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Event Notification Report for March 2, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/01/1999 - 03/02/1999

                              ** EVENT NUMBERS **

34725  34935  35334  35364  35396  35415  35419  35424  35426  35427  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   34725       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GARDEN CITY HOSPITAL                 |NOTIFICATION DATE: 09/02/1998|
|LICENSEE:  GARDEN CITY HOSPITAL                 |NOTIFICATION TIME: 11:35[EDT]|
|    CITY:  GARDEN CITY              REGION:  3  |EVENT DATE:        09/01/1998|
|  COUNTY:  WAYNE                     STATE:  MI |EVENT TIME:        23:30[EDT]|
|LICENSE#:  21-04072-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROGER LANKSBURY      RDO     |
|                                                |DON COOL             EO      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. LUTSIC                   |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| A PATIENT UNDERGOING TREATMENT FOR STAGE IV CANCER RECEIVED A VARIATION IN   |
| EXCESS OF 50% OF THE PRESCRIBED PALLIATIVE DOSE.                             |
|                                                                              |
| AT 2330EDT ON 9/1/98 A NURSE DURING ROUNDS DISCOVERED THAT A FEMALE PATIENT  |
| UNDERGOING TREATMENT FOR ENDOMETRIAL CANCER HAD REMOVED HER APPLICATOR       |
| CONTAINING THREE (3) CESIUM-137 SOURCES; 17.76 mCi, 25.05 mCi AND 25.0 mCi.  |
| THE PATIENT RECEIVED ONLY 278 OF THE 580 mGRAM RADIUM EQUIVALENT HOURS       |
| DOSE.  THE PRESCRIBING PHYSICIAN DOES NOT PLAN ON RESCHEDULING TREATMENT     |
| SINCE THE THERAPY WAS PALLIATIVE IN NATURE TO MINIMIZE BLEEDING.  THE        |
| LICENSEE INFORMED REGION 3(JONES).                                           |
|                                                                              |
| SEE HOO LOG FOR CONTACT INFORMATION.                                         |
|                                                                              |
| *** UPDATE ON 3/1/99 @ 1430 BY WEITZ TO GOULD ***  EVENT RETRACTION          |
|                                                                              |
| THE LICENSEE IS RETRACTING THIS EVENT BASED ON A RECOMMENDATION FROM REG 3   |
| THAT THE EVENT IS NOT REPORTABLE.                                            |
|                                                                              |
| REG 3 RDO(JORGENSEN) WAS NOTIFIED ALONG WITH NMSS(BRIAN SMITH).              |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   34935       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION DATE: 10/19/1998|
|LICENSEE:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION TIME: 18:28[EDT]|
|    CITY:  ROYAL OAK                REGION:  3  |EVENT DATE:        10/19/1998|
|  COUNTY:                            STATE:  MI |EVENT TIME:        10:40[EDT]|
|LICENSE#:  21-01333-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MIKE JORDAN          RDO     |
|                                                |MICHAEL WEBER, MNSS  EO      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHERYL SCHULTZ, RSO          |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - MEDICAL MISADMINISTRATION OF INCORRECT NECK AND CHEST SCAN DOSE -          |
|                                                                              |
| AT 1040 ON 10/19/98, A PATIENT SCHEDULED FOR A NECK AND CHEST SCAN WAS       |
| PRESCRIBED AND ADMINISTERED AN ORAL LIQUID DOSE OF 2.0 MILLICURIES OF        |
| SODIUM IODIDE (I-131).  THE PATIENT LEFT THE HOSPITAL AFTER THE DOSE WAS     |
| ADMINISTERED.  AFTER THE PATIENT HAD LEFT THE HOSPITAL, THE ADMINISTERING    |
| TECHNOLOGIST DISCOVERED THAT THERE WAS STILL 0.9 MILLICURIES OF              |
| CONCENTRATED I-131 LEFT IN THE DOSE VIAL.  HOSPITAL PERSONNEL CONTACTED      |
| THE PATIENT WHO RETURNED TO THE HOSPITAL.                                    |
|                                                                              |
| AT 1230 ON 10/19/98, THE PATIENT WAS ADMINISTERED A DOSE OF 1.0 MILLICURIES  |
| OF I-131 WITH A GENEROUS AMOUNT OF WATER.                                    |
|                                                                              |
| THERE WAS NO ADVERSE IMPACT TO THE PATIENT.  HOSPITAL PERSONNEL NOTIFIED     |
| THE PATIENT'S PHYSICIAN AND ARE DETERMINING CORRECTIVE ACTIONS.              |
|                                                                              |
| *** UPDATE ON 3/1/99 @ 1223 BY SCHULTZ TO GOULD ***   EVENT RETRACTION       |
|                                                                              |
| THE LICENSEE IS RETRACTING THIS EVENT AFTER A DISCUSSION WITH REG 3 ABOUT    |
| THE ERROR BEING FOUND WITHIN 5 MINS AND CORRECTED VERY RAPIDLY.              |
|                                                                              |
| THE REG 3 RDO(JORGENSEN) WAS NOTIFIED.                                       |
|                                                                              |
