U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/25/2003 - 07/28/2003
** EVENT NUMBERS **
39566 39631 39663 39888 39941 39997 40018 40021 40022 40023
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|Power Reactor |Event Number: 39566 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 02/06/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 13:03[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 02/06/2003|
+------------------------------------------------+EVENT TIME: 09:45[EST]|
| NRC NOTIFIED BY: JOHN KONOVALCHICK |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAMES NOGGLE R1 |
|10 CFR SECTION: |TERRY REIS NRR |
|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 |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| OFFSITE NOTIFICATION TO STATE AND LOCAL AGENCIES REGARDING TRITIUM SPILL |
| |
| "Notification was made to the state of New Jersey to report a spill of |
| radioactive material, specifically, tritium at a concentration of 6.92 E-5 |
| microcuries/ml. The material is presently contained on the property of |
| Salem Generating Station and was discovered at 0945 on February 6, 2003. |
| |
| "Soil samples obtained at a depth of 20 feet from 2 monitoring wells |
| indicates the presence of tritium. The monitoring wells are adjacent to |
| Salem Unit 1 and within the protected area. We recently sampled all |
| domestic water supplies and the results were negative. There is no |
| indication of any offsite release, there is no threat to the public or |
| company employees. We cannot determine at this time if this is an existing |
| or historic condition. We are continuing with additional analysis to |
| determine the source and extent of the condition." |
| |
| The licensee informed state agencies and the NRC resident inspector and will |
| inform the local agency of LAC. |
| |
| |
| * * * UPDATE ON 07/25/03 @ 1553 BY RUDOLPH CHAN TO CHAUNCEY GOULD * * * |
| |
| On July 25, 2003, PSEG made an update notification to the New Jersey |
| Department of Environmental Protection on the results of PSEG's ongoing |
| remediation work investigation plan for the previously reported tritium |
| spill. The update stated that additional samples from test wells have |
| identified presence of tritium at levels above background. Specifically, |
| sample results obtained from a new well placed as part of the ongoing |
| investigation indicated a tritium concentration of 3.5 E-3 |
| microcuries/milliliter. Additionally, a sample from an existing well |
| indicated a result of 1.25 E-4 microcuries/milliliter, which was higher than |
| previously observed at this location although from a different type of |
| well. Gamma scans of samples from both locations detected no other |
| radionuclides. There is no indication of any offsite release and there is |
| no threat to the public or company employees. We cannot determine at this |
| time if this is an existing or historic condition. We are reviewing the |
| situation with our expert panel to determine the proper location for |
| additional test wells to determine the source and extent of the condition. |
| |
| The NRC resident and regional inspectors have been made aware of the test |
| results. |
| |
| The NRC REG1 RDO (Daniel Holody) was informed. |
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|Power Reactor |Event Number: 39631 |
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| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 03/02/2003|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 16:00[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 03/02/2003|
+------------------------------------------------+EVENT TIME: 14:30[EST]|
| NRC NOTIFIED BY: CHARLES PIKE |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WALTER RODGERS R2 |
|10 CFR SECTION: |DAVID AYRES R2 |
|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 |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| OFFSITE NOTIFICATION TO STATE AGENCY OF EXPIRED GREEN SEA TURTLE FOUND AT |
| BARRIER NET |
| |
| "NRC notification [is] being made due to state notification to [the] Florida |
| Wildlife Commission regarding a Green Sea Turtle found dead at barrier net |
| pursuant to 10 CFR 50.72(b)(2)(xi)." |
| |
| The turtle was found on the surface at the barrier net with no injuries or |
| abnormalities except for fresh cuts common for turtles coming through pipes. |
| The cause of death is unknown at this time. A necropsy is planned. |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/15/03 @ 1033 EST FROM TEREZAKIS TO CROUCH * * * |
| |
| "On 3-15-03, a green sea turtle was retrieved from the plant's intake canal. |
