U.S. Nuclear Regulatory Commission Operations Center Event Reports For 03/24/98 - 03/25/98 ** EVENT NUMBERS ** 33949 33950 33951 33952 33953 33954 33955 33956 +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33949 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 03/24/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 03:07 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 03/23/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 09:20[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 03/24/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |MIKE JORDAN RDO | | DOCKET: 0707002 |SUSAN SHANKMAN, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: KEITH WILLIAMSON | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SPACING AND MODERATION CONTROL VIOLATIONS - NRC BULLETIN 91-01 RESPONSE | | (24-HOUR NOTIFICATION) | | | | OPERATIONS PERSONNEL DISCOVERED THAT NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) REQUIREMENT WAS NOT BEING MAINTAINED WITHIN THE X-333 PROCESS | | BUILDING AT 33-2-7 STAGE #8. NCSA PLANT018.A01, REQUIREMENTS #4 AND #5, | | STATE THAT DRY ACTIVE WASTE (DAW) BAGS SHALL HAVE HOLES IN THE BOTTOM TO | | ALLOW FOR SOLUTION DRAINAGE AND MUST BE STORED TWO FEET EDGE-TO-EDGE FROM | | ANY OTHER URANIUM-BEARING MATERIAL. AT THIS LOCATION, A DAW BAG WAS FOUND | | TO HAVE NO HOLES AND TO BE STORED WITHIN THE TWO-FOOT EDGE-TO-EDGE MINIMUM | | SPACING REQUIREMENT. THIS CONSTITUTES A LOSS OF CONTROL 'A' (MODERATION - | | INTERACTION) IN THE DOUBLE CONTINGENCY MATRIX FOR CONTINGENCY EVENT B.6.1. | | CONTROL 'B' (MASS) WAS MAINTAINED THROUGHOUT THIS EVENT. CONTROL 'A' WAS | | RE-ESTABLISHED UNDER THE DIRECTION OF NUCLEAR CRITICALITY SAFETY PERSONNEL. | | | | THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL, AND THERE WERE NO | | RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURES AS A RESULT OF THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR AND THE DEPARTMENT OF ENERGY ONSITE | | REPRESENTATIVE WERE NOTIFIED OF THIS EVENT BY PORTSMOUTH. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33950 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 03/24/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 03:14 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 03/23/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:45[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 03/24/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |MIKE JORDAN RDO | | DOCKET: 0707002 |SUSAN SHANKMAN, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: KEITH WILLIAMSON | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | VIOLATION OF MODERATION AND INTERACTION CONTROL - NRC BULLETIN 91-01 | | RESPONSE (24-HOUR NOTIFICATION) | | | | OPERATIONS PERSONNEL DISCOVERED THAT A NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) REQUIREMENT WAS NOT BEING MAINTAINED WITHIN THE BOUNDARY CONTROL | | STATION (BCS) OF THE X-333 PROCESS BUILDING. NCSA PLANT062.A00, | | REQUIREMENT #5, STATES IN PART, "EQUIPMENT SHALL BE SPACED A MINIMUM OF TWO | | (2) FEET EDGE-TO-EDGE." AT THE BCS, IT WAS DISCOVERED THAT REMOVED PROCESS | | EQUIPMENT WITH VISIBLE CONTAMINATION WAS DOUBLED BAGGED BUT WAS NOT SPACED | | AS SPECIFIED IN THE NCSA. THIS CONSTITUTES A LOSS