U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/07/95 - 08/08/95 ** EVENT NUMBERS ** 29161 29165 29166 29167 +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29161 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. VINCENT HOSPITAL |NOTIFICATION DATE: 08/04/95 | | CITY: WORCESTER REGION: 1 |NOTIFICATION TIME: 13:26 [ET]| | COUNTY: STATE: MA |EVENT DATE: 05/02/94 | |LICENSE#: 20-12869-01 AGREEMENT: N |EVENT TIME: 15:35[EDT]| | DOCKET: |LAST UPDATE DATE: 08/07/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JACK DURR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: PAUL IMBERGAMO | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ST. VINCENT HOSPITAL WHICH IS LOCATED IN WORCESTER, MASSACHUSETTS, | | IDENTIFIED THE POSSIBILITY OF USING A 5-MILLIGRAM, CESIUM-137, | | BRACHYTHERAPY SOURCE IN LIEU OF A 10-MILLIGRAM SOURCE. | | | | DURING THE PERFORMANCE OF A QUARTERLY INVENTORY AND SURVEY ON MAY 27, 1995, | | ST. VINCENT HOSPITAL DISCOVERED THAT TWO SOURCES HAD BEEN STORED IN THE | | WRONG SLOTS SINCE APRIL 24, 1994. A NOMINAL, 5-MILLIGRAM, CESIUM-137, | | STAINLESS STEEL, ENCAPSULATED, MICROSPHERE, BRACHYTHERAPY SOURCE WAS FOUND | | TO BE LOCATED IN THE SLOT FOR A SIMILAR 10-MILLIGRAM SOURCE; AND THE | | 10-MILLIGRAM SOURCE WAS FOUND TO BE LOCATED IN THE SLOT FOR THE 5-MILLIGRAM | | SOURCE. THESE SOURCES ARE CATEGORIZED BY BOTH COLOR CODING (RED AND | | PURPLE) AND STORAGE POSITION IN A SAFE. THE LICENSEE ALSO UTILIZED A | | DOUBLE CHECKING SYSTEM IN WHICH ONE INDIVIDUAL LOADED THE SOURCES IN THE | | SAFE AND ANOTHER INDIVIDUAL VERIFIED THEM. IN THIS CASE, THE COLORS HAD | | FADED AND WERE HARD TO DISTINGUISH INDIVIDUALLY. THE LICENSEE CURRENTLY | | PLANS TO REPAINT THE SOURCES AND POSSIBLY TO COME UP WITH A SOURCE MAP | | DIAGRAM TO IDENTIFY WHICH SOURCE IS TO BE PULLED PER CASE. | | | | THE LICENSEE'S INVESTIGATION REVEALED THAT THE 10-MILLIGRAM SOURCE HAD NOT | | BEEN USED FOR ANY APPLICATIONS INTENDED FOR A 5-MILLIGRAM SOURCE. HOWEVER, | | THERE WAS A POSSIBILITY THAT THE 5-MILLIGRAM SOURCE COULD HAVE POTENTIALLY | | BEEN USED IN LIEU OF THE 10-MILLIGRAM SOURCE. THERE WERE FIVE CASES WHERE | | THERE WAS A ONE IN SIX CHANCE THAT THE POTENTIAL DOSE DIFFERENCES BETWEEN | | THE PRESCRIBED AND DELIVERED DOSES WERE NOT ENOUGH TO CLASSIFY THEM AS | | EITHER RECORDABLE EVENTS OR MISADMINISTRATIONS. THERE WERE SIX CASES WHERE | | THERE WAS A ONE IN SIX CHANCE THAT THE POTENTIAL DOSE DIFFERENCES WOULD | | HAVE BEEN ENOUGH TO CLASSIFY THEM AS RECORDABLE EVENTS, BUT IT IS VERY | | UNLIKELY THAT THE WRONG SOURCE WAS USED IN THESE APPLICATIONS BECAUSE THE | | SOURCE WAS USED FOR A SEPARATE APPLICATOR AND STORED IN A SEPARATE LOCATION | | AND BECAUSE OF THE INDIVIDUAL'S WORK PRACTICES FOR LOADING SOURCES. THE | | LICENSEE DID, HOWEVER, IDENTIFY ONE CASE WHERE THERE WAS A ONE IN FIVE | | CHANCE THAT ONE HALF OF THE DIAGNOSED DOSAGE MAY HAVE BEEN ADMINISTERED BY | | ANOTHER INDIVIDUAL. | | | | THIS POTENTIAL MISADMINISTRATION INVOLVED A 2,000-CENTIGRAY PRESCRIPTION TO | | THE SURFACE OF A BURNETT APPLICATOR WITH A 20% CHANCE OF A 1,098-CENTIGRAY | | ADMINISTRATION. THIS EQUATES TO A POTENTIAL 45% UNDER DOSE FOR TREATING | | RECURRENT DISEASE ON AN ELDERLY PATIENT WITH MULTIPLE ILLNESSES. THIS | | IMPLANT WAS PUT INTO THE PATIENT AT 1535 ON MAY 2, 1994, AND IT WAS REMOVED | | AT 0815 ON MAY 4, 1994. | | | | THE LICENSEE NOTIFIED THE MEDICAL STAFF, AND THE APPROPRIATE PHYSICIANS | | DETERMINED THAT THERE WAS