U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/16/2003 - 06/17/2003
** EVENT NUMBERS **
39929 39940 39941 39942 39943 39944 39945
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|General Information or Other |Event Number: 39929 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/12/2003|
|LICENSEE: ST JOSEPH'S HOSPITAL |NOTIFICATION TIME: 15:59[EDT]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 06/11/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02279-000 AGREEMENT: Y |LAST UPDATE DATE: 06/12/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: OGDEN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INCORRECT TREATMENT AREA DISCOVERED DURING A BREAST CANCER TREATMENT |
| |
| At the beginning of the 6th treatment the physicist discovered a geographic |
| location error on the placement of a 3 curie +/- Iridium-192 source in the |
| patient for treatment of breast cancer. Discovered an input error on the |
| five previous treatments. Measurements should have been input to the Gamma |
| Med Plus (HDR device) in millimeters were mistakenly entered in centimeters. |
| Steps for the 20 millimeter source should have been in 1 millimeter |
| increments. Therefore, the source was actually never in the patient's body. |
| The physicist has estimated 70 Gray superficial dose to the skin at a depth |
| of up to 1 centimeter. Deep dose (beyond 1 centimeter) is estimated at 30 |
| Gray. The patient has developed a small red spot which is being monitored |
| by the hospital for potential blistering. The patient and the hospital have |
| agreed to re-start this patient's treatments. Corrective actions to prevent |
| a re-occurrence of this event will follow with the Licensee's 15 day written |
| report of the incident. Dose to original treatment site is in excess of 20% |
| of the intended dose. |
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|Power Reactor |Event Number: 39940 |
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| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 06/16/2003|
| UNIT: [] [2] [] STATE: MI |NOTIFICATION TIME: 08:38[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/16/2003|
+------------------------------------------------+EVENT TIME: 05:15[EDT]|
| NRC NOTIFIED BY: TODD CASPER |LAST UPDATE DATE: 06/16/2003|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID HILLS 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 N 0 Hot Shutdown |0 Hot Shutdown |
| | |
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EVENT TEXT
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| VALID FEEDWATER ISOLATION SYSTEM SIGNAL GENERATED |
| |
| A valid feedwater isolation signal (FWIS) was generated while controlling |
| steam generator water level near 82% wide range during heat-up activities to |
| take the plant from Mode 4 to Mode 3. The set point for FWIS is 67% narrow |
| range, which is relatively close to the 82% wide range the plant was being |
| controlled. Level was allowed to get slightly higher which activated the |
| FWIS. No isolation occurred as the valves were already closed and level was |
| being maintained with auxiliary feedwater. Level has been restored to less |
| than the set point. |
| |
| The licensee notified the NRC Resident Inspector. |
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|Hospital |Event Number: 39941 |
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| 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: 06/16/2003|
| 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| |
| | |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 39942 |
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| FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 06/16/2003|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 09:34[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 06/16/2003|
+------------------------------------------------+EVENT TIME: 07:43[CDT]|
| NRC NOTIFIED BY: TODD MORGAN |LAST UPDATE DATE: 06/16/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID HILLS R3 |
|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 93 Power Operation |93 Power Operation |
| | |
| | |
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EVENT TEXT
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| LOSS OF SAFETY PARAMETER DISPLAY SYSTEM FOR GREATER THAN 8 HOURS |
| |
| "At 0743 CDT on June 16, 2003, the Safety Parameter Display System (SPDS) |
| was out of service for greater than eight hours due to the loss of the |
| Nuclear Steam Supply (NSS) Computer, which provides the computer points for |
| SPDS. |
| |
| "10CFR50.72(b)(3)(xiii), which states 'the licensee shall notify the NRC as |
| soon as practical and in all cases |
| within 8 hours of the occurrence of any event that results in the major loss |
| of emergency assessment capability.' |
| |
| "The loss of SPDS is considered a major or loss of safety assessment |
| capability. The site defines a 'major loss' |
| of SPDS, 'when the SPDS function is not available in the control room for |
| greater than eight hours.' This is |
| consistent with NUREG-1022, EVENT REPORTING GUIDELINES 10CFR 50.72 and 50.73 |
| section 3.2.13, |
| Loss of Emergency Preparedness Capabilities. The NSS Computer went down at |