| NMSS EO(BRIAN SMITH) WAS NOTIFIED.                                           |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35334       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 01/29/1999|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 18:55[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        01/29/1999|
+------------------------------------------------+EVENT TIME:        18:00[EST]|
| NRC NOTIFIED BY:  COTTER                       |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVID SILK           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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
|  AN ERRONEOUS ASSUMPTION WAS MADE IN THE FIRE PROTECTION SAFE SHUTDOWN       |
| REPORT.                                                                      |
|                                                                              |
| A REVIEW ASSOCIATED WITH AN ENGINEERING FIRE PROTECTION SELF-ASSESSMENT HAS  |
| IDENTIFIED AN ERRONEOUS ASSUMPTION REGARDING AN OPERATOR ACTION CREDITED IN  |
| THE FIRE PROTECTION SAFE SHUTDOWN REPORT.  POTENTIAL FIRE-INDUCED SPURIOUS   |
| OPERATION OF THE REACTOR COOLANT SYSTEM (RCS) LOOP DRAIN VALVES 2RCS-MOV557A |
| , B, OR C, IN CONJUNCTION WITH SPURIOUS OPERATION OF THE DOWNSTREAM VALVES,  |
| RCS EXCESS LETDOWN VALVES 2CHS-HCV137 AND 2CHS-MOV201 WAS NOT ADEQUATELY     |
| CONSIDERED.  THE UNIT 2 FIRE PROTECTION SAFE SHUTDOWN REPORT STATES THAT IN  |
| THE EVENT OF A FIRE-INDUCED SPURIOUS OPERATION OF 2RCS-MOV557A, B, OR C, THE |
| OPERATOR COULD MANUALLY CLOSE EITHER 2CHS-MOV201 OR 2CHS-HCV137 TO ISOLATE   |
| THE RESULTING EXCESS LETDOWN FLOW.  OPERATION OF THESE VALVES FROM THE       |
| CONTROL ROOM DOES NOT SATISFY THE REQUIREMENT SINCE THE FIRE MAY HAVE        |
| DAMAGED THE CONTROL AND/OR POWER CIRCUITS.  LOCAL MANUAL OPERATION OF THESE  |
| VALVES WOULD NOT BE FEASIBLE WITHIN THE REQUIREMENTS OF THE SAFE SHUTDOWN    |
| ANALYSIS BECAUSE OF INACCESSIBILITY IN CONTAINMENT.                          |
|                                                                              |
| AT 1806, POWER WAS REMOVED FROM THE RCS LOOP DRAIN VALVES TO ISOLATE THIS    |
| POTENTIAL FLOW PATH AND THUS RESTORE COMPLIANCE WITH THEIR POST-FIRE SAFE    |
| SHUTDOWN ANALYSIS.                                                           |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE.                     |
|                                                                              |
| ******************** UPDATE AT 1457 ON 03/01/99 FROM GEORGE STOROLIS TO      |
| GOULD ********************                                                   |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "This notification is made to retract a prior NRC non-emergency event        |
| notification, made on January 29, 1999,                                      |
| at approximately 1855 hours.  The prior notification followed the            |
| determination of a design basis event, in                                    |
| accordance with 10CFR50.72(b)(ii)(B), and identified an inappropriate        |
| operator action credited in the Fire                                         |
| Protection Safe Shutdown Report (FPSSR).  The credited operator action       |
| involved local manual operation to                                           |
| close the reactor coolant system (RCS) excess letdown heat exchanger         |
| isolation 2CHS*MOV201 or the                                                 |
| downstream control valve 2CHS*HCV137 to terminate an unplanned letdown flow  |
| event through the RCS                                                        |
| excess letdown heat exchanger.  This unplanned letdown flow event would      |
| result from fire-induced operation                                           |
| (opening) of the RCS loop drain valves 2RCS*MOV557A, or B, or C, in          |
| conjunction with the 2CHS*MOV201                                             |
| and 2CHS*HCV137.  During the ongoing FPSSR self-assessment, it was           |
| recognized that the location of these                                        |
| valves within containment would preclude access to the valves.  Due to the   |
| combination of the normal RCS                                                |
| letdown flow and the unplanned RCS excess letdown flow, it was then          |
| determined that the plant design basis                                       |
| requirement of achieving approach to cold shutdown conditions within 72      |
| hours could not be assured."                                                 |
|                                                                              |
| "Subsequent Nuclear Engineering Department evaluation following the January  |
| 29, 1999, event notification has determined the maximum total time required  |
| to achieve cold shutdown with the inability to isolate the letdown flow      |
| path, is achievable within the 10 CFR [Part 50,] Appendix R design basis     |
| requirement of 72 hours.  This shutdown can be accomplished with the         |
| existing plant design and current operating procedures.  This evaluation     |
| included consideration of the maximum expected RCS letdown flow, the         |
