U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/13/2003 - 06/16/2003
** EVENT NUMBERS **
39913 39914 39931 39932 39937 39938 39939
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|General Information or Other |Event Number: 39913 |
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| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE: 06/10/2003|
|LICENSEE: SWEDISH HOSPITAL AND MEDICAL CENTER |NOTIFICATION TIME: 15:40[EDT]|
| CITY: SEATTLE REGION: 4 |EVENT DATE: 04/16/2002|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: WN-M008-1 AGREEMENT: Y |LAST UPDATE DATE: 06/10/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ARDEN C. SCROGGS | |
| HQ OPS OFFICER: ARLON COSTA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISADMINISTRATION |
| |
| The following agreement state report was received by the NRC Operations |
| Center via email: |
| |
| "This is notification of an event in Washington State as reported to the |
| Washington Department of Health, Division of Radiation Protection. |
| |
| "STATUS: new and closed |
| |
| "Licensee: Swedish Hospital and Medical Center |
| "City and State: Seattle, Washington |
| "License Number: WN-M008-1 |
| "Type of license: Broad B (medium broad) |
| |
| "Date of event: 16 April 2002 (the department was notified on 16 May 2003 |
| after the licensee performed a standard QA case review. The licensee |
| submitted a full report of the incident, dated 29 May 2003). |
| |
| "Location of Event: 747 Summit Avenue, Seattle, Washington |
| |
| "ABSTRACT: An error occurred due to incorrect determination of treatment |
| time. Treatments are planned by use of a graph. This treatment called for |
| a 3.0 mm vessel. When the graph was used to determine treatment time, a |
| time for using a larger vessel was incorrectly selected. This resulted in |
| an extended treatment causing a 25% overexposure to the patient. |
| |
| "When licensee staff discovered the error, the treatment protocol was |
| changed to require two qualified people to independently verify that the |
| treatment/dwell time has been correctly established. This changed was made |
| as a result of their case review procedure. |
| |
| "There was no media coverage. A Departmental investigation was not |
| performed due to the length of time between incident and notification, and |
| that the licensee had performed a self-imposed corrective action. The |
| department will follow-up during routine visits to ensure that the licensee |
| is operating per the new protocol. |
| |
| "What is the notification or reporting criteria involved? Misadministration |
| |
| "Activity and Isotope(s) involved: 53.5 mCi (maximum), |
| Strontium-90/Yttrium-90 as sealed sources. |
| |
| "Overexposures? The patient was the only person overexposed. There was no |
| overexposure to any member of the treatment team, staff, or general public. |
| |
| |
| "Lost, Stolen or Damaged? Not Applicable |
| |
| "Disposition/recovery: Treatment procedures were amended to require written |
| review of the intended treatment by both Radiation Oncologist and |
| Radiological Physicist. |
| |
| "Leak test: 21 February 2002, by the manufacturer. |
| |
| "Vehicle: Not Applicable |
| |
| "Release of activity? None |
| |
| "Activity intended: Not Applicable |
| |
| "Misadministered activity received: Not Applicable |
| |
| "Device: Novoste Beta-Cath, source train # 484/00. |
| |
| "Exposure: (intended/actual); 18.4 Gy/23 Gy |
| |
| "Consequences: Licensee now uses protocol that requires two people who |
| independently verify the correct vessel size, dwell time, and intended dose. |
| The excess exposure is not expected to produce any undesirable effects. |
| |
| "Was patient or responsible relative notified? Yes |
| |
| "Was written report provided? Yes |
| |
| "Was referring physician notified? Yes |
| |
| "Consultant used? No |
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|General Information or Other |Event Number: 39914 |
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| REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 06/10/2003|
|LICENSEE: EXXON MOBIL CHALMETTE |NOTIFICATION TIME: 15:17[EDT]|
| CITY: CHALMETTE REGION: 4 |EVENT DATE: 06/10/2003|
| COUNTY: STATE: LA |EVENT TIME: 08:40[CDT]|
