Event Notification Report for January 28, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/27/1999 - 01/28/1999
EVENT NUMBERS
35325353223532035329
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 35325
Rep Org: DETROIT MACOMB HOSPITAL
Licensee: DETROIT MACOMB HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: 21-01190-05
Agreement: N
Docket:
NRC Notified By: ARTHUR EWALD
HQ OPS Officer: BOB STRANSKY
Licensee: DETROIT MACOMB HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: 21-01190-05
Agreement: N
Docket:
NRC Notified By: ARTHUR EWALD
HQ OPS Officer: BOB STRANSKY
Notification Date: 01/29/1999
Notification Time: 11:28 [ET]
Event Date: 01/28/1999
Event Time: 16:10 [EST]
Last Update Date: 05/19/1999
Notification Time: 11:28 [ET]
Event Date: 01/28/1999
Event Time: 16:10 [EST]
Last Update Date: 05/19/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
TONY VEGEL (R3)
DONALD COOL (NMSS)
TONY VEGEL (R3)
DONALD COOL (NMSS)
MEDICAL MISADMINISTRATION DUE TO PATIENT INTERVENTION
During brachytherapy treatment of a patient's endobronchial area, the patient dislodged the catheter approximately 25 cm, causing the treatment site to receive only 3.8% of the prescribed dose. Additionally, the patient's nasal area received approximately 13 rads (13 cGy) due to the displacement. The licensee estimates that the catheter was dislodged for approximately 10 minutes before being discovered.
The patient's referring physician has been informed of this event.
* * * RETRACTED AT 1356 EDT ON 5/19/99 BY ART EWALD TO STEVE SANDIN * * *
The licensee is retracting this report based on review and consultation with the NRC. Notified R3DO(Clayton) and NMSS(Camper).
During brachytherapy treatment of a patient's endobronchial area, the patient dislodged the catheter approximately 25 cm, causing the treatment site to receive only 3.8% of the prescribed dose. Additionally, the patient's nasal area received approximately 13 rads (13 cGy) due to the displacement. The licensee estimates that the catheter was dislodged for approximately 10 minutes before being discovered.
The patient's referring physician has been informed of this event.
* * * RETRACTED AT 1356 EDT ON 5/19/99 BY ART EWALD TO STEVE SANDIN * * *
The licensee is retracting this report based on review and consultation with the NRC. Notified R3DO(Clayton) and NMSS(Camper).
Power Reactor
Event Number: 35322
Facility: HATCH
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARNES
HQ OPS Officer: CHAUNCEY GOULD
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARNES
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/28/1999
Notification Time: 17:20 [ET]
Event Date: 01/28/1999
Event Time: 16:30 [EST]
Last Update Date: 01/28/1999
Notification Time: 17:20 [ET]
Event Date: 01/28/1999
Event Time: 16:30 [EST]
Last Update Date: 01/28/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1)(i)(A) - PLANT S/D REQD BY TS 50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(1)(i)(A) - PLANT S/D REQD BY TS 50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
BRIAN BONSER (R2)
BRIAN BONSER (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
THE PLANT ENTERED LCO ACTION STATEMENT DUE TO TWO ADS VALVES BEING INOPERABLE.
THIS CONDITION OCCURRED WHEN 2B21-F013K SAFETY RELIEF VALVE OPENED AND THE PROCEDURE (34AB-OPS-007-1) DIRECTS OPERATORS TO REMOVE FUSES, WHICH WAS DONE, TO CLOSE THE VALVE. POWER REMOVED FROM THIS VALVE AND POWER PREVIOUSLY REMOVED FROM THE 2B21-F013C VALVE DUE TO A DC GROUND, PUT THE PLANT IN A TS LCO ACTION STATEMENT TO BE IN MODE 3 (WHICH THEY ARE CURRENTLY IN) WITHIN 12 HOURS AND BE BELOW 150 PSIG WITHIN 36 HOURS. THE PLANT IS CURRENTLY AT 300 PSIG AND PROCEEDING TO COLD SHUTDOWN.
THE RESIDENT INSPECTOR WAS NOTIFIED.
*** UPDATE ON 1/28/99 @ 1846 BY COLEMAN TO GOULD ***
THE LICENSEE DETERMINED THAT THE OPENING OF THE ADS VALVE WAS ALSO AN ESF ACTUATION.
THE LICENSEE PLANS TO INFORM THE RESIDENT INSPECTOR.
THE NRC OPERATIONS OFFICER NOTIFIED THE R2DO (BRIAN BONSER).
THIS CONDITION OCCURRED WHEN 2B21-F013K SAFETY RELIEF VALVE OPENED AND THE PROCEDURE (34AB-OPS-007-1) DIRECTS OPERATORS TO REMOVE FUSES, WHICH WAS DONE, TO CLOSE THE VALVE. POWER REMOVED FROM THIS VALVE AND POWER PREVIOUSLY REMOVED FROM THE 2B21-F013C VALVE DUE TO A DC GROUND, PUT THE PLANT IN A TS LCO ACTION STATEMENT TO BE IN MODE 3 (WHICH THEY ARE CURRENTLY IN) WITHIN 12 HOURS AND BE BELOW 150 PSIG WITHIN 36 HOURS. THE PLANT IS CURRENTLY AT 300 PSIG AND PROCEEDING TO COLD SHUTDOWN.
THE RESIDENT INSPECTOR WAS NOTIFIED.
*** UPDATE ON 1/28/99 @ 1846 BY COLEMAN TO GOULD ***
THE LICENSEE DETERMINED THAT THE OPENING OF THE ADS VALVE WAS ALSO AN ESF ACTUATION.
