U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/12/2003 - 06/13/2003
** EVENT NUMBERS **
39913 39914 39925 39926 39927 39928 39930 39931
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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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| | |
| | |
| | |
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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: 39925 |
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| FACILITY: WATTS BAR REGION: 2 |NOTIFICATION DATE: 06/12/2003|
| UNIT: [1] [] [] STATE: TN |NOTIFICATION TIME: 00:34[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/11/2003|
+------------------------------------------------+EVENT TIME: 23:45[EDT]|
| NRC NOTIFIED BY: MIKE EARLES |LAST UPDATE DATE: 06/12/2003|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK LESSER R2 |
|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 Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| GREATER THAN 30% OF THE OFFSITE NOTIFICATION SIRENS OUT OF SERVICE DUE TO |
| STORM |
| |
| Greater than 30% of the offsite prompt notification system sirens are out of |
| service due to storm related loss of power. Repairs are presently in |
| progress to restore power to the affected sirens (34 of 99). State and |
| Local agencies have been notified to implement compensatory measures if |
| required. |
| |
| The NRC Resident Inspector will be notified by the licensee. |
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|Power Reactor |Event Number: 39926 |
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| FACILITY: HADDAM NECK REGION: 1 |NOTIFICATION DATE: 06/12/2003|
| UNIT: [1] [] [] STATE: CT |NOTIFICATION TIME: 12:09[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 06/12/2003|
+------------------------------------------------+EVENT TIME: 11:20[EDT]|
| NRC NOTIFIED BY: CAMPBELL |LAST UPDATE DATE: 06/12/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHRISTOPHER CAHILL R1 |
|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 N 0 Decommissioned |0 Decommissioned |
| | |
| | |
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EVENT TEXT
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| NOTIFICATION AUTOMATICALLY MADE TO THE OFFSITE FIRE DEPARTMENT |
| |
| The well water booster pump catastrophically failed setting off the smoke |
| detector which sent a signal to the fire protection panel resulting in an |
| automatic notification to the fire department. The fire department |
| responded, but there was no fire. The smoke detector was probably set off |
| from smoke when the pump motor failed. |
| |
| The NRC was notified. |
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|Power Reactor |Event Number: 39927 |
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| FACILITY: WATTS BAR REGION: 2 |NOTIFICATION DATE: 06/12/2003|
| UNIT: [1] [] [] STATE: TN |NOTIFICATION TIME: 14:43[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/28/2003|
+------------------------------------------------+EVENT TIME: 20:58[EDT]|
| NRC NOTIFIED BY: MAYS |LAST UPDATE DATE: 06/12/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK LESSER R2 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| INVALID ACTUATION OF A CONTAINMENT VENT ISOLATION VALVE |
| |
| The following information is provided as a 60 day telephone notification to |
| NRC under 10 CFR 50.73 (a)(2)(iv)(A) in lieu of submitting a written LER to |
| report a condition that resulted in an invalid actuation of the WBN Train B |
| Containment Vent Isolation signal. NUREG1022, Revision 2 identifies the |
| information that needs to be reported as discussed below. |
| |
| (a) The specific train(s) and systems(s) that were actuated. |
| |
| On April 28, 2003, at 2058 EST, a Train B Containment Vent Isolation (CVI) |
| signal was received when the hand switch for the containment purge radiation |
| monitor was placed in off, unblocking the monitor. The high radiation alarm |
| was still locked in following maintenance on the monitor and was not cleared |
| before unblocking. The containment radiation monitor was inoperable and was |
| removed from service at the time the signal was received. The CVI was not |
| responding to an actual plant condition. |
| |
| (b) Whether each train actuation was complete or partial. |
| |
| The actuation was considered complete. The CVI signal for Train B |
| automatically isolated the containment vent system. The containment |
| radiation monitor was considered inoperable due to the maintenance. |
| |
| (c) Whether or not the system started and functioned successfully. |
| |
| Train B Containment Vent Isolation signal automatically actuated and |
| functioned successfully. The CVI signal was not in response to an actual |
| plant condition. The containment radiation monitors were returned to |
| service and the containment vent air cleanup unit was also returned to |
| service. |
| |
| |
| The NRC Resident Inspector was notified. |
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|Other Nuclear Material |Event Number: 39928 |
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| REP ORG: US AIR FORCE |NOTIFICATION DATE: 06/12/2003|
|LICENSEE: US AIR FORCE |NOTIFICATION TIME: 15:53[EDT]|
| CITY: LUKE AFB REGION: 4 |EVENT DATE: 06/11/2003|
| COUNTY: STATE: AZ |EVENT TIME: [MST]|
|LICENSE#: 42-23539-01AF AGREEMENT: Y |LAST UPDATE DATE: 06/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RAM BHAT | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|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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| AMERESIUM SOURCE LOST FOLLOWING F-16 CRASH |
| |
| The Air Force reported that a F-16 fighter jet crashed in Arizona near Luke |
| AFB yesterday with a 8 microcurie Americium - 241 source. The source could |
| not be found. |
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|Other Nuclear Material |Event Number: 39930 |
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| REP ORG: US AIR FORCE |NOTIFICATION DATE: 06/12/2003|
|LICENSEE: US AIR FORCE |NOTIFICATION TIME: 16:42[EDT]|
| CITY: CANNON AFB REGION: 4 |EVENT DATE: 06/10/2003|
| COUNTY: STATE: NM |EVENT TIME: [MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 06/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: REFOSCO | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|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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| LOST EXIT SIGN |
| |
| The US air Force reported that one tritium exit sign was determined missing |
| after an inventory check on 06/10/03 at Cannon AFB, NM. Prior to January - |
| February contractor work the sign was accounted for. |
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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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