Event Notification Report for December 12, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
12/11/2002 - 12/12/2002
** EVENT NUMBERS **
39426 39437 39438 39439
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|General Information or Other |Event Number: 39426 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 12/06/2002|
|LICENSEE: NORTHWEST COMMUNITY HOSPITAL |NOTIFICATION TIME: 13:13[EST]|
| CITY: ARLINGTON HEIGHTS REGION: 3 |EVENT DATE: 12/05/2002|
| COUNTY: STATE: IL |EVENT TIME: [CST]|
|LICENSE#: IL-01094-01 AGREEMENT: Y |LAST UPDATE DATE: 12/06/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KENNETH RIEMER R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - MEDICAL EVENT, DOSE GREATER THAN 20% LARGER THAN |
| PRESCRIBED |
| |
| "On December 5, 2002, the RSO at Northwest Community Hospital, Arlington |
| Heights IL, notified the department of a 'reportable' (misadministration) |
| event that occurred involving Intravascular Brachytherapy. The treatment |
| was for a 52 mm lesion using 85 mCi [millicuries] of P-32 (GDT source) in a |
| Guidant Corporation Galileo device. The prescribed dose was 20 gray. Using |
| a three step automated system, as the 1st step was completed, the |
| authorized user intervened and repositioned the markers for the system to |
| intentionally deliver an additional dose to this area of the lesion. After |
| completing the treatment. The calculated dose to the lesion was determined |
| to be 24.6 gray. This is greater than 20% over the prescribed dose for |
| this treatment and thus a reportable event. The RSO reported that the |
| clinical range for this treatment is 15-26 gray so no adverse health |
| effects are anticipated with this event. The RSO stated that a written |
| report would be filed with the department within the required 15 day |
| period. |
| |
| "Event Date 12/05/2002 License No: IL-01094-01 Licensee: Northwest |
| Community Hospital |
| City: Arlington Heights State: IL Event Class: MD2 - MEDICAL EVENT |
| Medical Event Information: Patient Number: 1 |
| % Overexposed: 23 |
| Procedure: BRACHY, REMOTE AFTERLOADER, |
| Dose in RAD: 2460 Organ: HEART Study: CARDIOVASCULAR SYSTEM |
| Radionuclide: P-32 |
| Administered By: PHYSICIAN Keywords: INTRAVASCULAR BRACHYTHERAPY" |
| |
| Item Number: IL020074 |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 39437 |
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| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 12/11/2002|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 02:41[EST]|
| RXTYPE: [1] GE-2 |EVENT DATE: 12/11/2002|
+------------------------------------------------+EVENT TIME: 02:30[EST]|
| NRC NOTIFIED BY: STEVE FULLER |LAST UPDATE DATE: 12/11/2002|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MICHELE EVANS R1 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| OFFSITE NOTIFICATION TO FAA |
| |
| Licensee made an offsite notification to FAA due to loss of power to plant |
| stack lighting. FAA assigned notification number MIV-212/061-RG. FAA was |
| again notified at 0230 EST that the stack lights were returned to service, |
| |
| Licensee notified NRC resident. |
| |
| RETRACTION BY FRANK CIGANIK TO ERIC THOMAS ON 12/11/02 AT 1736 |
| |
| "Reason for retraction: As per written guidance in NUREG-1022 (Event |
| Reporting Guidelines) Section 3.2.12, the NRC doesn't need to be informed |
| of problems with plant stack or water tower lighting" |
| |
| Licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 39438 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 12/11/2002|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 11:20[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/11/2002|
+------------------------------------------------+EVENT TIME: 11:20[EST]|
| NRC NOTIFIED BY: ROBERT BOESCH |LAST UPDATE DATE: 12/11/2002|
| HQ OPS OFFICER: JASON FLEMMING +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID LEW R1 |
|10 CFR SECTION: |PETER BIRMINGHAM IAT |
|DDDD 73.71(b)(1) SAFEGUARDS REPORTS | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| UNAUTHORIZED ENTRY INTO A VITAL PLANT AREA BY CONTRACT PERSONNEL |
| |
| An unauthorized entry into a vital area occurred by a contract employee. |
| Immediate compensatory measures were taken upon discovery. The licensee |
| notified the NRC Resident Inspector. Contact the HOO for additional details. |
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|Power Reactor |Event Number: 39439 |
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| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 12/12/2002|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 00:20[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 12/11/2002|
+------------------------------------------------+EVENT TIME: 18:13[EST]|
| NRC NOTIFIED BY: Jim Case |LAST UPDATE DATE: 12/12/2002|
| HQ OPS OFFICER: JASON FLEMMING +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |PATRICK HILAND R3 |
|10 CFR SECTION: | |
|AINC 50.72(b)(3)(v)(C) POT UNCNTRL RAD REL | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| RHR B MINIMUM CONTROL FLOW VALVE INOPERABLE |
| |
| "Scheduled maintenance activities were being performed on RHR B minimum flow |
| valve IE12-F064B which is a containment isolation valve. When the E12-F064 B |
| power supply was energized the Control Room indication for the valve |
| indicated intermediate. Local indication for the valve indicated the valve |
| was closed. When the valve control switch was taken to closed the valve was |
| observed to move 1/16 of an inch and the control room indication changed to |
| full close. The valve was closed and verified down powered on 12/09/02 to |
| comply with Tech Spec 3.6.1.3 Primary Containment Isolation Valves. |
| Maintenance test equipment was installed however no maintenance had been |
| performed." |
| |
| Licensee informed NRC resident inspector. |
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