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Event Notification Report for June 15, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           06/14/2001 - 06/15/2001

                              ** EVENT NUMBERS **

38009  38071  38072  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38009       |
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| FACILITY: COMANCHE PEAK            REGION:  4  |NOTIFICATION DATE: 05/18/2001|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 15:08[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        05/18/2001|
+------------------------------------------------+EVENT TIME:        12:30[CDT]|
| NRC NOTIFIED BY:  CASPERSEN                    |LAST UPDATE DATE:  06/14/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BLAIR SPITZBERG      R4      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| AN UNANALYZED CONDITION WAS FOUND WHEN AN EXISTING PIPE TRENCH BLOCKOUT      |
| PATHWAY SEPARATING TWO ROOMS WAS FOUND TO BE BLOCKED.                        |
|                                                                              |
| After reviewing the Unit 2 flooding calculation (environmental calculations  |
| for Auxiliary Feedwater and performing a walkdown of the area, it was        |
| determined that the calculation model which assumed an existing pipe trench  |
| blockout pathway separating the 2 rooms to be an open pathway.  This pathway |
| was found to be blocked leading to an unanalyzed condition.                  |
|                                                                              |
| A PRA evaluation was performed for this condition.  The result of this       |
| evaluation shows that the potential degraded condition due to the sealed     |
| pathway and missing backwater check valves in the drain lines does not pose  |
| a significant increase in the core damage risk.  However, an additional      |
| review on May 15, 2001, it was deemed that the cumulative risk increase is   |
| potentially significant assuming the condition existed since initial         |
| evaluation.  Therefore, this issue is being conservatively reported pursuant |
| to 10 CFR 50.72 (ii)(B).                                                     |
|                                                                              |
| No Technical Specification OPERABILITY issues are identified as a result of  |
| this event.  Additionally this event has been evaluated per GL 91-18 and     |
| actions are being taken to be in compliance with the flooding calculations.  |
|                                                                              |
| The NRC Resident Inspector will be notified.                                 |
|                                                                              |
| * * * RETRACTED AT 1657 EDT ON 6/14/01 BY STEVEN SEWELL TO FANGIE JONES * *  |
| *                                                                            |
|                                                                              |
| "On 5/18/01 at 1508 hours, Comanche Peak Unit 2 reported an unanalyzed       |
| condition per 10CFR50.72(b)(3)(ii)(B) [EN# 38009). Specifically, the         |
| reported condition involved Unit 2 flooding/environmental calculations for   |
| the Auxiliary Feedwater (AFW) system that assumed an existing pipe trench    |
| blockout pathway separating 2 rooms to be an open pathway. During a walkdown |
| of the area, it was determined that the pathway was scaled and backwater     |
| check valves did not exist in all floor drain lines from the three AFW pump  |
| rooms. This as-found configuration led to an unanalyzed condition where all  |
| three AFW pumps could be potentially incapacitated by a piping break in any  |
| one of the AFW pump rooms. This condition was determined to have existed     |
| since initial licensing and an initial, conservative, PRA evaluation of this |
| condition determined that the cumulative risk increase was potentially       |
| significant.                                                                 |
|                                                                              |
| "Subsequently, a detailed deterministic analysis was performed to determine  |
| the consequence of flooding given the as found conditions. That evaluation   |
| shows that in no case is there a flooding scenario that results in the loss  |
| of all three AFW pumps. Comanche Peak Unit 2 has three pump trains (two 50%  |
| capacity motor driven pumps and one 100% capacity steam turbine driven       |
| pump). The worst case scenario is flooding in one of the motor driven AFW    |
| pump rooms which results in the loss of both motor driven pumps. In this     |
| case, the evaluation shows that the turbine driven pump is not disabled.     |
| Further, the flood waters do not adversely impact any other safety related   |
| equipment modeled in the PRA. The deterministic evaluation further concluded |
| that a break occurring in the turbine driven pump room does not adversely    |
| impact either of the motor driven pump rooms.                                |
|                                                                              |
| "The results of this evaluation show that the potentially degraded condition |
| due to the sealed pathway and missing backwater check valves does not pose a |
| significant core damage risk increase as a result of potential consequential |
| equipment failures. Therefore. Comanche Peak requests that the 5/18/01       |
| 10CFR50.72(b)(3)(ii)(B) reportable event for Unit 2 be retracted."           |
|                                                                              |
| The licensee notified the NRC Resident Inspector.  The R4DO (John Pellet)    |
| has been notified.                                                           |
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|Hospital                                         |Event Number:   38071       |
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| REP ORG:  VIRGINIA CARDIOVASCULAR SPECIALIST   |NOTIFICATION DATE: 06/14/2001|
|LICENSEE:  VIRGINIA CARDIOVASCULAR SPECIALIST   |NOTIFICATION TIME: 14:59[EDT]|
|    CITY:  RICHMOND                 REGION:  2  |EVENT DATE:        06/13/2001|
|  COUNTY:                            STATE:  VA |EVENT TIME:        14:00[EDT]|
|LICENSE#:  4525406-01            AGREEMENT:  N  |LAST UPDATE DATE:  06/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE BOLAND          R2      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  YVONNE WEAVER                |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION - WRONG PATIENT WAS GIVEN DIAGNOSTIC DOSAGE        |
|                                                                              |
| There were 2 patients in the waiting room with similar names.  When the name |
| was called out, the wrong patient answered and was administered the dose of  |
| 32.7 mCi of Technetium Sestamibi Cardiolyte.  Subsequently, it was           |
| determined that the wrong patient received the dose.  The patient and        |
| attending physician have been notified.                                      |
|                                                                              |
| A written report will follow.                                                |
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|General Information or Other                     |Event Number:   38072       |
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| REP ORG:  ARKANSAS DEPARTMENT OF HEALTH        |NOTIFICATION DATE: 06/14/2001|
|LICENSEE:  R. D. PLANT CONTRACTING              |NOTIFICATION TIME: 16:09[EDT]|
|    CITY:  MURFREESBORO             REGION:  4  |EVENT DATE:        06/14/2001|
|  COUNTY:                            STATE:  AR |EVENT TIME:        10:00[CDT]|
|LICENSE#:  ARK756BP0405          AGREEMENT:  Y  |LAST UPDATE DATE:  06/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN PELLET          R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID SNELLINGS              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - MISSING TROXLER SURFACE DENSITY GAUGE               |
|                                                                              |
| The licensee notified the State of Arkansas about 10:00 AM CDT today         |
| 6/14/01, that a Troxler Model 4640B surface density gauge, containing 8 mCi  |
| of Cs-137, was missing from the back of his truck.  The gauge was known to   |
| be chained and locked in the back of the truck last night (6/13/01) around   |
| 7:00 PM CDT.  The chain and lock are still in the truck, undamaged.  The     |
| Howard County Sheriff's Department and Hope, Arkansas Police have been       |
| notified of the missing gauge.  There will be a press release sent to state  |
| police, surrounding states and local authorities.  NRC Region 4 (Vivian      |
| Campbell) has been notified.                                                 |
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