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Event Notification Report for September 10, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/09/1999 - 09/10/1999

                              ** EVENT NUMBERS **

36029  36037  36078  36139  36140  36141  36142  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36029       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 08/13/1999|
|    UNIT:  [1] [2] [3]               STATE:  SC |NOTIFICATION TIME: 18:18[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        08/13/1999|
+------------------------------------------------+EVENT TIME:        17:28[EDT]|
| NRC NOTIFIED BY:  MIKE HILL                    |LAST UPDATE DATE:  09/09/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES OGLE         R2      |
|10 CFR SECTION:                                 |JOSE CALVO           NRR     |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |FRANK CONGEL         IRO     |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |99       Power Operation  |
|2     N          Y       100      Power Operation  |99       Power Operation  |
|3     N          Y       100      Power Operation  |99       Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| -TS REQD SHUTDOWN OF ALL 3 UNITS DUE TO BOTH CONTROL ROOM VENT SYSTEM        |
| CHILLERS INOP                                                                |
|                                                                              |
| UNIT 1 AND UNIT 2 CONTROL ROOMS SHARE A COMMON VENTILATION SYSTEM; UNIT 3    |
| CONTROL ROOM HAS ITS OWN VENTILATION SYSTEM.  TWO CHILLERS SERVE THE         |
| VENTILATION SYSTEMS FOR ALL THREE CONTROL ROOMS.                             |
|                                                                              |
| AT 1659 ON 08/13/99, THE 'B' TRAIN CONTROL ROOM CHILLER TRIPPED DURING       |
| MAINTENANCE ACTIVITIES.  TECH SPEC 3.7.16 REQUIRES THE LICENSEE TO RESTORE   |
| THE INOPERABLE CHILLER TO OPERABLE STATUS WITHIN 30 DAYS OR SHUT ALL THREE   |
| UNITS DOWN.                                                                  |
|                                                                              |
| AT 1728 ON 08/13/99, THE 'A' TRAIN CONTROL ROOM CHILLER ALSO TRIPPED DURING  |
| MAINTENANCE ACTIVITIES.  TECH SPEC 3.0.3 REQUIRES THE LICENSEE TO START      |
| SHUTTING ALL THREE UNITS DOWN WITHIN ONE HOUR AND PLACE ALL THREE UNITS IN   |
| MODE 3 WITHIN 12 HOURS WITH BOTH CONTROL ROOM VENTILATION SYSTEM CHILLERS    |
| INOPERABLE.                                                                  |
|                                                                              |
| THE LICENSEE IS REDUCING THE POWER OF ALL THREE UNITS AT THE RATE OF 1% PER  |
| HOUR AND IS ATTEMPTING TO RESTORE AT LEAST ONE CHILLER TO OPERABLE STATUS.   |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
|                                                                              |
| * * * UPDATE AT 2336 ON 08/13/99 FROM SCOTT BATSON TO JOLLIFFE * * *         |
|                                                                              |
| AT 2240, THE LICENSEE RESTORED THE 'B' CHILLER TO OPERABLE STATUS USING THE  |
| 'A' PUMP AND EXITED TS 3.0.3.  TS 3.7.16 REMAINS IN EFFECT FOR THE 'A'       |
| CHILLER.  THE LICENSEE PLANS TO INCREASE POWER FROM A LOW LEVEL OF 87% AND   |
| HAS INFORMED THE NRC RESIDENT INSPECTOR.  THE NRC OPERATIONS OFFICER         |
| NOTIFIED THE R2DO CHUCK OGLE.                                                |
|                                                                              |
| *** UPDATE AT 1513 ON 9/9/99 FROM TODD TO POERTNER. ***                      |
|                                                                              |
| The following is a portion of a facsimile received from the licensee:        |
| "This event was initially reported due to initiation of shutdown of all      |
| three Oconee units in accordance with Tech Specs.  After all three units     |
| reached approximately 85% rated power, the Tech Spec condition was exited.   |
| The shutdown was terminated and the units returned to full power.  After     |
| further review, Duke Energy Company feels that the entry into the Tech Spec  |
| condition which required shutdown was INVALID, for reasons explained below.  |
| Because the units did actually initiate shutdown under the declared Tech     |
| Spec condition, Duke Energy Company does not consider it appropriate to      |
| retract the notification but is providing this update to indicate that the   |
| conditions did not meet other reportability requirements of 10 CFR 50.72 or  |
| 50.73."                                                                      |
|                                                                              |
| "This event was reported due to initiation of shutdown of all three Oconee   |
| units in accordance with Tech Spec 3.7.16, Condition E, which requires entry |
| into Tech Spec 3.0.3 when two trains of the Chilled Water (WC) system are    |
| inoperable. The WC system provides chilled water for the Control Room        |
| Ventilation System on all three Oconee Units.  Both the 'A' and 'B' chillers |
| had tripped when the initial report was made."                               |
|                                                                              |
| "The 'B' chiller was successfully restarted in combination with the 'A'      |
