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Event Notification Report for February 9, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/08/1999 - 02/09/1999

                              ** EVENT NUMBERS **

35324  35352  35353  35354  35355  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   35324       |
+------------------------------------------------------------------------------+
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| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 01/29/1999|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 09:48[EST]|
|   RXTYPE: [3] CE                               |EVENT DATE:        01/29/1999|
+------------------------------------------------+EVENT TIME:        07:57[CST]|
| NRC NOTIFIED BY:  VICTOR COLLINS               |LAST UPDATE DATE:  02/08/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       94       Power Operation  |94       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SECURITY REPORT -                                                            |
|                                                                              |
| UNACCOUNTED FOR PERSONNEL DOOR LOCK PULLER.  COMPENSATORY MEASURES           |
| IMMEDIATELY TAKEN UPON DISCOVERY.  THE LICENSEE NOTIFIED THE NRC RESIDENT    |
| INSPECTOR.  REFER TO THE HOO LOG FOR ADDITIONAL DETAILS.                     |
|                                                                              |
| * * * RETRACTION AT 1541 EST ON 2/8/99 FROM GREGORY SCOTT TO S.SANDIN * * *  |
|                                                                              |
| The licensee is retracting this event.  Contact the Headquarters Operations  |
| Officer for details. The licensee will inform the NRC Resident Inspector.    |
| Notified R4DO(Pellet)                                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35352       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: GRAND GULF               REGION:  4  |NOTIFICATION DATE: 02/08/1999|
|    UNIT:  [1] [] []                 STATE:  MS |NOTIFICATION TIME: 00:34[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        02/07/1999|
+------------------------------------------------+EVENT TIME:        22:38[CST]|
| NRC NOTIFIED BY:  HANKS                        |LAST UPDATE DATE:  02/08/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JEFF SHACKELFORD     R4      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|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  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE LICENSEE DECLARED RCIC INOPERABLE AND ENTERED A 14 DAY LCO ACTION        |
| STATEMENT.                                                                   |
|                                                                              |
| RCIC WAS DECLARED INOPERABLE WHEN A DIVISION II ISOLATION OCCURRED DUE TO AN |
| INVALID SIGNAL DURING THE PERFORMANCE OF A SURVEILLANCE.  THE CAUSE IS BEING |
| INVESTIGATED.  HPCS WAS VERIFIED OPERABLE WITHIN ONE HOUR , AS REQUIRED BY   |
| THE LCO ACTION STATEMENT, AT 2310 CST.  RCIC IS REQUIRED TO BE RETURNED TO   |
| SERVICE WITHIN 14 DAYS.  THE ISOLATION SIGNAL HAS BEEN RESET, BUT THE VALVES |
| ARE STILL CLOSED AND WILL NOT BE REOPENED UNTIL THE CAUSE OF THE ISOLATION   |
| HAS BEEN DETERMINED.                                                         |
|                                                                              |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35353       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK               REGION:  4  |NOTIFICATION DATE: 02/08/1999|
|    UNIT:  [1] [] []                 STATE:  KS |NOTIFICATION TIME: 13:43[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        02/08/1999|
+------------------------------------------------+EVENT TIME:        09:58[CST]|
| NRC NOTIFIED BY:  JIM GILMORE                  |LAST UPDATE DATE:  02/08/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOHN PELLET          R4      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     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  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - OFFSITE NOTIFICATION REGARDING A CHEMICAL SPILL INTO THE WOLF CREEK        |
| COOLING LAKE -                                                               |
|                                                                              |
| AT 0958 CST ON 02/08/1999, THE LICENSEE NOTIFIED THE STATE OF KANSAS THAT    |
| APPROXIMATELY 2000 GALLONS OF WATER CONTAINING AT MOST 50 GALLONS OF SODIUM  |
| HYPOCHLORITE AND 13 GALLONS OF SODIUM BROMIDE HAD SPILLED INTO THE WOLF      |
| CREEK COOLING LAKE.  A CHEMICAL INJECTION PUMP MECHANICAL SEAL FAILED AND    |
| CAUSED THE CHEMICAL SPILL AT THE PLANT INTAKE STRUCTURE.  THE CONCENTRATIONS |
| OF THE CHEMICAL SPILL EXCEEDED THE ALLOWABLE KANSAS STATE PERMIT LIMITS.     |
| THE LICENSEE STOPPED THE SPILL, PLACED ABSORBENT MATERIAL ON THE GROUND      |
| SURROUNDING THE SPILL AND REMOVED THE ABSORBENT MATERIAL.                    |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   35354       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WA DEPARTMENT OF HEALTH              |NOTIFICATION DATE: 02/08/1999|
|LICENSEE:  PROVIDENCE MEDICAL CENTER            |NOTIFICATION TIME: 11:45[EST]|
|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        12/16/1998|
|  COUNTY:                            STATE:  WA |EVENT TIME:        12:00[PST]|
|LICENSE#:  WN-MO45-1             AGREEMENT:  Y  |LAST UPDATE DATE:  02/08/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN PELLET          R4      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BOB VERELLEN                 |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - AGREEMENT STATE REPORT REGARDING MEDICAL MISADMINISTRATION -               |
|                                                                              |
| The following information was received via Email in the NRC Operations       |
| Center:                                                                      |
|                                                                              |
