Event Notification Report for June 19, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/18/2006 - 06/19/2006
Power Reactor
Event Number: 42658
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DENNIS GRIFFITH
HQ OPS Officer: JEFF ROTTON
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DENNIS GRIFFITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/21/2006
Notification Time: 10:02 [ET]
Event Date: 06/19/2006
Event Time: 16:00 [CDT]
Last Update Date: 06/22/2006
Notification Time: 10:02 [ET]
Event Date: 06/19/2006
Event Time: 16:00 [CDT]
Last Update Date: 06/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID GRAVES (R4)
OMID TABATABAI (NRR)
DAVID GRAVES (R4)
OMID TABATABAI (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
INITIAL PART 21 NOTIFICATION - PRIME MEASUREMENT PRODUCTS, MODELS 763 AND 763A GAGE PRESSURE TRANSMITTERS AND MODEL 764 DIFFERENTIAL PRESSURE TRANSMITTERS
"This report is made per 10CFR21.21 Notification of failure to comply or existence of a defect and its evaluation.
"Callaway Plant received a notification dated May 18, 2006, from PRIME Measurement Products (formerly ITT Barton) stating Barton Model 763 and 763A Gage Pressure Transmitters and Model 764 Differential Pressure Transmitters may have defective external lead-wire connectors, which could affect their performance during an accident. The notification provided by PRIME stated the affected transmitters were manufactured after May 1982 and shipped from the factory prior to April 1, 2006.
"The potential defect is characterized as follows: The transmitters' external lead wires enter the electronics enclosure through a hermetic seal called a connector assembly. The external lead wires are soldered to the glass sealed pins of the hermetic seal. Epoxy potting is used to structurally support the soldered wire connections and establish a seal to protect the solder connections from shorting, which could be caused by an electrically conductive accident environment. The defect is that the insulated portions of the wires in the connectors, manufactured after May 1982, may not be embedded deeply enough into the epoxy potting to provide an electrical connection that would not be affected in an accident environment.
"The notification also states that actual transmitter installation may preclude shorting of exposed conductors due to the existence of conduit, conduit seals, and special wire connectors which could protect the exposed wires at a defective connector from conductive moisture.
"Callaway Plant identified thirty applicable Barton transmitters and connector assemblies in warehouse stock. Inspections of these operational spare parts identified three connectors, which had exposed conductors external to their seal. One connector had this defect on one lead wire and two connectors had this defect on both lead wires.
"Callaway has also identified that thirty-nine potentially affected transmitters are installed in the plant. An inspection plan has been developed to perform the required inspections, based on safety significance, ALARA considerations, and potential accident environmental conditions. Additional reporting requirements associated with the installed components will be evaluated under 10CFR50.72 as required.
"On 06/19/06, Callaway Plant personnel completed evaluations and determined the defective connections constitute a defect per 10CFR21 require initial NRC notification within two days.
"The NRC resident inspectors have been notified of this issue."
* * * UPDATE FROM LICENSEE (D. GRIFFITH) TO M. RIPLEY 1515 EDT 06/22/06 * * *
"This report is a revision to report EN # 42658 reported on 06/21/2006.
Added statement: "The suppliers of the identified transmitters were Prime Measurement Products and Westinghouse Electric Corporation."
The licensee notified the NRC Resident Inspector. Notified NRR (O. Tabatabai), R4 DO (D. Graves)
"This report is made per 10CFR21.21 Notification of failure to comply or existence of a defect and its evaluation.
"Callaway Plant received a notification dated May 18, 2006, from PRIME Measurement Products (formerly ITT Barton) stating Barton Model 763 and 763A Gage Pressure Transmitters and Model 764 Differential Pressure Transmitters may have defective external lead-wire connectors, which could affect their performance during an accident. The notification provided by PRIME stated the affected transmitters were manufactured after May 1982 and shipped from the factory prior to April 1, 2006.
"The potential defect is characterized as follows: The transmitters' external lead wires enter the electronics enclosure through a hermetic seal called a connector assembly. The external lead wires are soldered to the glass sealed pins of the hermetic seal. Epoxy potting is used to structurally support the soldered wire connections and establish a seal to protect the solder connections from shorting, which could be caused by an electrically conductive accident environment. The defect is that the insulated portions of the wires in the connectors, manufactured after May 1982, may not be embedded deeply enough into the epoxy potting to provide an electrical connection that would not be affected in an accident environment.
