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Event Notification Report for March 28, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2006 - 03/28/2006

** EVENT NUMBERS **


42318 42440 42441

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42318
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: R.P. TODD
HQ OPS Officer: JOE O'HARA
Notification Date: 02/07/2006
Notification Time: 15:49 [ET]
Event Date: 02/06/2006
Event Time: 20:50 [EST]
Last Update Date: 03/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RUDOLPH BERNHARD (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION - NON-CONFORMING FIRE BARRIERS

"Event: Field inspections have discovered several instances of non-conformance with acceptance criteria for fire barriers. The non-conformance has been conservatively assumed to reduce the fire rating of the affected penetrations below the required three hours.

"At 2050 hours on 2-6-06 the Operations Shift Manager conservatively declared the all Oconee 'NRC committed' fire barrier penetration seals 'inoperable' pending further inspection.

"Initial Safety Significance: Per NUREG 1022, Section 3.2.4, loss of fire barrier separation of Appendix R trains is an unanalyzed condition. Some Oconee 'NRC committed' fire barriers provide train separation between Appendix R safe shutdown trains. At this time, no specific Appendix R train separation penetrations have been discovered to be non-conforming. The reportability determination is based on the decision to conservatively declare the penetrations inoperable. Implementation of hourly fire watches in the affected areas reduces the potential for a significant fire to develop in those areas.

"Corrective Actions: Operations entered Selected Licensee Commitment 16.9.5 and established an hourly firewatch in the affected areas. Further inspections continue. Evaluation of inspection findings and repairs will follow."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE AT 1500 EST ON 3/27/06 FROM R.P. TODD TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"Event: At 1549 on 2-7-06 Oconee Nuclear Station reported that field inspections had discovered instances of non-conformance with a Duke Energy installation specification for fire barrier penetrations in walls and floors. The non-conformance was conservatively assumed to reduce the fire rating of affected penetrations below the required three hours. Reportability was based on the conservative declaration that the penetrations were inoperable.

"Following additional inspections and review of the as-found conditions, Oconee has determined that the as-found conditions still provided a three hour fire barrier so the fire barrier penetrations were actually operable. Oconee has concluded that the event is not reportable and hereby retracts the ENS notification.

"Corrective Action(s): Fire barrier penetrations will be repaired to restore compliance with Duke Energy specifications."

The licensee will inform the NRC Resident Inspector. Notified R2DO(Carolyn Evans).

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General Information or Other Event Number: 42440
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: MARY HITCHCOCK MEMORIAL HOSPITAL
Region: 1
City: LEBANON State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: TWILA KENNA
HQ OPS Officer: DORIS LEWIS
Notification Date: 03/22/2006
Notification Time: 16:19 [ET]
Event Date: 03/03/2006
Event Time: [EST]
Last Update Date: 03/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE WRONG RADIOPHARMACEUTICAL

The following information was received via facsimile:

"NH Radiological Health Section 'Agency' was notified on March 7, 2006, by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital of the wrong radiopharmaceutical injected into a patient. [The] delay was caused by conflicting information concerning whether the dose administered exceeded the reporting threshold. Four millicuries of Tl-201 Cl [Thallium Chloride] was administered [via] IV to a patient instead of the intended Tc-99 pertechnetate. Due to the error, the administration resulted in a whole body dose of 5.2 Rem. The patient and both the Authorized User and referring physician were notified of the error and the correct radiopharmaceutical was administered.

"The Licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. [The] cause of [the] incident was identified as inattention to labeling on part of [the] technician. Remedial instruction was given to the technician.

NH Report ID No: NH-06-001

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General Information or Other Event Number: 42441
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CARDINAL HEALTH
Region: 4
City: COLTON State: CA
County:
License #: CA5218-36
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: BILL GOTT
Notification Date: 03/22/2006
Notification Time: 16:10 [ET]
Event Date: 03/22/2006
Event Time: [PST]
Last Update Date: 03/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
TRISH HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIATION EXPOSURE

The State provided the following information via email:

"The Manager Health Physics, Cardinal Health called to report an incident which occurred today out of their Colton, CA pharmacy. A generator was being shipped via contract carrier from Colton to their Palm Springs pharmacy. The wrong shielding was used. Instead of a [Transportation Index] TI 1 which it was shipped as it was actually a TI 20. Upon arriving at the Palm Springs pharmacy it had a surface reading of 1,000 mr/hr. Estimate 4 hours with the driver. [The Manager Health Physics] was not aware if the driver had a personnel exposure device or what type of vehicle was utilized or the distance the generator was from the driver."

CA Report Number: 032206

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Friday, March 30, 2012