| 2343 on June 15, 2003 (CDT). |
| The eight-hour unavailability of SPDS expired at 0743 on June 16, 2003 |
| (CDT). Repair efforts have been |
| underway continuously to restore the NSS Computer and return SPDS to |
| service. The expected return to |
| service for SPDS is on June 16, 2003. All other plant conditions are |
| normal." |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39943 |
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 06/16/2003|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 13:03[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 06/16/2003|
+------------------------------------------------+EVENT TIME: 08:01[EDT]|
| NRC NOTIFIED BY: KEN GRACIA |LAST UPDATE DATE: 06/16/2003|
| HQ OPS OFFICER: ARLON COSTA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RAYMOND LORSON R1 |
|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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| INABILITY TO ACTIVATE EMERGENCY SIRENS DUE TO EQUIPMENT FAILURE |
| |
| "It was discovered on 6/16/03 at 0755 that the plant sirens (Prompt Alert |
| Notification System) were out of service since Sunday 6/15/03 at 0757 [the |
| cause appears to be a continuous signal being transmitted by a siren]. The |
| system was restored to service at 0830 on 6/16/03." |
| |
| The licensee notified local authorities, the State and the NRC Resident |
| Inspector. |
| |
| Similar incidents involving emergency sirens have been reported on 6/10/03 |
| (See EN #39912) and on 6/11/03 (See EN # 39918). |
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|Fuel Cycle Facility |Event Number: 39944 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 06/16/2003|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 19:45[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 06/16/2003|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 06/16/2003|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |KENNETH RIEMER R3 |
| DOCKET: 0707001 |TIM MCGINTY IRO |
+------------------------------------------------+JANET SCHLUETER NMSS |
| NRC NOTIFIED BY: W. F. CAGE | |
| HQ OPS OFFICER: ARLON COSTA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| 4-HOUR REPORTABLE INCIDENT FOR WHICH A PRESS RELEASE WAS MADE |
| |
| "A fluorine gas release occurred in the C-410K facility while operators were |
| charging the gas system. The released gas caused a reaction which consumed a |
| small section of the gas system piping. No detectable quantities of the gas |
| were measured outside the affected facility. The Emergency Action Level |
| classification criteria for fluorine releases was not met. The release was |
| isolated by facility operators. The media requested information from the |
| plant concerning the release and the plant provided a verbal statement. This |
| statement constituted a 'media/press release' which required a 4 hour |
| notification to the NRC as required by plant procedure UE2-RA-RE1030, |
| 'Nuclear Regulatory Event Reporting'. |
| |
| "The NRC Senior Resident Inspector has been notified of this event." |
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|Power Reactor |Event Number: 39945 |
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| FACILITY: COLUMBIA GENERATING STATIREGION: 4 |NOTIFICATION DATE: 06/16/2003|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 20:36[EDT]|
| RXTYPE: [2] GE-5 |EVENT DATE: 06/16/2003|
+------------------------------------------------+EVENT TIME: 13:30[PDT]|
| NRC NOTIFIED BY: SCOTT BOYNTON |LAST UPDATE DATE: 06/16/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID GRAVES R4 |
|10 CFR SECTION: | |
|AINB 50.72(b)(3)(v)(B) POT RHR INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
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EVENT TEXT
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| UNEXPECTED ISOLATION SIGNAL DURING TESTING WHICH RESULTED IN A MOMENTARY |
| LOSS OF SHUTDOWN COOLING |
| |
| "This event notification is being made to report an event that could have |
| prevented the fulfillment of the safety function to remove residual heat. On |
| June 16, 2003, the plant was shutdown in Mode 4 with reactor vessel level |
| being maintained between 60-120 inches. Operators were performing |
| surveillance testing on the manual pushbutton isolation logic to the Nuclear |
| Steam Supply Shutoff System when an unexpected general outboard isolation |
| signal was received. This resulted in the closure of RHR-V-8 (RHR shutdown |
| cooling outboard containment isolation valve) and the interruption of |
| shutdown cooling. Reactor Recirculation Pump B remained in service providing |
| forced flow through the reactor core. Operators restored from the |
| surveillance, reset the isolation signal, and reopened RHR-V-8. Shutdown |
| cooling was restored 12 minutes after RHR-V-8 went closed. Reactor vessel |
| level and temperature remained stable during the period shutdown cooling was |
| not in service." |
| |
| The licensee's incident and review board determined that the procedure was |
| deficient in that it did not alert operators to the isolation signal which |
| functioned as required. The licensee will inform the NRC resident inspector. |
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