U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/17/2003 - 07/18/2003
** EVENT NUMBERS **
39986 40001 40004
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Hospital |Event Number: 39986 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF WISCONSIN - MADISON |NOTIFICATION DATE: 07/09/2003|
|LICENSEE: UNIVERSITY OF WISCONSIN |NOTIFICATION TIME: 18:07[EDT]|
| CITY: Madison REGION: 3 |EVENT DATE: 07/09/2003|
| COUNTY: Dane STATE: WI |EVENT TIME: 13:00[CDT]|
|LICENSE#: 48-09843-18 AGREEMENT: N |LAST UPDATE DATE: 07/17/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHRIS MILLER R3 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RONALD BRESELL | |
| HQ OPS OFFICER: ERIC THOMAS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL EVENT |
| |
| At 1300 CDT on 7/9/03, an underadministration of Yttrium-90 (Y-90) occurred |
| at the University of Wisconsin Hospital in Madison, WI. A patient being |
| treated for secondary liver cancer was to receive a dose of approximately 50 |
| millicuries of Y-90. The dose was delivered using a SIRTECH (Selective |
| Radiation Implantation) to pulse microspheres of Y-90 from a vial into the |
| liver via a needle and catheter. |
| |
| During the procedure, the SIRTECH did not develop enough pressure to deliver |
| the entire dose to the patient, and only about 8 percent of the Y-90 was |
| delivered to the patient (between 3-4 millicuries). The remainder of the |
| Y-90 microspheres were contained within the vial. |
| |
| There was no adverse affect on the patient due to this underadministration, |
| and the licensee is still investigating how to prevent a re-currence. The |
| patient was notified of the underadministration. |
| |
| * * * RETRACTION AT 0615 EDT ON 07/17/03 FROM BRESELL TO GOTT * * * |
| |
| The licensee determined that the technician had misinterpreted the |
| measurement of the Y-90 administered to the patient and determined that the |
| correct amount of Y-90 was administered. Because the correct amount of Y-90 |
| was administered, the licensee is retracting the event. The licensee |
| discussed this with Deborah Piskura, NRC Region III. |
| |
| Notified R3DO (Riemer) and NMSS EO (Pierson) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40001 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 07/17/2003|
| UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 06:57[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 07/16/2003|
+------------------------------------------------+EVENT TIME: 22:08[CDT]|
| NRC NOTIFIED BY: STEVEN HENRY |LAST UPDATE DATE: 07/17/2003|
| HQ OPS OFFICER: BILL GOTT +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LINDA SMITH R4 |
|10 CFR SECTION: |TERRYREIS NRR |
|NINF INFORMATION ONLY |TIM MCGINTY IRO |
| |MATT HAHN NSIR |
| |AL TARDIFF NSIR |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNDECLARED UNUSUAL EVENT |
| |
| At 0501 CDT on 07/17/03 the shift manager determined that a condition |
| existed for 10 minutes the previous evening which met the emergency plan |
| criteria but no emergency was declared. The basis for the emergency class |
| no longer existed at the time of discovery. Upon discovery he notified the |
| NRC Operations Center and the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 40004 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION |NOTIFICATION DATE: 07/17/2003|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 16:00[EDT]|
| COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 07/17/2003|
| COMMERCIAL LWR FUEL |EVENT TIME: 03:35[EDT]|
| |LAST UPDATE DATE: 07/17/2003|
| CITY: COLUMBIA REGION: 2 +-----------------------------+
| COUNTY: RICHLAND STATE: SC |PERSON ORGANIZATION |
|LICENSE#: SNM-1107 AGREEMENT: Y |JOHN PELCHAT R2 |
| DOCKET: 07001151 |CHARLIE MILLER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CARL SYNDER | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24-HOUR NRC 91-01 BULLETIN NOTIFICATION INVOLVING LOSS OF CRITICALITY |
| CONTROL |
| |
| The following is a portion of text from a fax submitted by the licensee: |
| |
| "Pump-Out to UNBSS Without Sample Results. |
| "Reason for Notification: An operator pumped out a batch from the clean |
| dissolver to the uranyl nitrate bulk storage tank prior to receiving the |
| required sample results for grams U-235 per liter, percent free acid, and |
| pH. |
| |
| "Double Contingency Protection: Double contingency protection for the bulk |
| storage tank is based on concentration control. Concentration control is |
| based upon maintaining uranyl nitrate that is pumped to the tanks at less |
| than 5 grams U-235/liter. The pH is maintained at a value of less than 2 to |
| ensure that the uranyl nitrate stays in solution. The percent free acid is |
| maintained at greater than 4 percent to ensure that the uranyl nitrate stays |
| in solution and depresses the freezing temperature of the solution to |
| prevent concentration by freezing. |
| |
| "It has been determined that less than previously documented double |
| contingency protection remained for the system and that greater than a safe |
| mass was involved., but a sufficient number of controls that were lost were |
| restored within 4 hours. In accordance with Westinghouse Operating License |
| (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a |
| 24-hour notification. |
| |
| "As Found Condition: See 'Reason for Notification' above. |
| |
| "Summary of Activity: (1) Pump outs to the bulk storage tanks were |
| stopped, (2) Samples for grams U-235/liter, pH, and %free acid were taken to |
| ensure the tanks were in specification, (3) Before the end of the shift, |
| sample results for grants U-235/liter, pH, and %free acid were determined to |
| be acceptable. |
| |
| "Conclusions: (1) Loss of double contingency protection occurred, (2) |
| Greater than a safe mass was involved, (3) At no time was the health or |
| safety to any employee or member of the public in jeopardy. No exposure to |
| hazardous material was involved, (4) The Incident Review Committee (IRC) |
| determined that this is a safety significant incident in accordance with |
| governing procedures, (5) Notification was the result of an event, not a |
| deficient NCS analysis, (6) A causal analysis will be performed." |
| |
| The licensee attributes the cause of this incident to personnel error. The |
| licensee will inform both NRC Region 2 and the NRC Headquarters PM. |
+------------------------------------------------------------------------------+
