U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/09/97 - 06/10/97 ** EVENT NUMBERS ** 32318 32409 32445 32451 32452 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32318 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MCGUIRE REGION: 2 |NOTIFICATION DATE: 05/12/97 | |UNIT: [1] [2] [ ] STATE: NC |NOTIFICATION TIME: 18:31 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/12/97 | +------------------------------------------------+EVENT TIME: 16:30[EDT]| |NRC NOTIFIED BY: JOSEPH HACKNEY |LAST UPDATE DATE: 06/09/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHRIS CHRISTENSEN RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 HOT STANDBY | 0 HOT STANDBY | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FOR FAILURE OF BOTH TRAINS OF AUXILIARY FEEDWATER DUE TO | | VORTEXING IN THE AUXILIARY FEEDWATER CONDENSATE STORAGE TANK IF THE TANK IS | | NOT ISOLATED BEFORE REACHING THE 17 INCH LEVEL. | | | | MCGUIRE CALCULATION MCC-1223.42-00-0037 INDICATES THE POTENTIAL FOR | | VORTEXING IN THE AUXILIARY FEEDWATER CONDENSATE STORAGE TANK IF THE TANK IS | | NOT ISOLATED PRIOR TO REACHING THE 17 INCH LEVEL. THE VORTEXING COULD | | INTRODUCE AIR INTO THE AUXILIARY FEEDWATER PUMP SUCTION RESULTING IN A | | FAILURE OF BOTH TRAINS OF AUXILIARY FEEDWATER TO PERFORM THEIR SAFETY | | RELATED FUNCTION. | | | | THE LICENSEE HAS IMPLEMENTED COMPENSATORY ACTIONS TO ENSURE SWAPOVER OF | | AUXILIARY FEEDWATER TO AN ASSURED RAW WATER SYSTEM PRIOR TO REACHING THE | | 17 INCH TANK LEVEL. THE LICENSEE PLANS TO KEEP THIS COMPENSATORY ACTION IN | | PLACE UNTIL AN ENGINEERING EVALUATION DETERMINES THAT VORTEXING DOES NOT | | COMPROMISE AUXILIARY FEEDWATER OPERABILITY OR UNTIL IMPLEMENTATION OF A | | SYSTEM MODIFICATION. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE ON 06/09/97 AT 1634 BY WASHAM TO GOULD * * * | | | | THE LICENSEE REPORTED THE POTENTIAL VORTEXING INVOLVING THE AUXILIARY | | FEEDWATER CONDENSATE STORAGE TANK HAS BEEN RESOLVED BY THEIR CALCULATIONS. | | THE RESULTS OF THIS ANALYSIS INDICATE THAT A VORTEX IN THE AUXILIARY | | FEEDWATER CONDENSATE STORAGE TANK WILL NOT IMPACT OPERABILITY OF THE | | AUXILIARY FEEDWATER PUMPS. COMPENSATORY ACTIONS ARE NO LONGER NEEDED TO | | MITIGATE THIS ISSUE. ADDITIONAL CALCULATIONS ARE BEING PERFORMED TO | | EVALUATE OTHER MECHANISMS THAT MAY AFFECT AUXILIARY FEEDWATER OPERABILITY. | | THE COMPENSATORY ACTIONS FOR SWAPOVER WILL REMAIN IN PLACE UNTIL OTHER | | MECHANISMS THAT AFFECT PAST OPERABILITY ARE EVALUATED BY ENGINEERING | | ANALYSIS. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | THE OPERATIONS OFFICER NOTIFIED R2DO PAUL FREDRICKSON. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32409 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 05/29/97 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 16:39 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/29/97 | +------------------------------------------------+EVENT TIME: 04:25[EDT]| |NRC NOTIFIED BY: EPPERSON |LAST UPDATE DATE: 06/09/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES HOSEY RDO | |NLTR LICENSEE 24 HR REPORT | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNITS 1 AND 2 ENTERED LCO 3.7.11.1.b WHEN THE HIGH PRESSURE FIRE PROTECTION | | SUPPRESSION WATER SYSTEM WAS ISOLATED MAKING FLOW PATH TO SPRINKLER SYSTEMS | | AND HOSE