Home
> NRC Library
> Document Collections
> Reports Associated With Events
> Event Notification Reports > 2002
Event Notification Report for July 23, 2002
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/22/2002 - 07/23/2002 ** EVENT NUMBERS ** 39068 39081 39082 39083 . !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39068 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: KENTUCKY DEPT OF RADIATION CONTROL |NOTIFICATION DATE: 07/18/2002| |LICENSEE: MONROE COUNTY MEDICAL CENTER |NOTIFICATION TIME: 11:40[EDT]| | CITY: TOMPKINSVILLE REGION: 2 |EVENT DATE: 07/12/2002| | COUNTY: STATE: KY |EVENT TIME: 16:00[CDT]| |LICENSE#: 202-247-24 AGREEMENT: Y |LAST UPDATE DATE: 07/18/2002| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |CHARLIE PAYNE R2 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JOHN A. VOLPE | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION | | | | "The Technologist (S.H) received a request to perform a Bone Scan on an | | impatient. She selected an MDP Dose (25.1 mCi) and proceeded to the room | | listed on requisition. She approached the patient stated the name. The | | patient acknowledged the name. The technologist explained the procedure | | and injected the patient. When the patient presented to the Nuclear | | Medicine Department with hospital chart it was discovered that the | | misadministration had occurred. The technologist notified the authorized | | user, the referring physician [and] the Radiation Safety officer. The | | referring physician agreed to notify the patient. The Technologist was | | reinstructed to check the hospital chart for a written order and verify the | | patients identity by checking the hospital ORM board." | | | | Used Tc-99m MDP Bone. | | | | *****RETRACTED ON 7/18/02 AT 15:27 EDT FROM VOLPE TO LAURA***** | | | | The licensee determined the event was NOT reportable since the dose was | | below the threshold (greater than 5 REM whole body or greater than 50 REM | | for organs) for reportability. | | | | Notified R2DO (C. PAYNE) and NMSS (F. Brown). | +------------------------------------------------------------------------------+ . +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39081 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 07/22/2002| | UNIT: [] [2] [] STATE: MI |NOTIFICATION TIME: 02:33[EDT]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/22/2002| +------------------------------------------------+EVENT TIME: 00:45[EDT]| | NRC NOTIFIED BY: JOHNSON |LAST UPDATE DATE: 07/22/2002| | HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |MONTE PHILLIPS R3 | |10 CFR SECTION: | | |ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | |2 A/R Y 100 Power Operation |0 Hot Standby | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR AUTOMATICALLY TRIPPED FROM 100% POWER ON REACTOR TRIP/TURBINE TRIP | | | | The reactor trip/turbine trip from 100% power was caused by a loss of main | | turbine condenser vacuum that occurred while flushing the condenser | | waterboxes. The cause is unknown and being investigated at this time. All | | control rods fully inserted, no ECCS actuated and all emergency and | | non-emergency systems functioned as designed. The main steam stop valves | | were manually closed to arrest RCS cooldown. RCS temperature was | | stabilized using the atmospheric relief valves. | | | | The NRC Resident Inspector was notified, | +------------------------------------------------------------------------------+ . +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39082 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 07/22/2002| | UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 19:14[EDT]| | RXTYPE: [1] GE-4 |EVENT DATE: 07/22/2002| +------------------------------------------------+EVENT TIME: 17:10[EDT]| | NRC NOTIFIED BY: GENE DORMAN |LAST UPDATE DATE: 07/22/2002| | HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |RICHARD CONTE R1 | |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 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY OF A HIGH PRESSURE COOLANT INJECTION (HPCI) FLOW CONTROLLER | | INDICATION OF 500 GPM DURING RESTORATION FROM A CORE SPRAY SYSTEM | | SURVEILLANCE TEST AND WITH THE HPCI SYSTEM IN STANDBY | | | | The following text is a portion of a facsimile received from the licensee: | | | | "During restoration from surveillance testing on the 'B' core spray system, | | the flow controller for the HPCI system (23FI-108-1) was observed to be | | reading 500 gpm with the HPCI system in standby. The HPCI system was | | declared inoperable, and [Technical Specification] 3.5.C.1.b was entered | | requiring [either] restoration of 'B' core spray or HPCI to operable status | | within 24 hours or [commencement of a unit] shutdown. 'B' core spray was | | restored to operability at 1732, and the plant exited [Technical | | Specification] 3.5.C.1.b and entered [Technical Specification] 3.5.C.1.a | | placing the plant in a [7-day limiting condition for operation (LCO)]." | | | | "Since no actuations occurred and [since] no shutdown was initiated, this is | | only reportable under 10CFR50.72(b)(3) criteria, specifically 10 CFR | | 50.72(b)(3)(v)(D). This is based on the guidance in NUREG 1022, Rev. 2. | | Since HPCI is a single train system, even though [technical specifications] | | allow a 7-day LCO, declaring HPCI [inoperable] is reportable." | | | | "The only unusual/not understood thing associated with this is the flow | | indication of 500 gpm. There were no actuations required so all equipment | | functioned and continues to function as expected. There are no radiological | | releases associated with this event." | | | | The licensee plans to notify the NRC resident inspector. | +------------------------------------------------------------------------------+ . +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 39083 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 07/22/2002| | UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 21:26[EDT]| | RXTYPE: [1] GE-3 |EVENT DATE: 07/22/2002| +------------------------------------------------+EVENT TIME: 16:30[CDT]| | NRC NOTIFIED BY: DUANE BISTODEAU |LAST UPDATE DATE: 07/22/2002| | HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: NON EMERGENCY |CHRIS MILLER 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 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INOPERABILITY OF BOTH CONTROL ROOM VENTILATION TRAINS | | | | The following text is a portion of a facsimile received from the licensee: | | | | "Both control room ventilation (CRV) trains [were] declared inoperable. | | While [the] 'B' CRV was inoperable for testing, [the] 'A' CRV chiller | | compressor tripped causing [the] 'A' CRV to be inoperable. [A] 24-hour | | [limiting condition for operation (LCO)] was entered per [Technical | | Specification] 3.17.A.3.a. 'B' CRV was restored to operable and [the] | | 24-hour LCO [was exited] at 1701 [CDT]. [The] 'A' CRV is in a 30-day LCO | | per [Technical Specification] 3.17.A.2.a. [The] 'A' CRV chiller compressor | | trip cause [is] unknown." | | | | The licensee plans to notify the NRC resident inspector as well as | | applicable state and local officials. | +------------------------------------------------------------------------------+ .