| capability to achieve cold shutdown boration conditions within 10 hours and  |
| meeting the overall requirement of achieving cold shutdown conditions within |
| 72 hours, and the capacity of one charging pump to meet the flow             |
| requirements during the shutdown/cooldown sequence, assuming maximum normal  |
| letdown flow."                                                               |
|                                                                              |
| "Under the assumed failure conditions, the maximum total letdown flow rate   |
| (normal and unplanned, due to the spurious valve openings) would be 202 gpm, |
| consisting of the following:                                                 |
|                                                                              |
| -  37 gpm for the excess flow path due to the fire-induced operation         |
| (opening) of the RCS loop drain valves                                       |
| 2RCS*MOV557A, or B, or C, in conjunction with the 2CHS*MOV201 and            |
| 2CHS*HCV137 or downstream                                                    |
| control valve 2CHS*HCV389, and                                               |
|                                                                              |
| -  165 gpm for the normal letdown flow path consisting of one 45-gpm orifice |
| and two 60-gpm orifices."                                                    |
|                                                                              |
| "In addition to that described above, the charging pump must supply flow, as |
| indicated, for the following:                                                |
|                                                                              |
| -  70 gpm for the charging pump recirculation flow (minimum flow of 60 gpm)  |
| [and]                                                                        |
|                                                                              |
| -  28 gpm seal water supply flow to the Reactor Coolant Pumps."              |
|                                                                              |
| "Comparison of the maximum total required charging pump flow rate (including |
| the flow from the excess letdown flow path created from the fire-induced     |
| opening of RCS valves described above) with the specific pump curves, shows  |
| adequate capability of a charging pump to provide this flow rate."           |
|                                                                              |
| "The time of 10 hours to borate to cold shutdown concentration described in  |
| the FPSSR requires a letdown/boration flow of approximately 12 gpm, based on |
| the most limiting reactivity conditions.  This flow requirement is well      |
| within the capability of the letdown and charging systems and, therefore,    |
| would be achievable."                                                        |
|                                                                              |
| "Based on the subsequent evaluation as described above, a condition did not  |
| exist which would have prevented meeting the design requirement to achieve   |
| approach to cold shutdown condition within 72 hours.  In addition, as a      |
| result of this event notification retraction, Licensee Event Reporting       |
| regarding this issue is not required nor is planned."                        |
|                                                                              |
| "Power will be restored to the RCS loop drain valves."                       |
|                                                                              |
| The licensee notified the NRC resident inspector.  The NRC operations center |
| notified the R1DO (Modes).                                                   |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35364       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CLINTON                  REGION:  3  |NOTIFICATION DATE: 02/11/1999|
|    UNIT:  [1] [] []                 STATE:  IL |NOTIFICATION TIME: 23:31[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        02/11/1999|
+------------------------------------------------+EVENT TIME:        19:45[CST]|
| NRC NOTIFIED BY:  ROBERT POWERS                |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GARY SHEAR           R3      |
|10 CFR SECTION:                                 |                             |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TORQUE VALUE USED ON THE MSIVs FOUND TO BE LESS THAN REQUIRED BY SEISMIC     |
| ANALYSES                                                                     |
|                                                                              |
| "During an evaluation of the torque values for the Main Steam Isolation      |
| Valve's (MSIV) actuator cylinder yoke                                        |
| upper flange studs, Clinton Power Station discovered that the torque value   |
| for the lower flange bolts as specified                                      |
| by the vendor manual and plant procedure is much smaller [than] that used in |
| the seismic qualification of the MSIV actuators. The Vendor manual specifies |
