U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/29/2003 - 05/30/2003
** EVENT NUMBERS **
39883 39884 39888 39889 39890 39891
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|General Information or Other |Event Number: 39883 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 05/27/2003|
|LICENSEE: GUIDANT CORPORATION |NOTIFICATION TIME: 10:17[EDT]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 05/23/2003|
| COUNTY: STATE: TX |EVENT TIME: 15:50[CDT]|
|LICENSE#: L05178-000 AGREEMENT: Y |LAST UPDATE DATE: 05/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JONES R4 |
| |LAWRENCE DOERFLEIN R1 |
+------------------------------------------------+TOM ESSIG NMSS |
| NRC NOTIFIED BY: OGDEN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
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EVENT TEXT
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| MALFUNCTION OF A HIGH DOSE RATE AFTERLOADER |
| |
| During a heart procedure at the Union Memorial Hospital in Maryland with a |
| Galileo III (HDR - High dose rate afterloader) device using a Phosphorus - |
| 32 source wire, of up to 600 millicuries, a malfunction occurred with the |
| active wire in place in the patient's heart. When the source was to be |
| retracted the source would not retract. The physician utilized the machine |
| interrupt to try to get the source to move to the shielded position and it |
| failed. The physician then pushed the system STOP button to get the source |
| to retract and it also failed to perform the retraction. The physician then |
| moved to the hand-wheel to retract the source, but this function also |
| malfunctioned. At this point the physician pulled the entire catheter and |
| dropped it to the Operating Room floor. The power cord was then removed |
| from the wall receptacle depriving the machine of power and then the source |
| retracted to the fully shielded position. The licensee was informed that |
| this would constitute a Therapy Event within the State of Texas and the |
| state would need a complete report and an emergency read of all badged |
| personnel in the OR during the procedure. The Licensee responded that the |
| machine was not within the State of Texas. A report to the state of Texas |
| is still required by License Condition # 16 due to failure of the drive |
| mechanism of the GALILEO III to retract the source to safe storage until the |
| fourth emergency procedure was performed. |
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|General Information or Other |Event Number: 39884 |
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| REP ORG: NEW MEXICO RAD CONTROL PROGRAM |NOTIFICATION DATE: 05/27/2003|
|LICENSEE: SPECTRATEK SERVICES |NOTIFICATION TIME: 12:49[EDT]|
| CITY: ALBUQUERQUE REGION: 4 |EVENT DATE: 05/23/2003|
| COUNTY: STATE: NM |EVENT TIME: 16:30[MDT]|
|LICENSE#: TA-172-21 AGREEMENT: Y |LAST UPDATE DATE: 05/27/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |WILLIAM JONES R4 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+CAUDLE JULIAN R2 |
| NRC NOTIFIED BY: WILLIAM FLOYD | |
| HQ OPS OFFICER: ERIC THOMAS | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT |
| |
| On 5/22/2003, the licensee sent a shipment of radioactive material to Elite |
| Airfreight in Houston, TX. On 5/23/2003 at approximately 1630 MDT, Elite |
| Airfreight contacted the licensee to inform them that only 2 of the 3 boxes |
| of radioactive material in the shipment had arrived in Houston. The |
| licensee contacted Federal Express, who tracked the missing package to the |
| Fedex facility in Memphis, TN. Fedex planned to send the missing package to |
| Houston on 5/24/2003. As of 5/27/2003, the package still had not arrived in |
| Houston. The licensee contacted Fedex again, and was told the package was |
| still in Memphis, and would be shipped to Houston today (5/27/2003). |
| |
| The missing package is a 12X12X12 inch fiberboard box containing 40 |
| millicuries of Antimony-124, and has a Transportation Index of 4. This |
| event is state of New Mexico event number NM03-02. |
| |
| Notified the R4 Duty Officer (W. Jones), R2 Duty Officer (C. Julian), and |
| NMSS (D. Broaddus) |
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|Power Reactor |Event Number: 39888 |
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| 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: 05/29/2003|
| 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 | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
| | |
|3 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| 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. |
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|Hospital |Event Number: 39889 |
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| REP ORG: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION DATE: 05/29/2003|
