Headquarters Daily report AUGUST 02, 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 - REGION I AUGUST 2, 1994 Licensee/Facility: Notification: Fox Chase Cancer Center MR Number: 1-94-0087 Fox Chase Cancer Center Date: 07/29/94 Philadelphia,Pennsylvania Dockets: 03003026 License No: 37-02766-01 Subject: REPORTED THERAPEUTIC MISADMINISTRATION RESULTING FROM TREATMENT WITH AN HDR DETERMINED NOT TO BE A MISADMINISTRATION Reportable Event Number: N/A Discussion: In PN I-28 dated April 18, 1994, a possible misadministration was reported at Fox Chase Cancer Center. This Morning Report provides an update to the PN. On April 15, 1994, the licensee's Radiation Safety Officer notified the Headquarter's Operations Officer that a possible therapeutic misadministation had occurred at their facility on August 18, 1993. A patient who was scheduled to receive two fractionated radiation doses to his esophagus of 700 centigray each actually received a 1000 centigray dose during the administration of the first fraction. The licensee immediately realized the error and compensated for the increased dose administered in the first fraction by reducing the dose in the second fraction to 400 centigray. At the time, the licensee did not believe that a misadministration had occurred. During a routine inspection of the licensee's facilities on April 14, 1994, an NRC inspector informed the licensee that the event was a misadministration because the administered dose for the first fraction exceeded the original prescribed dose for the first fraction by more than 20 percent. The licensee made the notifications required in 10 CFR 35.33(a). Because the regulations did not specifically address fractionated HDR therapies, only fractionated teletherapy doses, on May 2, 1994, a Technical Assistance Request (TAR) was submitted to NRC Headquarters. The TAR requested guidance on whether the event described was a misadministration. On July 7, 1994, NRC Headquarters responded that the event described did not constitute a misadministration because neither the rule language nor the Statements of Consideration for the proposed and final "Quality Management Program and Misadministrations" rule addressed the issue of fractionated brachytherapy. The inspector informed the licensee of this determination. Regional Action: The Region will issue a Notice of Violation for failure of the supervised users to follow written quality management procedures. This Morning Report provides an update to the PN. Contact: James P. Dwyer (610)337-5309 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION I AUGUST 2, 1994 Licensee/Facility: Notification: None MR Number: 1-94-0088 None Date: 08/02/94 Subject: Patient With Implanted Iodine-125 Seeds Shot Himself Reportable Event Number: N/A Discussion: On August 1, 1994, the State of Connecticut notified Region I that a person with implanted iodine-125 sources into his head and the base of tongue, had shot himself and died. The notification stated that the body was taken to the Medical Examiner's Office in Farmington, CT. The incident site, a parking lot near Town Hall Square in Woodbridge, CT, was washed down by the fire department and the run off went into a flood drain. The implant procedure was performed at Yale-New Haven Hospital. Region I contacted the RSO of Yale-New Haven Hospital and learned that the incident occurred on July 28, 1994. The implant procedure was performed on February 7, 1994 when 130 iodine-125 seeds with a total activity of approximately 60 millicuries were implanted. The radiation dose rate at a distance of 1 foot from the patient was 10.2 mR/hr on the day of the implant in February. The RSO estimated that the deceased had an activity of approximately 6.6 mCi at the time of the incident. A State inspector was on site to measure radiaiton levels at the incident site and in the drain. No removable contamination was detected in the Medical Examiner's Office or on the body bag. Regional Action: Region I will continue to receive updates from the State of Connecticut. Contact: Sattar Lodhi (610)337-5364 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II AUGUST 2, 1994 Licensee/Facility: Notification: Unknown MR Number: 2-94-0071 Newcor Steel Company Date: 08/02/94 Darlington,South Carolina Telephone call from State of FL Subject: RADIOACTIVE SOURCE FOUND IN SCRAP SHIPMENT Reportable Event Number: N/A Discussion: On August 2, 1994, the State of Florida advised the Region that a radioactive source was found in a scrap rail car after a radiac monitor alarmed as the car was entering the Newcor Steel Company in Darlington, South Carolina. The shipment of scrap originated at the Davis Joseph Scrap Yard in West Palm Beach, Florida. The source, which is believed to be a one millicurie Am-Be source, was returned to the State of Florida. The source is