Event Notification Report for July 10, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/09/2002 - 07/10/2002
** EVENT NUMBERS **
39040 39048 39049
.
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39040 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/03/2002|
|LICENSEE: SWEDISH MEDICAL CENTER |NOTIFICATION TIME: 12:09[EDT]|
| CITY: DENVER REGION: 4 |EVENT DATE: 06/24/2002|
| COUNTY: STATE: CO |EVENT TIME: [MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/03/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DALE POWERS R4 |
| | NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: STATE OF COLORADO | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION |
| |
| The following is taken, in-part, from a facsimile report: |
| |
| "A patient received 5 fractions of brachytberapy using an lr-192 HDR unit |
| and a tandem/ovoids applicator. During the treatment planning process, an |
| incorrect magnification factor for the orthogonal films on which the |
| Dosimetry was based had been used. This resulted in an underdose of |
| approximately 50% or more depending on the part of the treatment volume used |
| for comparison. |
| |
| "The initial and corrected dosimetry has been reviewed by 3 additional |
| physicists. The corrected Dosimetry has been verified using an independent |
| film digitization system and TPS. A composite Dosimetry summary of the |
| treatment as delivered has been prepared and verified. Based on that |
| information the prescribing physician will administer an additional |
| brachytherapy application to compensate for the lower than prescribed dose |
| from the initial 5 fractions. |
| |
| [The original prescribing physician] "contacted the patient tonight, 2 July |
| 2002. He reported the underdose, recommended an additional brachytherapy |
| procedure and described the misadministration report." |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39048 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 07/09/2002|
| UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 15:53[EDT]|
| RXTYPE: [1] CE |EVENT DATE: 07/09/2002|
+------------------------------------------------+EVENT TIME: 11:55[CDT]|
| NRC NOTIFIED BY: KEVIN R. BOSTON |LAST UPDATE DATE: 07/09/2002|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GAIL GOOD R4 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| TECH SPEC REQUIRED SHUTDOWN DUE TO THE LOSS OF BOTH CONTROL ROOM AIR
|
| CONDITIONING UNITS |
| |
| "Ft Calhoun Station entered Technical Specification 2.0.1 requiring plant |
| shutdown at 1155 due to having both Control Room air conditioning units |
| inoperable. The Tech Spec was exited at 1220 when one of the two installed |
| units was restarted and confirmed to be providing adequate cooling. Both |
| air conditioner units were inoperable for 25 minutes. No plant shutdown |
| preparations were made during this time. VA-46A remains inoperable with |
| Tech Spec 2.12.2(1) 30 day limiting condition of operation in effect. |
| |
| "At 1150 the Control Room temperature was observed to be rising but below |
| the 80 degree F log setpoint with the VA-46B unit running. |
| |
| "At 1155 preparations to start the other unit, VA-46A were made. These |
| startup preps require the momentary opening of the VA-46A disconnect switch, |
| rendering it inoperable during this short period. After starting VA-46A |
| maintenance technicians informed the Control Room staff that the VA-46A |
| compressors had tripped due to low oil level rendering the unit inoperable. |
| Maintenance technicians informed the Control Room that the VA-46B unit |
| compressors were found tripped at 1155 rendering it inoperable. |
| |
| "The VA-46B unit (the unit originally in operation at the start of this |
| event) was shutdown, reset, and restarted. All compressors loaded. Control |
| Room temperature were observed to be lowering. VA-46B unit was declared |
| operable at 1220. Tech Spec 2.0.1 was exited at 1220. |
| |
| "Highest temperature observed in the Control Room was 80 degrees" |
| |
| The licensee is investigating what caused the low oil level in the VA-46A |
| compressors. The NRC Resident Inspector was notified of this event by the |
| licensee. |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39049 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 07/10/2002|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 03:26[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 07/09/2002|
+------------------------------------------------+EVENT TIME: 23:04[CDT]|
| NRC NOTIFIED BY: KOTTENSTETTE |LAST UPDATE DATE: 07/10/2002|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GARY SHEAR R3 |
|10 CFR SECTION: | |
|AIND 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 94 Power Operation |94 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CONTAINMENT ATMOSPHERE DILUTION NITROGEN INVENTORY NOT MEETING TS
|
| REQUIREMENTS |
| |
| During routine daily instrument checks on July 9, 2002, the control room |
| operator found the Containment Atmosphere Dilution (CAD) Nitrogen inventory |
| just above the Technical Specification required inventory line of 67,000 scf |
| (2150 psig and 90�F). The previous day instrument check had the CAD |
| nitrogen inventory at 2250 psig and 94�F (approximately 69,000 scf). |
| |
| An operator was dispatched to the CAD compressor building to raise nitrogen |
| pressure by operating the CAD compressor. As the in-plant operator was |
| starting the CAD compressor, the control room operator again checked the |
| pressure and temperature of the CAD storage bottles and found that it fell |
| just below the require 67,000 scf line (2110 psig and 84�F). The startup of |
| the CAD compressor requires the draining of the suction receiver and opening |
| of the suction and discharge valves. This process consumed enough nitrogen |
| inventory to go below the Technical Specification value of 67,000 scf. |
| |
| At 2304, the CAD system was declared inoperable per Technical Specification |
| 3.6.3.1 A and a seven day LCO entered. The CAD compressor was operated to |
| restore CAD nitrogen volume and the CAD LCO was exited at 2330 when CAD |
| inventory was greater than the required Technical Specification of 67,000 |
| scf. |
| |
| During subsequent investigation, it had been determined that surveillance NS |
| 730301, Functional Check and Calibration of Containment Atmosphere Dilution |
| System had been performed during the dayshift on July 9, 2002. During this |
| surveillance, it performs a functional check of the CAD system by performing |
| a flow of nitrogen from the CAD bottles through a test rig thus using a |
| portion of the CAD nitrogen inventory. At the completion of the |
| surveillance, the check of the CAD nitrogen inventory was just above the |
| Technical Specification line. The surveillance was completed at 1404 and at |
| that time no action was undertaken to restore margin to the CAD nitrogen |
| inventory Technical Specification requirement. |
| |
| The NRC resident Inspector was notified |
+------------------------------------------------------------------------------+
.
Page Last Reviewed/Updated Thursday, March 25, 2021