Event Notification Report for April 12, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/11/2001 - 04/12/2001
** EVENT NUMBERS **
37672 37907 37908 37909 37910 37911 37912 37913
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Hospital |Event Number: 37672 |
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| REP ORG: FROEDTERT MEMORIAL LUTHERAN HOSP |NOTIFICATION DATE: 01/19/2001|
|LICENSEE: FROEDTERT MEMORIAL LUTHERAN HOSP |NOTIFICATION TIME: 16:59[EST]|
| CITY: MILWAUKEE REGION: 3 |EVENT DATE: 01/17/2001|
| COUNTY: STATE: WI |EVENT TIME: 18:30[CST]|
|LICENSE#: 48-04193 AGREEMENT: N |LAST UPDATE DATE: 04/11/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROGER LANKSBURY R3 |
| |ERIC LEEDS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARCUM MARTZ | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| POTENTIAL MEDICAL MISADMINISTRATION |
| |
| A patient being treated with a Leksell gamma system model 23004 type B |
| received a treatment to the wrong site. The intended dose or dose delivered |
| were not available. The dose was delivered to the wrong location because |
| the head frame had been installed in the wrong position. The correct site |
| was subsequently treated. The hospital is in the process of informing the |
| patient and the referring physician. The attending physician did not |
| believe the mistake would pose a problem to the patient. |
| |
| ***** UPDATE AT 1439 EDT ON 04/11/01 FROM MARCUM MARTZ TO LEIGH TROCINE |
| ***** |
| |
| After discussions with the NRC Region 3 staff (Bob Gattone), it was |
| determined that this event did not involve a medical misadministration. |
| Therefore, the licensee is retracting this event notification. |
| |
| The NRC operations officer notified the R3DO (Wright) and NMSS EO (Smith). |
| |
| Call the NRC operations officer for a licensee contact telephone number. |
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|Power Reactor |Event Number: 37907 |
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| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 05:55[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 04/10/2001|
+------------------------------------------------+EVENT TIME: 19:50[CDT]|
| NRC NOTIFIED BY: SCOT MAGLIO |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK SHAFFER R4 |
|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 N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| SECURITY REPORT |
| |
| Safeguards system degradation related to monitoring. Immediate compensatory |
| measures taken upon discovery. |
| |
| The licensee intends to notify the NRC Resident Inspector. |
| |
| Refer to the HOO Log for additional details. |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37908 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 11:17[EDT]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 10:35[EDT]|
| NRC NOTIFIED BY: BRAMLETT |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE ERNSTES R2 |
|10 CFR SECTION: |ED GOODWIN NRR |
|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 99 Power Operation |99 Power Operation |
|3 N N 0 Cold Shutdown |0 Cold Shutdown |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SECURITY REPORT |
| |
| Unescorted access granted inappropriately. Immediate compensatory measures |
| taken upon discovery. |
| |
| Refer to the HOO Log for additional details. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| See EN #37909. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37909 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [2] [] STATE: SC |NOTIFICATION TIME: 11:30[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/31/1999|
+------------------------------------------------+EVENT TIME: [EDT]|
| NRC NOTIFIED BY: JIMMY BURGESS |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE ERNSTES R2 |
|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
+------------------------------------------------------------------------------+
| SECURITY REPORT |
| |
| Unescorted access granted inappropriately. Immediate compensatory measures |
| taken upon discovery. |
| |
| Refer to the HOO Log for additional details. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| See EN #37908. |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37910 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [] [] STATE: KS |NOTIFICATION TIME: 11:37[EDT]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 04:50[CDT]|
| NRC NOTIFIED BY: SIMS |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK SHAFFER R4 |
|10 CFR SECTION: | |
|*COM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| LOSS OF EMERGENCY PLAN SIRENS |
| |
| The site reported the loss of six emergency plan sirens which constitutes a |
| major loss of emergency offsite communications for greater than one hour. |
| This was caused by a loss of power due to high winds and downed power lines. |
| Power was restored to the sirens at 0807 CDST. |
| |
| The NRC Resident Inspector was notified. The licensee will make a press |
| release to the news media. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37911 |