THE LICENSEE PLANS TO INFORM THE RESIDENT INSPECTOR.
THE NRC OPERATIONS OFFICER NOTIFIED THE R2DO (BRIAN BONSER).
Power Reactor
Event Number: 35320
Facility: HATCH
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARNES
HQ OPS Officer: CHAUNCEY GOULD
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARNES
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/28/1999
Notification Time: 14:07 [ET]
Event Date: 01/28/1999
Event Time: 12:02 [EST]
Last Update Date: 01/28/1999
Notification Time: 14:07 [ET]
Event Date: 01/28/1999
Event Time: 12:02 [EST]
Last Update Date: 01/28/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
BRIAN BONSER (R2)
BRIAN BONSER (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
GROUP 2 ISOLATION DUE TO REACTOR WATER LEVEL LESS THAN 3 INCHES.
A GROUP 2 ISOLATION OCCURRED WHEN THE REACTOR WATER LEVEL DECREASED TO 1 INCH FOLLOWING A PREPLANNED MANUAL REACTOR SCRAM DURING A PLANNED PLANT SHUTDOWN. THE FOLLOWING VALVES CLOSED AS PART OF THE GROUP 2 ISOLATION SIGNAL: FISSION PRODUCT MONITOR VALVES (2D11-F050, F051, F052, F053, F071, & F072), PRIMARY CONTAINMENT 18 INCH VENT VALVES (2T48-F319 & F320), PRIMARY CONTAINMENT PURGE VALVES (2T48-F309 & F324), H2-O2 ANALYZER VALVES (2P33-F002, F004, F005, F007, F012, F013, & F015), AND DRYWELL EQUIPMENT DRAIN SUMP ISOLATION VALVES (2611-F003 & F004). THE REACTOR WATER LEVEL WAS RESTORED TO GREATER THAN 3 INCHES AND ALL VALVES WERE REOPENED WITHIN 5 MINUTES. THE CAUSE OF THE LOW LEVEL WAS DUE TO THE VOIDS COLLAPSING AND RECOVERY WAS NOT QUICK ENOUGH TO PREVENT THE ISOLATION.
THE RESIDENT INSPECTOR WAS NOTIFIED.
A GROUP 2 ISOLATION OCCURRED WHEN THE REACTOR WATER LEVEL DECREASED TO 1 INCH FOLLOWING A PREPLANNED MANUAL REACTOR SCRAM DURING A PLANNED PLANT SHUTDOWN. THE FOLLOWING VALVES CLOSED AS PART OF THE GROUP 2 ISOLATION SIGNAL: FISSION PRODUCT MONITOR VALVES (2D11-F050, F051, F052, F053, F071, & F072), PRIMARY CONTAINMENT 18 INCH VENT VALVES (2T48-F319 & F320), PRIMARY CONTAINMENT PURGE VALVES (2T48-F309 & F324), H2-O2 ANALYZER VALVES (2P33-F002, F004, F005, F007, F012, F013, & F015), AND DRYWELL EQUIPMENT DRAIN SUMP ISOLATION VALVES (2611-F003 & F004). THE REACTOR WATER LEVEL WAS RESTORED TO GREATER THAN 3 INCHES AND ALL VALVES WERE REOPENED WITHIN 5 MINUTES. THE CAUSE OF THE LOW LEVEL WAS DUE TO THE VOIDS COLLAPSING AND RECOVERY WAS NOT QUICK ENOUGH TO PREVENT THE ISOLATION.
THE RESIDENT INSPECTOR WAS NOTIFIED.
General Information or Other
Event Number: 35329
Rep Org: SWAGELOK COMPANY
Licensee: SWAGELOK COMPANY
Region: 3
City: SOLON State: OH
County:
License #:
Agreement: N
Docket:
NRC Notified By: BRUCE FLUSCHE (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Licensee: SWAGELOK COMPANY
Region: 3
City: SOLON State: OH
County:
License #:
Agreement: N
Docket:
NRC Notified By: BRUCE FLUSCHE (FAX)
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/29/1999
Notification Time: 16:04 [ET]
Event Date: 01/28/1999
Event Time: 00:00 [EST]
Last Update Date: 01/29/1999
Notification Time: 16:04 [ET]
Event Date: 01/28/1999
Event Time: 00:00 [EST]
Last Update Date: 01/29/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID SILK (R1)
BRIAN BONSER (R2)
VERN HODGE (NRR)
DAVID SILK (R1)
BRIAN BONSER (R2)
VERN HODGE (NRR)
THE SWAGELOK COMPANY IS SUBMITTING A POSSIBLE 10CFR PART 21 NOTIFICATION BECAUSE OF A POSSIBLE MATERIAL DEFECT IN A SWAGELOK PIPE FITTING TEE, PART # SS-6-T. THE DEFECT IS A CRACK IN THE CENTER OF THE FORGING. THEY ARE CONTINUING THEIR ANALYSIS OF THE PART.
THIS PART WAS SUPPLIED TO PUBLIC SERVICE ELECTRIC & GAS(20 PCS.) IN HANCOCKS BRIDGE N.J. AND SOUTH CAROLINA ELECTRIC & GAS CO., VC SUMMER STATION(3 PCS.) THE PRODUCT ID IS R27GE0123B.
THIS PART WAS SUPPLIED TO PUBLIC SERVICE ELECTRIC & GAS(20 PCS.) IN HANCOCKS BRIDGE N.J. AND SOUTH CAROLINA ELECTRIC & GAS CO., VC SUMMER STATION(3 PCS.) THE PRODUCT ID IS R27GE0123B.