Event Time: 12:00 [PST]
Last Update Date: 03/18/2005
Notification Time: 11:30 [ET]
Event Date: 03/17/2005
Event Time: 12:00 [PST]
Last Update Date: 03/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TOM FARNHOLTZ (R4)
TOM ESSIG (NMSS)
TOM FARNHOLTZ (R4)
TOM ESSIG (NMSS)
ARGEEMENT STATE MEDICAL EVENT
The following information was provided by the State via e-mail (State text in quotes):
"At 2 PM on March 17, 2005, the Swedish Medical Center, Radiation Safety Officer reported that an incident occurred at 12 PM, March 17, due to a clogged filter in the i.v. tubing used to administer an Iodine 131 radioisotope. The clog occurred during the procedure and prevented the administration of the total prescribed dose.
"The dosimetric protocol of the I-131 administration requires a 'cold' infusion of AntiB Antibody prior to radioisotope administration. This cold administration needs to pass through a 0.22 micron filter. The manufacturer's protocol states that the radioisotope should also be administered through the filter. The protocol further indicates that if the filter clogs, that the remainder of the radioisotope is administered without the presence of the filter.
"When the filter clogged, the nuclear medicine technologist first attempted to flush the clog with saline and then bypass the filter to complete the administration. After the administration it was determined by dose calibrator that 43.7 MBq (1.18 mCi) of I-131 was trapped in the tubing behind the filter. The actual administered activity was about 146.2 MBq (3.95 mCi) of the prescribed 185 MBq (5 mCi) dose.
"Corrective Actions: Since the preliminary investigation indicates the cause of the misadministration was due to clogging of the filter, the Radiation Safety Officer has recommended immediately bypassing the filter during administration instead of attempting to unclog it. The RSO plans to contact the vendor to get a protocol clarification and will include that information in the formal written report."
The following information was provided by the State via e-mail (State text in quotes):
"At 2 PM on March 17, 2005, the Swedish Medical Center, Radiation Safety Officer reported that an incident occurred at 12 PM, March 17, due to a clogged filter in the i.v. tubing used to administer an Iodine 131 radioisotope. The clog occurred during the procedure and prevented the administration of the total prescribed dose.
"The dosimetric protocol of the I-131 administration requires a 'cold' infusion of AntiB Antibody prior to radioisotope administration. This cold administration needs to pass through a 0.22 micron filter. The manufacturer's protocol states that the radioisotope should also be administered through the filter. The protocol further indicates that if the filter clogs, that the remainder of the radioisotope is administered without the presence of the filter.
"When the filter clogged, the nuclear medicine technologist first attempted to flush the clog with saline and then bypass the filter to complete the administration. After the administration it was determined by dose calibrator that 43.7 MBq (1.18 mCi) of I-131 was trapped in the tubing behind the filter. The actual administered activity was about 146.2 MBq (3.95 mCi) of the prescribed 185 MBq (5 mCi) dose.
"Corrective Actions: Since the preliminary investigation indicates the cause of the misadministration was due to clogging of the filter, the Radiation Safety Officer has recommended immediately bypassing the filter during administration instead of attempting to unclog it. The RSO plans to contact the vendor to get a protocol clarification and will include that information in the formal written report."