| The turtle was determined to be in need of rehabilitation. The injuries to |
| the turtle are not causal to plant operation. Per the plant's turtle permit, |
| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified at |
| 0920 EST. This non-emergency notification is being made pursuant to 10 CFR |
| 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/19/03 AT 1222 EST FROM E. SUMNER TO RIPLEY * * * |
| |
| "On 03/19/03 @ 1105 hrs., one loggerhead turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injury to the turtle is not causal to plant operation. |
| Per the plant's turtle permit, the Florida Fish and Wildlife Conservation |
| Commission (FWCC) was notified at 1115 EST." |
| |
| The NRC Resident Inspector was notified. |
| |
| * * * UPDATED ON 3/31/03 AT 1159 EST FROM W.L. PARK TO A. COSTA * * * |
| |
| "On 3-31-03 [1105 EST], a loggerhead sea turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injuries to the turtle are not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission (FWCC) was notified at 1105 EST. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to the |
| notification of FWCC." |
| |
| The NRC Resident Inspector will be notified. |
| |
| * * * UPDATE 1235EST ON 4/9/03 FROM ANDY TEREZAKIS TO S.SANDIN * * * |
| |
| "On 4-9-03, a loggerhead sea turtle was retrieved from the plant's Intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC) |
| was notified at 1100 EST. This non-emergency notification is being made |
| pursuant to 10CFR50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The licensee informed the NRC resident inspector. Notified R2DO(Landis). |
| |
| *** UPDATE ON 5/2/03 AT 1826 FROM S. OEHRLE TO A. COSTA *** |
| |
| "On 5/2/03, a green sea turtle was retrieved from the intake canal. The |
| turtle required rehabilitation. The injuries were not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission was notified at 1445 EDT. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to |
| offsite notification." |
| |
| The Licensee will notify the NRC Resident Inspector. Notified R2DO |
| (Munday). |
| |
| **** update on 05/24/03 at 1417 EDT FROM JOE HESSLING TO JOHN MACKINNON |
| **** |
| |
| "On 5-24-03, a loggerhead sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| turtle was very underweight and lethargic, no injuries or anomalies noted. |
| Turtle's condition is not causal to plant operation. Per the plant's turtle |
| permit the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 1345 EDT. This non-emergency notification is being made |
| pursuant to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC. NRC R2DO |
| (TOM DECKER) notified. |
| |
| The NRC Resident Inspector was by notified of this event by the licensee. |
| |
| ****UPDATE ON 5/27/03 AT 10:49 FROM HESSLING TO LAURA**** |
| |
| "On 5-27-03, a loggerhead sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The turtle |
| was underweight, and missing lower posterior marginals on left side. |
| Turtle's injuries are not causal to plant operation. Per the plant's turtle |
| permit, the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 0850 EDT. This non-emergency notification is being made pursuant |
| to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| Notified R2DO (T. Decker) |
| |
| * * * UPDATE ON 06/17/03 AT 12:45 EDT FROM CALVIN WARD TO ARLON COSTA * * * |
| |
| "At approximately 12:45 p.m. on 6/17/03 a loggerhead turtle was rescued from |
| the St. Lucie Plant intake canal. The turtle was injured and will be |
| transported to the State authorized sea turtle rehabilitation facility. The |
| Florida Dept. of Environmental Protection (FDEP) was notified at 1:09 p.m. |
| as required by the St. Lucie Plant Sea Turtle Permit - see the attached sea |
| turtle stranding report (1 page). |
| |
| "Notification to the state government agency requires a four (4) Hr. |
| Non-Emergency Notification to the NRC per 10 CFR 50.72(b)(2)(xi). There were |
| no unusual plant evolutions in progress which may have contributed to this |
| event." |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (L. Wert). |
| |
| * * * UPDATE 0605 EDT ON 6/26/03 FROM STEVE MERRILL TO S. SANDIN * * * |
| |
| The licensee was informed by the FWCC that the green sea turtle requiring |
| rehabilitation which was retrieved from the plant's intake canal on 3/15/03 |
| had expired within 10 days of removal. Consequently, the licensee is |
| updating their 3/15/03 report to include this additional information. The |
| licensee will inform the NRC Resident Inspector. Notified R2DO(C. Ogle). |
| |
| * * * UPDATE 1506 EDT ON 07/01/03 FROM CALVIN WARD TO GOTT * * * |
| |
| On 04/02/03, a green sea turtle was retrieved from the intake canal. The |
