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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 37727 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 37865 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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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