OF CONTROL 'A' | | (INTERACTION) IN THE DOUBLE CONTINGENCY MATRIX FOR CONTINGENCY EVENT | | B.17.1. CONTROL 'B' (GEOMETRY/MASS) WAS MAINTAINED THROUGHOUT THIS EVENT. | | THE SPACING DEFICIENCY WAS CORRECTED AT 1500 HOURS UNDER THE DIRECTION OF | | NUCLEAR CRITICALITY SAFETY PERSONNEL. | | | | THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL, AND THERE WERE NO | | RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURES AS A RESULT OF THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR AND THE DEPARTMENT OF ENERGY ONSITE | | REPRESENTATIVE WERE NOTIFIED OF THIS EVENT BY PORTSMOUTH. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33951 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 03/24/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 03:18 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 03/23/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 03/24/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |MIKE JORDAN RDO | | DOCKET: 0707002 |SUSAN SHANKMAN, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: KEITH WILLIAMSON | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | VIOLATION OF THE 2-FOOT EDGE-TO-EDGE SPACING REQUIREMENT - NRC BULLETIN | | 91-01 RESPONSE (24-HOUR NOTIFICATION) | | | | OPERATIONS PERSONNEL DISCOVERED THAT A NUCLEAR CRITICALITY SAFETY APPROVAL | | (NCSA) REQUIREMENT WAS NOT BEING MAINTAINED WITHIN THE RADIOACTIVE MATERIAL | | AREA (RMA) OF THE X-333 PROCESS BUILDING. NCSA PLANT062.A00, REQUIREMENT | | #5, STATES IN PART, "EQUIPMENT SHALL BE SPACED A MINIMUM OF TWO (2) FEET | | EDGE-TO-EDGE." AT THE RMA, IT WAS DISCOVERED THAT REMOVED PROCESS | | EQUIPMENT WITH NO VISIBLE CONTAMINATION WAS NOT SPACED AS SPECIFIED IN THE | | NCSA. THIS CONSTITUTES A LOSS OF CONTROL 'A' (INTERACTION) IN THE DOUBLE | | CONTINGENCY EVENT B.17.1. CONTROL 'B' (GEOMETRY/MASS) WAS MAINTAINED | | THROUGHOUT THIS EVENT. THE SPACING DEFICIENCY WAS CORRECTED AT 1455 HOURS | | UNDER DIRECTION OF NUCLEAR CRITICALITY SAFETY PERSONNEL. | | | | THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL, AND THERE WERE NO | | RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURES AS A RESULT OF THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR AND THE ONSITE DEPARTMENT OF ENERGY | | REPRESENTATIVE WERE NOTIFIED OF THIS EVENT BY PORTSMOUTH. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33952 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 03/24/98 | |UNIT: [ ] [ ] [3] STATE: IL |NOTIFICATION TIME: 11:16 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 03/24/98 | +------------------------------------------------+EVENT TIME: 09:33[CST]| |NRC NOTIFIED BY: CAROL BARAJAS |LAST UPDATE DATE: 03/24/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N Y 99 POWER OPERATION | 99 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION ENTRY AFTER SCRAM DISCHARGE VOLUME BARTON LEVEL | | SWITCHES WERE DECLARED INOPERABLE | | | | | | AT 0933 CST ON 03/24/98, THE LICENSEE INITIATED A SHUTDOWN OF UNIT 3 AFTER | | ENTERING TECHNICAL SPECIFICATION 3.1.A.2, TABLE 3.1.A-1, ACTION 11, AT 0746 | | CST ON 03/24/98, WHICH REQUIRES THE UNIT TO BE IN HOT SHUTDOWN WITHIN 12 | | HOURS. THIS IS DUE TO THE SCRAM DISCHARGE VOLUME BARTON LEVEL SWITCHES | | POSSIBLY