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Event Notification Report for November 21, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/20/2002 - 11/21/2002

                              ** EVENT NUMBERS **

39385  39386  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   39385       |
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| REP ORG:  RESEARCH MEDICAL CENTER              |NOTIFICATION DATE: 11/19/2002|
|LICENSEE:  RESEARCH MEDICAL CENTER              |NOTIFICATION TIME: 17:02[EST]|
|    CITY:  KANSAS CITY              REGION:  3  |EVENT DATE:        10/11/2002|
|  COUNTY:                            STATE:  MO |EVENT TIME:             [CST]|
|LICENSE#:  24-18625-01           AGREEMENT:  N  |LAST UPDATE DATE:  11/20/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |C.W. (BILL) REAMER   NMSS    |
|                                                |BRENT CLAYTON        R3      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STEPHEN SLACK                |                             |
|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NOTIFICATION OF MEDICAL EVENT INVOLVING DIAGNOSTIC OVERDOSE OF IODINE-131    |
|                                                                              |
| Research Medical Center reported that they had a diagnostic                  |
| misadministration that occurred on 10/11/02.  The event was reported after   |
| it was discovered by an auditor.                                             |
|                                                                              |
| The patient was administered 3.6 millicuries of I-131 instead of the         |
| prescribed dose of 3.0 millicuries. The iodine was being administered for a  |
| whole body scan for thyroid carcinoma.                                       |
|                                                                              |
| The patient and referring physician will be notified by the licensee.        |
|                                                                              |
| * * * RETRACTION ON 11/20/02 AT 1427 EST FROM STEPHEN SLACK TO HOWIE CROUCH  |
| * * *                                                                        |
|                                                                              |
| Licensee retracted event based on conversation with Region 3 NMSS. Basis for |
| retraction is that patient does not have a thyroid.                          |
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|Power Reactor                                    |Event Number:   39386       |
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| FACILITY: BRUNSWICK                REGION:  2  |NOTIFICATION DATE: 11/20/2002|
|    UNIT:  [] [2] []                 STATE:  NC |NOTIFICATION TIME: 11:30[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        09/27/2002|
+------------------------------------------------+EVENT TIME:        10:42[EST]|
| NRC NOTIFIED BY:  STEVE TABOR                  |LAST UPDATE DATE:  11/20/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID AYRES          R2      |
|10 CFR SECTION:                                 |                             |
|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| INVALID SPECIFIED SYSTEM ACTUATION WHILE PERFORMING MAINTENANCE              |
|                                                                              |
| "EVENT DESCRIPTION                                                           |
|                                                                              |
| "This report is being made in accordance with 50.73 (a)(1), which states,   |
| in part, 'In the case of an invalid actuation reported under 50.73          |
| (a)(2)(iv), other than actuation of the reactor protection system (RPS) when |
| the reactor is critical, the licensee may, at its option, provide a          |
| telephone notification to the NRC Operations Center within 60 days after     |
| discovery of the event instead of submitting a written LER.' These invalid   |
| actuations are being reported under 50.73 (a)(2)(iv)(A). NUREG-1022, Rev.   |
| 2, states that the report should provide the following information:          |
|                                                                              |
| "The specific train(s) and system(s) that were actuated                      |
|                                                                              |
| "Whether each train actuation was complete or partial                        |
|                                                                              |
| "Whether or not the system started and functioned successfully.              |
|                                                                              |
| "On September 27, 2002, at 1042 hours, during the performance of Maintenance |
| Surveillance Test (OMST-RWCU41R), 'RWCU System Isolation Logic System        |
| Functional Test,' technician actions to perform positive identification of a |
| logic relay prior to performing visual verification of contacts on that      |
| relay as specified within the surveillance procedure instructions, resulted  |
| in invalid actuations. The actuations included the Primary Containment       |
| Isolation system (PCIS) Group 6 (i.e., Containment Atmosphere                |
| Control/Dilution, Containment Atmosphere Monitoring, and Post Accident       |
| Sampling Systems) and Division A (i.e., inboard) PCIS Group 2 valves (i.e.,  |
| the Drywell Equipment and Floor Drains). Both Standby Gas Treatment (SBGT)   |
| system trains A and B started and the Reactor Building ventilation system    |
| isolated. The actuations of PCIS Group 6 and Division A Group 2 valves and   |
| Reactor Building ventilation were complete and the affected equipment        |
| responded as designed to the invalid signal (i.e., the valves and dampers    |
| that were open, at the time of the event, closed). By 1115 hours, the PCIS   |
| Group 2 and 6 isolation logic circuits were reset and associated valves      |
| reopened as required by plant condition, the Reactor Building ventilation    |
| system was returned to service, and both SBGT trains A and B were placed In  |
| standby.                                                                     |
|                                                                              |
| "Discussion of the causes and corrective actions associated with this event  |
| are documented in the corrective action program in AR 72925."                |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
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