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Event Notification Report for February 26, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/25/1999 - 02/26/1999

                              ** EVENT NUMBERS **

35402  35403  35404  35405  35406  35407  35408  

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|Power Reactor                                    |Event Number:   35402       |
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| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 02/25/1999|
|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 09:03[EST]|
|   RXTYPE: [1] GE-3                             |EVENT DATE:        02/25/1999|
+------------------------------------------------+EVENT TIME:        08:05[EST]|
| NRC NOTIFIED BY:  ERIC OLSON                   |LAST UPDATE DATE:  02/25/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD BARKLEY      R1      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
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| DISCOVERY OF EMERGENCY DIESEL GENERATOR BUILDING TEMPERATURE LESS THAN       |
| DESIGN DUE AN ONGOING SEVERE WINTER STORM  (Refer to event numbers 33658 and |
| 33938 for previous similar occurrences reported to the NRC Operations Center |
| by Pilgrim 1.)                                                               |
|                                                                              |
| The design temperature for the building that houses the emergency diesel     |
| generators is 60F.  However, at 0805 on 02/25/99, it was discovered that    |
| temperature for the area that houses the 'A' emergency diesel generator was  |
| 59F.  This was due to an ongoing severe winter storm with winds out of the  |
| northeast which introduced cold air to the emergency diesel generator        |
| building.  Temperature returned to 60F at approximately 0830, but it is     |
| expected that it may decrease below the design temperature throughout the    |
| storm as long as the winds are coming out of the northeast.                  |
|                                                                              |
| The licensee stated that this problem has occurred in the past and           |
| referenced Licensee Event Report (LER) 98-004-01.  Corrective actions for    |
| this LER involved changing the emergency diesel generator building design    |
| temperature to 40F.  This design change is currently being processed but    |
| has not yet been approved.                                                   |
|                                                                              |
| The licensee currently has an engineering evaluation in place to justify     |
| emergency diesel generator operability with building temperatures as low as  |
| 40F.  Therefore, both emergency diesel generators are considered to be      |
| operable, and the unit is not currently in a technical specification         |
| limiting condition for operation as a result of this issue.                  |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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|Fuel Cycle Facility                              |Event Number:   35403       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 02/25/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 11:13[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        02/24/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        12:05[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  02/25/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |BRUCE JORGENSEN      R3      |
|  DOCKET:  0707002                              |DON COOL, NMSS       EO      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF MINOR UF6 LEAKAGE IN THE X-330 BUILDING AND CONFIRMED VALID     |
| CASCADE AUTOMATIC DATA PROCESSING (CADP) ACTUATION (24-HOUR REPORT)          |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth:     |
|                                                                              |
| "At approximately 1205 hours on 02/24/99, operations personnel investigating |
| a smokehead alarm that occurred at 1005 found visible evidence of minor UF6  |
| leakage on a valve in the evacuation header for position 3 of the liquid     |
| withdrawal station at tails.  Finding this visible evidence of UF6 leakage   |
| confirmed that the actuation of the CADP UF6 smoke detection safety system   |
| was valid.  This discovery concludes the investigation that was started on   |
| 02/22/99 to determine if three smokehead alarm actuations that occurred on   |
| 02/19/99 were actual or invalid signals.  When the alarms were initially     |
| received, operations personnel responded and performed an investigation in   |
| accordance with response procedures.  Their initial inspections did not      |
| reveal any evidence of UF6 leakage which would indicate the alarm actuations |
| were valid.  On 02/22/99, additional actions were taken to investigate the   |
| alarms which included isolating sections of piping near the smokeheads.      |
| Visual inspections and leak tests performed on this section of piping did    |
| not reveal any evidence of UF6 leakage.  On 02/24/99, with the suspected     |
| section of piping isolated, another alarm was received.  This led the        |
| operations personnel to re-inspect equipment which did not previously show   |
| any evidence of leakage.  This inspection revealed evidence of minor leakage |
| which was not previously visible.  This evidence confirmed that a valid CADP |
| actuation had occurred."                                                     |
|                                                                              |
| "This is reportable to the NRC as a valid actuation of a 'Q' safety system   |
| in accordance with the Safety Analysis Report, Section 6.9."                 |
|                                                                              |
| "There was no loss of hazardous/radioactive material or                      |
| radioactive/radiological contamination exposure as a result of this event."  |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector and the Department  |
| of Energy site representative.                                               |