| chilled water pump. Based on this, one train of WC was declared operable.    |
| Tech Spec 3.0.3 and 3.7.16, Condition E were exited. Tech Spec 3.7.16        |
| Condition B remained in effect. The shutdown of the Oconee units was         |
| terminated.  An update notification containing this information was made at  |
| 2336 hours on 8-13-99."                                                      |
|                                                                              |
| "Subsequently, troubleshooting found that the 'B' Chilled Water pump tripped |
| due to a faulty relay, which caused the 'B' Chiller trip. The 'A' Chiller    |
| was inoperable due to inadequate refrigerant charge combined with excess     |
| oil. Both the 'B' Chilled Water pump and the 'A' Chiller were repaired and   |
| returned to service allowing Tech Spec 3.7.16, Condition B to be exited on   |
| 8-17-99."                                                                    |
|                                                                              |
| "An Operability Evaluation concluded that the combination of 'A' Chilled     |
| Water pump with the 'B' Chiller was Operable throughout the event. This      |
| conclusion is based on the following facts:                                  |
|                                                                              |
| 1) The Oconee Chilled Water system was designed as a non-safety system.      |
| 2) Operation following a Design Basis Event requires manual alignment and    |
| restart.                                                                     |
| 3) Restart is not required for an extended period (greater than 18 hours).   |
| 4) Operation in this alignment is included in the applicable procedure.      |
| 5) No maintenance was required on either the 'A' WC pump or the 'B'          |
| Chiller.                                                                     |
|                                                                              |
| Therefore, the entry into Tech Spec 3.7.16, Condition E, and 3.0.3 was       |
| invalid."                                                                    |
|                                                                              |
| "Also, the Operability Evaluation found that the 'A' chiller had been        |
| confirmed to be operable on 7-27-99 when it was run as part of a post        |
| maintenance test following PM of the 'A' Chilled Water Pump. The Operability |
| Evaluation concluded that the 'A' Chiller became inoperable after that date. |
| Therefore, the 30 day action statement of Tech Spec 3.7.16, Condition B for  |
| one WC train out of service was not exceeded."                               |
|                                                                              |
| "As a result of this Operability Evaluation, Duke Energy has concluded that  |
| there are no conditions reportable under 50.73 associated with this event."  |
|                                                                              |
| The NRC resident inspector has been notified.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36037       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 08/18/1999|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 09:00[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        08/17/1999|
+------------------------------------------------+EVENT TIME:        09:10[EDT]|
| NRC NOTIFIED BY:  BOB KIDDER                   |LAST UPDATE DATE:  09/09/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |FEMA, DOE, USDA, HHS FAX     |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |EPA, DOT (VIA NRC)   FAX     |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RELEASE OF CHLORINATED WATER TO STORM DRAIN AND OFFSITE NOTIFICATION         |
|                                                                              |
| The licensee discovered that, due to valve leakage, a small amount of        |
| chlorine was released to a storm drain. The following information was        |
| submitted to the NRC Operations Center by facsimile:                         |
|                                                                              |
| "The service water backwash valve on strainer 'd' was experiencing severe    |
| leakage past the valve. The system engineer estimated approximately 200 gpm  |
| leakage occurred. During this time, the system chlorination evolution        |
| occurred for 40 minutes. The forebay water was treated to a concentration of |
| 1 ppm. The result is that an estimated 0.067 lbs of chlorine was discharged  |
| to the storm drain. The reportable quantity for chlorine is 10 lbs. There is |
| no reportability requirement for CERCLA; however, an NPDES noncompliance did |
| occur. Reportability is being investigated. The strainer valve has been      |
| isolated to prevent it from operating until repairs are complete."           |
|                                                                              |
| This event is reportable to the NRC within 24 hours in accordance with       |
| Section 4.1 of the site Environmental Protection Plan. In addition, the      |
| licensee is notifying the US EPA of this release. The NRC resident inspector |
| has been informed of this notification.                                      |
|                                                                              |
