U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/18/98 - 06/19/98 ** EVENT NUMBERS ** 34275 34293 34402 34409 34410 34411 34412 34413 34414 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34275 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 05/21/98 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 17:56 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/21/98 | +------------------------------------------------+EVENT TIME: 14:55[EDT]| |NRC NOTIFIED BY: DANIEL MURRAY |LAST UPDATE DATE: 06/18/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GENE KELLY RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY OF CONDITION THAT COULD RESULT IN A SAFETY FUNCTION NOT BEING | | FULFILLED | | | | THE LICENSEE DISCOVERED, DURING A UPDATED SAFETY ANALYSIS REPORT REVIEW, | | THAT THE ELECTRIC STRIP HEATERS IN THE EMERGENCY DIESEL GENERATORS (EDG) | | ARE NOT SEISMICALLY QUALIFIED AND ARE POWERED FROM THE SAME NONCLASS 1E | | POWER SUPPLY. THE NONCLASS 1E PANEL ALSO SUPPLIES POWER TO DIESEL SUPPORT | | EQUIPMENT THROUGH CONTACTS IN THE CLASS 1E MOTOR CONTROL CENTERS. THESE | | ARE IN VIOLATION OF IEEE STANDARDS 279, 308, AND 244 AND RESULT IN A | | CONDITION THAT COULD HAVE PREVENTED THE FULFILLMENT OF THE SAFETY FUNCTION | | OF THE EDGs. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1733 ON 06/18/98 BY A. HARTNER TO JOLLIFFE * * * | | | | BASED ON INPUT FROM LICENSEE ENGINEERING DEPARTMENT PERSONNEL, DOCUMENTED | | IN TECHNICAL EVALUATION REPORT #11944, THE LICENSEE CONCLUDED THAT THE | | CONCERN IDENTIFIED IN CONDITION REPORT #981132, "EMERGENCY DIESEL | | GENERATORS #EE-EG-1 AND #EE-EG-2 RENDERED INOPERABLE DUE TO SEISMIC | | QUALIFICATION DEFICIENCIES AND COMMON MODE FAILURE" IS NOT APPLICABLE TO | | THE REPORTING CRITERIA OF 10CFR50.72 AND 10CFR50.73. | | | | THEREFORE, THE LICENSEE DESIRES TO RETRACT THIS EVENT REPORT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | OFFICER NOTIFIED THE R1DO HERB WILLIAMS. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34293 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 05/28/98 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 12:10 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 05/27/98 | +------------------------------------------------+EVENT TIME: 16:30[EDT]| |NRC NOTIFIED BY: M. DAVID |LAST UPDATE DATE: 06/18/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JACK DURR RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | 24-HOUR NOTIFICATION PER CONDITION OF LICENSE AS REQUIRED BY TECH SPECS | | | | SECTION 2G OF THE SEABROOK STATION OPERATING LICENSE REQUIRES THE REPORTING | | OF VIOLATIONS OF SECTION 2C OF THE LICENSE WITHIN 24 HOURS. ONE OF THE | | CONDITIONS STATES THAT THE FACILITY SHALL BE OPERATED IN ACCORDANCE WITH | | THE TECHNICAL SPECIFICATIONS (TECH SPECS OR TS). | | | | IN ACTION PRECIPITATED FROM AN EARLIER EVENT REPORT, #34181 OF MAY 5, 1998, | | A REVIEW OF INSTRUMENTATION WAS UNDERTAKEN BY A TEAM. THE REVIEW TEAM | | DISCOVERED THAT THE STEAM GENERATOR PRESSURE PROTECTION CHANNEL CALIBRATION | | PROCEDURES DID NOT INCLUDE VERIFICATION OF THE RATE TIME CONSTANT VALUE OF | | THE NEGATIVE RATE-HIGH STEAM PRESSURE FUNCTION. THIS FUNCTION IS REQUIRED | | AS PART OF THE ENGINEERED SAFETY FEATURES DURING MODE 3 OPERATION BELOW THE | | P-11 PERMISSIVE SETPOINT. THE PLANT WAS LAST IN MODE 3 IN JANUARY, 1998. | | | | THE STEAM GENERATOR PRESSURE CHANNEL CALIBRATION PROCEDURES WILL BE REVISED | | TO INCLUDE VERIFICATION OF THE RATE TIME CONSTANT PORTION OF THE NEGATIVE | | RATE-HIGH STEAM PRESSURE RATE FUNCTION. THE INSPECTION OF ALL SAFETY | | RELATED RATE/LAG AND LEAD/LAG