Event Notification Report for June 17, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/16/2003 - 06/17/2003
Power Reactor
Event Number: 39946
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: SEAN EAGLETON
HQ OPS Officer: STEVE SANDIN
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: SEAN EAGLETON
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2003
Notification Time: 18:47 [ET]
Event Date: 06/17/2003
Event Time: 15:57 [EDT]
Last Update Date: 06/17/2003
Notification Time: 18:47 [ET]
Event Date: 06/17/2003
Event Time: 15:57 [EDT]
Last Update Date: 06/17/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAYMOND LORSON (R1)
HERB BERKOW (NRR)
RAYMOND LORSON (R1)
HERB BERKOW (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF EMERGENCY SIREN CAPABILITY DUE TO EQUIPMENT FAILURE
"At 15:57 on 6/17/03, the network link used to activate all Emergency Sirens was inoperable. As a result of the failed link, a total of 154 sirens in Westchester, Orange, Putnam and Rockland Counties in New York were inoperable. The network link was restored at 16:44 on 6/17/03; all Emergency Sirens are currently operable.
"Parties Notified: Westchester, Orange, Putnam and Rockland Counties, New York State and the IPEC NRC Resident Inspector were notified."
"At 15:57 on 6/17/03, the network link used to activate all Emergency Sirens was inoperable. As a result of the failed link, a total of 154 sirens in Westchester, Orange, Putnam and Rockland Counties in New York were inoperable. The network link was restored at 16:44 on 6/17/03; all Emergency Sirens are currently operable.
"Parties Notified: Westchester, Orange, Putnam and Rockland Counties, New York State and the IPEC NRC Resident Inspector were notified."
Power Reactor
Event Number: 39947
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SAM BELCHER
HQ OPS Officer: STEVE SANDIN
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SAM BELCHER
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2003
Notification Time: 23:35 [ET]
Event Date: 06/17/2003
Event Time: 16:20 [CDT]
Last Update Date: 06/17/2003
Notification Time: 23:35 [ET]
Event Date: 06/17/2003
Event Time: 16:20 [CDT]
Last Update Date: 06/17/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DALE POWERS (R4)
DALE POWERS (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
HPCS SYSTEM RENDERED INOPERABLE DUE TO PERSONNEL ERROR
Text to follow from fax
"While performing scheduled maintenance activities on SWP-P2C, Standby Service Water Pump P2C, operators inadvertently removed an adjacent 4160 volt switchgear breaker, E22-ACB002, which supplies the High Pressure Core Spray Pump, at 16:20 Central Daylight Time (CDT) on June 17, 2003 while operating at 100% power. The HPSC pump breaker is adjacent to the SWP-P2C breaker on the same switchgear. This action rendered the High Pressure Core Spray system (HPCS) inoperable and unable to fulfill the HPCS safety function to mitigate the consequences of an accident. This inadvertent action was immediately recognized by the control room operating team and immediate actions were taken to restore the system to operable. The pump breaker was promptly restored and functional testing of the HPCS pump was completed at 16:36 CDT on June 17, 2003. The High Pressure Core Spray system was restored to full operable status within 16 minutes. All other divisional Emergency Core Cooling Systems (ECCS) were operable. The Reactor Core Isolation Cooling System (RCIC) was also operable during this time period. Investigation into the removal of the HPCS pump breaker is in progress."
The licensee informed the NRC resident inspector.
Text to follow from fax
"While performing scheduled maintenance activities on SWP-P2C, Standby Service Water Pump P2C, operators inadvertently removed an adjacent 4160 volt switchgear breaker, E22-ACB002, which supplies the High Pressure Core Spray Pump, at 16:20 Central Daylight Time (CDT) on June 17, 2003 while operating at 100% power. The HPSC pump breaker is adjacent to the SWP-P2C breaker on the same switchgear. This action rendered the High Pressure Core Spray system (HPCS) inoperable and unable to fulfill the HPCS safety function to mitigate the consequences of an accident. This inadvertent action was immediately recognized by the control room operating team and immediate actions were taken to restore the system to operable. The pump breaker was promptly restored and functional testing of the HPCS pump was completed at 16:36 CDT on June 17, 2003. The High Pressure Core Spray system was restored to full operable status within 16 minutes. All other divisional Emergency Core Cooling Systems (ECCS) were operable. The Reactor Core Isolation Cooling System (RCIC) was also operable during this time period. Investigation into the removal of the HPCS pump breaker is in progress."