| * * * UPDATE 0942 9/9/1999 FROM SANFORD TAKEN BY STRANSKY * * *              |
|                                                                              |
| "On 8/17/99, the Perry Nuclear Power Plant (PNPP) discharged an estimated    |
| 0.067 pounds of chlorine to a storm drain from the Service Water System. The |
| storm drain is not an acceptable discharge path for treated Service Water    |
| per the National Pollution Discharge Elimination System (NPDES) permit. On   |
| 8/18/99, the Ohio Environmental Protection Agency (EPA) was notified of the  |
| chlorine discharge to the storm drain. Subsequently, an NRC notification was |
| made in accordance with 10CFR50.72(b)(2)(vi) for notification of other       |
| government agencies (i.e., Ohio EPA). This notification also included a 24   |
| hour report in accordance with the EPP for an event that could result in     |
| significant environmental Impact. The EPP report was conservatively made     |
| since the environmental impact had not been fully evaluated.                 |
|                                                                              |
| "The EPP requires, in part, that any occurrence of an unusual or important   |
| event that indicates or could result in significant environmental impact     |
| causally related to plant operations shall be recorded and reported to the   |
| NRC within 24 hours with a written report submitted within 30 days. The site |
| environmentalist's evaluation determined that the chlorine content in the    |
| service water was extremely low (1 ppm using the most conservative estimate) |
| and there was no significant effect or impact on the environment. Therefore, |
| the EPP reporting was not required and a written report will not be          |
| submitted. The NRC notification per 10CFR50.72 is not affected by this       |
| update."                                                                     |
|                                                                              |
| The NRC resident inspector has been informed of this update. Notified R3DO   |
| (Phillips).                                                                  |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36078       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BYRON                    REGION:  3  |NOTIFICATION DATE: 08/27/1999|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 02:10[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        08/26/1999|
+------------------------------------------------+EVENT TIME:        22:30[CDT]|
| NRC NOTIFIED BY:  TROY LEAF                    |LAST UPDATE DATE:  09/09/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MELVYN LEACH         R3      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SAFEGUARDS SYSTEM DEGRADATION RELATED TO POWER SUPPLY FUNCTIONS              |
|                                                                              |
| At 0030 CDT on 08/27/99, it was determined that a security event which       |
| occurred at 2230 CDT on 08/26/99 met the reportability requirements of 10    |
| CFR 73.71(b), Part 73, Appendix G, paragraph 1(c).  The event involved a     |
| safeguards system degradation related to power supply functions.             |
| Compensatory measures were taken upon discovery.  (Contact the NRC           |
| operations officer for additional details and for a site contact telephone   |
| number.)                                                                     |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
|                                                                              |
| * * * RETRACTION 1133 9/9/1999 FROM SWANSON TAKEN BY STRANSKY * * *          |
|                                                                              |
| The degradation reported in the initial notification does not meet the       |
| reportability requirements of 10 CFR 73.71, and this notification has been   |
| retracted. The NRC resident inspector has been informed of this retraction   |
| by the licensee. Notified R3DO (Phillips).                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36139       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: TURKEY POINT             REGION:  2  |NOTIFICATION DATE: 09/08/1999|
|    UNIT:  [3] [4] []                STATE:  FL |NOTIFICATION TIME: 23:12[EDT]|
|   RXTYPE: [3] W-3-LP,[4] W-3-LP                |EVENT DATE:        09/08/1999|
+------------------------------------------------+EVENT TIME:        22:30[EDT]|
| NRC NOTIFIED BY:  ANDRE DALL'AU                |LAST UPDATE DATE:  09/09/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT HAAG          R2      |
|10 CFR SECTION:                                 |                             |
|AARC 50.72(b)(1)(v)      OTHER ASMT/COMM INOP   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|4     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BOTH UNITS EXPERIENCED A TEMPORARY LOSS OF THE EMERGENCY RESPONSE DATA       |
| SYSTEM.                                                                      |
|                                                                              |
| "DISCOVERED @ 2230 ERDADS AND ERDS STOPPED UPDATING DATA @ 2200.  ERDS       |
| CALLED OUT OF SERVICE AND TROUBLESHOOTING UNDERWAY TO DETERMINE CAUSE.       |
| UNKNOWN AT THIS TIME IF FAILURE ASSOCIATED WITH Y2K.  SYSTEM STARTED         |
