U.S. Nuclear Regulatory Commission
                             Operations Center
 
                             Event Reports For
                            06/03/96 - 06/04/96
 
                             ** EVENT NUMBERS **
 
30576  30577  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!! 
+----------------------------------+              +-----------------------+     
|HOSPITAL                          |              |EVENT NUMBER:  30576   |     
+----------------------------------+              +-----------------------+     
+------------------------------------------------+-----------------------------+
|LICENSEE: BRONX VA MEDICAL CENTER               |NOTIFICATION DATE: 06/03/96  |
|    CITY: NEW YORK               REGION: 1      |NOTIFICATION TIME: 09:53 [ET]|
|  COUNTY:                         STATE: NY     |EVENT DATE:        05/31/96  |
|LICENSE#: 31-00636-07         AGREEMENT: Y      |EVENT TIME:        16:00[EDT]|
|  DOCKET:                                       |LAST UPDATE DATE:  06/03/96  |
|                                                +-----------------------------+
|                                                |PERSON           ORGANIZATION|
|                                                |JENNY JOHANSEN       RDO     |
|                                                |                             |
+------------------------------------------------+                             |
|NRC NOTIFIED BY: TOM BAUER                      |                             |
|HQ OPS OFFICER:  DOUG WEAVER                    |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS: NOT APPLICABLE                 |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------+-----------------------------+

                                   EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| A PATIENT WAS SUPPOSED TO RECEIVE 30 mCi OF Tc-99m TAGGED WITH DTPA FOR A    |
| KIDNEY SCAN.  A SALINE SOLUTION WAS USED INSTEAD OF DTPA.  NO ADVERSE        |
| AFFECTS ON THE PATIENT ARE EXPECTED.  THE PATIENT AND HIS DOCTOR ARE AWARE   |
| OF THE MISADMINISTRATION AND ANOTHER SCAN WILL BE SCHEDULED.                 |
|                                                                              |
| A CONTACT PHONE NUMBER IS AVAILABLE IN THE HOO LOG.                          |
|                                                                              |
| * * * UPDATE AT 1053 BY BAUER TAKEN BY WEAVER * * *                          |
| BASED ON DISCUSSIONS WITH THE REGION, THE LICENSEE HAS DECIDED TO RETRACT    |
| THIS EVENT.  THE ACTUAL ACTIVITY OF Tc-99m INJECTED WAS 14.7 mCi.  THIS      |
| AMOUNT OF Tc-99m DID NOT RESULT IN A REPORTABLE DOSE TO THE PATIENT.  THE    |
| HOO INFORMED THE R1DO (JOHANSEN).                                            |
+------------------------------------------------------------------------------+

+----------------------------------+              +-----------------------+     
|POWER REACTOR                     |              |EVENT NUMBER:  30577   |     
+----------------------------------+              +-----------------------+     
+------------------------------------------------+-----------------------------+
|FACILITY: QUAD CITIES                REGION:  3 |NOTIFICATION DATE: 06/03/96  |
|UNIT:     [ ] [2] [ ]                 STATE: IL |NOTIFICATION TIME: 18:35 [ET]|
|RX TYPE: [1] GE-3,[2] GE-3                      |EVENT DATE:        06/03/96  |
+------------------------------------------------+EVENT TIME:        16:50[CDT]|
|NRC NOTIFIED BY: DAVE KIMLER                    |LAST UPDATE DATE:  06/03/96  |
|HQ OPS OFFICER:  RUDY KARSCH                    +-----------------------------+
+------------------------------------------------+       NOTIFICATIONS         |
|EMERGENCY CLASS: NOT APPLICABLE                 +-----------------------------+
|10 CFR SECTION:                                 |JIM MCCORMICKBARGER   RDO    |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+--------------+--+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|  INIT RX MODE   |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|     |                                             |                          |
|  2  |   N          N        0     REFUELING       |     0    REFUELING       |
|     |                                             |                          |
+-----+---------------------------------------------+--------------------------+

                                   EVENT TEXT
+------------------------------------------------------------------------------+
| THE UNIT 2 EMERGENCY DIESEL GENERATOR (EDG) HAS BEEN INOPERABLE SINCE MAY    |
| 1992 DUE TO A FUEL OIL TRANSFER PUMP WHICH MAY FAIL TO START.                |
|                                                                              |
| EACH UNIT HAS A DEDICATED EDG AND AN EDG WHICH CAN BE CONNECTED TO EITHER    |
| UNIT CALLED THE SWING DIESEL.  THIS PROBLEM AFFECTS ONLY THE UNIT 2          |
| DEDICATED EDG, NOT THE SWING DIESEL.  DUE TO A CABLE LENGTH AND              |
| UNDERVOLTAGE ISSUE, THE EDG FUEL OIL TRANSFER PUMP MOTOR MAY FAIL TO         |
| PERFORM ITS FUNCTION DURING A LOSS OF COOLANT ACCIDENT WITH DEGRADED         |
| VOLTAGE (OFFSITE POWER AVAILABLE AND EDG UNLOADED).  IF THE FUEL OIL         |
| TRANSFER PUMP FAILS TO START, THE EDG WILL STOP WHEN THE FUEL IN THE DAY     |
| TANK IS EXPENDED.  UNIT 2 WOULD HAVE BEEN PLACED INTO AN UNANALYZED          |
| CONDITION ANY TIME THE SWING DIESEL WAS OUT OF SERVICE.  THIS EVENT IS       |
| RELATED TO EVENT REPORTS 30532 AND 30548 WHICH ALSO ADDRESS MOTOR OPERATION  |
| UNDER DEGRADED VOLTAGE CONDITIONS.  THE LICENSEE WILL INFORM THE NRC         |
| RESIDENT INSPECTOR.                                                          |
+------------------------------------------------------------------------------+