| 200 ft-lbs while plant procedures specify 200 to 240 ft-lbs. However, the GE |
| seismic qualification document NEDE-30725 uses 620 ft-lbs.                   |
|                                                                              |
| "A review of the seismic qualification indicated that the minimum applied    |
| torque of 200 ft-lbs is acceptable for                                       |
| mode 4 (cold shutdown), the plant's current mode of operation.               |
|                                                                              |
| " This condition during a seismic event could cause the valve stem to bind   |
| which could have prevented MSIV                                              |
| operation. Thus, a notification is being made per 10 CFR 50.72(b)(2)(iii)(c) |
| [because] this condition could have                                          |
| prevented the fulfillment of the safety function of systems that are needed  |
| to control the release of radioactive                                        |
| material."                                                                   |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| *** UPDATE ON 3/1/99 @ 1817 BY POWERS TO GOULD ***  EVENT RETRACTION         |
|                                                                              |
| FURTHER EVALUATION OF THIS CONDITION HAS DETERMINED THAT THIS EVENT IS NOT   |
| REPORTABLE.  THE TORQUE VALUE OF 200 FT-LBS HAS BEEN EVALUATED IN NUCLEAR    |
| STATION ENGINEERING DEPT. CALCULATION IP-Q-0438, REVISION 0, AND FOUND TO    |
| NOT AFFECT THE SEISMIC QUALIFICATION OF THE MSIV ACTUATORS.  HOWEVER,        |
| ENGINEERING CHANGE NOTICE 31374 HAS BEEN ISSUED TO CHANGE THE DESIGN         |
| SPECIFIED TORQUE VALUE FOR THE AFFECTED FASTENERS TO 400 FT-LBS (+/-10%      |
| LUBRICATED).                                                                 |
|                                                                              |
| THE RESIDENT INSPECTOR WAS NOTIFIED.         REG 3 RDO(JORGENSEN) WAS        |
| NOTIFIED.                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35396       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY                    REGION:  2  |NOTIFICATION DATE: 02/23/1999|
|    UNIT:  [1] [2] []                STATE:  VA |NOTIFICATION TIME: 17:58[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        02/23/1999|
+------------------------------------------------+EVENT TIME:        14:30[EST]|
| NRC NOTIFIED BY:  THOMAS SOWERS                |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT HAAG          R2      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY REPORT                                                      |
|                                                                              |
| A contract supervisor was determined to be in possession of a controlled     |
| substance.  The employee's access to the plant has been terminated.          |
| (Contact the NRC Operations Officer for additional details.)                 |
|                                                                              |
| The licensee informed the NRC Resident Inspector.                            |
|                                                                              |
| *** UPDATE ON 3/1/99 @ 1446 BY SOWERS TO GOULD ***                           |
|                                                                              |
| THE FOR CAUSE DRUG SCREEN RESULTS WERE CONFIRMED POSITIVE.                   |
|                                                                              |
| THE RESIDENT INSPECTOR WAS NOTIFIED.                                         |
|                                                                              |
| THE REG 2 RDO(HAAG) WAS NOTIFIED.                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35415       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  SAN DIEGO MEDICAL CENTER             |NOTIFICATION DATE: 02/26/1999|
|LICENSEE:  VA MEDICAL SYSTEM                    |NOTIFICATION TIME: 17:31[EST]|
|    CITY:  SAN DIEGO                REGION:  4  |EVENT DATE:        02/26/1999|
|  COUNTY:                            STATE:  CA |EVENT TIME:        08:10[PST]|
|LICENSE#:  04-15030-01           AGREEMENT:  Y  |LAST UPDATE DATE:  03/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ELMO COLLINS         R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MIKE ZORN                    |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAAA 20.1906(d)          SURFACE CONTAMINATION E|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PACKAGE RECEIVED WITH SURFACE CONTAMINATION ABOVE LIMITS                     |
|                                                                              |
| At 0810 PST, a courier delivered a shipment of radiopharmaceuticals from the |
| SYNCOR pharmacy in San Diego, CA.  Upon receipt, the licensee performed a    |
| routine wipe sample of the external surfaces of the outer container (ammo    |
| box), and discovered contamination in excess of the reporting requirements   |
| of 10 CFR 20.1906.  Initial wipes indicated up to 30,000 CPM of gross        |