NO CLINICAL SIGNIFICANCE TO THE POTENTIAL UNDER | | DOSAGE TREATMENTS FOR ANY OF THESE EVENTS. THE LICENSEE OPTED NOT TO | | NOTIFY THE PATIENT INVOLVED IN THE POTENTIAL MISADMINISTRATION. | | | | * * * UPDATE AT 1103 EDT ON 8/7/95 FROM INBERGAMO TAKEN BY KARSCH * * * | | THE INVENTORY WAS CONDUCTED ON JULY 27, 1995, NOT MAY 27, 1995, AS STATED | | ABOVE. R1DO (DURR) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29165 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 08/07/95 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 11:08 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/07/95 | +------------------------------------------------+EVENT TIME: 09:20[CDT]| |NRC NOTIFIED BY: MAT ROBERT |LAST UPDATE DATE: 08/07/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL J. JORDAN RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 99 POWER OPERATION | 99 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PERIMETER SECURITY ZONES INOPERABLE AND UNCOMPENSATED FOR. | | | | ON 8/4/95, SIXTEEN PERIMETER SECURITY ZONES WERE INOPERABLE BETWEEN 1629 | | AND 1759 CDT DUE TO LIGHTNING STORMS. COMPENSATORY MEASURES WERE NOT MET | | WITHIN TEN MINUTES AS REQUIRED. THIS CONDITION WAS NOT DISCOVERED UNTIL | | 8/7/95 AT 0920 CDT. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29166 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 08/07/95 | |UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 12:24 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 08/07/95 | +------------------------------------------------+EVENT TIME: 10:00[EDT]| |NRC NOTIFIED BY: LINGLE |LAST UPDATE DATE: 08/07/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CASTO RDO | |APRE 50.72(b)(2)(vi) 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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED OFFSITE AGENCIES REGARDING SMALL OIL SPILL ONSITE. | | | | THE LICENSEE NOTIFIED LOCAL AND STATE AGENCIES AS WELL AS THE NATIONAL | | RESPONSE CENTER REGARDING A SMALL OIL SHEEN LOCATED ON THE LAKE. | | APPROXIMATELY 1 PINT OF OIL WAS SPILLED FROM THE KEOWEE HYDROELECTRIC PLANT | | DURING PREPARATIONS FOR AN OUTAGE. THE LICENSEE HAS DEPLOYED BOOMS TO | | CONTAIN THE SPILL. THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE | | LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29167 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 08/07/95 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 18:33 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 07/29/95 | +------------------------------------------------+EVENT TIME: 19:00[EDT]| |NRC NOTIFIED BY: DAMMANN |LAST UPDATE DATE: 08/07/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JORDAN RDO | |AENS 50.72(b)(1)(v) ENS INOPERABLE | | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE LOST FTS AND COMMERCIAL OFFSITE TELEPHONE COMMUNICATIONS. | | | | THE LICENSEE REPORTED THAT ON 7/29/95, FTS2000 AND COMMERCIAL TELEPHONE | | CAPABILITIES WERE LOST FROM THE SITE. THE LICENSEE STATED THAT, AT THE | | TIME, CONTROL ROOM OPERATORS WERE AWARE THAT LOCAL TELEPHONE SERVICE WAS | | UNAVAILABLE, BUT WERE UNAWARE THAT BOTH FTS 2000 AND COMMERCIAL LONG | | DISTANCE TELEPHONE SERVICES WERE ALSO UNAVAILABLE. A SERVICE REPORT FROM | | THE LOCAL TELEPHONE COMPANY WAS RECEIVED TODAY WHICH DOCUMENTED THE EXTENT | | OF THE SERVICE DISRUPTION. THE NRC RESIDENT HAS BEEN INFORMED BY THE | | LICENSEE. | +------------------------------------------------------------------------------+