| turtle required rehabilitation. The injuries were not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission was notified. This non-emergency notification is |
| being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to offsite notification. |
| On 07/01/03 licensee QA discovered that the injury had occurred and that the |
| NRC had not been notified within the 4 hours. The failure to report the |
| event within the regulatory time is being investigated and has been entered |
| into the stations corrective action program. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (Munday) |
| |
| * * * UPDATE 1750 EDT ON 07/07/03 FROM JOE HESSLING TO MACKINNON * * * |
| |
| On 07/07/03, a Loggerhead sea turtle was retrieved from the plants' intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| Turtle permit, the Florida Fish and Wildlife Conversation Commission (FWCC) |
| was notified at 1715 EDT. This non-emergency is being made pursuant to 10 |
| CFR 50.72(b)(2)(xi) due to the notification of FWCC. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (Munday). |
| |
| |
| * * * UPDATE ON 07/25/03 @ 1510 BY CALVIN WORD TO STEVE SANDIN * * * |
| |
| On 7/25/03, a sea turtle was retrieved from the plant's intake canal. The |
| turtle was determined to be in need of rehabilitation. The injuries to the |
| turtle are not causal to plant operation. Per the plant's turtle permit, |
| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified. |
| This non-emergency notification is being made pursuant to 10 CFR |
| 50.72(b)(2)(xi) due to the notification of FWCC. |
| |
| The licensee notified the NRC Resident Inspector and other Government |
| Agencies |
| |
| |
| Reg 2 RDO(Anne Boland) was informed |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39663 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE: 03/12/2003|
|LICENSEE: PM TESTING LABORATORY |NOTIFICATION TIME: 11:11[EST]|
| CITY: Tacoma REGION: 4 |EVENT DATE: 03/05/2003|
| COUNTY: STATE: WA |EVENT TIME: 20:00[PST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |THOMAS ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ARDEN SCROGGS | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| WA AGREEMENT STATE REPORT ON POSSIBLE OVEREXPOSURE INCIDENT |
| |
| |
| "Licensee: PM TESTING LABORATORY |
| "Licensee number: WN-11R047-1 |
| "Type of licensee: Industrial Radiography |
| |
| "Date of event: March 5, 2003 |
| "Location of event: Port of Tacoma, WA. German cargo ship 'Big Lift' |
| |
| "ABSTRACT: (as reported by licensee's representative) A radiographer and |
| Assistant Radiographer were performing radiography at the Port of Tacoma, on |
| a German cargo ship 'Big Lift' on March 5, 2003, at approximately 10 PM |
| [PST]. The work required the radiographers to use a cherry-picker type |
| lifting vehicle to access the work area since the area was about 100 feet |
| above deck level. The Radiographer and Assistant were both in the lift |
| bucket, 2 feet apart, at the time of the incident. The industrial |
| radiographic device (Amersham Corporation Model 660B, containing |
| approximately 70 curies of iridium 192) with connected guide tube, |
| collimator and control cables had been lifted into position and secured in |
| the area of the intended exposure. The exposure device had been made ready |
| for the exposure. The operation required the Radiographer and Assistant to |
| move the lift as far from the exposure area as possible while extending the |
| control cable. |
| |
| "As the lift was being positioned away from the work area it swayed, this |
| startled the radiographer who dropped the control cable. The sway also |
| caused the lift's engine to stall. The action of dropping the control cable |
| to the extent of its length and resulting sudden stop at the end of the drop |
| caused the source to become unshielded. Their survey meter immediately went |
| off scale on the highest scale and their alarm-rate meters were alarming. |
| |
| "It took the radiographers, by their estimate, about 30 seconds to restart |
| the [lift] vehicle, move the bucket so they could recapture the control |
| cable and secure the source. When they were able to check their pocket |
| ion-chambers, they found them off scale. Work was stopped for the day and |
| both film badges were sent for processing. |
| |
| "Results from film badge processing and analysis indicated the Radiographer |
| received a whole body exposure of 1600 millirem. This coincided with the |
| calculations made by the Radiographer after the incident. The film badge for |
| the Assistant indicated an exposure of 1,423,000 millirem. When the badge |
