Event Notification Report for November 21, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/20/2002 - 11/21/2002
** EVENT NUMBERS **
39385 39386
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Hospital |Event Number: 39385 |
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| REP ORG: RESEARCH MEDICAL CENTER |NOTIFICATION DATE: 11/19/2002|
|LICENSEE: RESEARCH MEDICAL CENTER |NOTIFICATION TIME: 17:02[EST]|
| CITY: KANSAS CITY REGION: 3 |EVENT DATE: 10/11/2002|
| COUNTY: STATE: MO |EVENT TIME: [CST]|
|LICENSE#: 24-18625-01 AGREEMENT: N |LAST UPDATE DATE: 11/20/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |C.W. (BILL) REAMER NMSS |
| |BRENT CLAYTON R3 |
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| NRC NOTIFIED BY: STEPHEN SLACK | |
| HQ OPS OFFICER: HOWIE CROUCH | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
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| | |
| | |
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EVENT TEXT
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| NOTIFICATION OF MEDICAL EVENT INVOLVING DIAGNOSTIC OVERDOSE OF IODINE-131 |
| |
| Research Medical Center reported that they had a diagnostic |
| misadministration that occurred on 10/11/02. The event was reported after |
| it was discovered by an auditor. |
| |
| The patient was administered 3.6 millicuries of I-131 instead of the |
| prescribed dose of 3.0 millicuries. The iodine was being administered for a |
| whole body scan for thyroid carcinoma. |
| |
| The patient and referring physician will be notified by the licensee. |
| |
| * * * RETRACTION ON 11/20/02 AT 1427 EST FROM STEPHEN SLACK TO HOWIE CROUCH |
| * * * |
| |
| Licensee retracted event based on conversation with Region 3 NMSS. Basis for |
| retraction is that patient does not have a thyroid. |
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|Power Reactor |Event Number: 39386 |
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| FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 11/20/2002|
| UNIT: [] [2] [] STATE: NC |NOTIFICATION TIME: 11:30[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 09/27/2002|
+------------------------------------------------+EVENT TIME: 10:42[EST]|
| NRC NOTIFIED BY: STEVE TABOR |LAST UPDATE DATE: 11/20/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID AYRES R2 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 SPECIFIED SYSTEM ACTUATION WHILE PERFORMING MAINTENANCE |
| |
| "EVENT DESCRIPTION |
| |
| "This report is being made in accordance with �50.73 (a)(1), which states, |
| in part, 'In the case of an invalid actuation reported under �50.73 |
| (a)(2)(iv), other than actuation of the reactor protection system (RPS) when |
| the reactor is critical, the licensee may, at its option, provide a |
| telephone notification to the NRC Operations Center within 60 days after |
| discovery of the event instead of submitting a written LER.' These invalid |
| actuations are being reported under �50.73 (a)(2)(iv)(A). NUREG-1022, Rev. |
| 2, states that the report should provide the following information: |
| |
| "The specific train(s) and system(s) that were actuated |
| |
| "Whether each train actuation was complete or partial |
| |
| "Whether or not the system started and functioned successfully. |
| |
| "On September 27, 2002, at 1042 hours, during the performance of Maintenance |
| Surveillance Test (OMST-RWCU41R), 'RWCU System Isolation Logic System |
| Functional Test,' technician actions to perform positive identification of a |
| logic relay prior to performing visual verification of contacts on that |
| relay as specified within the surveillance procedure instructions, resulted |
| in invalid actuations. The actuations included the Primary Containment |
| Isolation system (PCIS) Group 6 (i.e., Containment Atmosphere |
| Control/Dilution, Containment Atmosphere Monitoring, and Post Accident |
| Sampling Systems) and Division A (i.e., inboard) PCIS Group 2 valves (i.e., |
| the Drywell Equipment and Floor Drains). Both Standby Gas Treatment (SBGT) |
| system trains A and B started and the Reactor Building ventilation system |
| isolated. The actuations of PCIS Group 6 and Division A Group 2 valves and |
| Reactor Building ventilation were complete and the affected equipment |
| responded as designed to the invalid signal (i.e., the valves and dampers |
| that were open, at the time of the event, closed). By 1115 hours, the PCIS |
| Group 2 and 6 isolation logic circuits were reset and associated valves |
| reopened as required by plant condition, the Reactor Building ventilation |
| system was returned to service, and both SBGT trains A and B were placed In |
| standby. |
| |
| "Discussion of the causes and corrective actions associated with this event |
| are documented in the corrective action program in AR 72925." |
| |
| The NRC Resident Inspector has been notified. |
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