BEING INOPERABLE DUE TO NON-CONSERVATIVE SETPOINTS. THERE ARE | | FOUR BARTON LEVEL SWITCHES IN QUESTION; TWO OF EACH INPUT INTO A REACTOR | | PROTECTION SYSTEM (RPS) CHANNEL (TWO TO RPS 'A' AND TWO TO RPS 'B'). | | REACTOR PROTECTION SYSTEM CHANNEL 'A' WAS PLACED IN A TRIP CONDITION AT | | 0840 CST ON 03/24/98 PER TECHNICAL SPECIFICATION 3.1.A.2 AFTER BOTH RPS | | CHANNELS WERE DECLARED INOPERABLE. THE LICENSEE IS VERIFYING THE AS-FOUND | | DATA ON THE SCRAM DISCHARGE VOLUME LEVEL SWITCHES. THE SCRAM DISCHARGE | | VOLUME LEVEL SWITCHES' CALCULATION FROM 1991 MAY BE IN ERROR IN THE | | NON-CONSERVATIVE DIRECTION. THE 41-GALLON SCRAM DISCHARGE VOLUME TRIP | | SETPOINT (MEASURED IN MILLIAMPS) MAY BE SET LESS CONSERVATIVELY THAN IT | | SHOULD HAVE BEEN SET. | | | | ALL EMERGENCY CORE COOLING SYSTEMS AND THE EMERGENCY DIESEL GENERATORS ARE | | FULLY OPERABLE IF NEEDED. THE ELECTRICAL GRID IS STABLE. | | | | THE LICENSEE FOUND OUT ABOUT THIS PROBLEM FROM A TELEPHONE CONVERSATION | | WITH QUAD CITIES. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33953 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: GEORGETOWN UNIVERSITY HOSPITAL |NOTIFICATION DATE: 03/24/98 | | CITY: WASHINGTON REGION: 1 |NOTIFICATION TIME: 11:40 [ET]| | COUNTY: STATE: DC |EVENT DATE: 03/02/98 | |LICENSE#: 080170904 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 03/24/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RICHARD BARKLEY RDO | | |FRED COMBS/NMSS EO | +------------------------------------------------+RICHARD BARRETT/AEOD IRD | |NRC NOTIFIED BY: SCHANKS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | GEORGETOWN UNIVERSITY HOSPITAL REPORTED A LOSS OF ONE PALLADIUM-103 SEED. | | | | A PATIENT WAS DUE TO RECEIVE 100 PALLADIUM-103 SEEDS (1.21 MILLICURIES | | EACH) FOR PERMANENT IMPLANT. AT THE START OF THE IMPLANT, 100 SEEDS WERE | | VERIFIED TO BE IN THE OPERATING ROOM AREA. UPON THE COMPLETION OF THE | | IMPLANT, ONLY 99 SEEDS WERE VERIFIED TO BE IN THE PATIENT AS SEEN IN THE | | X-RAY. THE LICENSEE MADE A COMPLETE SURVEY (WITH A RADIATION MONITOR) OF | | THE OPERATING ROOM AREA, ALL WASTE MATERIAL, THE LINENS, AND ALL EQUIPMENT | | USED DURING THE PROCEDURE AND DID NOT RECEIVE ANY RADIATION READINGS. THE | | LICENSEE BELIEVES IT MAY HAVE BEEN WASHED DOWN THE DRAIN DURING CLEANUP OF | | THE INSTRUMENTS USED DURING THE IMPLANT. THE LICENSEE COULD NOT SURVEY THE | | DRAIN/SEWER SYSTEM. | | | | (REFER TO THE HOO LOG FOR LICENSEE CONTACT INFORMATION.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33954 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 03/24/98 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 16:29 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 03/24/98 | +------------------------------------------------+EVENT TIME: 15:30[EST]| |NRC NOTIFIED BY: PAUL DAVID REED |LAST UPDATE DATE: 03/24/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT SUMMERS 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 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FAILURE OF DISCHARGE MONITOR | | | | THE pH AND TEMPERATURE ENVIRONMENTAL DISCHARGE MONITORS FAILED DUE TO A | | FAILURE OF POWER SUPPLY CARDS. COMPENSATORY MANUAL SAMPLING EVERY 4 HOURS | | HAS BEEN STARTED. THERE IS