Event Notification Report for March 28, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/27/2001 - 03/28/2001
** EVENT NUMBERS **
37727 37865
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 37727 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 02/08/2001|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 17:35[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 02/08/2001|
+------------------------------------------------+EVENT TIME: 14:47[EST]|
| NRC NOTIFIED BY: ROLAND |LAST UPDATE DATE: 03/27/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RONALD BELLAMY R1 |
|10 CFR SECTION: | |
|*DEG 50.72(b)(3)(ii)(A) DEGRAD COND DURING OP | |
|*INC 50.72(b)(3)(v)(C) POT UNCNTRL RAD REL | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| BOTH REACTOR RECIRCULATING SAMPLE LINE CONTAINMENT ISOLATION VALVES DECLARED |
| INOPERABLE |
| |
| During operation of Unit 2 at 100% power, it has been determined that both |
| Primary Containment Isolation Valves for the Reactor Recirculating Sample |
| Line are inoperable. During restoration from maintenance activities on the |
| line, the outboard isolation valve[HV243F020] failed to stroke closed. |
| Following several attempts the valve was closed. The valve was declared |
| inoperable, and as required by Technical Specifications an attempt was made |
| to close the inboard isolation valve[HV243F019]. The inboard valve also |
| failed to close. The air supply was isolated to the outboard valve to |
| deactivate it, and the pathway was confirmed to be isolated. The problem |
| with the outboard valve is due to a bad solenoid. The problem with the |
| inboard valve is under investigation. They were able to get both valves |
| closed when the inboard valve finally closed on its own an hour later. |
| |
| The NRC Resident Inspector was notified. |
| |
| * * * UPDATE 1244EST ON 3/27/01 FROM BOESCH TO S. SANDIN * * * |
| |
| This report is retracted based on the following: |
| |
| "ENS Notification # 37727 on 02/08/01 at 1735 reported that both Unit 2 |
| Reactor Recirculating System sample line Primary Containment Isolation |
| Valves (PCIVs) were declared inoperable. This event is now being retracted. |
| |
| "The original notification stated that during restoration from maintenance |
| activities on the sample line, the outboard PCIV (HV243F020) initially |
| failed to stroke closed via a manual signal from the control room. The |
| inboard PCIV (HV243F019) also failed to close via a manual signal from the |
| control room. HV243F020 was subsequently closed via a manual signal and |
| deactivated to ensure primary containment integrity. Based on the |
| information at the time of the event, HV243F019 and HV243F020 were |
| determined to be incapable of performing their design basis function of |
| closing automatically when the condition was initially observed. The initial |
| condition was reported under 10CFR50.72(b)(3)(v)(C), loss of safety function |
| to mitigate the consequences of an accident and 10CFR50.72(b)(3)(ii)(A), |
| nuclear power plant including its principal safety barriers being seriously |
| degraded. Investigation of the initial condition was not immediately pursued |
| since containment integrity was |
| maintained with HV243F020 deactivated closed, the penetration was not |
| required for sampling purposes and the Unit 2 Refueling Outage was scheduled |
| to begin 3/10/01. |
| |
| "The subsequent investigation and Engineering evaluation of HV243F020 during |
| the Unit 2 Refueling Outage showed that the design basis function of closing |
| automatically to ensure primary containment integrity was not impacted |
| during the initial observation on 2/8/01. Therefore, HV243F020 had been |
| capable of isolating the subject primary containment penetration and an ENS |
| notification per 10CFR50.72(b)(3)(v)(C) and 10CFR50.72(b)(3)(ii)(A) was not |
| required." |
| |
| The licensee informed the NRC resident inspector. Notified R1DO(Evans). |
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|Hospital |Event Number: 37865 |
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| REP ORG: PARKVIEW HOSPITAL |NOTIFICATION DATE: 03/27/2001|
|LICENSEE: PARKVIEW HOSPITAL |NOTIFICATION TIME: 13:45[EST]|
| CITY: FORT WAYNE REGION: 3 |EVENT DATE: 03/26/2001|
| COUNTY: STATE: IN |EVENT TIME: 11:45[CST]|
|LICENSE#: 13-01284-02 AGREEMENT: N |LAST UPDATE DATE: 03/27/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE BURGESS R3 |
| |JOSIE PICCCONE |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOHN AGNEW (RSO) | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION INVOLVING A HIGHER THAN PRESCRIBED THERAPEUTIC |
| DOSE OF I-131 DELIVERED |
| |
| An elderly 65 year old female patient was prescribed a therapeutic 125 |
| millicurie dose of I-131. The administering technician inadvertently |
| delivered 160 millicuries of I-131. The error is attributed to the past |
| practice of physicians ordering 150 millicuries doses (+/- 10%) which is |
| what the technician ordered from the nuclear pharmacy without explicitly |
| verifying the prescribing physician's order. The patient and referring |
| physician were informed of the misadministration by the prescribing |
| physician. Administrative measures including separate verification of the |
| prescribed dosage have been implemented by the licensee to prevent |
| recurrence. The prescribing physician concluded that there was no change in |
| the clinical outcome and that the increased dosage did not pose a high risk |
| for the patient. The licensee will submit a written followup report. |
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