The licensee informed the NRC resident inspector.
General Information or Other
Event Number: 39957
Rep Org: ILLINOIS DEPT OF NUCLEAR SAFETY
Licensee: GOOD SHEPHERD HOSPITAL
Region: 3
City: BARRINGTON State: IL
County:
License #: IL-01620-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: ARLON COSTA
Licensee: GOOD SHEPHERD HOSPITAL
Region: 3
City: BARRINGTON State: IL
County:
License #: IL-01620-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: ARLON COSTA
Notification Date: 06/23/2003
Notification Time: 17:26 [ET]
Event Date: 06/17/2003
Event Time: 00:00 [CDT]
Last Update Date: 06/23/2003
Notification Time: 17:26 [ET]
Event Date: 06/17/2003
Event Time: 00:00 [CDT]
Last Update Date: 06/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PATRICK LOUDEN (R3)
C.W. (BILL) REAMER (NMSS)
PATRICK LOUDEN (R3)
C.W. (BILL) REAMER (NMSS)
AGREEMENT STATE REPORT- WRONG PATIENT SELECTED
"Today, June 23, 2003, a consultant to Good Shepherd Hospital (IL-01620-01) in Barrington, IL called concerning a reportable medical event [discovery date 06/20/2003]. On June 17th the licensee was scheduled to provide a therapeutic dose of 15 milliCi [milliCuries] of I-131 to a patient by capsule. Instead, the patient received a capsule with an assayed dose of 10.8 milliCi. Apparently, two treatments were scheduled for the day and a second patient was prescribed a dose of 11 milliCi and the technician failed to administer the correct dose to the patient. The second patient did not receive any treatment that day and was rescheduled for last Friday. (A separate call to the pharmacy confirmed two doses were delivered on Tuesday, one of 15 milliCi and a second [dose] of 11 milliCi and another dose of 10 milliCi was provided on Friday.)
"At this time, the radiation oncologist does not believe there will be any appreciable effect to the patient, but will continue to follow through with the evaluation to determine if an additional dose is necessary to achieve the optimal results. The licensee has advised the referring physician verbally and in writing. They have determined it would not be appropriate to notify the patient[s] given their condition and medical situation.
"The licensee has spoken with the responsible technician about ensuring the correct dose is administered to the correct patient. The licensee is in the process of changes procedures at the site so that two individuals must independently confirm the correct patient identification and dosage information immediately prior to administration.
"The licensee was advised as the need for timely reporting or these events and that a formal report must be filed within 15 days as per 32 Ill. Adm. Code 335.1080."
"Today, June 23, 2003, a consultant to Good Shepherd Hospital (IL-01620-01) in Barrington, IL called concerning a reportable medical event [discovery date 06/20/2003]. On June 17th the licensee was scheduled to provide a therapeutic dose of 15 milliCi [milliCuries] of I-131 to a patient by capsule. Instead, the patient received a capsule with an assayed dose of 10.8 milliCi. Apparently, two treatments were scheduled for the day and a second patient was prescribed a dose of 11 milliCi and the technician failed to administer the correct dose to the patient. The second patient did not receive any treatment that day and was rescheduled for last Friday. (A separate call to the pharmacy confirmed two doses were delivered on Tuesday, one of 15 milliCi and a second [dose] of 11 milliCi and another dose of 10 milliCi was provided on Friday.)
"At this time, the radiation oncologist does not believe there will be any appreciable effect to the patient, but will continue to follow through with the evaluation to determine if an additional dose is necessary to achieve the optimal results. The licensee has advised the referring physician verbally and in writing. They have determined it would not be appropriate to notify the patient[s] given their condition and medical situation.
"The licensee has spoken with the responsible technician about ensuring the correct dose is administered to the correct patient. The licensee is in the process of changes procedures at the site so that two individuals must independently confirm the correct patient identification and dosage information immediately prior to administration.
"The licensee was advised as the need for timely reporting or these events and that a formal report must be filed within 15 days as per 32 Ill. Adm. Code 335.1080."