Morning Report for November 5, 1999
Headquarters Daily Report NOVEMBER 05, 1999 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS X REGION I X REGION II X REGION III X REGION IV X PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION I NOV. 05, 1999 Licensee/Facility: Notification: MR Number: 1-99-0043 The Medical Center At Princeton Date: 11/04/99 Princeton,New Jersey NRC Operations Center Dockets: 03002489 License No: 29-06750-01 Subject: BRACHYTHERAPY INCIDENT Discussion: On November 4, 1999, the licensee notified the NRC Operations Center of an incident during a brachytherapy procedure. At 0915 hours on November 4, 1999, a patient undergoing a brachytherapy procedure notified the hospital staff that the brachytherapy source applicator had become dislodged. The hospital staff contacted the authorized user that had inserted the sources and were instructed to relocate the applicator to the foot of the bed. The hospital's physicist estimates that the source was in the vicinity of the patient's thigh for approximately 15 minutes and at the foot of the bed for another 18 minutes before being placed in a lead container. The patient was scheduled to be treated for 22.79 hours with 21.8 milligram radium equivalent (54.8 millicurie) cesium-137 sources. The actual treatment time was 18.45 hours. The licensee is in the process of calculating the local area dose to the patient's thigh and feet. The patient's referring physician will be notified. According to the authorized user, the patient did not receive any adverse health consequences from this incident. Regional Action: On November 9, 1999, an NRC inspection will be conducted to follow up on this incident. Contact: Penny Lanzisera (610)337-5169 Mohamed Shanbaky (610)337-5209 _ REGION I MORNING REPORT PAGE 2 NOVEMBER 5, 1999 Licensee/Facility: Notification: New York Power Authority MR Number: 1-99-0044 Indian Point 3 Date: 11/05/99 Buchanan,New York PE/PC Dockets: 50-286 PWR/W-4-LP Subject: SUBSTANDARD GASKET MATERIAL FOR THE MAIN TURBINE TRIP OIL SYSTEM Discussion: During November 3-4, IP3 had to take the main turbine offline to replace a defective gasket in the turbine trip oil system. The gasket was of the wrong material and had been supplied by Westinghouse, who may have also supplied the same material to other plants. NYPA became aware of a problem with substandard gasket material after it caused a turbine/reactor trip at St. Lucie on October 29, 1999. The St. Lucie trip occurred 14 days after on-line power operations and it was traced to the installation of a substandard gasket in the main turbine trip oil system by a Siemens-Westinghouse work group during a recent outage. Because of the short duration for failure, IP3 began a prompt shutdown on November 3. Once the turbine was off-line, the main turbine trip oil system was opened, and the gasket for the low bearing oil trip device was inspected. NYPA maintenance workers noted that a leak had already developed and there was a visible tear through the body of the gasket. The gasket was replaced and the plant returned to power. NYPA had previously identified that there were three sensors in the turbine trip oil system in which the substandard gasket material could have been installed. The potential locations included the main bearing oil pressure sensor, the turbine vacuum sensor, or the thrust bearing sensor. Based on a detailed review of the material in the warehouse and the material records for the gaskets they received, NYPA concluded that the faulty gasket had to have been installed in the main bearing oil pressure sensor. This was later confirmed through the off-line inspection. NYPA also concluded that the gaskets installed in the other locations were acceptable. Preliminary indications are that the inferior gaskets have been supplied to utilities using Westinghouse turbine generators starting in April 1999. Five nuclear plants are believed to have received the gaskets and they include St. Lucie, IP3, Salem, Robinson, and Arkansas Nuclear One. St. Lucie and IP-3 both have had outages since April and have been adversely affected by the bad gasket material Salem has identified and removed the substandard material from their warehouse. The affected plants and Westinghouse are aware of the problem. The material has been identified as being of substandard construction under a valid Westinghouse part number being supplied by an as yet to be identified sub-supplier. Regional Action: Routine Resident Follow-up. Forwarded for review of generic implications. REGION I MORNING REPORT PAGE 3 NOVEMBER 5, 1999 MR Number: 1-99-0044 (cont.) Contact: John Rogge (610)337-5146 _
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Page Last Reviewed/Updated Wednesday, March 24, 2021