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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!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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