| UPDATING DUE TO TROUBLESHOOTING ACTIVITIES @ 2305."                          |
|                                                                              |
| THE  LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR.                        |
|                                                                              |
| * * * UPDATE 0313 9/9/1999 FROM DALL'AU TAKEN BY STRANSKY * * *              |
|                                                                              |
| "ERDS and ERDADS powered and declared functional at 2330 9/8/99. All         |
| troubleshooting and testing complete with ERDS and ERDADS declared back in   |
| service at 0250 9/9/99. Intermittent disk failures of the primary computer,  |
| not any Y2K related failures, were determined to be the cause of the loss of |
| data."                                                                       |
|                                                                              |
| The NRC resident inspector will be informed of this update. Notified R2DO    |
| (Haag).                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36140       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: GRAND GULF               REGION:  4  |NOTIFICATION DATE: 09/09/1999|
|    UNIT:  [1] [] []                 STATE:  MS |NOTIFICATION TIME: 14:45[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        09/09/1999|
+------------------------------------------------+EVENT TIME:        11:48[CDT]|
| NRC NOTIFIED BY:  ERNEST MATHES                |LAST UPDATE DATE:  09/09/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GARY SANBORN         R4      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DIVISION III EMERGENCY DIESEL GENERATOR (EDG) FAILURE.                       |
|                                                                              |
| The division III EDG was emergency stopped during a 24 hour surveillance     |
| run.  Preliminary indications are that the generator bearing failed as       |
| indicated by high bearing temperature and sparks from the generator area     |
| just prior to emergency stopping the EDG.  The diesel was started at 1055    |
| CDT and secured at 1148 CDT.   The licensee is investigating the cause of    |
| the failure.                                                                 |
|                                                                              |
| The NRC resident inspector has been notified.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36141       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  DC FABRICATORS                       |NOTIFICATION DATE: 09/09/1999|
|LICENSEE:  DC FABRICATORS                       |NOTIFICATION TIME: 15:30[EDT]|
|    CITY:  FLORENCE                 REGION:  1  |EVENT DATE:        09/09/1999|
|  COUNTY:                            STATE:  NJ |EVENT TIME:             [EDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  09/09/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TOM MOSLAK           R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+GARY SANBORN         R4      |
| NRC NOTIFIED BY:  DONALD BRAMBLE               |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ALLOY IDENTIFICATION INSTRUMENT LOST DURING SHIPMENT                         |
|                                                                              |
| On March 14, 1999, DC Fabricators shipped a small alloy identification       |
| instrument to Texas Nuclear Technology via UPS.  In early August, DC         |
| Fabricators determined that the instrument had not arrived at Texas Nuclear  |
| Technology.  The device contains 45 millicuries of Fe-55 and 4 millicuries   |
| of Cd-109.  UPS is looking for the device but has been unable to locate it   |
| to date.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36142       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  KANSAS DEPT OF HEALTH                |NOTIFICATION DATE: 09/09/1999|
|LICENSEE:  UNIVERSITY OF KANSAS MEDICAL CENTER  |NOTIFICATION TIME: 17:33[EDT]|
|    CITY:  KANSAS CITY              REGION:  4  |EVENT DATE:        09/08/1999|
|  COUNTY:                            STATE:  KS |EVENT TIME:        11:45[CDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  09/09/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GARY SANBORN         R4      |
|                                                |JOSIE PICCONE        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RONALD FRASS (FAX)           |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION.                                         |
|                                                                              |
| A patient was administered 5.4 millicuries of Indium-111.  The patient was   |
| supposed to receive a dose of Chromium-51 for a blood volume test.  The      |
| preliminary investigation indicates a dose of 14 rads (cGy)  to the spleen   |
| and less than 5 rads whole body.  The University of Kansas Medical Center    |
| (KUMC) RSO was not available when the potential misadministration occurred,  |
| and informed the Kansas Department Of Health And Environment (KDHE) upon her |
| return to the office.  The KDHE and KUMC investigations have commenced.  At  |
| this time, KUMC has no further information regarding this event.             |
+------------------------------------------------------------------------------+