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Event Notification Report for March 23, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/22/2005 - 03/23/2005

** EVENT NUMBERS **


41501 41511 41512 41513 41514 41515

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM FARNHOLTZ (R4)
TOM ESSIG (NMSS)

Event Text

ARGEEMENT STATE MEDICAL EVENT

This following informing was provided by the licensee vial e-mail (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."

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Power Reactor Event Number: 41511
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: PAUL REIMERS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/22/2005
Notification Time: 04:21 [ET]
Event Date: 03/22/2005
Event Time: 03:47 [EST]
Last Update Date: 03/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEPHEN CAHILL (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
4 M/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR MANUALLY TRIPPED FOLLOWING LOSS OF MAIN FEED PUMP

The licensee provided the following information via fax (licensee text in quotes)

"The 4A SGFP [Steam Generator Feed Pump] tripped, initiating a Turbine Runback. Operators manually inserted a Reactor Trip at 15% Steam Generator level. The reactor tripped and all control rods inserted. Auxiliary Feedwater automatically initiated as expected. All systems operated as expected except the 4A SGFP discharge MOV which has no [position] indication [in the main control room and is being] investigated."

Decay heat is being removed by atmospheric steam dumps. The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 41512
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BRETT BOISMENU
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/22/2005
Notification Time: 08:10 [ET]
Event Date: 03/22/2005
Event Time: [EST]
Last Update Date: 03/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
MOHAMED SHANBAKY (R1)

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

FOR CAUSE FITNESS FOR DUTY TEST FAILURE

A contract supervisor had a confirmed positive for alcohol during a "for-cause" fitness for duty test. The contractor's site access was denied, the contractor was escorted off site and provided a ride home. Contact the Headquarters Operations Officer for additional details.

The NRC Resident will be notified by the site.

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Power Reactor Event Number: 41513
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MATHEW ARSENAULT
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/22/2005
Notification Time: 12:25 [ET]
Event Date: 03/22/2005
Event Time: 11:02 [EST]
Last Update Date: 03/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MOHAMED SHANBAKY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 61 Power Operation

Event Text

PLANT SHUTTING DOWN TO MODE 3 FROM 100% POWER DUE TO A REACTOR TRIP BREAKER BEING INOPERABLE.

A plant shutdown to mode 3( 0% power) was started at 1102 on 3/22/05. The shutdown was required per T.S. 3.3-1 Table 3.3-1, item 19, action 9. Reactor trip breaker "A" is inoperable. T.S.3.3.1, Table 3.3-1 item 19, action requires a shutdown to mode 3 within 6 hours. Plant must be in mode 3 by 1622 EST on 3-22-05. They are currently troubleshooting on the reactor trip breaker.


The NRC Resident Inspector was notified.

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Other Nuclear Material Event Number: 41514
Rep Org: U.S. ARMY ROCK ISLAND IL
Licensee: U.S. ARMY ROCK ISLAND IL
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/22/2005
Notification Time: 13:50 [ET]
Event Date: 03/10/2005
Event Time: 11:00 [CST]
Last Update Date: 03/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
LAURA KOZAK (R3)
GREG PICK (R4)
TOM ESSIG (MNSS)

Event Text

TRITIUM CONTAMINATION FROM A BROKEN M1A1 COLLIMATOR

The following information was provided by the licensee by fax.


"On 17 March 2005, the TACOM-RI RSO received a call from the Ft. Sill RSO informing the licensee that he discovered 3 ea broken M1A1 collimators (nsn 1240-00-332-1780 sealed source registration no. NR-155-S-102-S). Each M1A1 collimator contains a 10 curie sealed source lamp. One collimator (s/n 933) was discovered in a training area. After this collimator was discovered, the Ft Sill RSO immediately proceeded to inspect all M1A1 collimators found in the 3/30th Field Artillery, sections 2nd, 3rd, and 6th. As a result of this inspection, the RSO discovered two additional broken M1A1 collimators, (s/n's 8644, 4116). The RSO immediately took survey wipes of the collimators and areas where they were located. There was no physical damage on the exterior of the devices or cases containing the devices. Physical damage was observed of the tritium sealed source cell itself, however exterior lenses were intact on all three collimators. It could not be determined how the damage occurred. Leak tests were performed on the three collimators with the following results s/n 933 (837,000 dpm or 3.7E-4 millicuries), s/n 8644 (6,950 dpms or 3.1E-7 millicuries), and s/n 4116 (26,300 dpms or 1.2E-5 millicuries). Only Collimator s/n 933 exceeded reportable limits [110,000 DPM]. The RSO secured the purging and training areas upon discovery of the broken devices and conducted area survey in the purging area, conex trailers (where collimators are stored) and training area. None of the areas surveyed had removable tritium contamination in excess of 5,000 dpms. Tritium bioassay samples were taken on individuals (approx 10) who may have actually handled the broken M1A1 collimators. Bioassay samples will be analyzed at the US Army lab, CHPPM Aberdeen, MD. At the time of this report, the bioassay results were not available, The Ft Sill RSO has secured the three collimators in a low-level rad waste storage site for future disposal."

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Hospital Event Number: 41515
Rep Org: HARPER UNIVERSITY HOSPITAL
Licensee: HARPER UNIVERSITY HOSPITAL
Region: 3
City: Detroit State: MI
County:
License #: 21-04127-02
Agreement: N
Docket:
NRC Notified By: THOMAS M. KUMPURIS
HQ OPS Officer: ARLON COSTA
Notification Date: 03/22/2005
Notification Time: 12:28 [ET]
Event Date: 03/21/2005
Event Time: 10:00 [EST]
Last Update Date: 03/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
LAURA KOZAK (R3)
THOMAS ESSIG (NMSS)

Event Text

MEDICAL EVENT - TOTAL DOSAGE DELIVERED IS LESS THAN THE PRESCRIBED DOSAGE

During a quarterly review of written directives by hospital personnel, it was noted that a patient was administered a dosage of 12.51 millicuries of the isotope NaI-131 for hyperthyroidism instead of the prescribed dosage of 21 millicuries. Radiopharmaceutical unit dose dispensing records as well as internal scheduling paperwork confirm that the 12 millicuries dosage was in fact ordered and subsequently administered to the correct patient. The root cause of this event has been determined by the licensee to be lack of strict attention to detail and they have evaluated their policy and procedures to prevent reoccurrence. The attending physician has reviewed the patient's records and felt that there would be no adverse affect due to this misadministration. He will notify the patient regarding this incident.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012