STANDPIPES INOPERABLE. | | | | THE LICENSEE ISOLATED THE HIGH PRESSURE FIRE PROTECTION SUPPRESSION WATER | | SYSTEM FOR A PLANNED OUTAGE TO REPLACE SECTIONALIZATION VALVES AND SELECTED | | PIPING. WHEN THE SYSTEM WAS ISOLATING, THE FLOW PATH TO SPRINKLER SYSTEMS | | AND HOSE STANDPIPES IDENTIFIED BY TS 3.7.11.2 AND 3.7.11.4 WERE MADE | | INOPERABLE. THE LCO ACTION STATEMENT REQUIRES THAT A BACKUP FIRE | | SUPPRESSION SYSTEM BE ESTABLISHED WITHIN 24 HOURS. | | | | A BACKUP FIRE SUPPRESSION WATER SYSTEM WAS ALREADY IN PLACE PRIOR TO THE | | PLANNED ISOLATION OF THE FLOWPATH. THIS BACKUP SYSTEM ENSURED COMPLIANCE | | WITH TS 3.7.11.1, ACTION b.1. THE HIGH PRESSURE FIRE PROTECTION SYSTEM | | OUTAGE IS PLANNED FOR APPROXIMATELY FOUR DAYS. AFTER COMPLETION OF WORK | | AND RETURN OF THE SYSTEM TO AN OPERABLE STATUS, THE BACKUP SYSTEM WILL BE | | REMOVED. THIS PLANNED OUTAGE IS PART OF THE HIGH PRESSURE FIRE PROTECTION | | SYSTEM UPGRADE WHICH IS INCLUDED IN THE OVERALL IMPROVEMENT PLAN FOR FIRE | | PROTECTION AT SEQUOYAH. | | | | THE RESIDENT INSPECTOR WAS INFORMED. | | | | * * * UPDATE ON 06/09/97 AT 1444 BY HARRIS TO GOULD * * * | | | | ON 05/29/97, THE LICENSEE ENTERED THE ABOVE LCO ACTION STATEMENT WHEN THEY | | REPLACED THE HIGH PRESSURE FIRE PROTECTION (HPFP) SUPPRESSION | | SECTIONALIZING VALVES AND PIPING IN THE REACTOR BUILDING HIGH PRESSURE FIRE | | SUPPRESSION SYSTEMS. THE HPFP SYSTEM WAS RETURNED TO SERVICE ON 06/04/97 | | AND THE LCO WAS EXITED. | | | | AT 0050 ON 6/9/97, THE PLANT REENTERED LCO 3.7.11.1.b ACTION STATEMENT, | | WHEN TWO SECTIONALIZING VALVES WERE CLOSED TO CONTINUE THE PLANNED WORK OF | | REPLACING PIPING. COMPENSATORY MEASURES WERE ESTABLISHED PRIOR TO CLOSING | | THE SECTIONALIZING VALVES. AS WORK IS COMPLETED, THE SECTIONALIZING VALVES | | WILL BE RECONFIGURED TO RETURN TO SERVICE THAT PORTION OF THE SYSTEM AND | | REMOVE ANOTHER, SUCH THAT ONLY ONE SECTION IS REMOVED AT A TIME WHILE ALL | | OTHER PORTIONS OF THE SYSTEM REMAIN OPERABLE. WORK IS EXPECTED TO BE | | COMPLETE IN MID AUGUST, 1997. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | THE OPERATIONS OFFICER NOTIFIED R2DO PAUL FREDRICKSON. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32445 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ALEXIAN BROTHERS HOSPITAL |NOTIFICATION DATE: 06/06/97 | | CITY: ST. LOUIS REGION: 3 |NOTIFICATION TIME: 20:55 [ET]| | COUNTY: STATE: MO |EVENT DATE: 06/06/97 | |LICENSE#: AGREEMENT: N |EVENT TIME: 18:00[CDT]| | DOCKET: 03002303 |LAST UPDATE DATE: 06/09/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRENT CLAYTON RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: H. ROBICHAUX | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION AT ALEXIAN BROTHERS HOSPITAL LOCATED IN ST LOUIS. | | | | A TECHNICIAN WAS ADMINISTERING TWO UNIT DOSES OF Tc-99m FOR BONE SCANS, | | AND PREPARED A KIT WITH Tc-99m TO PERFORM A RENAL FUNCTION SCAN. AFTER | | ADMINISTERING THE BONE SCAN DOSES, THE TECHNICIAN NOTICED THAT ONE OF | | THE PATIENTS WAS PASSING THE Tc-99m THROUGH THE KIDNEYS AND INTO THE | | BLADDER. AFTER ADMINISTERING THE OTHER DOSE, THE TECHNICIAN NOTICED THAT | | THE THIRD PATIENT WAS SHOWING A BONE UPTAKE. THE PHYSICIANS FOR BOTH | | PATIENTS WERE CONTACTED, AND NO HEALTH EFFECTS WERE EXPECTED TO OCCUR AS | | A RESULT OF THIS