|LICENSE#: LA-2247-L01 AGREEMENT: Y |LAST UPDATE DATE: 06/10/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SCOTT BLACKWELL | |
| HQ OPS OFFICER: ARLON COSTA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - REFINERY FIRE INVOLVING POTENTIAL DAMAGE TO |
| NUCLEAR GAUGE |
| |
| The following agreement state report was received at the Operations Center |
| via fax: |
| |
| "Radiation source involved in fire [at 500 West St Bernard Hwy, Chalmette, |
| LA]. The gauge was closed and had normal readings of 0.25 mR/hr. Area |
| barricaded and restricted. A leak test was being performed. The gauge was |
| being overnighted to Ohmart for analysis. The gauge contained 1600 mCi |
| [millicuries] of Cs-137." |
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|Power Reactor |Event Number: 39931 |
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| FACILITY: GRAND GULF REGION: 4 |NOTIFICATION DATE: 06/13/2003|
| UNIT: [1] [] [] STATE: MS |NOTIFICATION TIME: 02:44[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 06/13/2003|
+------------------------------------------------+EVENT TIME: 00:30[CDT]|
| NRC NOTIFIED BY: FRANK WEAVER |LAST UPDATE DATE: 06/13/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID GRAVES R4 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| EMERGENCY SIREN ACUTATED |
| |
| "Grand Gulf Control Room was notified by the Louisiana Office of Emergency |
| Preparedness that an Emergency Siren was initiated. There is no reason for |
| this siren to have actuated. The siren has been secured and deenergized. |
| This event is being reported due to the local media broadcasting a no |
| emergency message. The total number of emergency sirens remains above |
| 75%(precent)." |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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|Power Reactor |Event Number: 39932 |
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| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 06/13/2003|
| UNIT: [1] [] [] STATE: VA |NOTIFICATION TIME: 08:51[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 06/13/2003|
+------------------------------------------------+EVENT TIME: 05:36[EDT]|
| NRC NOTIFIED BY: J. SHELL |LAST UPDATE DATE: 06/13/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK LESSER R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 1 Startup |0 Hot Shutdown |
| | |
| | |
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EVENT TEXT
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| MANUALLY REACTOR TRIP DUE TO INDICATION OF MISALIGNED ROD |
| |
| "While inserting Shutdown Bank "B" during the Rod Swap portion of physics |
| testing, Rod J-7 indicated a rapid drop from approximately 100 steps to 47 |
| steps on the CERPI (Computer Enhanced Rod Position Indication) panel. The |
| reactor operator stopped insertion of "B" shutdown bank and the CERPI |
| indication for rod J-7 remained at 47 steps. The remaining CERPIs in "B" |
| shutdown bank varied from 96 to 100 steps |
| |
| "I&C and Engineering investigated and found no problems with the CERPI |
| indication. Physics testing was terminated and the reactor was manually |
| tripped and 1-E-0 initiated. All systems functioned as required on the |
| trip. Rod Drop time data from the CERPI program shows all rods in Shutdown |
| Bank "B" had a drop time 1.24 to 1.27 seconds with the exception of J-7, |
| which had a drop time of 1.04 seconds. |
| |
| "An investigation is ongoing as to the cause of rod J-7 indication." |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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|Power Reactor |Event Number: 39937 |
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| FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 06/14/2003|
| UNIT: [2] [3] [] STATE: PA |NOTIFICATION TIME: 02:05[EDT]|
| RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 06/13/2003|
+------------------------------------------------+EVENT TIME: 20:21[EDT]|
| NRC NOTIFIED BY: BREIDENBAUGH |LAST UPDATE DATE: 06/14/2003|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: |CHRISTOPHER CAHILL R1 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| LOSS OF BOTH OFFSITE POWER SOURCES TO TECHNICAL SUPPORT CENTER |
| |
| "During severe thunderstorms in the area power was lost to the onsite |
