Event Notification Report for April 11, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/10/2006 - 04/11/2006
Power Reactor
Event Number: 42491
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ANDREW HEWITT
HQ OPS Officer: JOE O'HARA
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ANDREW HEWITT
HQ OPS Officer: JOE O'HARA
Notification Date: 04/11/2006
Notification Time: 12:37 [ET]
Event Date: 04/11/2006
Event Time: 09:24 [EDT]
Last Update Date: 04/11/2006
Notification Time: 12:37 [ET]
Event Date: 04/11/2006
Event Time: 09:24 [EDT]
Last Update Date: 04/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAMES NOGGLE (R1)
JAMES NOGGLE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 65 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
"At 0924 Unit 2 experienced multiple Fire Protection System Deluge Valve actuations for the Main Filter Banks, System Station Service Transformers (SSSTs) 2A and 2B, the Main Transformer, Condensate Polishing building ventilation charcoal filter and Decontamination building ventilation charcoal filter. The Transformers were unaffected by the spray actuation and remained operable.
"No actual fire occurred or was observed for these components or areas. The Motor driven and Engine Driven Fire Pumps automatically started upon the actuations. These above noted areas and components received water spray down until manually isolated.
"It was verified that both of the Charcoal Main Filter Banks (TS 3.7.8.1) had become wetted down by the spray actuation. With the charcoal main filter banks wet, their filtering capability becomes impacted and is being evaluated. These filter components were declared inoperable.
"At 0924, Unit 2 entered the actions of Tech. Spec. 3.0.3. The requirements of Tech Spec 3.0.3 are:
"Within 1 hour action shall be initiated to place the unit in Hot Standby within the following 6 hours, Hot Shutdown within the following 6 hours, and Cold Shutdown within the subsequent 24 hours. At 1055 Unit 2 commenced shutdown at 20%/hr.
"The cause of the multiple actuations is not understood at this time. An Event Response Team has been formed to investigate the issue."
All other safety related systems are operable. The action required for the licensee to exit this Tech Spec required shutdown will be to restore the charcoal filter banks to operable status. The licensee estimates the investigation, troubleshooting, and repair efforts to last approximately 40 hours.
The licensee notified the NRC Resident Inspector.
"At 0924 Unit 2 experienced multiple Fire Protection System Deluge Valve actuations for the Main Filter Banks, System Station Service Transformers (SSSTs) 2A and 2B, the Main Transformer, Condensate Polishing building ventilation charcoal filter and Decontamination building ventilation charcoal filter. The Transformers were unaffected by the spray actuation and remained operable.
"No actual fire occurred or was observed for these components or areas. The Motor driven and Engine Driven Fire Pumps automatically started upon the actuations. These above noted areas and components received water spray down until manually isolated.
"It was verified that both of the Charcoal Main Filter Banks (TS 3.7.8.1) had become wetted down by the spray actuation. With the charcoal main filter banks wet, their filtering capability becomes impacted and is being evaluated. These filter components were declared inoperable.
"At 0924, Unit 2 entered the actions of Tech. Spec. 3.0.3. The requirements of Tech Spec 3.0.3 are:
"Within 1 hour action shall be initiated to place the unit in Hot Standby within the following 6 hours, Hot Shutdown within the following 6 hours, and Cold Shutdown within the subsequent 24 hours. At 1055 Unit 2 commenced shutdown at 20%/hr.
"The cause of the multiple actuations is not understood at this time. An Event Response Team has been formed to investigate the issue."
All other safety related systems are operable. The action required for the licensee to exit this Tech Spec required shutdown will be to restore the charcoal filter banks to operable status. The licensee estimates the investigation, troubleshooting, and repair efforts to last approximately 40 hours.
The licensee notified the NRC Resident Inspector.
Hospital
Event Number: 42511
Rep Org: UNITED HOSPITAL CENTER
Licensee: UNITED HOSPITAL CENTER
Region: 1
City: CLARKSBURG State: WV
County:
License #: 4701458-01
Agreement: N
Docket:
NRC Notified By: JAMES ISRAEL - RSO
HQ OPS Officer: JOHN KNOKE
Licensee: UNITED HOSPITAL CENTER
Region: 1
City: CLARKSBURG State: WV
County:
License #: 4701458-01
Agreement: N
Docket:
NRC Notified By: JAMES ISRAEL - RSO
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/19/2006
Notification Time: 14:13 [ET]
Event Date: 04/11/2006
Event Time: 11:40 [EDT]
Last Update Date: 04/19/2006
Notification Time: 14:13 [ET]
Event Date: 04/11/2006
Event Time: 11:40 [EDT]
Last Update Date: 04/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (NMSS)
DANIEL HOLODY (R1)
GREG MORELL (NMSS)
MEDICAL EVENT - ADMINISTRATION OF GREATER THAN 50 PERCENT OF PRESCRIBED DOSE TO PATIENTS
The RSO of the United Hospital Center called about a misadministration to 2 female patients being treated for cervical cancer. Each patient was to receive a total of 3000 centigrays, distributed via 6 treatments of 500 centigrays each. The treatment was a high dose rate Brachytherapy insertion of a 4.4 Curie Ir-192 sealed source into the cervical area. On their first treatment, patient #1 received 1040 centigrays at 11:40 EDT on 04/11/06, and patient #2 received 1058 centigrays at 11:45 EDT on 4/18/06. The attending physician is now going to alter the remaining treatments to 350 centigrays/treatment for each patient, thereby keeping the original total dose to the required 3000 centigrays/patient.
The reason given for the misadministration was human error. The operator did not check the magnification reading on the computer before administrating the dose to each patient. The referring physician will be discussing this error with each patient when they come in for their next treatment on 4/21/06.
The RSO of the United Hospital Center called about a misadministration to 2 female patients being treated for cervical cancer. Each patient was to receive a total of 3000 centigrays, distributed via 6 treatments of 500 centigrays each. The treatment was a high dose rate Brachytherapy insertion of a 4.4 Curie Ir-192 sealed source into the cervical area. On their first treatment, patient #1 received 1040 centigrays at 11:40 EDT on 04/11/06, and patient #2 received 1058 centigrays at 11:45 EDT on 4/18/06. The attending physician is now going to alter the remaining treatments to 350 centigrays/treatment for each patient, thereby keeping the original total dose to the required 3000 centigrays/patient.
The reason given for the misadministration was human error. The operator did not check the magnification reading on the computer before administrating the dose to each patient. The referring physician will be discussing this error with each patient when they come in for their next treatment on 4/21/06.