cylindrical in shape, approximately 1 centimeter long by 0.5 centimeter in diameter, with a marking Am-241 noted on one side. Markings on the other side are somewhat obliterated but has a partial identification which states "M8711." The Office of Radiation Control, Tallahassee office, is researching the source and device catalog in an attempt to make a final identification. The State will hold the source for disposal at a future date, unless the original owner can be identified. Based on the limited information provided, Florida requested NRC assistance in the identification of the original source device. There has been no media interest. Regional Action: Region II will continue to follow this matter and assist the State in the identification of the source device. Contact: Robert Trojanowski (404)331-5597 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION III AUGUST 2, 1994 Licensee/Facility: Notification: Wisconsin Public Service Corp. MR Number: 3-94-0137 Kewaunee 1 Date: 08/02/94 Kewaunee,Wisconsin RI VIA PC Dockets: 50-305 PWR/W-2-LP Subject: VISIT BY SLOVENIAN INSPECTORS Reportable Event Number: N/A Discussion: Messrs. Djordje Vojnovic and Darko Korosec of the Slovenian Nuclear Safety Administration began a two week site visit at the Kewaunee and Point Beach nuclear plants on August 1, 1994. The intent of the visit is to observe NRC resident inspector activities. Regional Action: Information only Contact: M.J. FARBER (708)829-9605 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION IV AUGUST 2, 1994 Licensee/Facility: Notification: Southern California Edison & San MR Number: 4-94-0073 Diego Gas & Electric Co. Date: 08/02/94 San Onofre 3 CALL FROM LICENSEE TO FIELD OFFICE San Clemente,California Dockets: 50-362 PWR/CE Subject: ELECTRICAL FAULT IN CONTROL ROOM EQUIPMENT Reportable Event Number: N/A Discussion: The purpose of this Morning Report is to provide an updated root cause for the electrical fire that occurred in the control room at 2:00 a.m. on July 27, 1994. On July 27, 1994, Unit 3 operators were increasing load on train A Emergency Diesel Generator (EDG) 3G002 for a semiannual surveillance test. Volts Amps Reactive (VAR) indication became erratic and the operators observed smoke and sparks coming from the main control room panel (CR63), from which the diesel was being operated. Small flames were observed. The operators tripped the diesel and extinguished the overheated components in the rear of the panel within two minutes. Emergency Diesel Generator 3G002 was declared inoperable. Subsequent investigation revealed overheating damage to a power supply, twelve meters and 18 wires associated with panel CR63. The licensee determined that the cause of the fire was an electrical short in the safety-related 125 VDC circuits being supplied from battery 3D1. The initiating event for the short was bolt failure on Roto-switch RTS-9. The licensee had experienced previous failures of this type of switch as discussed in LER 50-362/93-007-00. The bolt failure on switch RTS-9 caused an open circuit on the current transformer (CT) secondary winding feeding the EDG VAR transducer. When the primary voltage to the CT was energized, the open-circuited CT secondary winding voltage rose to a high value and shorted across terminals within the EDG VAR transducer. This short tied the negative bus of the 125 VDC 3D1 bus to ground. The resultant transient caused the failure of a capacitor in the EDG differential relay. The capacitor shorted the 125 VDC 3D1 positive bus to ground. With solid grounds on both the positive and negative 125 VDC 3D1 buses, the intermediate meter circuits were damaged. The fault was isolated by wiring failure. The licensee replaced various equipment associated with EDG 3G002, and retested the EDG satisfactorily by starting the EDG and performing a one-hour loaded run. The licensee inspected the other EDG roto-switches in Units 2 and 3 and did not identify any additional failures. In addition, the licensee corrected problems identified in other associated circuits on the 3D1 bus. The licensee committed to replace the Roto-switches during the next refueling outage for each unit and to review the design of the 3D1 bus and perform checks as necessary to ensure that no additional equipment on this bus was damaged by the transient. Further, the licensee committed to change the circuit design to isolate the EDG meter circuits from the main 3D1 bus. Regional Action: The Region IV staff followed the licensee's root cause determination and corrective actions and held conference calls with licensee management. The resident and project inspectors will follow the licensee's design review and any associated actions taken to verify that all equipment associated with 125 VDC bus 3D1 is undamaged. Contact: D. Acker (510)975-0315 J. Russell (714)492-2641