| processor was contacted and asked to reanalyze the film they stated they got |
| the same exposure. |
| |
| "Since both radiographers were within 2 feet of each other in the lift |
| basket and calculations confirmed that the Radiographer's exposure was 1600 |
| milliRem, it appears the exposure to the Assistant was incorrectly |
| determined. In addition, the Assistant is not exhibiting any signs of an |
| excessive exposure. The company is submitting a report of the incident. The |
| Division is performing an investigation. Media, at present, are not |
| involved. |
| |
| "What is the notification or reporting criteria involved? WAC 246-221-260, |
| Reports of overexposures and excessive levels and concentrations. |
| |
| "Activity and Isotope(s) involved? 70 curies of Iridium 192. |
| |
| "Overexposure? Until the investigation indicates otherwise, the process |
| report of the Assistant's film badge indicates a whole body exposure of |
| about 1,423,000 milliRem. The over exposure is apparently not real since |
| calculations using exposure time, distance and source activity and a second |
| film badge, worn by another individual closely associated with the first all |
| indicate exposure is unusual but much lower. Staff will investigate." |
| |
| * * * UPDATE 1326 EDT on 7/25/03 FROM A. SCROGGS VIA EMAIL TO THE OPS CENTER |
| * * * |
| |
| The following is a portion of an email received from the Dept. of Health, |
| Rad Materials Section: |
| |
| "The initial report indicated that an Assistant Radiographer appeared to |
| have received an overexposure. The Department's investigation determined |
| this not to be true. |
| |
| "As a result of the department's investigation of the event and review of |
| the radiography company's assumptions and calculations, the Assistant's |
| exposure was determined to be 1600 millirem. Although this is a significant |
| and unusual exposure, given the circumstances of the event, the department |
| considers that any health effects would be minimal. |
| |
| "The event is considered to be closed." |
| |
| Notified R4DO (Pruett) and NMSS (Greeves). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39888 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 05/29/2003|
| UNIT: [] [] [3] STATE: AL |NOTIFICATION TIME: 05:43[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 05/29/2003|
+------------------------------------------------+EVENT TIME: 02:39[CDT]|
| NRC NOTIFIED BY: RAY SWAFFORD |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CAUDLE JULIAN R2 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
| | |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DEGRADED ACCIDENT MITIGATION FEATURE |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| "On 05/29/2003 at 0239 [CDT], during performance of 3-SR-3.5.1.7, HPCI [High |
| Pressure Coolant Injection] Main and Booster Pump Developed Head and |
| Flowrate Test at Rated Reactor Pressure, following release of the HPCI Trip |
| Push button, the HPCI Turbine Stop Valve, 3-FCV-73-18, did not return to the |
| OPEN position as required by the surveillance. The SR [Surveillance |
| Requirement] was stopped. |
| |
| "This is reportable as an 8 hour report in accordance with |
| 10CFR50.72(b)(3)(v)[(D) as 'Any event or condition that at the time of |
| discovery could have prevented the fulfillment of the safety function of |
| structures or systems that are needed to: (D) Mitigate the consequences of |
| an accident.' |
| |
| "This is also reportable as a 60 day written report in accordance with |
| 10CFR50.73(a)(2)(vii) as 'Any event where a single cause or condition caused |
| at least one independent train or channel to become inoperable in a single |
| system designed to: (D) Mitigate the consequence of an accident.'" |
| |
| The licensee has notified the NRC Resident Inspector. |
| |
| |
| * * * UPDATE ON 07/25/03 @ 1456 BY NACOSTE TO GOULD * * * RETRACTION |
| |
| This report is being retracted. Upon further evaluation, it was determined |
| that failure of the HPCI stop valve to re-open, (after successful |
| performance of the HPCI flow test) did not result in a condition that could |
| have prevented the fulfillment of the safety function. The HPCI stop valve |
| did not re-open due to failure of the overspeed trip device to reset. This |
| overspeed trip device only actuates during a HPCI turbine overspeed |
| condition or it can be manually actuated to test the stop valve trip and |
| reset function. In this case, since no overspeed condition occurred, the |
| actuation was most likely the result of testing activities. HPCI reset |
| following an overspeed trip is not a safety function of HPCI, and is not |
