Event Notification Report for January 04, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/03/2002 - 01/04/2002
General Information or Other
Event Number: 38614
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SOUTH BROWARD HOSPITAL DISTRICT
Region: 2
City: HOLLYWOOD State: FL
County:
License #: 008-1
Agreement: Y
Docket:
NRC Notified By: ADAMS
HQ OPS Officer: CHAUNCEY GOULD
Licensee: SOUTH BROWARD HOSPITAL DISTRICT
Region: 2
City: HOLLYWOOD State: FL
County:
License #: 008-1
Agreement: Y
Docket:
NRC Notified By: ADAMS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/08/2002
Notification Time: 10:09 [ET]
Event Date: 01/04/2002
Event Time: 00:00 [EST]
Last Update Date: 01/08/2002
Notification Time: 10:09 [ET]
Event Date: 01/04/2002
Event Time: 00:00 [EST]
Last Update Date: 01/08/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS DECKER (R2)
ANITA TURNER (NMSS)
THOMAS DECKER (R2)
ANITA TURNER (NMSS)
AGREEMENT STATE - MEDICAL MISADMINISTRATION
Patient was undergoing a Pterygium treatment to the eye lid on January 4, 2002. This was the 3rd session and it was to be a 44 second session delivering a dose of 1,000 rad. A nurse, who was timing the exposure using a stop watch, was distracted by all the activity going on in the area and the exposure actually lasted one minute and 49 seconds. A dose of 2,480 rads was delivered a 148% overexposure. The patient and the physician have been notified. Worst case is that the patient's eye may have some scar tissue form. Licensee is buying new stop watches with audio alarms and is giving in-service training to nurses. This office was notified the on January 4, 2002 by phone. Licensee will submit a written report within 15 days. Further action is referred to Radioactive Materials.
Patient was undergoing a Pterygium treatment to the eye lid on January 4, 2002. This was the 3rd session and it was to be a 44 second session delivering a dose of 1,000 rad. A nurse, who was timing the exposure using a stop watch, was distracted by all the activity going on in the area and the exposure actually lasted one minute and 49 seconds. A dose of 2,480 rads was delivered a 148% overexposure. The patient and the physician have been notified. Worst case is that the patient's eye may have some scar tissue form. Licensee is buying new stop watches with audio alarms and is giving in-service training to nurses. This office was notified the on January 4, 2002 by phone. Licensee will submit a written report within 15 days. Further action is referred to Radioactive Materials.
Power Reactor
Event Number: 38626
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: MARK HANNEMAN
HQ OPS Officer: FANGIE JONES
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: MARK HANNEMAN
HQ OPS Officer: FANGIE JONES
Notification Date: 01/11/2002
Notification Time: 18:14 [ET]
Event Date: 01/04/2002
Event Time: 09:32 [CST]
Last Update Date: 01/11/2002
Notification Time: 18:14 [ET]
Event Date: 01/04/2002
Event Time: 09:32 [CST]
Last Update Date: 01/11/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVID HILLS (R3)
DAVID HILLS (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 95 | Power Operation | 95 | Power Operation |
INVALID ACTUATION OF PARTIAL GROUP II ISOLATION
"While performing Post Maintenance Testing (PMT) on Primary Containment Isolation Valve (PCIV) 2-9208A (Unit 2 Drywell Air Sample Valve) a fuse in the control circuit blew when the 2-9208A valve was given an open signal. This caused a partial Group II Isolation (Invalid Actuation) consisting of a loss of indication to 14 PCIVs and the automatic closure of 11 PCIVs. Additionally the Traversing In-Core Probes (TIP) automatically retracted and the 5 associated ball valves closed.
"All plant systems responded as expected for the fuse opening. The fuse was replaced and the PCIVs that repositioned were returned to their normal position. The 2-9208A was removed from service. TIP runs were restarted. This event did not have any adverse effect on plant operation.
"Troubleshooting found a shorted wire connection in the junction box for the 2-9208A solenoid. The wire connection was repaired and the 2-9208A valve PMT was performed satisfactorily."
The licensee notified the NRC Resident Inspector.
"While performing Post Maintenance Testing (PMT) on Primary Containment Isolation Valve (PCIV) 2-9208A (Unit 2 Drywell Air Sample Valve) a fuse in the control circuit blew when the 2-9208A valve was given an open signal. This caused a partial Group II Isolation (Invalid Actuation) consisting of a loss of indication to 14 PCIVs and the automatic closure of 11 PCIVs. Additionally the Traversing In-Core Probes (TIP) automatically retracted and the 5 associated ball valves closed.
"All plant systems responded as expected for the fuse opening. The fuse was replaced and the PCIVs that repositioned were returned to their normal position. The 2-9208A was removed from service. TIP runs were restarted. This event did not have any adverse effect on plant operation.
"Troubleshooting found a shorted wire connection in the junction box for the 2-9208A solenoid. The wire connection was repaired and the 2-9208A valve PMT was performed satisfactorily."
The licensee notified the NRC Resident Inspector.