Event Notification Report for May 2, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/01/2001 - 05/02/2001

                              ** EVENT NUMBERS **

37902  37956  37957  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37902       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CRYSTAL RIVER            REGION:  2  |NOTIFICATION DATE: 04/09/2001|
|    UNIT:  [3] [] []                 STATE:  FL |NOTIFICATION TIME: 11:08[EDT]|
|   RXTYPE: [3] B&W-L-LP                         |EVENT DATE:        04/09/2001|
+------------------------------------------------+EVENT TIME:        09:54[EDT]|
| NRC NOTIFIED BY:  RICHARD SWEENEY              |LAST UPDATE DATE:  05/01/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CAUDLE JULIAN        R2      |
|10 CFR SECTION:                                 |                             |
|*PRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO THE NATIONAL MARINE AND FISHERIES SERVICE AS A       |
| RESULT OF THE ENDANGERED SEA TURTLES NON-LETHAL TAKE LIMIT BEING EXCEEDED    |
|                                                                              |
| "On April 09, 2001 at 0940 the 40th non-lethal sea turtle take in the        |
| biennial period occurred.                                                    |
|                                                                              |
| "In accordance with Crystal River Unit #3 Operating License, Appendix B,     |
| Environmental Protection Plan (Non-Radiological),  'Endangered or threatened |
| sea turtles shall be protected in accordance with the Incidental Take        |
| Statement issued by the National Marine and Fisheries Service (NMFS).'  The  |
| NMFS has established numerical limits on live takes, lethal takes causally   |
| related to plant operation, and lethal takes not related to plant            |
| operations.                                                                  |
|                                                                              |
| "The NMFS must be notified within five days whenever:                        |
|                                                                              |
| a.  The 40th non-lethal take occurs in the biennial period, or               |
| b.  The third causally related mortality occurs in the biennial period, or   |
| c.   The sixth non-causally related mortality occurs in the biennial         |
| period.                                                                      |
|                                                                              |
| "The current biennial period for monitoring sea turtle takes began January   |
| 1, 2001.                                                                     |
|                                                                              |
| "Thus, in accordance with Crystal Unit #3 Administrative Instruction 571,    |
| Sea Turtle Rescue and Handling Guidance, the NMFS must be notified within    |
| five days.                                                                   |
|                                                                              |
| "In accordance with Crystal River Unit #3 Compliance Procedure 151, External |
| Reporting Requirements, this 40th non-lethal sea turtle take is Reportable   |
| as a 4-Hour Report under 10 CFR 50.72(b)(2)(xi) as this event is related to  |
| the protection of the environment for which a notification to other          |
| government agencies has been or will be made."                               |
|                                                                              |
| The licensee will inform the NRC resident inspector.                         |
|                                                                              |
| * * * UPDATE 0944EDT ON 4/10/01 FROM R. SWEENEY TO S. SANDIN * * *           |
|                                                                              |
| "On April 10, 2001 at 0859 the 41st non-lethal sea turtle take in the        |
| biennial period occurred."                                                   |
|                                                                              |
| The licensee informed the NRC resident inspector.  Notified R2DO(Julian).    |
|                                                                              |
| ***** UPDATE RECEIVED AT 0911 ON 04/17/01 FROM CHRISTOPHER PELLERIN TO LEIGH |
| TROCINE *****                                                                |
|                                                                              |
| The 42nd, non-lethal, sea turtle take in the biennial period occurred at     |
| 0810 on April 17, 2001.                                                      |
|                                                                              |
| The licensee notified the NRC resident inspector.  The NRC operations        |
| officer notified the R2DO (Ernstes).                                         |
|                                                                              |
| * * * UPDATE 1125 EDT ON 5/1/01 FROM DAVID SCHULKER TO FANGIE JONES * * *    |
|                                                                              |
| "On May 1, 2001 at 0805 a turtle was identified as the 43rd rescued, live    |
| sea turtle in this biennial period.  This sea turtle will be kept for a      |
| short observation period and then safely returned to the environment."       |
|                                                                              |
| The licensee will inform the NRC Resident Inspector and the National         |
| Wildlife and Fisheries Service.  Notified R2DO(Jay Henson).                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37956       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  HAMOT MEDICAL CENTER                 |NOTIFICATION DATE: 05/01/2001|
|LICENSEE:  HAMOT MEDICAL CENTER                 |NOTIFICATION TIME: 14:28[EDT]|
|    CITY:  ERIE                     REGION:  1  |EVENT DATE:        04/26/2001|
|  COUNTY:                            STATE:  PA |EVENT TIME:        15:00[EDT]|
|LICENSE#:  37-00444-02           AGREEMENT:  N  |LAST UPDATE DATE:  05/01/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |HAROLD GRAY          R1      |
|                                                |FREDERICK STURZ      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. LEONARD COOVER           |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PATIENT RECEIVED ONLY 110 OF THE 150 MILLICURIES  I-131 PRESCRIBED DUE TO    |
| TECHNICIAN ERROR                                                             |
|                                                                              |
| A patient undergoing treatment for thyroid cancer was prescribed a dose of   |
| 150 millicuries of I-131.  The nuclear pharmacy dispensed the dose in three  |
| capsules which was confirmed by assay at the hospital.  The technician       |
| administered the dose at approximately 1500EDT on Thursday, 4/26.  The empty |
| container was returned to the nuclear pharmacy on Friday, 4/26.  Upon        |
| inspection of the returned container on Monday, 4/30, pharmacy personnel     |
| found a capsule containing approximately 40 millicuries I-131 stuck inside.  |
| The on-staff radiologist and patient were informed.  The patient will be     |
| monitored for the next six months and a decision involving any additional    |
| treatment will be made at that time.   The prescribing physician will be     |
| informed of the misadministration by the radiologist. The administering      |
| technician was administratively disciplined and the issue of delivering dose |
| will be addressed as a training item.                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37957       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 05/01/2001|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 20:22[EDT]|
|   RXTYPE: [3] CE                               |EVENT DATE:        05/01/2001|
+------------------------------------------------+EVENT TIME:        17:00[CDT]|
| NRC NOTIFIED BY:  GORDON PICKERING             |LAST UPDATE DATE:  05/01/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GAIL GOOD            R4      |
|10 CFR SECTION:                                 |                             |
|*UNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNANALYZED CONDITION DUE TO INADEQUATE FIRE PROTECTION INVOLVING POWER       |
| SUPPLIES FOR EDG FUEL OIL TRANSFER PUMPS                                     |
|                                                                              |
| "During a review of the site Appendix R program, W3 [Waterford 3]            |
| Engineering personnel discovered that the power supplies to both of the      |
| Emergency Diesel Generator Fuel Oil Transfer Pumps were not protected in     |
| accordance with 10CFR 50 Appendix R. The 480V power cables for both trains   |
| were found unprotected in Fire Area RAB 27. A fire in this room could        |
| potentially damage both Emergency Diesel Generator Fuel Oil Transfer Pumps   |
| power supply cables and would then impact the amount of time the Emergency   |
| Diesel Generators could operate. Due to the fire barriers missing on the     |
| above equipment and not providing the required amount of separation of safe  |
| shutdown trains, this condition is considered an unanalyzed condition that   |
| significantly degrades plant safety. This condition is reportable under      |
| 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly        |
| degrades plant safety.                                                       |
|                                                                              |
| "As a compensatory action fire watches have been established for the         |
| affected area in accordance with the site Technical Requirements Manual."    |
|                                                                              |
| The licensee informed the NRC resident inspector.                            |
+------------------------------------------------------------------------------+


Page Last Reviewed/Updated Thursday, March 25, 2021