CIRCUITS HAS BEEN COMPLETED AND NO OTHER | | DISCREPANCIES WERE NOTED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1531 ON 06/18/98 BY PAUL FREEMAN TO JOLLIFFE * * * | | | | BASED UPON ADDITIONAL REVIEW OF THE APPROPRIATE CALIBRATION PROCEDURES AND | | THE ANALOG CHANNEL OPERATIONAL TESTS IN EFFECT PRIOR TO 05/28/98, THE | | LICENSEE CONCLUDED THAT THE TECH SPEC SURVEILLANCE REQUIREMENT FOR THE RATE | | TIME CONSTANT PORTION OF THE NEGATIVE RATE-HIGH STEAM PRESSURE FUNCTION WAS | | SATISFIED. | | | | THEREFORE, THE PLANT OPERATING LICENSE CONDITIONS WERE SATISFIED AND THUS, | | THE LICENSEE DESIRES TO RETRACT THIS EVENT REPORT. | | | | THE LICENSEE HAS REVISED THE STEAM GENERATOR PRESSURE CHANNEL CALIBRATION | | PROCEDURES TO ENSURE THAT THE TIME CONSTANT VALUES IN TECH SPECS ARE SET | | CONSERVATIVELY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | THE NRC OPERATIONS OFFICER NOTIFIED R1DO HERB WILLIAMS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34402 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 06/16/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 08:44 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 06/16/98 | +------------------------------------------------+EVENT TIME: 05:54[CDT]| |NRC NOTIFIED BY: HOLLAND |LAST UPDATE DATE: 06/18/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRENT CLAYTON 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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN AUTOMATIC TRANSFER OF A SAFETY BUS OCCURRED DUE TO A POWER INTERRUPTION. | | | | A SHORT (0.3 SEC) INTERRUPTION IN POWER TO THE 138KV OFFSITE POWER SOURCE | | CAUSED AN AUTOMATIC TRANSFER OF THE '1C1' 4160V SAFETY BUS FROM THE | | EMERGENCY RESERVE AUXILIARY TRANSFORMER (ERAT) TO THE RESERVE AUXILIARY | | TRANSFORMER. THIS POWER INTERRUPTION WAS CAUSED BY A STORM IN THE AREA. | | THE OTHER TWO SAFETY-RELATED BUSES POWERED BY THE ERAT DID NOT TRANSFER, | | AND THEIR LOADS REMAINED ENERGIZED. NONE OF THE EMERGENCY DIESEL | | GENERATORS STARTED DURING THIS EVENT. CURRENTLY RESTORATION ACTIVITIES ARE | | UNDERWAY. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | | | | ***UPDATE 06/17/98 @ 2356 ET BY M. FUNKHOUSER TAKEN BY MACKINNON*** | | | | AS A RESULT OF THE ABOVE EVENT ALL INSTRUMENT AIR AND SERVICE AIR | | CONTAINMENT ISOLATION VALVES CLOSED (THE CLOSING OF THESE VALVES IS THE ESF | | ACTUATION). THE SIX INSTRUMENT AIR AND SERVICE CONTAINMENT ISOLATION VALVES | | THAT CLOSED WERE REOPENED. R3DO (BRENT CLAYTON) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT NOTIFICATION UPDATE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34409 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 06/18/98 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 08:10 [ET]| |RX TYPE: [1] CE |EVENT DATE: 06/18/98 | +------------------------------------------------+EVENT TIME: 06:40[CDT]| |NRC NOTIFIED BY: COOK |LAST UPDATE DATE: 06/18/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |IAN BARNES RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | ENTERED TECHNICAL SPECIFICATION SHUTDOWN DUE TO CONTROL ROOM AIR | | CONDITIONING UNIT VA-46B BEING DECLARED INOPERABLE. | | | | AT 0640 CT ON 6/18/98, CONTROL ROOM A/C UNIT VA-46B WAS DECLARED INOPERABLE | | DUE TO FAILURE TO COOL THE CONTROL ROOM. THE UNIT'S COMPRESSOR OPERATES | | PROPERLY BUT IT IS NOT PRODUCING COLD AIR. DIESEL GENERATOR # 1 WAS DANGER | | TAGGED OUT FOR MAINTENANCE AT THE TIME. CONTROL ROOM HVAC IS CONSIDERED TO | | BE SAFEGUARDS EQUIPMENT. VA-46B IS POWERED FROM DIESEL GENERATOR # 2. | | TECHNICAL SPEC ALLOWS ONE DIESEL GENERATOR TO BE INOPERABLE AS LONG AS ALL | | REQUIRED SAFEGUARDS EQUIPMENT ON THE OPPOSITE DIESEL IS OPERABLE. THE | | LICENSEE ENTERED TECHNICAL SPECIFICATION 2.0.1 (6 HOURS TO HOT SHUTDOWN). | | THE LICENSEE IS IN THE PROCESS OF REMOVING TAGS ON DIESEL GENERATOR # 1 SO | | THAT AIR CONDITIONING UNIT VA-46A CAN BE OPERATED. THE LICENSEE IS MAKING | | PREPARATIONS TO SHUT DOWN THE UNIT. DIESEL GENERATORS #1 & #2 ARE NOT THE | | SAFETY RELATED EMERGENCY DIESEL GENERATORS. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | ***UPDATE AT 0952 ET ON 6/18/98 BY COOK TAKEN BY MACKINNON*** | | | | TECH SPEC REQUIRED SHUTDOWN (2.0.1) WAS EXITED AT 0828 CT AFTER DIESEL | | GENERATOR # 1 WAS STARTED AND AIR CONDITIONING UNIT VA-46A WAS PLACED IN | | SERVICE. R4DO (IAN BARNES) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT UPDATE BY THE | | LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34410 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 06/18/98 | |UNIT: [1] [2] [ ] STATE: NY |NOTIFICATION TIME: 09:24 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 06/18/98 | +------------------------------------------------+EVENT TIME: 08:40[EDT]| |NRC NOTIFIED BY: G POLINSKY |LAST UPDATE DATE: 06/18/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HERB WILLIAMS RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | |GREG SMITH, IAT R1 | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SECURITY EVENT - | | | | SAFEGUARDS SYSTEM DEGRADATION DUE TO MINIMUM SECURITY PERSONNEL STAFFING | | REQUIREMENTS NOT MET. IMMEDIATE COMPENSATORY MEASURES TAKEN UPON DISCOVERY. | | | | NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 34411 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FRANK W. HAKE ASSOCIATES |NOTIFICATION DATE: 06/18/98 | | CITY: MEMPHIS REGION: 2 |NOTIFICATION TIME: 13:33 [ET]| | COUNTY: STATE: TN |EVENT DATE: 06/17/98 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 17:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/18/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT SCHIN RDO | | |DON COOL, MNSS EO | +------------------------------------------------+JOSEPH GIITTER IRD | |NRC NOTIFIED BY: REDDY, NAT RESPONSE CTR |KEVIN MOORE DOE | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - TRANSPORTATION EVENT - | | | | THE NATIONAL RESPONSE CENTER REPORTED THAT A TRAILER TRUCK OWNED BY FRANK | | W. HAKE ASSOCIATES, MEMPHIS, TN, CARRYING LIMITED QUANTITIES OF METAL | | SCAFFOLDING (LOW LEVEL FIXED CONTAMINATION) WAS INVOLVED IN A MINOR TRAFFIC | | ACCIDENT ON I-40, EXIT 182, NEAR KINGSTON SPRINGS, TN. SEVERAL 1.5 INCH | | DIAMETER METAL POLES ARE NOW PROTRUDING ABOUT 6 INCHES FROM THE REAR DOORS | | OF THE TRUCK TRAILER. THE TRUCK IS NOW LOCATED AT A TRUCK STOP ON I-40. | | NO RADIOACTIVE MATERIALS WERE RELEASED OUTSIDE OF THE TRAILER. THERE WERE | | NO PERSONNEL INJURIES. | | | | THE FOLLOWING HAVE BEEN NOTIFIED BY THE NATIONAL RESPONSE CENTER: | | TN STATE POLICE (MEMPHIS), OFFICE OF MOTOR CARRIER SAFETY (GOLAS), EPA | | REGION IV (BITTENGER), NTSB HIGHWAY (SACCCOIA), RSPA OFFICE OF HAZARDOUS | | MATERIALS (O'NEIL). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34412 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: OHIO DEPT OF HEALTH |NOTIFICATION DATE: 06/18/98 | | CITY: COLUMBUS REGION: 3 |NOTIFICATION TIME: 13:43 [ET]| | COUNTY: STATE: OH |EVENT DATE: 06/18/98 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:40[EDT]| | DOCKET: |LAST UPDATE DATE: 06/18/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRENT CLAYTON RDO | | | | +------------------------------------------------+DOE, EPA, FEMA, HHS FAX | |NRC NOTIFIED BY: RUTH VANDEGRIFT |USDA, DOT (NRC) FAX | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NMAT MATL IN UNCNTRL AREA | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - Co-60 FOUND IN LEAD CONTAINER IN DECEASED PERSON'S ESTATE - | | | | RUTH VANDEGRIFT, OHIO DEPARTMENT OF HEALTH, BUREAU OF RADIATION PROTECTION, | | COLUMBUS, OHIO, REPORTED THAT TOM GROVER, AN INDUSTRIAL RADIOGRAPHER, | | FOUND IN THE ESTATE OF HIS DECEASED FATHER-IN-LAW, FORMERLY AN INDUSTRIAL | | RADIOGRAPHER, A SMALL LEAD CONTAINER 2.5 INCHES LONG X 3 INCHES IN DIAMETER | | AND 1-1.5 INCHES THICK. MR GROVER OPENED THE CONTAINER AND OBSERVED THE | | CONTENTS LABELED COBALT-60. MR GROVER TOOK THE CONTAINER TO HIS WORK | | LOCATION IN METAMORA, OHIO, 20 MILES WEST OF TOLEDO. MR GROVER SURVEYED | | THE CONTAINER AND OBTAINED READINGS OF 20 MR/HR ON THE OUTSIDE SURFACE OF | | THE CONTAINER. MR GROVER SECURED THE CONTAINER, ISOLATED IT, AND | | RESTRICTED PERSONNEL ACCESS TO THE CONTAINER. | | | | TWO HEALTH PHYSICS TECHNICIANS FROM OHIO DEPT OF HEALTH, BUREAU OF | | RADIATION PROTECTION ARE TRAVELING TO METAMORA TO INSPECT THE CONTAINER | | AND ITS CONTENTS. | | | | MS VANDEGRIFT HAS DISCUSSED THIS EVENT WITH NRC REGION 3 MONTE PHILLIPS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34413 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FOXCHASE CANCER CENTER |NOTIFICATION DATE: 06/18/98 | | CITY: PHILADELPHIA REGION: 1 |NOTIFICATION TIME: 13:54 [ET]| | COUNTY: STATE: PA |EVENT DATE: 03/04/98 | |LICENSE#: 3702766-01 AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/18/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HERB WILLIAMS RDO | | |JOSE PICCONE, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: NANCY MOLDOSSKY | | |HQ OPS OFFICER: HENRY BAILEY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION EVENT - | | | | A LOW DOSE RATE (LDR) TREATMENT WAS BEING ADMINISTERED TO THE CERVIX OF A | | PATIENT ON 03/03/98, WHEN THE PATIENT REMOVED THE SOURCE. THE INTENDED | | DOSE WAS 2000 CENTIGRAYS, HOWEVER, ONLY 1431 CENTIGRAYS WERE RECEIVED WITH | | THE LDR TREATMENT. THE REMOVAL OF THE SOURCE WAS PROMPTLY DISCOVERED AND | | IT WAS PROMPTLY RETRIEVED AND STORED. THE PATIENT'S PHYSICIAN WAS NOTIFIED | | AND THE REMAINING DOSE WAS ADMINISTERED BY A HIGH DOSE RATE (HDR) | | TREATMENT. THERE WERE NO SIGNIFICANT KNOWN ADVERSE AFFECTS TO THE PATIENT. | | | | THE LICENSEE WILL FORWARD A WRITTEN REPORT TO NRC REGION I. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34414 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: RHODE ISLAND HOSPITAL |NOTIFICATION DATE: 06/18/98 | | CITY: PROVIDENCE REGION: 1 |NOTIFICATION TIME: 16:04 [ET]| | COUNTY: STATE: RI |EVENT DATE: 06/03/98 | |LICENSE#: 7D-051-01 AGREEMENT: Y |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/18/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HERB WILLIAMS RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CHARLES McMAHON (BY FAX) | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MEDICAL MISADMINISTRATION EVENT - | | | | CHARLES McMAHON, RHODE ISLAND DEPARTMENT OF HEALTH, OFFICE OF OCCUPATIONAL | | & RADIOLOGICAL HEALTH, REPORTED BY FAX THAT A PATIENT IN RHODE ISLAND | | HOSPITAL, PROVIDENCE, RI, WAS ADMINISTERED ONLY 7 mCi OF A PRESCRIBED | | 10 mCi DOSE OF I-131, BECAUSE ONLY ONE 7 mCi CAPSULE OF A TWO CAPSULE | | DOSE WAS ADMINISTERED. THE OTHER CAPSULE (3 mCi) WAS "FOUND" DURING AN | | INVENTORY OR SURVEY OF THE HOT LAB ON 06/17/98. | | | | MR McMAHON PLANS TO PROVIDE ADDITIONAL INFORMATION TO THE NRC WHEN MORE | | DETAILED INFORMATION BECOMES AVAILABLE. | +------------------------------------------------------------------------------+