+------------------------------------------------------------------------------+
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| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 12:06[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 11:18[EDT]|
| NRC NOTIFIED BY: DON SHEEHAN |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES LINVILLE R1 |
|10 CFR SECTION: | |
|*PRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| NATIONAL WEATHER SERVICE TONE-ALERT RADIOS OUT OF SERVICE FOR PLANNED |
| MAINTENANCE |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "[The] Emergency Planning Department at Nine Mile Point [Unit 1 was] |
| notified by Jim Holman of [the] Oswego County Emergency Planning Department |
| that the tone-alert radios for the National Weather Service (NWS) were out |
| of service (OOS) as of 1118 on 04/11/01 and are expected to be returned to |
| service (RTS) at 1400 on 04/11/01. The system was taken OOS for planned |
| maintenance. [The] Sheriff's Department [is] prepared to perform route |
| alerts if necessary per procedure EPIP-EPP-30 (Prompt Notification System |
| Problem Response). [The] control room [was] notified [of the event] at 1125 |
| on 04/11/01." |
| |
| "(10 CFR 50.72(b) and 10 CFR 50.72(a)(2) apply.)" |
| |
| The licensee notified the NRC resident inspector and county sheriff. The |
| licensee also plans to notify applicable local and state agencies. |
| |
| (Refer to event #37912 for a similar event notification from Fitzpatrick.) |
| |
| * * * UPDATE ON 4/11/01 AT 1523 BY SHEEHAN TO GOULD * * * |
| |
| The radio was back in service at 1515. |
| |
| The NRC Resident Inspector will be notified. Reg 1 RDO(Linville) was |
| notified |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37912 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 12:24[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 11:18[EDT]|
| NRC NOTIFIED BY: NICHOLAS AVRAKOTOS |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES LINVILLE R1 |
|10 CFR SECTION: | |
|*PRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| NATIONAL WEATHER SERVICE TONE-ALERT RADIOS OUT OF SERVICE FOR PLANNED |
| MAINTENANCE |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "[The] Control Room [and] Emergency Planning Department [were] notified (via |
| [the] Nine Mile Point Unit 1 Control Room) by Jim Holman of [the] Oswego |
| [County] Emergency Management Office that the tone-alert radios for the |
| National Weather Service (NWS) were out of service (OOS) as of 1118 on |
| 04/11/01 and are expected to be returned to service (RTS) at 1400 on |
| 04/11/01. The system was taken OOS for planned maintenance. [The] Oswego |
| Sheriff's Department is prepared to perform route alerts if necessary." |
| |
| "Review - 10 CFR 50.72(b) [and] 10 CFR 50.72(a)(2)" |
| |
| The licensee notified the NRC resident inspector and plans to notify |
| applicable local and state agencies. |
| |
| (Refer to event #37911 for a similar event notification from Nine Mile |
| Point.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37913 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 04/11/2001|
| UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 19:01[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 04/11/2001|
+------------------------------------------------+EVENT TIME: 17:15[CDT]|
| NRC NOTIFIED BY: TIM WITSCHEN |LAST UPDATE DATE: 04/11/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GEOFFREY WRIGHT R3 |
|10 CFR SECTION: | |
|*INC 50.72(b)(3)(v)(C) POT UNCNTRL RAD REL | |
|*IND 50.72(b)(3)(v)(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
+------------------------------------------------------------------------------+
| FAILURE OF STANDBY GAS TREATMENT SYSTEM CHARCOAL FILTERS TO PASS A TECHNICAL |
| SPECIFICATION REQUIRED SURVEILLANCE |
| |
| The licensee reported that the 'A' train of standby gas treatment did not |
| pass a test involving an in-place charcoal absorber test with halogenated |
| hydrocarbon tracer (freon). This technical specification required |
| surveillance test is performed approximately every 18-months. |
| |
| The unit was placed in a 7-day limiting condition for operation for the 'A' |
| train of standby gas treatment prior to the test. The unit remains in that |
| LCO as a result of this test. The 'B' train is currently operable. |
| |
| The licensee's investigation is in progress. At this time, the licensee |
| believes that the problem is the result of bypass leakage. The licensee |
| plans to verify the root cause and retest the system tomorrow. |
| |
| This event was reported as an event or condition that at the time of |
| discovery could have prevented the fulfillment of the safety function of |
| structures or systems that are needed to control the release of radioactive |
| material and mitigate the consequences of an accident. |
| |
| The licensee notified the NRC resident inspector and plans to notify state |
| and local officials. |
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