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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  
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|General Information or Other                     |Event Number:   39040       |
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| 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        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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."                       |
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|Power Reactor                                    |Event Number:   39048       |
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| 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  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 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.                                                                    |
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|Power Reactor                                    |Event Number:   39049       |
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| 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  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 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 90F).  The previous day instrument check had the CAD         |
| nitrogen inventory at 2250 psig and 94F (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 84F).  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                                      |
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