|LICENSEE: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION TIME: 08:54[EDT]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 05/29/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: 37-0018-07 AGREEMENT: N |LAST UPDATE DATE: 05/29/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LAWRENCE DOERFLEIN R1 |
| |DOUGLAS BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROB FORREST | |
| HQ OPS OFFICER: ARLON COSTA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
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EVENT TEXT
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| LOSS OF RADIOACTIVE SOURCE |
| |
| "On Tuesday April 29, 2003, a laboratory supervisor at the Hospital of the |
| University of Pennsylvania (HUP) notified Environmental Health and Radiation |
| Safety that a package of 250 [microcurie] of P-32 was not received by her |
| lab as expected on April 25, 2003. The package was shipped as an excepted |
| package not subject to external labeling. |
| |
| "The package was delivered by materials management staff and left in the |
| hallway near the laboratory with other supplies instead of being delivered |
| directly to the lab as required. |
| |
| "The radiation safety investigation determined that housekeeping staff |
| removed the package unopened from the hallway and disposed of it in the |
| regular trash. Based on the activity and exposure rate, this package did |
| not present an exposure to any employee or member of the general public. |
| |
| "Corrective actions have been initiated with laboratory, materials |
| management and housekeeping staff to prevent reoccurrence." |
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|Power Reactor |Event Number: 39890 |
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| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 05/29/2003|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 12:40[EDT]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 05/28/2003|
+------------------------------------------------+EVENT TIME: 07:30[CDT]|
| NRC NOTIFIED BY: GARY HARRINGTON |LAST UPDATE DATE: 05/29/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
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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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| DISCOVERY OF A CONTROLLED SUBSTANCE WITHIN THE KEWAUNEE PLANT PROTECTED |
| AREA |
| |
| "On 5/28/03 at approximately 0730 CDT on-site testing of a substance proved |
| positive for a controlled substance. The substance was found by a member of |
| plant staff on the plant grounds within the protected area. The plant staff |
| member took possession of the substance and immediately contacted Security |
| staff personnel for assistance. There were no personnel noted in the area of |
| the substance [at the time of discovery]. After confirming the substance, it |
| was turned over to Kewaunee County Sheriff's Department." |
| |
| Contact the Headquarters Operations Officer for additional details. |
| |
| The licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39891 |
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| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 05/30/2003|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 00:43[EDT]|
| RXTYPE: [1] CE |EVENT DATE: 05/29/2003|
+------------------------------------------------+EVENT TIME: 21:18[CDT]|
| NRC NOTIFIED BY: DON KURTTI |LAST UPDATE DATE: 05/30/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KRISS KENNEDY R4 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
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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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| 161 KV WAS DECLARED INOPERABLE DUE TO THE PREDICTED POST TRIP VOLTAGE BELOW |
| SETPOINT |
| |
| The following information was obtained from the licensee via facsimile: |
| |
| " [Abnormal Operating Procedure] AOP-31 '161KV GRID MALFUNCTIONS' was |
| entered due to the predicted post trip 161 KV voltage dropping to 160.6 KV |
| on the PCMMINT [Personal Computer Monitoring of Missouri, Iowa and Nebraska |
| Transmission] computer monitoring program. 161 KV was declared inoperable |
| due to the predicted post trip voltage being below the 160.7 KV setpoint. |
| Tech Spec 2.7(2)C, 72 hour LCO was entered. Both emergency diesel |
| generators are operable. |
| |
| "Main generator VARS [Volt-Amperes Reactive] were raised from 100 to 150 |
| MVARS lagging in an attempt to raise predicted post trip voltage. Predicted |
| voltage rose above 161 KV for approx. 5 minutes and then lowered below 161 |
| KV again to 160.8 KV and is now fluctuating. System Operations was notified |
| and stated that 161 KV actual voltage remained at approx. 164 KV and that |
| the electrical grid was stable. |
| |
| "Design Engineering was notified and hypothesizes that MAPP [Mid-America |
| Power Pool] values into PCMMINT program may not be valid and that they will |
| attempt to validate the inputs." |
| |
| The licensee has notified the NRC Resident Inspector. |
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