Event Notification Report for April 25, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/24/2000 - 04/25/2000
** EVENT NUMBERS **
36922 36923 36924 36925 36926
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|General Information or Other |Event Number: 36922 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 04/24/2000|
|LICENSEE: ST JAMES HOSPTIAL & HEALTH CENTER |NOTIFICATION TIME: 15:23[EDT]|
| CITY: CHICAGO HEIGHTS REGION: 3 |EVENT DATE: 04/20/2000|
| COUNTY: STATE: IL |EVENT TIME: 12:00[CDT]|
|LICENSE#: IL-01289-01 AGREEMENT: Y |LAST UPDATE DATE: 04/24/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GARY SHEAR R3 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOESPH KLINGER | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| PROJECTED DOSES TO A PATIENT MAY BE OFF BY GREATER THAN 20 PERCENT |
| |
| ST. JAMES HOSPITAL CALLED THE ILLINOIS DEPARTMENT OF NUCLEAR SAFETY TO |
| REPORT A MEDICAL THERAPY EVENT. FOUR IRIDIUM-192 SEEDS (APPROX. 5mCi each) |
| WERE INSERTED THROUGH A PATIENTS NOSE TO TREAT THE BILE DUCT ON TUESDAY. |
| THE PHYSICIAN HAD MARKED THE TUBE AT THE NOSE AS A REFERENCE POINT. ON |
| THURSDAY THE PHYSICIAN NOTICED THAT THE REFERENCE POINT HAD MOVED. ST. |
| JAMES HOSPITAL PERFORMED AN X-RAY AND NOTICED THAT THE SOURCES WERE NO |
| LONGER AT THE TREATMENT SITE. THE LICENSEE BELIEVES THAT THE DOSE TO THE |
| INTENDED AREA WILL BE OUTSIDE THE RANGE OF THE 20% LIMIT. THE LICENSEE |
| BELIEVES THE TREATMENT WENT AS PLANNED FOR THE FIRST 24 HOURS AND THAT THE |
| SEEDS MOVED SOMETIME DURING THE SECOND 24 HOURS. TOTAL TREATMENT TIME WAS |
| SUPPOSED TO HAVE BEEN 70 HOURS. |
| |
| THE LICENSEE IS PERFORMING A DOSE ASSESSMENT NOW AND WILL FORWARD A WRITTEN |
| REPORT TO THE ILLINOIS DEPARTMENT OF NUCLEAR SAFETY WITHIN 15 DAYS. THE |
| LICENSEE PLANS TO CONTINUE THE TREATMENT ONCE THEY HAVE A BETTER ESTIMATE OF |
| DOSES TO THE TREATMENT SITE. |
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|Other Nuclear Material |Event Number: 36923 |
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| REP ORG: SYNCOR INTERNATIONAL CORP |NOTIFICATION DATE: 04/24/2000|
|LICENSEE: SYNCOR INTERNATIONAL CORP |NOTIFICATION TIME: 15:26[EDT]|
| CITY: STAMFORD REGION: 1 |EVENT DATE: 04/24/2000|
| COUNTY: STATE: CT |EVENT TIME: 05:00[EDT]|
|LICENSE#: 04-26507-01MD AGREEMENT: N |LAST UPDATE DATE: 04/24/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN WHITE R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+PHIL HARRELL R4 |
| NRC NOTIFIED BY: DAVID PELLICCIARINI | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAAA 20.1906(d) SURFACE CONT/ EXT RAD | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SURFACE CONTAMINATION FOUND ON PACKAGE DELIVERED TO SYNCOR STAMFORD, CT |
| PHARMACY. |
| |
| A PACKAGE DELIVERED TO THE SYNCOR STAMFORD, CT. PHARMACY FACILITY FROM |
| NORTHERN WESTCHESTER HOSPITAL, MOUNT KISCO, NY., WAS FOUND TO HAVE OUTSIDE |
| SURFACE CONTAMINATION LEVEL OF 645,000 DPM/100 SQUARE CENTIMETER. THE |
| SURFACE CONTAMINATION OF THE PACKAGE WAS LIMITED TO THE TOP CORNER OF THE |
| PACKAGE. THE HIGHEST SURFACE CONTACT RADIATION LEVEL ON THE PACKAGE WAS |
| 0.5MR/HR (TOP CORNER OF THE PACKAGE). THE SURFACE CONTAMINATION WAS FROM |
| Tc-99m (145KeV GAMMA EMITTER, HALF LIFE OF ABOUT 6 HOURS). THE PACKAGE WAS |
| OPENED AND NO SURFACE CONTAMINATION WAS FOUND INSIDE THE PACKAGE. THE |
| DRIVER OF THE VEHICLE AND THE INSIDE OF THE VEHICLE THAT TRANSPORTED THE |
| PACKAGE WERE SURVEYED AND NO CONTAMINATION WAS FOUND. NORTHERN WESTCHESTER |
| HOSPITAL WAS NOTIFIED BY SYNCOR OF THIS EVENT. SYNCOR NOTIFIED NRC REGION 4 |
| (JEFF CRUZ) OF THIS EVENT. |
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|Power Reactor |Event Number: 36924 |
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| FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 04/24/2000|
| UNIT: [1] [] [] STATE: AL |NOTIFICATION TIME: 16:26[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 04/24/2000|