NO ADVERSE AFFECT ON THE PLANT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND THE STATE OF | | CONNECTICUT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33955 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 03/24/98 | |UNIT: [ ] [2] [ ] STATE: MN |NOTIFICATION TIME: 16:59 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 03/24/98 | +------------------------------------------------+EVENT TIME: 15:25[CST]| |NRC NOTIFIED BY: DOUG SMITH |LAST UPDATE DATE: 03/24/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FLOODING CONCERN COULD RENDER MSIVs INOPERABLE. (REFER TO EVENT | | #33948 FOR A SIMILAR ISSUE AT PRAIRIE ISLAND UNIT 1 ON 03/23/98.) | | | | DURING AN ENGINEERING REVIEW OF APPENDIX 'I' OF THE UPDATED SAFETY ANALYSIS | | REPORT, A POTENTIAL FLOODING PROBLEM DUE TO A FEEDWATER LINE BREAK WAS | | FOUND. THE FLOODING COULD RENDER BOTH TRAINS OF LOOP 'A' MAIN STEAM | | ISOLATION VALVE (MSIV) ACTUATION LOGIC INOPERABLE. THIS CONSTITUTES A | | TECHNICAL SPECIFICATION 3.0.C ENTRY REQUIRING PLANT SHUTDOWN. THE PLANT IS | | TAKING IMMEDIATE ACTION TO PREVENT FLOODING IN THE AREA BY REMOVING NORMAL | | VENTILATION DUCTWORK. THIS ACTION IS EXPECTED TO BE COMPLETED PRIOR TO THE | | TIME FRAME FOR UNIT SHUTDOWN, SO NO POWER REDUCTION IS EXPECTED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33956 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HARPER HOSPITAL |NOTIFICATION DATE: 03/24/98 | | CITY: DETROIT REGION: 3 |NOTIFICATION TIME: 17:03 [ET]| | COUNTY: STATE: MI |EVENT DATE: 03/23/98 | |LICENSE#: 21-04127-02 AGREEMENT: N |EVENT TIME: 14:00[EST]| | DOCKET: |LAST UPDATE DATE: 03/24/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MIKE JORDAN RDO | | |JOHN SURMEIER, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: GARY EZZELL | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION WITH A HIGH DOSE RATE BRACHYTHERAPY | | | | A MEDICAL MISADMINISTRATION FOR A CANCER TREATMENT INVOLVING A | | MISPOSITIONED SOURCE WAS IDENTIFIED WHEN THE FIFTH FRACTION OR DOSE (386 | | CENTIGRAYS PER FRACTION) WAS BEING ADMINISTERED. IT WAS NOTED THAT THE | | PREVIOUS TWO FRACTION ADMINISTRATIONS HAD NOT BEEN POSITIONED CORRECTLY. | | THE STATED REQUIREMENT WAS FOR THE INSERTION OF THE ADMINISTRATION | | CYLINDER, WITHDRAW FOUR CENTIMETERS, AND EXPOSE THE IRIDIUM-192 SOURCE TO | | ADMINISTER ONE FRACTION TO THE AREA OF TREATMENT. THE THIRD AND FOURTH | | ADMINISTRATIONS WERE WERE NOT WITHDRAWN THE FOUR CENTIMETERS TO PROPERLY | | EXPOSE THE PROPER AREA OF TREATMENT. THE PRESCRIBING PHYSICIAN ORDERED A | | SIXTH FRACTION TO BE ADMINISTERED TO THE PROPER AREA FOR A COMPLETED | | TREATMENT OF THE AREA. IN ADDITION, THE PHYSICIAN DETERMINED THAT THERE | | WERE NO UNTOWARD CONSEQUENCES TO THE MISPOSITIONED EXPOSURE. THE PATIENT | | WAS INFORMED, AND THE REFERRING PHYSICIAN WILL BE INFORMED. | | | | THE SPECIFIC CIRCUMSTANCES WERE DETERMINED TO BE CAUSED BY IMPROPER | | PROCEDURAL COMPLIANCE. THE SETUP WAS TO BE CHECKED BY A SECOND PERSON, AND | | IT WAS NOT. THE INCIDENT IS UNDER REVIEW, AND THE INDIVIDUAL INVOLVED WAS | | COUNSELLED. | | | | (REFER TO THE HOO LOG FOR LICENSEE CONTACT INFORMATION.) | +------------------------------------------------------------------------------+