| Technical Support Center (TSC) for approximately 90 minutes. These storms |
| caused both offsite power sources to the TSC to de-energize at 2021. Grid |
| operators began restoration activities immediately and power was restored to |
| the facility at approximately 2200. Investigation is in progress for the |
| cause of the line tripping." |
| |
| The licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39938 |
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| FACILITY: HARRIS REGION: 2 |NOTIFICATION DATE: 06/14/2003|
| UNIT: [1] [] [] STATE: NC |NOTIFICATION TIME: 14:32[EDT]|
| RXTYPE: [1] W-3-LP |EVENT DATE: 06/14/2003|
+------------------------------------------------+EVENT TIME: 10:53[EDT]|
| NRC NOTIFIED BY: BAKER |LAST UPDATE DATE: 06/14/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK LESSER R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| REACTOR MANUALLY TRIPPED DUE TO MAIN FEEDWATER PUMP TRIP |
| |
| At 10053 ,on 6/14/03, the reactor was manually tripped from 100% in response |
| to a trip of the "B" main feedwater pump (MFP). Both motor-driven auxiliary |
| feedwater pumps and the turbine driven auxiliary feedwater pump auto |
| started due to the lo-lo steam generator level. Operations personnel |
| responded to the event in accordance with applicable plant procedures and |
| the plant was stabilized at normal operating no-load reactor coolant system |
| (RCS) temperature and pressure following the reactor trip. The cause of the |
| MFP trip is still under investigation. All rods fully inserted no ECCS |
| actuation occurred and the PORV lifted and fully reseated. |
| |
| The NRC Resident Inspector was notified. |
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|Power Reactor |Event Number: 39939 |
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| FACILITY: HARRIS REGION: 2 |NOTIFICATION DATE: 06/15/2003|
| UNIT: [1] [] [] STATE: NC |NOTIFICATION TIME: 14:45[EDT]|
| RXTYPE: [1] W-3-LP |EVENT DATE: 06/15/2003|
+------------------------------------------------+EVENT TIME: 09:28[EDT]|
| NRC NOTIFIED BY: BRIAN BAKER |LAST UPDATE DATE: 06/15/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK LESSER R2 |
|10 CFR SECTION: | |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Hot Standby |0 Hot Standby |
| | |
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EVENT TEXT
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| AUTOMATIC ACTUATION OF THE AUXILIARY FEEDWATER SYSTEM WHILE IN HOT STANDBY |
| |
| "At 0928, on 6/15/03, with the reactor shut down in Mode 3, a feedwater |
| isolation signal and an automatic start of both Motor-Driven Auxiliary |
| Feedwater Pumps (AFW) occurred due to the trip of the last running Main |
| Feedwater Pump. The event occurred as the plant operators closed the reactor |
| trip breakers per plant procedure OP-104 in preparation for a reactor |
| startup. The Main Feedwater Regulating Valves (MFRVs) were in automatic and |
| the MFRV block valves were open. With reactor coolant system average |
| temperature at less than 564þF and the reactor trip breakers open, a MFRV |
| close signal is established via the P-4 permissive. Closing the reactor trip |
| breakers removed the permissive P-4 block signal that was maintaining the |
| MFRVs closed. This allowed the MFRVs to open to the full open demand |
| position. With the MFRVs feeding the steam generators and no load conditions |
| on the secondary plant, steam generator level exceeded the HI-HI level |
| setpoint of 78%. This generated a turbine trip signal, a Main Feedwater |
| isolation signal, and a trip of the Main Feedwater Pumps. The trip of the |
| last running Main Feedwater Pump generated the automatic AFW actuation. This |
| condition is being reported as actuation of Auxiliary Feedwater System in |
| accordance with 1O CFR 50.72(b)(3)(iv)(A). |
| |
| "A reactor trip signal was not generated during this event and no control |
| Rods had been withdrawn from the reactor core at the time of the event. |
| |
| "The NRC Resident Inspector was notified." |
| |
| The plant is stable in mode 3 and the AFW system is running to maintain |
| steam generator levels. All systems functioned as required. |
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