| credited in the accident analysis for HPCI. Therefore, the failure of the |
| HPCI stop valve to reset and reopen is not a condition that could have |
| prevented the fulfillment of the safety function of HPCI, and this event is |
| not reportable. |
| |
| The NRC Resident Inspector was notified. |
| |
| Notified Reg 2 RDO (Anne Boland) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 39941 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: GUTHRIE HEALTH CARE |NOTIFICATION DATE: 06/16/2003|
|LICENSEE: GUTHRIE HEALTH CARE |NOTIFICATION TIME: 09:20[EDT]|
| CITY: SAYRE REGION: 1 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: 37-01893-01 AGREEMENT: N |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RAYMOND LORSON R1 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOON PARK | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE |
| |
| A patient was referred for treatment, due to reoccurring prostate cancer, to |
| the hospital where he had previously had treatment. Seeds were implanted |
| around May 2001. A scan of the previous treatment of implanted seeds |
| determined that many of the seeds were not located in the prostate, but in |
| adjacent tissue where they would have been ineffective in treatment. Also, |
| a review of the records indicated a scan was performed in early 2002, but |
| was not followed up on. The patient and referring physician have been |
| informed. The hospital is conducting an investigation into the event and |
| also developing a plan to provide appropriate treatment for the patient. |
| |
| * * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * * |
| |
| Post-op dosimetry on one patient was determined to be a misadministration. |
| The dose that covered the prostate was more than 20 percent different from |
| the prescription as well as the penile bulb dose being close to 50 percent |
| of the prescription dose. Efforts are being made to contact the affected |
| patient. The licensee will continue efforts to obtain post-op dosimetry on |
| the rest of the patients related to this incident so that evaluations for |
| misadministration can be performed. |
| |
| Notified R1DO (Della Greca) and NMSS EO (Pierson). |
| |
| * * * UPDATE ON 07/25/03 AT 0921 EDT FROM JOON PARK TO JOHN MACKINNON * * * |
| |
| Post-op dosimetry for two patients were determined to be a |
| misadministration. The patients had their prostates treated some time in |
| the year 2001. The iodine-125 seeds were placed 2 to 3 centimeters below |
| the area where they were supposed to be located. The improper location of |
| the iodine-125 seeds caused more than 50% of the prescribed dose to be |
| delivered to an un-intended organ. The patients will be notified. |
| |
| Notified R1DO (Dan Holody) and NMSS EO (Trish Holahan). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39997 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 07/15/2003|
| UNIT: [1] [2] [] STATE: TX |NOTIFICATION TIME: 16:35[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/15/2003|
+------------------------------------------------+EVENT TIME: 15:15[CDT]|
| NRC NOTIFIED BY: MICHAEL SCHAEFER |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |LINDA SMITH R4 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 22 OFFSITE EMERGENCY SIRENS INOPERABLE |
| |
| |
| "South Texas Project is making this eight hour notification IAW 50.72 (b) |
| (3) (xiii) for "Loss of Offsite Response Capability". Currently, due to |
| local power outages, 10 sirens are available and 22 sirens are not |
| available. Compensatory actions are in place to alert the public if |
| necessary. There are three compensatory actions: local law enforcement |
| officials are prepared to respond to areas where the sirens are not |
| available to alert the public, a community alert network is in place to |
| activate a phone tree to local residents and tone alert radios with |
| residents. Power restoration and recovery actions are in progress." State |
| and local officials will be notified of this event by the licensee. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
| |
| * * * UPDATE ON 7/25/03 AT 1112 EDT FROM SCOTT HEAD TO GERRY WAIG * * * |
| |
| The licensee reported that all 22 of the sirens previously reported as "not |
| available" have been returned to service as of 0900 CDT on 7/24/03. All |
| Offsite Notification Sirens are operable and available at this time. |
| Notified NRC Region 4 DO (Troy Pruett). |
| |
| The licensee has notified the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40018 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 07/25/2003|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 12:17[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 07/19/2003|
