U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/16/2003 - 01/17/2003
** EVENT NUMBERS **
39508 39510 39515 39516
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|General Information or Other |Event Number: 39508 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 01/14/2003|
|LICENSEE: ST FRANCIS HOSPITAL |NOTIFICATION TIME: 15:02[EST]|
| CITY: TULSA REGION: 4 |EVENT DATE: 01/13/2003|
| COUNTY: STATE: OK |EVENT TIME: 19:30[CST]|
|LICENSE#: OK-07163-01 AGREEMENT: Y |LAST UPDATE DATE: 01/15/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GARY SANBORN R4 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: MIKE BRODRIECK | |
| HQ OPS OFFICER: JASON FLEMMING | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING LOST SOURCES |
| |
| The Licensee report the loss of five .355 microcurie, I-125 brachytherapy |
| seeds. The seeds were model # IAI-125A and they were inventoried upon |
| receipt from the manufacture, Iso-Aid. The seeds were being washed prior to |
| sterilization (this is a deviation from procedure) and the Licensee believes |
| they were washed down the drain to the public sewer system. The Licensee |
| reports that surveys do not indicate that they are in the sink or trap. |
| |
| ***UPDATE 01/15/03 1202 EST MIKE BRODRIECK TO MIKE NORRIS*** |
| |
| The seeds are actually .355 millicurie sources. Notified NMSS (Brown) and |
| R4DO (Sanborn). |
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|Hospital |Event Number: 39510 |
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| REP ORG: PENNSYLVANIA HOSPITAL |NOTIFICATION DATE: 01/15/2003|
|LICENSEE: PENNSYLVANIA HOSPITAL |NOTIFICATION TIME: 13:49[EST]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 01/13/2003|
| COUNTY: STATE: PA |EVENT TIME: 12:00[EST]|
|LICENSE#: 37-06864-06 AGREEMENT: N |LAST UPDATE DATE: 01/16/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| | |
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| NRC NOTIFIED BY: DR. LEONARD SHABASON | |
| HQ OPS OFFICER: HOWIE CROUCH | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LEXC 35.3045(a)(2) DOSE > SPECIFIED EFF LI| |
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EVENT TEXT
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| DAMAGED IODINE-125 SEED RESULTS IN DOSE THAT DIFFERS FROM PRESCRIBED DOSE BY |
| >20 % |
| |
| "On Monday January 13, 2003 a prostate implant was performed on [DELETED]. |
| The seeds that were used were Amersham's Echoseed. Each seed had an |
| activity of 0.472 [millicurie] apparent activity (NIST 1999) on the day of |
| the implant. The actual activity is 1.78 times the apparent activity which |
| results in an actual activity of 0.84 [millicurie]. |
| |
| "During the implant there was difficulty in removing a cartridge. Once the |
| cartridge was removed, there was some activity that registered in the Mick |
| gun. A blood clot that registered radioactivity was expelled from the gun |
| and was isolated and the implant proceeded. This involved the last seed in |
| a Mick disposable cartridge. |
| |
| "Once the implant was completed, the blood clot was examined and was found |
| to contain a fragment of a seed. The entire operating room was checked |
| carefully to see if the other portion of the seed was anywhere on the |
| operating room. There was no contamination found in any of the instruments |
| or in any of the used cartridges with the GM probe. No seeds or any |
| activity was discovered during cystography or in any of the trash in the |
| operating room. The feet of all the individuals involved in the procedure |
| were checked in case a seed adhered to a shoe covering. It was assumed that |
| the remainder of the seed was placed in the patient's prostate. The |
| radiation oncologist ordered that the patient be given a blocking dose of |
| iodine in the form of Lugol's solution. The radiation oncologist informed |
| the patient that he was being placed on this medication because of the |
| possibility that a leaking seed was implanted." |
| |
| The prescribing physician has informed the patient. |
| |
| * * * UPDATE ON 1/16/03 AT 1123 BY SHABASONS TO GOULD * * * |
| |
| The licensee originally reported this event under 10 CFR 35.3045(a)(1) and |
| called to change it to 10 CFR 35.3045(a)(2). The licensee estimates that |
| the thyroid dose is <5 Rem. |
| |
| The NRC Headquarters Operations Officer notified the R1DO (Richard Barkley) |
| of this update. |
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|Power Reactor |Event Number: 39515 |
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| FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 01/16/2003|
| UNIT: [] [] [3] STATE: CT |NOTIFICATION TIME: 17:13[EST]|
| RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 01/16/2003|
+------------------------------------------------+EVENT TIME: 16:40[EST]|
| NRC NOTIFIED BY: RALPH YOUNG |LAST UPDATE DATE: 01/16/2003|
| HQ OPS OFFICER: JASON FLEMMING +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RICHARD BARKLEY R1 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
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| | |
|3 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| UNANALYZED CONDITION AT MILLSTONE 3 |
| |
| "This report is being submitted to report an unanalyzed condition that could |
| significantly degrade plant safety in accordance with |
| 10CFR50.72(b)(3)(ii)(B). As the result of an engineering analysis, it was |
| determined that the fire safe shutdown strategy may not be adequate to |
| ensure that the plant can achieve and maintain safe shutdown for certain |
