Headquarters Daily Report OCTOBER 31, 1995 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS û REGION I û REGION II û REGION III û REGION IV û PRIORITY ATTENTION REQUIRED MORNING REPORT - HEADQUARTERS OCTOBER 31, 1995 MR Number: H-95-0134 NRR DAILY REPORT ITEM GENERIC COMMUNICATIONS Information Notice 95-50, "SAFETY DEFECT IN GAMMAMED 12i BRONCHIAL CATHETER CLAMPING ADAPTER," was issued on October 30, 1995. This notice was issued to all high dose rate (HDR) afterloader licensees to alert them to the manufacturer's recommendation to discontinue use of the GammaMed 12i bronchial catheter adapter. Two recent incidents are decribed where the catheter pulled out of the clamping adapter. In both incidents, the clamping adapter clamped onto the source drive cable initiating an emergency source retraction. However, the faulty clamping adapter design prevented the source from being retracted into the device's shielded safe. In one incident, the patient was exposed to high radiation levels from the source, and in both incidents, the device operators were exposed to unnecessary radiation. Contact: Robert L. Ayres, NMSS (301) 415-5746 _ REGION II MORNING REPORT PAGE 2 OCTOBER 31, 1995 Licensee/Facility: Notification: MR Number: 2-95-0088 State Of Florida (Nascar Complex) Date: 10/31/95 Homestead,Florida Subject: Turkey Point; Re: Offsite Emergency Preparedness Discussion: Recently, the Turkey Point resident inspector advised the Region that a NASCAR Motorsport Complex was constructed within the Turkey Point 10 Mile-EPZ, 5.5 miles due west of the site. During major NASCAR events the complex is expected to draw 60,000 to 70,000 spectators. Additionally, the complex has parking space available for 20,000 vehicles, one third of which can accommodate RV type vehicles. The inaugural race for the new complex is scheduled to take place during the period of November 3-5, 1995. FEMA Region IV was not aware of this major change to the Turkey Point EPZ until notified by Region II on October 19, 1995. Since then, representatives of FEMA IV have met with State, Dade County, and race track officials to discuss off-site emergency preparedness concerns, i.e., Alert and Notification, and possible evacuation of the complex. Dade County, Emergency Management, provided FEMA IV with DRAFT interim compensatory measures which, once finalized, will be instituted to accommodate the upcoming event scheduled for this weekend. Representatives of the Regional Assistance Committee (RAC) are providing assistance to both FEMA IV and the State/local government in the review of these draft compensatory measures. FEMA IV has committed to formally advise the Region on November 2, 1995 of the results of their review. FEMA IV has advised the State that the DRAFT Interim Compensatory Measures will eventually have to be incorporated, as a major change, into the State Site-Specific Radiological Emergency Response Plan for the Turkey Point facility. Regional Action: The Regional Representative on the FEMA IV Regional Assistance Committee will continue to coordinate with FEMA on this matter. Contact: R. Trojanowski (404)331-5597 _ REGION III MORNING REPORT PAGE 3 OCTOBER 31, 1995 Licensee/Facility: Notification: MR Number: 3-95-0162 Boone Hospital Center Date: 10/23/95 Columbia,Missouri BY LETTER Dockets: 03002304 License No: 24-01565-01 Subject: PATIENT LEAVES HOSPITAL WITH IRIDIUM-192 IMPLANT Discussion: Licensee reported to Region III by letter on October 23, 1995, that a patient implanted with Iridium-192 ribbon to the floor of the mouth left the hospital premises with the implant still in place. A patient was being treated for head and neck cancer using both external beam and a brachytherapy boost. On October 3, 1995, the patient was implanted with 4 mgRaeq of Iridium-192 seeds encased in nylon ribbon to the floor of the mouth. Following the implant, the patient exhibited aggressive behavior and, at about 5:00 a.m. on October 5, 1995, left the hospital premises with the implant in place. The nurse in charge contacted security immediately, who apprehended the patient approximately two blocks from the hospital and returned the patient to his room. The patient was out of the hospital for approximately 10 minutes and at no time was the patient out of sight of the nursing or security staff. The radiation oncologist was contacted and the Iridium-192 ribbons were removed from the patient, inventoried and placed in storage at approximately 5:30 a.m. on October 5, 1995. Dose assessments performed by the licensee show that the security guards would have received a maximum of 12 millirem. Members of the general public who may have been in the vicinity of the patient for 1 minute would have received a maximum of 1 millirem. Regional Action: A Region III inspector discussed the reportable event with the Senior Medical Physicist on October 30, 1995. The licensee's actions will be reviewed during the next inspection. Contact: JEFFREY MUMPER (708)829-9828 THOMAS J. KOZAK (708)829-9866 _ REGION III MORNING REPORT PAGE 4 OCTOBER 31, 1995 Licensee/Facility: Notification: Commonwealth Edison Co. MR Number: 3-95-0163 La Salle 1 Date: 10/28/95 Marseilles,Illinois RI VIA TELEPHONE Dockets: 50-373 BWR/GE-5 Subject: PREMATURE SSPV DIAPHRAGM HARDENING AT LASALLE Discussion: Scram Solenoid Pilot Valve (SSPV) Buna-N diaphragms exhibited local hardening in less than the recommended service life of 3 to 3.5 years. This re-occurring problem with the SSPV diaphragms is understood by General Electric but the previous recommended service life was 3 to 3.5 years. The most recent diaphragm that exhibited hardening had been in service 2 years 11 months. Specifically, during half scram testing one control rod drifted from position 48 to position 46. During trouble shooting, it was determined that localized hardening of the SSPV diaphragm was the root cause. LaSalle has been on a program for replacement of the Buna-N SSPV diaphragms with Viton diaphragms. On Unit 1, 25 percent of the SSPVs have been replaced, 25 percent are currently being replaced, with the remainder scheduled for the upcoming refueling outage. On Unit 2, 75 percent have been replaced, and the rest scheduled for replacement on line before May 1996. The population of SSPVs on Unit 1 (25 percent) with this service life will be replaced on line with completion scheduled for November 21, 1995. The remainder of the SSPVs with the Buna-N diaphragms will be monitored prior to their replacement in an attempt to detect similar problems. Regional Action: The residents will continue to monitor ComEd's corrective actions. Contact: BRENT CLAYTON (708)829-9602 _