MISADMINISTRATION. | | | | * * * UPDATE AT 1116 ON 06/09/97 BY H. ROBICHAUX TAKEN BY GOULD * * * | | | | AFTER REVIEWING 10CFR PART 20, THE LICENSEE DETERMINED THAT THE ABOVE | | OCCURRENCES DID NOT EXCEED PART 20 LIMITS. BOTH PATIENTS WERE GIVEN THE | | CORRECT DOSE AND ISOTOPE BUT IN THE WRONG CHEMICAL FORM. THE BONE SCAN | | PATIENT WAS TO BE GIVEN 26mCi OF Tc-99m (MDP) BUT WAS GIVEN 26mCi OF Tc-99m | | (O4) AND THE HEPATOBILIARY SCAN PATIENT WAS TO HAVE RECEIVED 8mCi OF Tc-99m | | (HEPATOLITE) BUT INSTEAD RECEIVED 8 mCi OF Tc-99m (MDP). THUS, THE | | LICENSEE DESIRES TO RETRACT THIS EVENT. | | | | THE OPERATIONS OFFICER NOTIFIED R3DO JIM CREED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32451 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WASHINGTON HOSPITAL CENTER |NOTIFICATION DATE: 06/09/97 | | CITY: WASHINGTON REGION: 1 |NOTIFICATION TIME: 12:14 [ET]| | COUNTY: STATE: DC |EVENT DATE: 06/05/97 | |LICENSE#: 08-03604-03 AGREEMENT: N |EVENT TIME: 10:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/09/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RICHARD KEIMIG RDO | | |FRED COMBS, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: BASS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |AAIR 50.72(b)(2)(iv)(A) AIRBORNE RAD RELEASE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE WASHINGTON HOSPITAL CENTER RELEASED XENON-133 TO THE ATMOSPHERE. | | | | WHILE HOSPITAL PERSONNEL WERE PERFORMING AN EXPERIMENT, 200 MILLICURIES OF | | XENON-133 WERE RELEASED TO THE ATMOSPHERE. AT THE TIME OF THE RELEASE | | THERE WERE THREE PERSONS IN THE ROOM. THE ESTIMATED EXPOSURE TO THE THREE | | INDIVIDUALS WAS 60 MR PER PERSON AS READ FROM THEIR FILM BADGES. THE | | INDIVIDUALS EVACUATED THE ROOM WITHIN 5 MINUTES OF THE RELEASE. THE ROOM | | WAS ISOLATED FOR TWO DAYS WITH THE EXHAUST FAN RUNNING AT THE RATE OF | | 3.4E+7 CCM/MIN. THE AIR EVACUATION TIME FOR THE ROOM IS 18 MINUTES. THE | | ROOM IS CURRENTLY CLEAR. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32452 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SACRED HEART HOSPITAL |NOTIFICATION DATE: 06/09/97 | | CITY: EAU CLAIRE REGION: 3 |NOTIFICATION TIME: 14:23 [ET]| | COUNTY: STATE: WI |EVENT DATE: 06/06/97 | |LICENSE#: 48-03116-01 AGREEMENT: N |EVENT TIME: 18:15[CDT]| | DOCKET: |LAST UPDATE DATE: 06/09/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES CREED RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: BOGE | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | Tc-99m (MDP) FOR A DIAGNOSTIC BONE SCAN ADMINISTERED TO THE WRONG PATIENT | | AT THE SACRED HEART HOSPITAL LOCATED IN EAU CLAIRE, WISCONSIN. | | | | A SACRED HEART HOSPITAL TECHNOLOGIST ADMINISTERED A DOSE OF Tc-99m (MDP) | | FOR A DIAGNOSTIC BONE SCAN TO THE WRONG PATIENT. BOTH THE PATIENT AND THE | | PATIENT'S DOCTOR WERE INFORMED OF THE ERROR. HOSPITAL DOCTORS DETERMINED | | THAT THERE SHOULD BE NO ADVERSE AFFECTS TO THE PATIENT. | | | | * * * UPDATE AT 1559 ON 06/09/97 BY BOGE TO GOULD * * * | | | | AFTER FURTHER REVIEW, THE LICENSEE IS RETRACTING THIS EVENT SINCE IT WAS A | | DIAGNOSTIC TEST WHOSE DOSE LIMIT WAS FAR BELOW THE LIMIT REQUIRED TO BE | | REPORTED AS A MEDICAL MISADMINISTRATION. | | | | THE OPERATIONS OFFICER NOTIFIED R3DO JIM CREED. | +------------------------------------------------------------------------------+