| Subject:   Washington Incident Notification #WA-99-003                       |
|                                                                              |
| This is notification/update of an event in Washington state as reported to   |
| or investigated by the WA Department of Health, Division of Radiation        |
| Protection.                                                                  |
|                                                                              |
| Licensee:  Providence Medical Center                                         |
| City and state:  Seattle, WA.                                                |
| License number:   WN-M045-1                                                  |
| Type of License:   Medical, Broad Type  A                                    |
|                                                                              |
| Date of Event:  16 December 1998                                             |
|                                                                              |
| Location of Event:   Licensee's facility, Radiation Oncology Dept.           |
|                                                                              |
| ABSTRACT:                                                                    |
| The licensee, a Broad Medical, had reviewed and approved the clinical trial  |
| of the Guidant Intravascular Radiotherapy project.  The project uses a       |
| modified Nucletron high dose rate afterloader (HDR) and an Omnitron          |
| International, Inc. Phosphorus-32 brachytherapy source model NC-P32-3N with  |
| an activity of approximately 150 millicuries.  The trial is to evaluate      |
| local radiation for the prevention of restenosis after coronary              |
| angioplasty.                                                                 |
|                                                                              |
| On 16 December 1998, the Guidant Clinical Research Coordinator introduced a  |
| new type catheter, provided training for the licensee's personnel and        |
| supervised the use of the new catheter system on a patient. The licensee     |
| reported that the source was thought to have been seen at the proper         |
| location for the planned treatment using fluoro and the inactive source      |
| wire.  The treatment was completed.                                          |
|                                                                              |
| On 11 January 1999, the Guidant Coordinator informed the licensee that the   |
| new catheter required the use of a different connector on the front end of   |
| the afterloader and that, if not used, the source would not be at the proper |
| treatment site and therefore the treatment on 16 Dec would not have been     |
| correct.                                                                     |
|                                                                              |
| On 13 January 1999, the license performed some tests and confirmed that a    |
| misadministration had occurred. Their review indicates that the source was   |
| approximately 34 cm from the intended treatment site.  In their second       |
| written report to the state the licensee estimated dose to the vessel wall   |
| to range from 108 Gy worst case, to 70 Gy as a  most realistic dose.         |
|                                                                              |
| MAJOR ISSUES:                                                                |
|                                                                              |
| 1. THE INABILITY TO CONFIRM THE LOCATION OF THE SOURCE USING FLUORO when     |
| fluoro visualization is indicated in the project's description and           |
| procedures as an essential verification for the use of this device.          |
|                                                                              |
| 2. THE INCOMPLETE TRAINING AND DIRECTION PROVIDED THE LICENSEE BY THE        |
| GUIDANT PERSONNEL WHEN DEVICE EQUIPMENT CHANGES WERE MADE ON 16 DECEMBER     |
| 1998.                                                                        |
|                                                                              |
| What is the notification or reporting criteria involved?  WAC 246-240-050    |
| "NOTIFICATIONS, RECORDS, AND REPORTS OF THERAPY MISADMINISTRATIONS."         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35355       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PEACH BOTTOM             REGION:  1  |NOTIFICATION DATE: 02/08/1999|
|    UNIT:  [2] [] []                 STATE:  PA |NOTIFICATION TIME: 17:45[EST]|
|   RXTYPE: [2] GE-4,[3] GE-4                    |EVENT DATE:        02/08/1999|
+------------------------------------------------+EVENT TIME:        17:00[EST]|
| NRC NOTIFIED BY:  PAT NAVIN                    |LAST UPDATE DATE:  02/08/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |LAURIE PELUSO        R1      |
|10 CFR SECTION:                                 |                             |
|AARC 50.72(b)(1)(v)      OTHER ASMT/COMM INOP   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE DUE TO A FAILED COMPUTER -      |
|                                                                              |
| DURING COMPUTER TESTING, THE UNIT 2 PLANT MONITORING SYSTEM COMPUTER FAILED, |
| RENDERING THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE.  PLANT      |
| TECHNICIANS ARE RESTORING THE FAILED COMPUTER.  THE LICENSEE WILL INFORM THE |
| NRC RESIDENT INSPECTOR.                                                      |
|                                                                              |
| * * * UPDATE AT 2213 ON 02/08/99 FROM JIM KOVALCHICK TO JOLLIFFE * * *       |
|                                                                              |
| AT 2157, THE LICENSEE RESTORED THE UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM TO |
| OPERABLE STATUS.  THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.  THE NRC |
| OPERATIONS OFFICER NOTIFIED R1DO (LAURIE PELUSO).                            |
+------------------------------------------------------------------------------+