U.S. Nuclear Regulatory Commission Operations Center Event Reports For 02/08/1999 - 02/09/1999 ** EVENT NUMBERS ** 35324 35352 35353 35354 35355 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35324 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 01/29/1999| | UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 09:48[EST]| | RXTYPE: [3] CE |EVENT DATE: 01/29/1999| +------------------------------------------------+EVENT TIME: 07:57[CST]| | NRC NOTIFIED BY: VICTOR COLLINS |LAST UPDATE DATE: 02/08/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |CHARLES MARSCHALL R4 | |10 CFR SECTION: | | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |3 N Y 94 Power Operation |94 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SECURITY REPORT - | | | | UNACCOUNTED FOR PERSONNEL DOOR LOCK PULLER. COMPENSATORY MEASURES | | IMMEDIATELY TAKEN UPON DISCOVERY. THE LICENSEE NOTIFIED THE NRC RESIDENT | | INSPECTOR. REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. | | | | * * * RETRACTION AT 1541 EST ON 2/8/99 FROM GREGORY SCOTT TO S.SANDIN * * * | | | | The licensee is retracting this event. Contact the Headquarters Operations | | Officer for details. The licensee will inform the NRC Resident Inspector. | | Notified R4DO(Pellet) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35352 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: GRAND GULF REGION: 4 |NOTIFICATION DATE: 02/08/1999| | UNIT: [1] [] [] STATE: MS |NOTIFICATION TIME: 00:34[EST]| | RXTYPE: [1] GE-6 |EVENT DATE: 02/07/1999| +------------------------------------------------+EVENT TIME: 22:38[CST]| | NRC NOTIFIED BY: HANKS |LAST UPDATE DATE: 02/08/1999| | HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JEFF SHACKELFORD R4 | |10 CFR SECTION: | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE DECLARED RCIC INOPERABLE AND ENTERED A 14 DAY LCO ACTION | | STATEMENT. | | | | RCIC WAS DECLARED INOPERABLE WHEN A DIVISION II ISOLATION OCCURRED DUE TO AN | | INVALID SIGNAL DURING THE PERFORMANCE OF A SURVEILLANCE. THE CAUSE IS BEING | | INVESTIGATED. HPCS WAS VERIFIED OPERABLE WITHIN ONE HOUR , AS REQUIRED BY | | THE LCO ACTION STATEMENT, AT 2310 CST. RCIC IS REQUIRED TO BE RETURNED TO | | SERVICE WITHIN 14 DAYS. THE ISOLATION SIGNAL HAS BEEN RESET, BUT THE VALVES | | ARE STILL CLOSED AND WILL NOT BE REOPENED UNTIL THE CAUSE OF THE ISOLATION | | HAS BEEN DETERMINED. | | | | THE RESIDENT INSPECTOR WILL BE NOTIFIED. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35353 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 02/08/1999| | UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 13:43[EST]| | RXTYPE: [1] W-4-LP |EVENT DATE: 02/08/1999| +------------------------------------------------+EVENT TIME: 09:58[CST]| | NRC NOTIFIED BY: JIM GILMORE |LAST UPDATE DATE: 02/08/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JOHN PELLET R4 | |10 CFR SECTION: | | |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 | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - OFFSITE NOTIFICATION REGARDING A CHEMICAL SPILL INTO THE WOLF CREEK | | COOLING LAKE - | | | | AT 0958 CST ON 02/08/1999, THE LICENSEE NOTIFIED THE STATE OF KANSAS THAT | | APPROXIMATELY 2000 GALLONS OF WATER CONTAINING AT MOST 50 GALLONS OF SODIUM | | HYPOCHLORITE AND 13 GALLONS OF SODIUM BROMIDE HAD SPILLED INTO THE WOLF | | CREEK COOLING LAKE. A CHEMICAL INJECTION PUMP MECHANICAL SEAL FAILED AND | | CAUSED THE CHEMICAL SPILL AT THE PLANT INTAKE STRUCTURE. THE CONCENTRATIONS | | OF THE CHEMICAL SPILL EXCEEDED THE ALLOWABLE KANSAS STATE PERMIT LIMITS. | | THE LICENSEE STOPPED THE SPILL, PLACED ABSORBENT MATERIAL ON THE GROUND | | SURROUNDING THE SPILL AND REMOVED THE ABSORBENT MATERIAL. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35354 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: WA DEPARTMENT OF HEALTH |NOTIFICATION DATE: 02/08/1999| |LICENSEE: PROVIDENCE MEDICAL CENTER |NOTIFICATION TIME: 11:45[EST]| | CITY: SEATTLE REGION: 4 |EVENT DATE: 12/16/1998| | COUNTY: STATE: WA |EVENT TIME: 12:00[PST]| |LICENSE#: WN-MO45-1 AGREEMENT: Y |LAST UPDATE DATE: 02/08/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |JOHN PELLET R4 | | | | +------------------------------------------------+ | | NRC NOTIFIED BY: BOB VERELLEN | | | HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - AGREEMENT STATE REPORT REGARDING MEDICAL MISADMINISTRATION - | | | | The following information was received via Email in the NRC Operations | | Center: | | | | Subject: Washington Incident Notification #WA-99-003 | | | | This is notification/update of an event in Washington state as reported to | | or investigated by the WA Department of Health, Division of Radiation | | Protection. | | | | Licensee: Providence Medical Center | | City and state: Seattle, WA. | | License number: WN-M045-1 | | Type of License: Medical, Broad Type A | | | | Date of Event: 16 December 1998 | | | | Location of Event: Licensee's facility, Radiation Oncology Dept. | | | | ABSTRACT: | | The licensee, a Broad Medical, had reviewed and approved the clinical trial | | of the Guidant Intravascular Radiotherapy project. The project uses a | | modified Nucletron high dose rate afterloader (HDR) and an Omnitron | | International, Inc. Phosphorus-32 brachytherapy source model NC-P32-3N with | | an activity of approximately 150 millicuries. The trial is to evaluate | | local radiation for the prevention of restenosis after coronary | | angioplasty. | | | | On 16 December 1998, the Guidant Clinical Research Coordinator introduced a | | new type catheter, provided training for the licensee's personnel and | | supervised the use of the new catheter system on a patient. The licensee | | reported that the source was thought to have been seen at the proper | | location for the planned treatment using fluoro and the inactive source | | wire. The treatment was completed. | | | | On 11 January 1999, the Guidant Coordinator informed the licensee that the | | new catheter required the use of a different connector on the front end of | | the afterloader and that, if not used, the source would not be at the proper | | treatment site and therefore the treatment on 16 Dec would not have been | | correct. | | | | On 13 January 1999, the license performed some tests and confirmed that a | | misadministration had occurred. Their review indicates that the source was | | approximately 34 cm from the intended treatment site. In their second | | written report to the state the licensee estimated dose to the vessel wall | | to range from 108 Gy worst case, to 70 Gy as a most realistic dose. | | | | MAJOR ISSUES: | | | | 1. THE INABILITY TO CONFIRM THE LOCATION OF THE SOURCE USING FLUORO when | | fluoro visualization is indicated in the project's description and | | procedures as an essential verification for the use of this device. | | | | 2. THE INCOMPLETE TRAINING AND DIRECTION PROVIDED THE LICENSEE BY THE | | GUIDANT PERSONNEL WHEN DEVICE EQUIPMENT CHANGES WERE MADE ON 16 DECEMBER | | 1998. | | | | What is the notification or reporting criteria involved? WAC 246-240-050 | | "NOTIFICATIONS, RECORDS, AND REPORTS OF THERAPY MISADMINISTRATIONS." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35355 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 02/08/1999| | UNIT: [2] [] [] STATE: PA |NOTIFICATION TIME: 17:45[EST]| | RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 02/08/1999| +------------------------------------------------+EVENT TIME: 17:00[EST]| | NRC NOTIFIED BY: PAT NAVIN |LAST UPDATE DATE: 02/08/1999| | HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |LAURIE PELUSO R1 | |10 CFR SECTION: | | |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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ |2 N Y 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE DUE TO A FAILED COMPUTER - | | | | DURING COMPUTER TESTING, THE UNIT 2 PLANT MONITORING SYSTEM COMPUTER FAILED, | | RENDERING THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE. PLANT | | TECHNICIANS ARE RESTORING THE FAILED COMPUTER. THE LICENSEE WILL INFORM THE | | NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 2213 ON 02/08/99 FROM JIM KOVALCHICK TO JOLLIFFE * * * | | | | AT 2157, THE LICENSEE RESTORED THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM TO | | OPERABLE STATUS. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE NRC | | OPERATIONS OFFICER NOTIFIED R1DO (LAURIE PELUSO). | +------------------------------------------------------------------------------+