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+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35404       |
+------------------------------------------------------------------------------+
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| REP ORG:  INDIANA UNIVERSITY MEDICAL CENTER    |NOTIFICATION DATE: 02/25/1999|
|LICENSEE:  INDIANA UNIVERSITY MEDICAL CENTER    |NOTIFICATION TIME: 11:21[EST]|
|    CITY:  INDIANAPOLIS             REGION:  3  |EVENT DATE:        02/24/1999|
|  COUNTY:  MARION                    STATE:  IN |EVENT TIME:        12:17[CST]|
|LICENSE#:  13-02752-03           AGREEMENT:  N  |LAST UPDATE DATE:  02/25/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE JORGENSEN      R3      |
|                                                |DON COOL, NMSS       EO      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARK RICHARD                 |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION INVOLVING RECEIPT OF A BRACHYTHERAPY DOSE THAT WAS |
| 24% LOW                                                                      |
|                                                                              |
| On 10/29/98, a patient at Indiana University Medical Center located in       |
| Indianapolis, IN, was being treated with a three-channel, low-dose-rate,     |
| brachytherapy device containing Cesium-137 sources in the form of small      |
| pellets.  When nurses entered the room to attend the patient, the sources    |
| were retracted, and there were problems resuming the treatment.  The         |
| problems were initially believed to be the result of a power problem.  The   |
| on-call medical physicist was contacted, power problem recovery steps were   |
| followed, and the treatment was resumed.  The following morning, a resident  |
| physician noticed that only one of the three channels on the brachytherapy   |
| device was actually operating (treating the patient) and that the sources in |
| the other two channels were still in the shielded position.  Therefore, the  |
| problem was the result of a pellet problem rather than a power problem and   |
| different recovery steps should have been followed.  The medical physicist   |
| was contacted, and the treatment resumed.  When the patient was informed     |
| that the treatment time would need to be lengthened to compensate for the    |
| delay in reactivating two of the three channels, the patient refused the     |
| additional treatment.  The prescribed dose was 2,500 centigray, and the      |
| patient actually received 1,900 centigray.                                   |
|                                                                              |
| On 11/09/98, the licensee sent an Incident Report to NRC Region III (Bob     |
| Gattone).  NRC Region III sent a Technical Assistance Request to NRC         |
| Headquarters regarding reportability, and a response stating that this       |
| incident was reportable was received by licensee via facsimile at 1217 CST   |
| on 02/24/99.                                                                 |
|                                                                              |
| (Call the NRC Operations Center for a site contact telephone number.)        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35405       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  METCALF INSTITUTE OF RAD ONCOLOGY    |NOTIFICATION DATE: 02/25/1999|
|LICENSEE:  HOSPITAL CENTER AT ORANGE            |NOTIFICATION TIME: 11:49[EST]|
|    CITY:  ORANGE                   REGION:  1  |EVENT DATE:        02/25/1999|
|  COUNTY:  ESSEX                     STATE:  NJ |EVENT TIME:        09:55[EST]|
|LICENSE#:  29-03038-02           AGREEMENT:  N  |LAST UPDATE DATE:  02/25/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RICHARD BARKLEY      R1      |
|                                                |DON COOL (EO)        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. JOSE BARBA               |                             |
|  HQ OPS OFFICER:  HENRY BAILEY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SOURCE DRAWER FAILURE ON AN ATC Co-60 MACHINE                                |
|                                                                              |
| THE METCALF INSTITUTE OF RADIATION AT THE HOSPITAL CENTER AT ORANGE LOCATED  |
| IN ORANGE, NJ, REPORTED AN INCIDENT WHERE A PATIENT WAS EXPOSED FOR 15 TO 20 |
| SECONDS WHEN THE SOURCE DRAWER ON AN ATC Co-60 MACHINE FAILED.  SEVERAL      |
| ATTENDING PERSONNEL ALSO WERE EXPOSED FOR 5 TO 10 SECONDS.   THE SOURCE      |
| STRENGTH WAS 6,000 CURIES.  NO DOSAGE CALCULATIONS HAD BEEN PERFORMED AT THE |
| TIME OF THIS EVENT NOTIFICATION.                                             |
|                                                                              |
| A SIMULATION FILM WAS BEING TAKEN IN PREPARATION FOR A TREATMENT ON THE      |
| PATIENT.  THE SOURCE FAILED TO RETURN TO THE SHIELDED POSITION EVEN WHEN THE |
| EMERGENCY STOP WAS ACTUATED.  THE ROOM WAS SEALED AND LOCKED, AND THE SOURCE |
| DRAWER WAS THEN CLOSED REMOTELY.  ALL OPERATIONS WITH THIS MACHINE HAVE BEEN |
| SUSPENDED.                                                                   |
|                                                                              |
| THE LICENSEE NOTIFIED NRC REGION I (DR. NEELAM BHALLA) AND PLANS TO SUBMIT A |
| WRITTEN REPORT TO THE NRC.                                                   |
|                                                                              |
| (CALL THE NRC OPERATIONS CENTER FOR A LICENSEE CONTACT TELEPHONE NUMBER.)    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   35406       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  PYCO, INC.                           |NOTIFICATION DATE: 02/25/1999|
|LICENSEE:  PYCO, INC.                           |NOTIFICATION TIME: 17:03[EST]|
|    CITY:  PENNDEL                  REGION:  1  |EVENT DATE:        02/25/1999|
|  COUNTY:                            STATE:  PA |EVENT TIME:        17:03[EST]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  02/25/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROBERT HAAG          R2      |
|                                                |VERN HODGE (via fax) NRR     |
+------------------------------------------------+RICHARD BARKLEY      R1      |