| activity for a swab that had been run over all surfaces of the container.    |
| The package contained two vials of radiopharmaceuticals; 10 mCi of Tc-99m    |
| META solution, and 10 mCi of Ga-67 (not NRC regulated).  The licensee did    |
| not report any damage to the vials, and they were administered to patients.  |
| No contamination occurred at the medical center as a result of this          |
| shipment.                                                                    |
|                                                                              |
| A more detailed survey of the container revealed up to 50,000 cpm/300cm2.    |
| The licensee did not determine the isotope of the contaminant.  A            |
| representative of SYNCOR visited the medical center, and took several wipe   |
| samples for isotopic identification.  The licensee plans to investigate this |
| event with SYNCOR.                                                           |
|                                                                              |
|                                                                              |
| *** UPDATE ON 3/1/99 @ 1322 BY ZORN(FAX) TO GOULD ***                        |
|                                                                              |
| BASED ON WIPE SURVEYS, THREE SEPARATE LOCATIONS ON THE EXTERIOR SURFACE OF   |
| THE SYNCOR PACKAGE BORE RADIOACTIVE CONTAMINATION IN EXCESS OF THE 22 DPM/SQ |
| CM 49 CFR 173.443 LIMIT.  THE THREE AREAS MEASURED AS FOLLOWS:               |
|                                                                              |
| PACKAGE WIPE LOCATION                                CALCULATED DPM/SQ CM    |
|                                                                              |
| BOTTOM THIRD OF FRONT SIDE                                            89.7   |
| MIDDLE THIRD OF FRONT SIDE                                                   |
| 74.8                                                                         |
| MOST OF RIGHT SIDE                                                           |
| 206.3                                                                        |
| (THESE VALUES WERE OBTAINED BY USING A COUNTING EFFICIENCY OF ~89% FOR       |
| Tc-99m AND Ga-67)                                                            |
|                                                                              |
| FOR EACH OF THESE THREE AREAS LISTED ABOVE, AN AREA OF 300 SQ CM WAS WIPED   |
| WITH AN ALCOHOL SWAB AND ANALYZED IN A SEARLE 1195 GAMMA COUNTER.            |
|                                                                              |
| THE SUMMARY OF THE DETAILS IS AS FOLLOWS:                                    |
|                                                                              |
| 1. AT 0810, A  SYNCOR COURIER PLACED A RADIOACTIVE MATERIAL PACKAGE ON       |
| COUNTER IN ROOM 4059.  THE PACKAGE CONTAINED ONE UNIT DOSE OF TECHNETIUM-99m |
| AND ONE UNIT DOSE OF GALLIUM-67 (EACH UNIT  DOSE HAD AN ACTIVITY OF 10       |
| MILLICURIES).                                                                |
|                                                                              |
| 2. ON RECEIPT OF THE PACKAGE ITS EXTERIOR WAS SWIPED AND PLACED INTO A GAMMA |
| COUNTER.                                                                     |
|                                                                              |
| 3. AFTER RECORDING EXPOSURE RATES FROM THE PACKAGE SURFACE AND AT 1 METER,   |
| THE WIPE SAMPLE WAS CHECKED AT ~30000 CPM.                                   |
|                                                                              |
| 4. TWO SUCCESSIVE REWIPES OF THE PACKAGE EXTERIOR YIELDED ~25000 AND ~11000  |
| CPM, RESPECTIVELY.                                                           |
|                                                                              |
| 5. SYNCOR WAS THAN CONTACTED TO INFORM THEM THAT THE PACKAGE WAS             |
| CONTAMINATED AND THAT THEY SHOULD CHECK THE DELIVERY DRIVER AND TRUCK FOR    |
| CONTAMINATION.                                                               |
|                                                                              |
| 6. THE VASDHS RAD SAFETY OFFICER WAS NOTIFIED.                               |
|                                                                              |
| 7. THE ASSISTANT RAD SAFETY OFFICER WAS INSTRUCTED TO MAKE A THROUGH         |
| EVALUATION OF THE PACKAGE.                                                   |
|                                                                              |
| 8. THE PACKAGE WAS THEN MOVED FROM ROOM 4509 TO ROOM 6056.                   |
|                                                                              |
| 9. FOURTEEN MORE WIPES OF FOURTEEN AREAS OF THE ENTIRE PACKAGE EXTERIOR      |
| SURFACE WERE MADE.  THE AREA RANGED FROM 75 SQ CM TO 300 SQ CM.              |
|                                                                              |
| 10.  THE 14 WIPES WERE ANALYZED IN A GAMMA COUNTER AND IT WAS DETERMINED     |
