U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/29/94 - 12/30/94 ** EVENT NUMBERS ** 28194 28195 28196 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28194 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 12/29/94 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 02:33 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/28/94 | +------------------------------------------------+EVENT TIME: 20:53[CST]| |NRC NOTIFIED BY: URQUHART |LAST UPDATE DATE: 12/29/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |STEVEN VIAS RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE REPORTED DAMAGE TO THE STAINLESS STEEL SPENT FUEL POOL FLOOR. | | | | THIS INCIDENT OCCURRED WHILE THEY WERE CONDUCTING A SPENT FUEL POOL CLEANUP | | CAMPAIGN AND WHILE REMOVING A 350LB 15' BY 3" DIA. USED SHROUD HEAD BOLT, | | IT FELL TO THE BOTTOM OF THE POOL. THIS BOLT PENETRATED THE SS FUEL POOL | | FLOOR AND LEFT A 3" HOLE ALLOWING APPROXIMATELY 2000 GAL OF WATER TO DRAIN | | TO THE SPENT FUEL POOL CONCRETE LINER. THIS LOWERED THE WATER LEVEL OF THE | | SPENT FUEL POOL BY 2" FROM ITS NORMAL LEVEL. THE LINER CONTAINED THE WATER | | AND DRAINED IT OFF TO THE RAD WASTE AS DESIGNED. WHEN THE LEAK WAS NOTICED, | | THEY CLOSED THE NORMALLY OPEN LINER DRAIN VALVE AS PER PROCEDURE AND THAT | | TERMINATED THE LEAK FROM THE SPENT FUEL POOL. THEY OPENED THEIR MAKEUP | | WATER VALVE TO THE FUEL POOL UNTIL LEVEL WAS RESTORED TO THE POOL AT 21:10. | | THE POOL LEVEL HAS REMAINED NORMAL SINCE THEN AND THEY HAVE STATIONED A | | CONSTANT POOL WATCH ON THE REFUEL FLOOR. THEY HAVE ACTIVATED AN EVENT | | REVIEW TEAM AND REPAIR TEAM. THERE WERE NO RELEASES, RAD LEVEL INCREASES OR | | CONTAMINATION. THEY DO CURRENTLY HAVE FUEL IN THE POOL. THE RI WAS | | INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28195 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MT. VERNON HOSPITAL |NOTIFICATION DATE: 12/29/94 | | CITY: ALEXANDRIA REGION: 2 |NOTIFICATION TIME: 11:52 [ET]| | COUNTY: STATE: VA |EVENT DATE: 12/29/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 09:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/29/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |STEVEN VIAS RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: MIKE ROTCHFORD | | |HQ OPS OFFICER: WILLIAM HUFFMAN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT INJECTED WITH WRONG IMAGING RADIOPHARMACEUTICAL. | | | | A PATIENT WAS PRESCRIBED 29.9 MILLICURIES OF TECHNETIUM-99m CARDIOLITE FOR | | A CARDIAC IMAGING STUDY. INSTEAD, THE PATIENT WAS INJECTED WITH 28.9 | | MILLICURIES OF TECHNETIUM-99m PERTECHNITATE USED FOR GASTRIC IMAGING. | | | | THE ERROR WAS DISCOVERED WHEN THE PATIENT WAS PLACED UNDER THE IMAGING | | CAMERA. NO ADVERSE HEALTH AFFECTS ARE ANTICIPATED. THE PATIENT AND | | PHYSICIAN HAVE BEEN INFORMED. | | | | THE ERROR WAS DUE TO A COMBINATION OF EVENTS. THE WRONG RADIOPHARMICEUTICAL | | (IN TYPE AND QUANTITY) WAS SHIPPED FROM SYNCOR INTERNATIONAL CORPORATION. | | THE RADIOPHARMACEUTICAL, HOWEVER, WAS PROPERLY LABELED. RECEIPT INSPECTION | | DID NOT CATCH THE ERROR AND THE ADMINISTERING TECHNICIAN DID NOT VERIFY THE | | PRESCRIPTION WITH THE LABEL. | | | | A FOLLOWUP WRITTEN REPORT BY THE LICENSEE WILL BE PROVIDED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28196 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 12/30/94 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 04:17 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 12/30/94 | +------------------------------------------------+EVENT TIME: 03:45[EST]| |NRC NOTIFIED BY: HILL |LAST UPDATE DATE: 12/30/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |JOHN MADERA RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |ELINOR ADENSAM EO | | |CARR FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 80 POWER OPERATION | 80 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DECLARED AN UNUSUAL EVENT DUE TO A HYDROGEN LEAK FROM THEIR | | HYDROGEN STORAGE TANKS. | | | | DURING OPERATOR ROUNDS, THEY DETERMINED THAT THERE WAS A HYDROGEN LEAK | | POSSIBLY FROM A SAFETY VALVE ON A HEADER WHICH IS CONNECTED TO THE TANKS. | | THE TANKS ARE LOCATED OUTSIDE AT THE NORTH END OF THE TURBINE BUILDING AND | | SUPPLY HYDROGEN TO THE MAIN GENERATOR. THESE TANKS WERE BEING USED AS THE | | RESERVE BANK AND NOT SUPPLYING HYDROGEN TO THE GENERATOR AT THIS TIME. THEY | | BLED DOWN AND ISOLATED THE BANK FROM THE HEADER TERMINATING THE LEAK FROM | | THE SAFETY VALVE. THEY CLEARED THE AREA OF ALL PERSONNEL. THE RI, STATE AND | | LOCAL AGENCIES WERE NOTIFIED. | | | | ***UPDATE AT 04:42 BY HILL TO GOULD*** THE NOUE WAS TERMINATED AT 04:30 DUE | | TO THE HYDROGEN LEAK BEING ISOLATED WHEN THEY ISOLATED THE HEADER FROM THE | | REST OF THE SYSTEM. THEY WILL EVALUATE AND CORRECT THE PROBLEM AFTER | | HYDROGEN HAS DISSIPATED FROM THE AREA. THE RI, STATE AND LOCAL AGENCIES | | HAVE BEEN NOTIFIED. | +------------------------------------------------------------------------------+