+------------------------------------------------+EVENT TIME: 12:53[CDT]|
| NRC NOTIFIED BY: WES CUMBEE |LAST UPDATE DATE: 04/24/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ANN BOLAND R2 |
|10 CFR SECTION: | |
|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 Refueling |0 Refueling |
| | |
| | |
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EVENT TEXT
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| AUTOMATIC START OF THE PENETRATION ROOM FILTRATION SYSTEM DURING MAINTENANCE |
| ACTIVITIES. |
| |
| Maintenance investigation of a high vibration on "1B" Spent Fuel Pool |
| Exhaust fan resulted in the trip of the Spent Fuel Pool ventilation and |
| subsequent autostart of the Penetration Room Filtration System. All systems |
| operated as required. |
| |
| Operations restarted the Spent Fuel Pool ventilation and secured the |
| Penetration Room Filtration System. |
| |
| An investigation into this event is in progress. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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|Power Reactor |Event Number: 36925 |
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| FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 04/24/2000|
| UNIT: [] [2] [3] STATE: AL |NOTIFICATION TIME: 17:01[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 04/23/2000|
+------------------------------------------------+EVENT TIME: 22:08[CDT]|
| NRC NOTIFIED BY: JOE BENNETT |LAST UPDATE DATE: 04/24/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ANN BOLAND R2 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
|3 N N 0 Refueling |0 Refueling |
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EVENT TEXT
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| EMERGENCY DIESEL GENERATOR "3ED" RECEIVED AND AUTOMATIC START SIGNAL. |
| |
| On 04/21/00 at 2208, the "3ED" Emergency Diesel Generator received an |
| automatic start signal due to degraded voltage as a result of testing |
| activities associated with the "3ED" 4 kv Shutdown Board. At the time the |
| start was received, the Diesel Generator and the 4 kv Shutdown Board were |
| considered inoperable for their Technical Specification functions, therefore |
| the event was not deemed reportable as an Engineered Safety Feature (ESF) |
| actuation. Further review of the event by the plant staff along with the |
| Senior Resident Inspector concluded that this event should have been |
| considered an ESF actuation, since the automatic start was not preplanned, |
| and the Diesel Generator started as the result of a valid initiation |
| signal. |
| |
| The NRC Resident will be notified of this event notification by the |
| licensee. |
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|Power Reactor |Event Number: 36926 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 04/24/2000|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 17:06[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/24/2000|
+------------------------------------------------+EVENT TIME: 14:03[EDT]|
| NRC NOTIFIED BY: ARDIE KISSINGER |LAST UPDATE DATE: 04/24/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN WHITE R1 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| INVALID ISOLATED SIGNAL WAS GENERATED |
| |
| During operation of Unit 2 at 100% power, it has been determined that the |
| inboard Primary Containment Isolation Valves associated with the Containment |
| Radiation Monitors (CRMs) received an invalid isolation signal. During |
| maintenance activities in the panel to change out a previously failed relay |
| for the "A" CRM, the relay for automatic isolation was disturbed and an |
| invalid signal was generated. The relay inputs a close signal to the |
| inboard valves of both CRM's, and the invalid signal caused the "B" CRM to |
| isolate. The licensee is investigating this event. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021