U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/03/97 - 06/04/97 ** EVENT NUMBERS ** 32421 32430 32431 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32421 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 05/31/97 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 09:29 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 05/31/97 | +------------------------------------------------+EVENT TIME: 06:21[EDT]| |NRC NOTIFIED BY: JERRY FREEMAN |LAST UPDATE DATE: 06/03/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAURIE PELUSO RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | INADVERTENT EMERGENCY DIESEL GENERATOR START DUE TO A PERSONNEL ERROR | | DURING THE PERFORMANCE OF SURVEILLANCE TESTING | | | | DURING THE PERFORMANCE OF SURVEILLANCE TESTING FOR THE #1 EMERGENCY DIESEL | | GENERATOR, A CONTROL ROOM OPERATOR MADE AN ERROR AND INADVERTENTLY STARTED | | THE #2 EMERGENCY DIESEL GENERATOR. THE #2 EMERGENCY DIESEL GENERATOR CAME | | UP TO IDLE SPEED AND DID NOT LOAD. IT HAS SINCE BEEN SECURED. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1643EDT ON 6/3/97 FROM DAVID PIETROUSKI TO S. SANDIN * * * | | | | THE LICENSEE COMPLETED A REVIEW OF THIS EVENT AND DETERMINED THAT IT WAS | | NOT REPORTABLE. CONSEQUENTLY, THE LICENSEE IS RETRACTING THIS REPORT. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE HOO NOTIFIED R1DO | | (SILK). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32430 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MARQUETTE GENERAL HOSPITAL |NOTIFICATION DATE: 06/03/97 | | CITY: MARQUETTE REGION: 3 |NOTIFICATION TIME: 09:41 [ET]| | COUNTY: MARQUETTE STATE: MI |EVENT DATE: 06/02/97 | |LICENSE#: 21-05432-04 AGREEMENT: N |EVENT TIME: 19:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/03/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRENT CLAYTON RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. RICHARD MORELAND | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNDERDOSE AND TREATMENT OF AN INCORRECT SITE DUE TO MOVEMENT OF AN IRIDIUM | | RIBBON DURING AN ENDO-ESOPHAGEAL TREATMENT | | | | AT 1455 ON JUNE 2, 1997, THE LICENSEE INSERTED AN IRIDIUM RIBBON INTO A | | PATIENT FOR AN ENDO-ESOPHAGEAL TREATMENT. THE IMPLANTED IRIDIUM RIBBON | | CONTAINED 13 SEEDS AND HAD A TOTAL ACTIVITY OF 28.53 MILLICURIES. AT 1900, | | A NURSE WENT IN TO THE PATIENT'S ROOM TO GIVE THE PATIENT SOME MEDICATION | | AND NOTICED THAT THE TUBE CONTAINING THE IRIDIUM RIBBON HAD BEEN DISPLACED | | IN THE BACK OF THE PATIENT'S MOUTH. THE PATIENT'S DOCTOR WAS CALLED, AND | | THE DOCTOR REMOVED THE TUBE AND IMPLANT AT 1930. FURTHER INVESTIGATION | | REVEALED THAT THE PATIENT HAD SOME INVOLUNTARILY COUGHING SPELLS BETWEEN | | 1700 AND 1900 AND THAT THE INDIVIDUAL NOTICED THAT THE TUBE CONTAINING THE | | IMPLANT HAD MOVED. THE PATIENT DID NOT REPORT THIS TO ANYONE. | | | | THE PRESCRIBED DOSE WAS 2,912 MILLIREM TO BE DELIVERED OVER A 26-HOUR | | PERIOD. IT IS CURRENTLY ESTIMATED THAT THE PATIENT RECEIVED A DOSE OF | | APPROXIMATELY 224 MILLIREM TO THE PRESCRIBED LOCATION OVER A 2-HOUR PERIOD | | AND A DOSE OF APPROXIMATELY 280 MILLIREM TO AN UNKNOWN LOCATION (BECAUSE | | THE TUBE MOVED) OVER A PERIOD OF 2-1/2 HOURS. IT IS ALSO ESTIMATED THAT | | THE REMAINING DOSE TO BE DELIVERED TO THE PRESCRIBED LOCATION WILL BE | | APPROXIMATELY 2,688 MILLIREM OVER A 24-HOUR PERIOD. THE LICENSEE STATED | | THAT THERE WOULD BE NO ADVERSE HEALTH AFFECTS TO THE PATIENT AS A RESULT OF | | THIS INCIDENT. | | | | THE LICENSEE NOTIFIED THE NRC REGION 3 OFFICE (THOMAS YOUNG) AT ABOUT 0900 | | ON JUNE 3, 1997. (REFER TO THE HOO LOG FOR A LICENSEE STREET ADDRESS AND | | TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32431 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TROJAN REGION: 4 |NOTIFICATION DATE: 06/03/97 | |UNIT: [1] [ ] [ ] STATE: OR |NOTIFICATION TIME: 15:20 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 06/03/97 | +------------------------------------------------+EVENT TIME: 09:45[PDT]| |NRC NOTIFIED BY: GERALD PERRIN |LAST UPDATE DATE: 06/03/97 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAIR SPITZBERG 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 N 0 DECOMMISSIONED | 0 DECOMMISSIONED | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED OFFSITE AGENCIES OF A SMALL DIESEL FUEL OIL SPILL. | | | | APPROXIMATELY TWO CUPS OF DIESEL FUEL OIL WAS SPILLED WHILE FILLING A | | VEHICLE. RAIN WATER TRANSPORTED THE DIESEL OIL TO THE COLUMBIA RIVER. THE | | LICENSEE NOTIFIED THE DOT NATIONAL RESPONSE CENTER, THE OREGON DEPARTMENT | | OF ENVIRONMENTAL QUALITY AND THE RESIDENT OREGON DEPARTMENT OF ENERGY | | REPRESENTATIVE. THESE AGENCIES DETERMINED THAT THE AMOUNT OF THE SPILL WAS | | NOT A CONCERN. | +------------------------------------------------------------------------------+