| NRC NOTIFIED BY:  WILLIAM SZARY                |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 10 CFR PART 21 REPORT REGARDING FAULTY RESISTANCE TEMPERATURE DETECTORS      |
| (RTD)                                                                        |
|                                                                              |
| The following text is a portion of a facsimile received from PYCO, Inc.:     |
|                                                                              |
| "A deviation has been detected in that a limited number of 200 OHM DUPLEX    |
| RTD assemblies have been fabricated by PYCO using THIN-FILM RTD sensors      |
| instead of the WIRE-WOUND RTD sensors specified for the assembly. RTD        |
| assemblies fabricated using wire-wound sensors have been tested and          |
| qualified by PYCO for nuclear use under our nuclear qualification test       |
| program. RTD assemblies fabricated using thin-film sensors have not been     |
| tested by PYCO to IEEE-323 and IEEE-344 requirements."                       |
|                                                                              |
| "Externally, thin-film and wire-wound RTDs have the same physical            |
| appearance, shape, and electrical characteristics. Both the wire-wound and   |
| thin-film sensors meet the requirements of the International Industrial      |
| Standard IEC-751, 'Industrial Platinum Resistance Thermometer Sensors'."     |
|                                                                              |
| These RTDs have been sold to Carolina Power and Light and South Carolina     |
| Electric and Gas for use at the Robinson, Brunswick, and Summer plants.      |
|                                                                              |
| (Call the NRC Operations Center for a contact telephone number.)             |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35407       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 02/25/1999|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 18:41[EST]|
|   RXTYPE: [3] CE                               |EVENT DATE:        02/25/1999|
+------------------------------------------------+EVENT TIME:        14:18[CST]|
| NRC NOTIFIED BY:  BILL MCKINNEY                |LAST UPDATE DATE:  02/25/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ELMO COLLINS         R4      |
|10 CFR SECTION:                                 |                             |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PRESSURIZER NOZZLE LEAKAGE DISCOVERED DURING REFUELING OUTAGE                |
|                                                                              |
| During a visual inspection, evidence of reactor coolant system leakage was   |
| found on two inconel instrument nozzles located on the top head of the       |
| pressurizer.  The leakage was in the annulus area where the nozzle           |
| penetrates the pressurizer head.  The nozzles are welded on the inner        |
| diameter of the pressurizer and are joined to instrument valves RC-310 and   |
| RC-311.                                                                      |
|                                                                              |
| The NRC resident inspector has been informed of this notification by the     |
| licensee.                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35408       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GREATER LA MEDICAL CENTER            |NOTIFICATION DATE: 02/25/1999|
|LICENSEE:  VA MEDICAL SYSTEM                    |NOTIFICATION TIME: 19:50[EST]|
|    CITY:  LOS ANGELES              REGION:  4  |EVENT DATE:        02/24/1999|
|  COUNTY:                            STATE:  CA |EVENT TIME:             [PST]|
|LICENSE#:  04-00181-12           AGREEMENT:  Y  |LAST UPDATE DATE:  02/25/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ELMO COLLINS         R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ED LEIDHOLDT                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|IBBE 30.50(b)(2)(i)      ACCID MIT EQUIP FAILS  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MALFUNCTION OF DOOR INTERLOCK FOR TELETHERAPY UNIT                           |
|                                                                              |
| On 02/24/99, while conducting a test of the treatment room door interlock    |
| associated with a Co-60 teletherapy unit, the treatment timer stopped and    |
| the source retracted when the door was opened (expected), but the timer then |
| restarted and the source became exposed again after the door was closed (not |
| expected). The source then retracted once again after the treatment timer    |
| expired.  The treatment timer should not have restarted until manually       |
| directed to do so from the operator console.  The teletherapy unit is a      |
| Theratronix model T-780,                                                     |
| containing 3,500 Ci of Co-60.  A vendor technician responded to the site but |
| was unable to reproduce the event.  However, the licensee reported that the  |
| technician was able to reproduce a similar problem by bumping the door very  |
| slightly and allowing it to quickly reclose.  The licensee also reported     |
| that the hand pendant associated with the treatment couch recently           |
| malfunctioned (in a reproducible way) until the machine was switched off and |
| then back on, when the malfunction ceased.  The technician was unable to     |
| reproduce this malfunction.                                                  |
|                                                                              |
| The unit appears to be working properly at this time although the licensee   |
| has locked the treatment room until all radiation therapists can be briefed  |
| on the potential for this malfunction.                                       |
|                                                                              |
| No patients or personnel were in the room at the time of the test.           |
|                                                                              |
| (Call the NRC Operations Center for contact names and telephone numbers.)    |
+------------------------------------------------------------------------------+