| fire scenarios. |
| |
| "On January 16, 2003, with Millstone Unit 3 in Mode 1 at 100% power, and as |
| a result of transient analysis of certain fire shutdown scenarios, it was |
| determined that postulated extended loss of all seal cooling events have the |
| potential for over-pressurization of the Reactor Coolant Pump (RCP) No.1 |
| seal leak-off line. The RCP No. 1 seal return line is designed to recover |
| low pressure and temperature leak-off volume and return it to the volume |
| control tank or charging pump suction. In response to a Cable Spreading |
| Area, Control Room, or Instrument Rack Room fire, operation could be |
| impacted because Emergency Operating Procedures (EOPs) may not adequately |
| mitigate the scenario where a loss of all RCP seal cooling results in |
| increased RCP seal leakage. This increased seal leakage assumption causes |
| above normal pressure and temperature fluid conditions within the No. 1 seal |
| return line. The over-pressurization that may occur could challenge the seal |
| leak-off line structural integrity and a pressure boundary failure is |
| considered possible. Per BTP 9.5-1, the credited injection pathway needs to |
| be sufficient to preclude draining of the pressurizer below the indicating |
| range. Because this condition would significantly complicate shutdown in the |
| event of fire in these areas, this condition is being reported as an |
| unanalyzed condition that significantly degrades plant safety, pursuant to |
| 10 CFR 50.72 (b)(3)(ii)(B). |
| |
| "This condition assumes a fire of sufficient magnitude to cause a loss of |
| all AC power which results in an extended loss of all seal cooling. This is |
| considered to be a low probability event. |
| |
| "Compensatory measures are in place and include continuous fire watches in |
| the Cable Spreading Area and the Instrument Rack Room. The continuous fire |
| watch in the Control Room is satisfied by the presence of the Control Room |
| staff. Additional fire extinguishers in impacted areas are in place. |
| Administrative control requiring prior Shift Manager approval have been |
| implemented to set limits on ignition source permits, use of transient |
| combustibles, and use of flammable liquids within the impacted areas. |
| Compensatory measures will remain until needed EOP revisions, plant |
| modifications, or further analysis are made to address this condition. This |
| condition remains under evaluation in accordance with the Millstone |
| Corrective Action Program." |
| |
| The Licensee has informed the NRC Resident of this event. |
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|General Information or Other |Event Number: 39516 |
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| REP ORG: SCIENTECH |NOTIFICATION DATE: 01/16/2003|
|LICENSEE: |NOTIFICATION TIME: 21:52[EST]|
| CITY: IDAHO FALLS REGION: 4 |EVENT DATE: 01/15/2003|
| COUNTY: STATE: ID |EVENT TIME: [MST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 01/16/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD BARKLEY R1 |
| |JAY HENSON R2 |
+------------------------------------------------+DAVID HILLS R3 |
| NRC NOTIFIED BY: MARTIN BOOSKA |TAD MARSH NRR |
| HQ OPS OFFICER: GERRY WAIG |JACK FOSTER via fax NRR |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
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EVENT TEXT
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| 10 CFR 21.21 POTENTIAL DEFECTIVE COMPONENTS |
| |
| The following is taken from a facsimile received from Scientech, Inc.: |
| |
| "SCIENTECH, Inc.'s subsidiary, NUS Instruments, Inc. (NUSI) has determined |
| that Basic Components, supplied in two CMM 900 Modules to |
| Entergy-Fitzpatrick (P.O. #4500510231) and one CMM900 module to |
| Constellation-Nine Mile Point (P.O. #00-31440) contain a defect that is |
| reportable under 10CFR21. Additionally, NUSI has determined that other |
| clients (see attached list) have been supplied assemblies containing |
| components that may contain similar defects. NUSI is currently in the |
| process of determining all affected model numbers and serial numbers. |
| |
| "NUSI determined that this potential defect was reportable on January 9, |
| 2003 and the SCIENTECH, Inc. President was informed January 15, 2003. All |
| potentially affected clients are being notified concurrently with this |
| notification. |
| |
| "The defective component, OPA2111KP, was manufactured by Burr-Brown (aka TI |
| or Texas Instruments-Tucson) and installed by NUSI in assemblies shipped to |
| one or more of the clients identified in the attached client list. At this |
| time only assemblies containing the OPA2111KP component have failed, as |
| reported by Entergy-Fitzpatrick and Constellation-Nine Mile Point. NUSI has |
| opened a 10CFR21 file concerning these components and has numbered it as |
| 21-03-01. |
| |
| "TI has identified three additional part numbers (OPA111, 0PA404, and 3656) |
| that NUSI currently uses that were manufactured by Tl utilizing the same |
| process that was used for the manufacture of the defective OPA2111KP |
| component; these other part numbers will require further evaluation. |
| |
| "A formal written report will be provided within 30 days of this |
| notification." |
| |
| Potentially affected plants include: |
| |
| Region 1: Nine Mile Point, Millstone, Fitzpatrick, IP2 &3, Beaver Valley, |
| Salem/Hope Creek (PSE&G), Ginna, Pilgrim. |
| Region 2: Brunswick, Robinson, Harris, Crystal River 3. |
| Region 3: Kewaunee |
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