| THAT THREE AREAS BORE CONTAMINATION IN EXCESS OF THE LIMITS.                 |
|                                                                              |
| 11. SYNCORE WAS NOTIFIED THAT THE PACKAGE THEY HAD DELIVERED TO VASDHS HAD   |
| EXTERIOR CONTAMINATION IN EXCESS OF THE 10 CFR 70.87(i) LIMITS.              |
|                                                                              |
| 12. THE RADIONUCLIDE WAS IDENTIFIED AS Tc-99m.                               |
|                                                                              |
| REG 4 RDO(JONES) WAS NOTIFIED.                                               |
|                                                                              |
| NMSS EO(BRIAN SMITH) WAS NOTIFIED.                                           |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35419       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FITZPATRICK              REGION:  1  |NOTIFICATION DATE: 02/27/1999|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 22:39[EST]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        02/27/1999|
+------------------------------------------------+EVENT TIME:        21:56[EST]|
| NRC NOTIFIED BY:  STEVE CAROLIN                |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD BARKLEY      R1      |
|10 CFR SECTION:                                 |                             |
|AINT 50.72(b)(1)(vi)     INTERNAL THREAT        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |65       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FIRE ONSITE LASTING LESS THAN 10 MINUTES                                     |
|                                                                              |
| At 2156, the 'A' circulating water pump tripped, and the control room        |
| received indication of a fire in the pump motor.  The onsite fire brigade    |
| responded, and the fire was extinguished at 2204.  The licensee reported     |
| that the pump motor does not appear to be extensively damaged and that no    |
| other equipment was involved in the fire.  Reactor power was reduced to 65%  |
| of rated due to the unavailability of the circulating water pump.  No        |
| personnel injuries were reported.                                            |
|                                                                              |
| The licensee will inform the NRC resident inspector of this event.           |
|                                                                              |
| ********************  UPDATE AT 1129 ON 03/01/99 FROM BOB STEIGERWALD TO     |
| TROCINE ********************                                                 |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "This notification retracts an earlier report made February 27, 1999, at     |
| 2156, per 10CFR50.72(b)(1)(vi), due to a fire in the 'A' circulating water   |
| pump motor junction box. The motor was de-energized, and the fire was        |
| extinguished within 10 minutes. The emergency plan was not entered. The fire |
| did not affect the ability of plant personnel in the performance of duties   |
| required for safe operation of the plant."                                   |
|                                                                              |
| "The reporting criteria for fires is based on events that endanger the       |
| safety of the plant or interfere with personnel in the performance of duties |
| necessary for safe plant operations.  This was a small fire in a motor       |
| junction box, located in the non-safety-related area of the screenwell, that |
| was extinguished when the motor was de-energized.  Safe plant operation was  |
| not affected by the event.  Therefore, the 10CFR50.72(b)(1)(vi) event        |
| notification is being retracted."                                            |
|                                                                              |
| The licensee notified the NRC resident inspector.  The NRC operations        |
| officer notified the R1DO (Modes).                                           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35424       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 03/01/1999|
|    UNIT:  [] [2] []                 STATE:  SC |NOTIFICATION TIME: 00:17[EST]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        02/28/1999|
+------------------------------------------------+EVENT TIME:        20:40[EST]|
| NRC NOTIFIED BY:  MIKE HILL                    |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT HAAG          R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       98       Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| -AUTO Rx TRIP ON HIGH RCS PRESSURE DUE TO MAIN TURBINE CONTROL VALVES        |
| FAILING CLOSED-                                                              |
|                                                                              |
| At 1609 on 02/28/99, the Unit 2 electro-hydraulic control system lost        |
| various power supplies. Main steam pressure increased from a normal 900 psig |
| to 942 psig and reactor power increased from 100% to 100.4%.  The main       |