+------------------------------------------------+EVENT TIME: [EDT]|
| NRC NOTIFIED BY: JEFF GROFF |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE MARIE STONE R3 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FITNESS FOR DUTY REPORT INVOLVING A LICENSED OPERATOR |
| |
| A licensed operator tested negative during a for-cause test after reporting |
| he had taken a controlled substance without a prescription. The licensee |
| has removed the individual from watchstanding duties and will determine |
| corrective actions. |
| |
| The licensee will inform the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 40021 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: FEDERAL MOGUL |NOTIFICATION DATE: 07/25/2003|
|LICENSEE: FEDERAL MOGUL |NOTIFICATION TIME: 14:30[EDT]|
| CITY: SOUTH BEND REGION: 3 |EVENT DATE: 07/25/2003|
| COUNTY: STATE: IN |EVENT TIME: [CST]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 07/25/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ANNE MARIE STONE R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PAUL FRODYMA | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SOURCE MISSING FROM FIXED LOCATION GENERAL LICENSE THICKNESS GAUGE |
| |
| Federal Mogul Corporation at their South Bend, Indiana facility produces |
| teflon coated pistons. In the production process, a fixed gauge |
| manufactured by Oxford Instruments is employed to measure the teflon coating |
| thickness using a beta backscatter probe. The gauge was last calibrated on |
| 12/02 at which time the technician noted two (2) screws were missing on the |
| faceplate. However, no repairs were made at that time. Earlier this year |
| technicians replaced the missing screws not realizing that the source had |
| fallen out and was no longer in the instrument. A survey and search of the |
| area did not identify or recover the source. The instrument is a model |
| GM-2, S/N 610130P, containing less than 1200 microCuries Promethium-147. |
| |
| Call the Headquarter Operations Officer for contact information. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40022 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 07/25/2003|
| UNIT: [] [2] [] STATE: TX |NOTIFICATION TIME: 14:54[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/25/2003|
+------------------------------------------------+EVENT TIME: 13:18[CDT]|
| NRC NOTIFIED BY: DAVID BUTLER |LAST UPDATE DATE: 07/25/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |TROY PRUETT R4 |
|10 CFR SECTION: | |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 12 Power Operation |1 Startup |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC AUXILIARY FEEDWATER ACTUATION DUE TO MAIN FEEDWATER PUMP TRIP |
| |
| While at 12% power, the operating Main Feedwater Pump "2-B" tripped on low |
| suction pressure, possibly due to an entrained air bubble in one of the |
| feedwater heaters. This resulted in an automatic AFW signal due to a loss |
| of all feedwater (the "2-A" MFW was in the tripped condition since it was |
| not required). Operators manually tripped the Main Turbine to minimize |
| steam demand and stabilize the plant. All systems functioned as required. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40023 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 07/27/2003|
| UNIT: [] [2] [] STATE: MN |NOTIFICATION TIME: 02:14[EDT]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/26/2003|
+------------------------------------------------+EVENT TIME: 21:39[CDT]|
| NRC NOTIFIED BY: STEVE SEILHYMER |LAST UPDATE DATE: 07/27/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE MARIE STONE R3 |
|10 CFR SECTION: | |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LOSS OF POWER TO 4160 V BUS DUE TO A GROUND FAULT |
| |
| "A ground fault on the tertiary winding of 10 TR Substation Transformer |
| resulted in a loss of power to Unit 2 Safeguard 4160 V Bus 26. Bus 26 Load |
| Sequencer automatically initiated voltage restoration to re-power the bus |
| from 2RY Station Reserve Transformer. Load Sequencer operation also |
| generated automatic load rejection and load restoration of Bus 26 loads." |
| |
| All safeguards loads on Bus 26 that would have been rejected by the |
| sequencer were not running. Containment fan cooling units were restored. |
| Manually restored reactor coolant pump seal injection. Tertiary Cooling |
| Systems that provide flow to the cooling towers are still off. All other |
| systems functioned as required. |
| |
| The licensee will notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
