Headquarters Daily report JULY 20, 1994 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS X REGION I X REGION II X REGION III X REGION IV X *************************************************************************** PRIORITY ATTENTION REQUIRED MORNING REPORT - HEADQUARTERS JULY 20, 1994 MR Number: H-94-0064 NRR DAILY REPORT ITEM GENERIC COMMUNICATIONS BRANCH/EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT OFFICE OF NUCLEAR REACTOR REGULATION Subject: N/A NRC Information Notice 94-42, Supplement 1, "Cracking in the Lower Region of the Core Shroud in Boiling-Water Reactors," was issued July 19, 1994. The NRC issued this supplement to NRC Information Notice (IN) 94-42, "Cracking in the Lower Region of the Core Shroud in Boiling-Water Reactors," to give addressees more information on the core shroud cracking at Dresden Unit 3 and Quad Cities Unit 1. Technical contacts: M. Mitchell, NRR (301) 504-2735 T. Greene, NRR (301) 504-1175 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION I JULY 20, 1994 Licensee/Facility: Notification: Hamot Medical Center MR Number: 1-94-0080 Hamot Medical Center Date: 07/19/94 Erie,Pennsylvania License No: 37-00444-02 Subject: REPORTED POSSIBLE BRACHYTHERAPY MISADMINISTRATION Reportable Event Number: N/A Discussion: On July 16, 1994, the Hamot Medical Center of Erie, Pennsylvania, contacted the NRC Operations Center to report a possible misadministration (Event No. 27543). The licensee reported that on July 16, 1994, a potential underexposure misadministration occurred. A brachytherapy implant for cancer of the cervix using cesium-137 sealed sources in an implant tandem was removed after the patient complained of discomfort and an ultrasound scan revealed that the tandem had perforated the patient's uterus. Based on the findings of the ultrasound scan the physician altered his prescription and the written directive to reflect the termination of the radiation treatment after 23 hours and a dose of 1375 rads (cGys) rather than the 3540 rads (cGys) initially prescribed in the written directive based on the number of sources, source strengths and length of time for the implant. Regional Action: Region I discussed the event with NMSS and concluded that this was not a misadministration. The licensee was informed that the event was not a misadministration because the prescribed dose to the patient was changed after evaluation by the authorized user and in accordance with the written directive. 10 CFR 35.2 defines a written directive for brachytherapy as a written order for a specific patient, dated and signed by an authorized user which contains: (1) prior to implantation, the radioisotope, number of sources, and source strengths; and (2) after implantation but prior to completion of the procedure, the radioisotope, treatment site, and total source strength and exposure time (or equivalently the total dose). This definition recognizes that medical complications may occur which can require medical intervention and a change in the final prescribed dose to the patient. Contact: Jenny M. Johansen (610)337-5304 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II JULY 20, 1994 Licensee/Facility: Notification: Tennessee Valley Authority MR Number: 2-94-0064 Browns Ferry 1 2 3 Date: 07/20/94 Decatur,Alabama Dockets: 50-259,50-260,50-296 BWR/GE-4,BWR/GE-4,BWR/GE-4 Subject: BROWNS FERRY ENGINEERING AND MATERIALS MANAGER TRANSFERS TO CORPORATE HEADQUARTERS Reportable Event Number: N/A Discussion: On July 12, TVA announced that effective July 11, Jon Rupert, Browns Ferry Engineering and Materials Manager, would be transferring to TVA headquarters in Chattanooga, TN to assume the duties of Chief Engineer of TVA Nuclear. David Burrell, the Browns Ferry Lead Electrical Engineer, has been appointed as the Acting Engineering and Materials Manager until a permanent replacement is named. Regional Action: None. Contact: Mark S. Lesser (404)331-0342 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION III JULY 20, 1994 Licensee/Facility: Notification: Norco Alloys Corp. MR Number: 3-94-0129 Royal Oak Date: 07/20/94 Royal Oak,Michigan MI DEPT/HEALTH RG3 15 JUL 94 Dockets: 03020927 License No: 21-23332-01 Subject: CONTAMINATED SCRAP METAL Reportable Event Number: N/A Discussion: On July 15, 1994, the Michigan Dept. of Health notified Region III of a shipment of contaminated scrap metal which was returned to Norco Alloys, Royal Oak, MI, from Canada, on June 15, 1994. The scrap metal was analyzed by the Michigan Dept. of Health and was found to contain 0.098% thorium by weight. The scrap originated from a Massachusetts company, a non- NRC licensee. In accordance with the Draft Federal Radiological Response Plan, the matter has been referred to the EPA. Regional Action: Region III notified EPA. Contact: MICHAEL WEBER (708)829-9825 JACK GROBE (708)829-9837