| turbine control valves had throttled closed for unknown reasons causing the  |
| main steam pressure to increase.  Main feedwater was throttled to reduce     |
| main steam header pressure since the turbine header pressure control station |
| had no effect.  Unit 2 was stabilized at 98.5% power with the main steam     |
| pressure at 938 psig and the main feedwater master control stations and the  |
| reactor control station in manual.                                           |
|                                                                              |
| At 2040 on 02/28/99, Unit 2 automatically tripped from 98% power due to a    |
| reactor protection system actuation (reactor coolant system high pressure    |
| trip).  All control rods inserted completely.  The main steam code safety    |
| valves lifted to dump steam to the atmosphere for approximately 10 minutes.  |
| Plant operators verified that the valves reseated properly.  Steam is being  |
| dumped to the main condenser.  The main feedwater system remained            |
| operational throughout the event.  The reactor control station was in        |
| automatic at the time of the trip.  Unit 2 is stable in hot shutdown mode.   |
|                                                                              |
| The licensee is investigating the cause of the main turbine control valves   |
| failing closed and plans to make necessary repairs.                          |
|                                                                              |
| Units 1 and 3 remain at 100% power and were unaffected by this event.        |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35426       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HATCH                    REGION:  2  |NOTIFICATION DATE: 03/01/1999|
|    UNIT:  [1] [2] []                STATE:  GA |NOTIFICATION TIME: 20:18[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        03/01/1999|
+------------------------------------------------+EVENT TIME:        19:29[EST]|
| NRC NOTIFIED BY:  BUTLER                       |LAST UPDATE DATE:  03/01/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT HAAG          R2      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Hot Shutdown     |0        Hot Shutdown     |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BOTH MAIN AND BACKUP PROMPT NOTIFICATION SYSTEMS WERE OUT OF SERVICE.        |
|                                                                              |
| THE NOAA WEATHER RADIO SIGNALS WERE NOT BEING RECEIVED AT HATCH FOR          |
| APPROXIMATELY 6 MINUTES.  IT APPEARS THAT DUE TO A LOOSE WIRE ON THE         |
| MICROPHONE, NOAA HAD NOT RECORDED ANYTHING ON THE TAPE THAT IS TRANSMITTED   |
| TO THE LICENSEE.  THE PROBLEM WAS CORRECTED AT 1935.                         |
|                                                                              |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35427       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VOGTLE                   REGION:  2  |NOTIFICATION DATE: 03/02/1999|
|    UNIT:  [] [2] []                 STATE:  GA |NOTIFICATION TIME: 04:32[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        03/02/1999|
+------------------------------------------------+EVENT TIME:        02:06[EST]|
| NRC NOTIFIED BY:  LEE MANSFIELD                |LAST UPDATE DATE:  03/02/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT HAAG          R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - MANUAL Rx TRIP FROM 100% DUE TO CLOSURE OF LOOP 3 MAIN FEEDWATER ISOLATION |
| VALVE -                                                                      |
|                                                                              |
| WHILE IN THE PROCESS OF HANGING AN OUTAGE CLEARANCE TAG ON UNIT 1 EQUIPMENT  |
| (SEE EVENT #35421), PLANT TECHNICIANS ERRONEOUSLY PULLED THE FUSES TO THE    |
| UNIT 2 LOOP 3 MAIN FEEDWATER ISOLATION VALVE (#2HV-5229) TO #3 STEAM         |
| GENERATOR CAUSING THE VALVE TO CLOSE.  CONTROL ROOM OPERATORS OBSERVED THE   |
| LOW WATER LEVEL IN #3 STEAM GENERATOR AND THE STEAM FLOW/FEED FLOW MISMATCH  |
| ANNUNCIATORS.                                                                |
|                                                                              |
| AT 0206 ON 03/02/99, CONTROL ROOM OPERATORS MANUALLY TRIPPED THE REACTOR     |
| FROM 100% POWER.  ALL CONTROL RODS INSERTED COMPLETELY.  THE AUXILIARY       |
| FEEDWATER SYSTEM ACTUATED, AS EXPECTED.  STEAM IS BEING DUMPED TO THE MAIN   |
| CONDENSER.                                                                   |
|                                                                              |
| DURING THE TRIP, AN ELECTRO-HYDRAULIC CONTROL (EHC) SYSTEM POWER SUPPLY      |
| FAILED CAUSING ERRONEOUS INDICATIONS OF MAIN CONDENSER VACUUM AND EHC        |
| PRESSURE.                                                                    |
|                                                                              |
| UNIT 2 IS STABLE IN MODE 3 (HOT STANDBY).                                    |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
+------------------------------------------------------------------------------+