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Event Notification Report for March 28, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/27/2001 - 03/28/2001

                              ** EVENT NUMBERS **

37727  37865  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   37727       |
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| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 02/08/2001|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 17:35[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        02/08/2001|
+------------------------------------------------+EVENT TIME:        14:47[EST]|
| NRC NOTIFIED BY:  ROLAND                       |LAST UPDATE DATE:  03/27/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RONALD BELLAMY       R1      |
|10 CFR SECTION:                                 |                             |
|*DEG 50.72(b)(3)(ii)(A)  DEGRAD COND DURING OP  |                             |
|*INC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| BOTH REACTOR RECIRCULATING SAMPLE LINE CONTAINMENT ISOLATION VALVES DECLARED |
| INOPERABLE                                                                   |
|                                                                              |
| During operation of Unit 2 at 100% power, it has been determined that both   |
| Primary Containment Isolation Valves for the Reactor Recirculating Sample    |
| Line are inoperable.  During restoration from maintenance activities on the  |
| line, the outboard isolation valve[HV243F020] failed to stroke closed.       |
| Following several attempts the valve was closed.  The valve was declared     |
| inoperable, and as required by Technical Specifications an attempt was made  |
| to close the inboard isolation valve[HV243F019].  The inboard valve also     |
| failed to close.  The air supply was isolated to the outboard valve to       |
| deactivate it, and the pathway was confirmed to be isolated.  The problem    |
| with the outboard valve is due to a bad solenoid.   The problem with the     |
| inboard valve is under investigation.  They were able to get both valves     |
| closed when the inboard valve finally closed on its own an hour later.       |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| * * * UPDATE 1244EST ON 3/27/01 FROM BOESCH TO S. SANDIN * * *               |
|                                                                              |
| This report is retracted based on the following:                             |
|                                                                              |
| "ENS Notification # 37727 on 02/08/01 at 1735 reported that both Unit 2      |
| Reactor Recirculating System sample line Primary Containment Isolation       |
| Valves (PCIVs) were declared inoperable. This event is now being retracted.  |
|                                                                              |
| "The original notification stated that during restoration from maintenance   |
| activities on the sample line, the outboard PCIV (HV243F020) initially       |
| failed to stroke closed via a manual signal from the control room. The       |
| inboard PCIV (HV243F019) also failed to close via a manual signal from the   |
| control room. HV243F020 was subsequently closed via a manual signal and      |
| deactivated to ensure primary containment integrity. Based on the            |
| information at the time of the event, HV243F019 and HV243F020 were           |
| determined to be incapable of performing their design basis function of      |
| closing automatically when the condition was initially observed. The initial |
| condition was reported under 10CFR50.72(b)(3)(v)(C), loss of safety function |
| to mitigate the consequences of an accident and 10CFR50.72(b)(3)(ii)(A),     |
| nuclear power plant including its principal safety barriers being seriously  |
| degraded. Investigation of the initial condition was not immediately pursued |
| since containment integrity was                                              |
| maintained with HV243F020 deactivated closed, the penetration was not        |
| required for sampling purposes and the Unit 2 Refueling Outage was scheduled |
| to begin 3/10/01.                                                            |
|                                                                              |
| "The subsequent investigation and Engineering evaluation of HV243F020 during |
| the Unit 2 Refueling Outage showed that the design basis function of closing |
| automatically to ensure primary containment integrity was not impacted       |
| during the initial observation on 2/8/01. Therefore, HV243F020 had been      |
| capable of isolating the subject primary containment penetration and an ENS  |
| notification per 10CFR50.72(b)(3)(v)(C) and 10CFR50.72(b)(3)(ii)(A) was not  |
| required."                                                                   |
|                                                                              |
| The licensee informed the NRC resident inspector.  Notified R1DO(Evans).     |
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|Hospital                                         |Event Number:   37865       |
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| REP ORG:  PARKVIEW HOSPITAL                    |NOTIFICATION DATE: 03/27/2001|
|LICENSEE:  PARKVIEW HOSPITAL                    |NOTIFICATION TIME: 13:45[EST]|
|    CITY:  FORT WAYNE               REGION:  3  |EVENT DATE:        03/26/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        11:45[CST]|
|LICENSE#:  13-01284-02           AGREEMENT:  N  |LAST UPDATE DATE:  03/27/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE BURGESS        R3      |
|                                                |JOSIE PICCCONE               |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOHN AGNEW (RSO)             |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION INVOLVING A HIGHER THAN PRESCRIBED THERAPEUTIC     |
| DOSE OF I-131 DELIVERED                                                      |
|                                                                              |
| An elderly 65 year old female patient was prescribed a therapeutic 125       |
| millicurie dose of I-131.  The administering technician inadvertently        |
| delivered 160 millicuries of I-131.  The error is attributed to the past     |
| practice of physicians ordering 150 millicuries doses (+/- 10%) which is     |
| what the technician ordered from the nuclear pharmacy without explicitly     |
| verifying the prescribing physician's order.  The patient and referring      |
| physician were informed of the misadministration by the prescribing          |
| physician.  Administrative measures including separate verification of the   |
| prescribed dosage have been implemented by the licensee to prevent           |
| recurrence.  The prescribing physician concluded that there was no change in |
| the clinical outcome and that the increased dosage did not pose a high risk  |
| for the patient.  The licensee will submit a written followup report.        |
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