"The notification also states that actual transmitter installation may preclude shorting of exposed conductors due to the existence of conduit, conduit seals, and special wire connectors which could protect the exposed wires at a defective connector from conductive moisture.
"Callaway Plant identified thirty applicable Barton transmitters and connector assemblies in warehouse stock. Inspections of these operational spare parts identified three connectors, which had exposed conductors external to their seal. One connector had this defect on one lead wire and two connectors had this defect on both lead wires.
"Callaway has also identified that thirty-nine potentially affected transmitters are installed in the plant. An inspection plan has been developed to perform the required inspections, based on safety significance, ALARA considerations, and potential accident environmental conditions. Additional reporting requirements associated with the installed components will be evaluated under 10CFR50.72 as required.
"On 06/19/06, Callaway Plant personnel completed evaluations and determined the defective connections constitute a defect per 10CFR21 require initial NRC notification within two days.
"The NRC resident inspectors have been notified of this issue."
* * * UPDATE FROM LICENSEE (D. GRIFFITH) TO M. RIPLEY 1515 EDT 06/22/06 * * *
"This report is a revision to report EN # 42658 reported on 06/21/2006.
Added statement: "The suppliers of the identified transmitters were Prime Measurement Products and Westinghouse Electric Corporation."
The licensee notified the NRC Resident Inspector. Notified NRR (O. Tabatabai), R4 DO (D. Graves)
General Information or Other
Event Number: 42748
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: MCKAY-DEE HOSPITAL CENTER
Region: 4
City: OGDEN State: UT
County:
License #: UT 2900147
Agreement: Y
Docket:
NRC Notified By: PHILLIP GRIFFIN
HQ OPS Officer: MIKE RIPLEY
Licensee: MCKAY-DEE HOSPITAL CENTER
Region: 4
City: OGDEN State: UT
County:
License #: UT 2900147
Agreement: Y
Docket:
NRC Notified By: PHILLIP GRIFFIN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/01/2006
Notification Time: 14:55 [ET]
Event Date: 06/19/2006
Event Time: 00:00 [MDT]
Last Update Date: 03/13/2007
Notification Time: 14:55 [ET]
Event Date: 06/19/2006
Event Time: 00:00 [MDT]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JEFFREY CLARK (R4)
GREG MORELL (NMSS)
JEFFREY CLARK (R4)
GREG MORELL (NMSS)
UTAH AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via facsimile:
"On July 11, 2006, the licensee indicated to a Division inspector that a 'misadministration' had occurred.
"The licensee sent a letter dated July 17, 2006, to the Division indicating that a 'medical event' had occurred. The letter did not contain sufficient information to determine if the incident was an actual medical event. Multiple attempts were made to contact the RSO who reported the incident to verify that it was a medical event. The RSO was on vacation during most of July 2006.
"The RSO contacted the Division by telephone on August 1, 2006, and confirmed that a medical event had occurred.
"Event Description: On June 19, 2006, two patients were scheduled at the same time for radioactive treatment of hyperthyroidism. One patient was scheduled for 15 mCi of I-131, and the other patient was scheduled for 29 mCi of 1-131. The patient who was scheduled for 15 mCi of 1-131 ingested 29.0 mCi of 1-131. The error was identified by the licensee prior to the administration of I-131 to the other patient. The other patient's dose was corrected, and the patients' physicians were informed of the incident."
Utah Event Report ID: UT-06-0002
* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *
The State provided the following information via facsimile:
"On July 11, 2006, the licensee indicated to a Division inspector that a 'misadministration' had occurred.
"The licensee sent a letter dated July 17, 2006, to the Division indicating that a 'medical event' had occurred. The letter did not contain sufficient information to determine if the incident was an actual medical event. Multiple attempts were made to contact the RSO who reported the incident to verify that it was a medical event. The RSO was on vacation during most of July 2006.
"The RSO contacted the Division by telephone on August 1, 2006, and confirmed that a medical event had occurred.
"Event Description: On June 19, 2006, two patients were scheduled at the same time for radioactive treatment of hyperthyroidism. One patient was scheduled for 15 mCi of I-131, and the other patient was scheduled for 29 mCi of 1-131. The patient who was scheduled for 15 mCi of 1-131 ingested 29.0 mCi of 1-131. The error was identified by the licensee prior to the administration of I-131 to the other patient. The other patient's dose was corrected, and the patients' physicians were informed of the incident."
Utah Event Report ID: UT-06-0002
* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *