U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/19/2003 - 02/20/2003
** EVENT NUMBERS **
39585 39587 39589 39596
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|General Information or Other |Event Number: 39585 |
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| REP ORG: IOWA DEPARTMENT OF PUBLIC HEALTH |NOTIFICATION DATE: 02/14/2003|
|LICENSEE: UNIVERSITY OF IOWA |NOTIFICATION TIME: 11:22[EST]|
| CITY: IOWA CITY REGION: 3 |EVENT DATE: 02/06/2003|
| COUNTY: STATE: IA |EVENT TIME: [CST]|
|LICENSE#: 0037-1-52-AAB AGREEMENT: Y |LAST UPDATE DATE: 02/14/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |SONIA BURGESS R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GEORGE JOHNS | |
| HQ OPS OFFICER: MIKE RIPLEY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - MEDICAL EVENT |
| |
| The Iowa Department of Public Health provided the following via fax: |
| |
| "Here is a summary of the event that occurred a week ago: |
| |
| "The University of Iowa (Iowa Radioactive Materials License No. 0037-1 |
| -52-AAB) provided a 700 Rad (7 Gy [Gray]) dose to an unintended site using a |
| Varian-TEM Ltd. Model VariSource HDR Remote Afterloader. The planned area |
| of treatment was a tumor in the bronchial area. |
| |
| "The licensee measured and tested a catheter using the dummy source. After |
| the test, the catheter was placed in a box and sent for sterilization. On |
| February 6, 2003. the licensee used what they thought was the correct |
| catheter during one fraction. |
| |
| "When the patient returned on February 13, 2002, for the second fraction, a |
| medical physicist discovered that the catheter was 30 centimeters too |
| short. |
| |
| "The dose was delivered to the skin in the nasal passages rather than the |
| bronchial area. The attending physician was present at the time the error |
| was discovered and has been informed. The patient has been advised of the |
| error and given the option of discontinuing treatment. The patient has |
| elected to undergo treatment for the correct site. |
| |
| "The cause of the error is currently under investigation and the licensee's |
| report, which is due to IDPH by February 28, 2003, will address corrective |
| actions." |
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|General Information or Other |Event Number: 39587 |
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| REP ORG: STATE OF CALIFORNIA |NOTIFICATION DATE: 02/14/2003|
|LICENSEE: UNIVERSITY OF CALIFORNIA AT SAN DIEGO|NOTIFICATION TIME: 16:55[EST]|
| CITY: SAN DIEGO REGION: 4 |EVENT DATE: 02/13/2003|
| COUNTY: SAN DIEGO STATE: CA |EVENT TIME: 07:30[PST]|
|LICENSE#: 1339-37 AGREEMENT: Y |LAST UPDATE DATE: 02/14/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| |PATRICIA HOLAHAN NMSS |
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| NRC NOTIFIED BY: BARBARA HAMRICK | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT- UNIVERSITY OF CALIFORNIA AT SAN DIEGO SAFETY |
| EQUIPMENT FAILS TO FUNCTION |
| |
| The following information was obtained via e-mail from California Department |
| of Health Services, Radiological Health Branch: |
| |
| "At approximately 7:30 am [PST], February 13, 2003, the University of |
| California at San Diego (California Radioactive Materials No. 1339-37) was |
| performing one of the monthly Quality Assurance (QA) tests on their High |
| Dose Rate Afterloader (HDRA). They had a treatment scheduled for later that |
| morning, and the guide tubes and extenders were already attached in |
| preparation for the treatment. During the typical monthly check, the |
| licensee disconnects two of the guide tubes, and attaches the QA catheter, |
| placing one end in the well chamber to measure the source strength, and that |
| is what occurred this time. However, when the channel was set to run the QA |
| test, the operator inadvertently set the wrong channel, and the source was |
| extended into one of the guide tubes, rather than through the QA catheter |
| and into the well chamber. When the operator tried to retract the source, |
| it would not retract. |
| |
| "The operator used a survey meter at the door of the treatment room to |
| verify the source was still out, and re-confirmed that with the indication |
| on the room monitor. After several attempts to retract the source from the |
| console, the operator entered the room, and placed all the guide tubes into |
| the emergency source pig, and closed the lid. The operator states the |
| dose-rate in the room, with the source in the pig was reduced to |
| approximately 3 milliR/hr at one foot from the pig. He estimates he was |
| within one meter of the unshielded source for no more than 5 seconds, and |
| that his hand was within one foot of the source for approximately 3 seconds. |
| Currently, the licensee estimates the dose to the operator as under 100 |
| millirem whole body. They have sent his dosimeter for emergency processing. |
| It is unknown at this time if he was wearing an extremity dosimeter. |
| |
| "After placing the guide tubes with the source in the pig, the operator left |
| the room, locked it, and contacted Nucletron Corporation to service the |
| device. The licensee contacted the State of California with this |
| information at approximately 10:30 am PST on February 14, 2003. The State |
| of California is investigating this event, and will provide updated |
| information as needed. This event would be reportable to the NRC pursuant |
| to 10 CFR 30.50(b)(2), and to the State of California under the comparable |
| California regulation (17 CCR 30295)." |
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|Power Reactor |Event Number: 39589 |
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| FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 02/16/2003|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 03:10[EST]|
| RXTYPE: [1] CE |EVENT DATE: 02/16/2003|
+------------------------------------------------+EVENT TIME: 02:53[EST]|
| NRC NOTIFIED BY: STAN ROGERS |LAST UPDATE DATE: 02/19/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |Patrick Hiland IRO |
|10 CFR SECTION: |SONIA BURGESS R3 |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |JOHN ZWOLINSKI NRR |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| NOUE DECLARED DUE TO REDUCED PLANT SERVICE WATER FLOW |
| |
| Licensee reported that service water pump intake bay level decreased |
| requiring the shutdown of one dilution water pump to increase bay level to |
| normal. Flow was reduced on the operating dilution water pump by throttling |
| the discharge flow to maintain bay level at the normal operating level. The |
| cause of the reduced service water bay level is being investigated. The |
| licensee has notified the State of Michigan and VanBuren county. The |
| licensee will contact the NRC Resident Inspector. |
| |
| Notified FEMA of this event |
| |
| * * * UPDATE AT 0418 EST ON 2/16/03 BY GERRY WAIG * * * |
| |
| NRC entered monitoring phase of normal mode for this event at 0418 EST on |
| 2/16/03 after decision maker brief (Jim Dyer, Geoffrey Grant, Tony Vegel, |
| Pat Hiland, and John Zwolinski). |
| |
| * * * UPDATE AT 0825 EST ON 2/16/03 BY GERRY WAIG * * * |
| |
| NRC exited monitoring phase of normal mode for this event at 0825 EST on |
| 2/16/03 after briefing (J. Dyer/ R3 IRC members, S. Collins, J. Zwolinski, |
| R. Zimmerman, D. Wessman, W. Kane, & P. Hiland). |
| |
| * * * UPDATE AT 1600 EST ON 2/16/03 BY HOWIE CROUCH * * * |
| |
| Divers are at Palisades and preparing to inspect (most likely tomorrow). |
| The plant is stable and the bay level is stable. The plant continues in the |
| Unusual Event. Exit criteria will be root cause discovery. It was noted |
| that South Haven municipal water (near Palisades) was experiencing like |
| symptoms. |
| |
| * * * UPDATE AT 1301 EST ON 2/19/03 BY HOWIE CROUCH * * * |
| |
| The licensee has terminated the NOUE declared on 2/16/03. The licensee has |
| restored full capability to provide make-up water to the plant's service |
| water intake (ultimate heat sink). The NRC Resident Inspector has been |
| notified by the licensee. Headquarters Operations Officer notified R3DO |
| (Miller), NRR EO (Zwolinski), FEMA and DIRO (Hiland). |
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|Power Reactor |Event Number: 39596 |
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| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 02/19/2003|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 15:43[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 02/13/2003|
+------------------------------------------------+EVENT TIME: 09:54[CST]|
| NRC NOTIFIED BY: JAMES CUNNINGHAM |LAST UPDATE DATE: 02/19/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| OFFSITE NOTIFICATION DUE TO SERIOUS PHYSICAL INJURY AT AMEREN UE CALLAWAY |
| PLANT |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| "At 0954 [CST] on February 13, 2003, the Control Room was notified of a |
| personnel injury in the Turbine building. After examination by the site |
| doctor, the individual was transported off site for treatment. Subsequently, |
| on February 18, 2003, the individual was admitted to the hospital for |
| further treatment. |
| |
| Preliminary investigation indicates that the individual was struck in the |
| face with a flying object. The individual was using a filter change out tool |
| and attempting to disconnect a 2" Camflex plug. The line was apparently |
| pressurized resulting in ejection of the plug toward the individual's face |
| when it was disconnected. |
| |
| The Missouri Public Service Commission was notified at 2:02 pm CST on |
| February 19,2003 of the serious injury. |
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