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Event Notification Report for March 29, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/26/1999 - 03/29/1999

                              ** EVENT NUMBERS **

35164  35354  35399  35506  35516  35517  35518  35519  35520  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   35164       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WASHINGTON DEPARTMENT OF HEALTH      |NOTIFICATION DATE: 12/17/1998|
|LICENSEE:  PROFESSIONAL SERVICE INDUSTRIES, INC |NOTIFICATION TIME: 14:52[EST]|
|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        12/16/1998|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PST]|
|LICENSE#:  WN-IR021-1            AGREEMENT:  Y  |LAST UPDATE DATE:  03/27/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |IAN BARNES           R4      |
|                                                |WILLIAM KANE         NMSS    |
+------------------------------------------------+ROSEMARY HOGAN       IRD     |
| NRC NOTIFIED BY:  TERRY FRAZEE                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - OVEREXPOSURE OF INDIVIDUAL                          |
|                                                                              |
| The following information was received via email in the NRC Operations       |
| Center:                                                                      |
|                                                                              |
| Licensee: Professional  Service Industries, Inc.                             |
| City and state: Seattle, WA                                                  |
| License number: WN-IR021-1                                                   |
| Type of license: Radiography                                                 |
| Date of Event: December 16, 1998                                             |
| Location of Event: Seattle, WA                                               |
|                                                                              |
| ABSTRACT: The licensee had set up for a series of 2 minute ceiling shots in  |
| the parking garage of an office building in Seattle.  One radiographer       |
| monitored the floor above the parking garage while the shot took place.      |
| It is not clear at this time why or how, but two contractor employees were   |
| inside the parking garage with the second radiographer during the shots.     |
| During one shot the radiographer was talking with the contractor employees.  |
| Apparently, one of the contractor employees walked away and, for reasons not |
| known at this time, approached the source collimator.  The contractor        |
| employee's actions caused the collimator to become                           |
| dislodged from the source guide tube.  The contractor employee reassembled   |
| the source and guide tube at the same time that the radiographer became      |
| aware of the situation.  The radiographer immediately shouted a warning and  |
| ran to crank in the source.  The licensee RSO was notified and radiography   |
| operations were suspended.  The licensee began an immediate investigation,   |
| including a re-enactment, and notified the state radiation control program.  |
| Preliminary dose estimates for the extremities range from 600 to 1700 REM.   |
| The whole body exposure is estimated to be approximately 50 REM.  The        |
| overexposed individual's physician has already contacted REAC/TS.  An        |
| investigation team from the state radiation control program is on site.      |
|                                                                              |
| Activity and Isotope(s) involved: 60 Curies of Iridium-192.                  |
|                                                                              |
| * * * UPDATE ON 3/27/99 AT 1300 EST BY E-MAIL FROM TERRY FRAZEE TO FANGIE    |
| JONES * * *                                                                  |
|                                                                              |
| "Preliminary dose estimates for the extremities ranged from 600 to 1700 cSv  |
| (rem).  The whole body exposure was initially estimated to be approximately  |
| 50 cSv (rem).  An investigation team from the state radiation control        |
| program went to the site.  The Washington Radiation Control Program          |
| estimated that the individual received less than or equal to 5 cSv (rem)     |
| whole body, 680 cSv (rem) to the right thumb, 100 cSv (rem) to the right     |
| index finger, and 170 cSv (rem) to the palm of the left hand.  A cytogenetic |
| study verified that the whole body dose was in the range of less than 1 to   |
| 15 cSv (rem).  No physical signs of radiation damage to the contractor       |
| employee's hands were observed during the weeks following exposure.   The    |
| cause of the incident is attributed to the inattention of the radiographer.  |
| The licensee committed to re-train and complete an accelerated schedule of   |
| field audits on radiography personnel prior to resumption of radiography.    |
| This incident is closed."                                                    |
|                                                                              |
| The Headquarters Operations Officer notified R4DO (Charles Cain), NMSS EO    |
| (Robert Pierson), and IRO (Joseph Giitter).                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|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:  03/27/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN PELLET          R4      |
|                                                |FRED COMBS, NMSS     EO      |
+------------------------------------------------+                             |
| 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."         |
|                                                                              |
| * * * UPDATE ON 3/27/99 AT 1301 EST BY E-MAIL FROM TERRY FRAZEE TO FANGIE    |
| JONES * * *                                                                  |
|                                                                              |
| "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.  The licensee's estimated dose to          |
| the vessel wall was between 7,000 cGy (rad) and  10,800 cGy (rad).           |
|                                                                              |
| "On January 27, 1999, the state of Louisiana approved a SS&D evaluation for  |
| a new source wire containing markers to allow better visualization of the    |
| source.  The licensee will not resume the project until the new              |
| source wire is in place and has been thoroughly tested for visibility under  |
| fluoroscopy.  This incident file is closed."                                 |
|                                                                              |
| The Headquarters Operations Officer notified R4DO (Charles Cain), NMSS EO    |
| (Robert Pierson), and IRO (Joseph Giitter).                                  |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35399       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 02/24/1999|
|    UNIT:  [1] [] []                 STATE:  AZ |NOTIFICATION TIME: 19:12[EST]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        02/09/1999|
+------------------------------------------------+EVENT TIME:        10:45[MST]|
| NRC NOTIFIED BY:  DAN MARKS                    |LAST UPDATE DATE:  03/26/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ELMO COLLINS         R4      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF MISPOSITIONED OUTLET VALVES ON THE UNIT 1 ESSENTIAL CHILLERS    |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On February 9, 1999, at 0510 MST, Unit 1 essential chillers 1MECAE01 and    |
| 1MECBE01 were started in support of maintenance work in-progress on other    |
| equipment.  At approximately 1045 [MST], the temperatures of the essential   |
| chiller oil reservoirs were found to be reading 193F/190F, respectively.   |
| Within the next 15 minutes, the temperatures increased to 200F/195F,       |
| respectively.  Inspections revealed that oil cooler outlet valves ECAV321    |
| and ECAV421 were required to be adjusted to bring the oil cooler             |
| temperatures within the normal band of 140 - 150F.  Preliminary evaluations |
| indicate that craft personnel may have mispositioned the valves during the   |
| recent installation of insulation on adjacent chiller lines.  At             |
| approximately 1045 MST on February 9, 1999, the valves were adjusted, and    |
| the oil temperatures were returned within acceptable limits.  Reasonable     |
| operator actions corrected the temperature problem; however, an apparent     |
| human error (valve mispositioning) did occur that could have prevented the   |
| fulfillment of a safety function were it not corrected.  The Unit 2 and Unit |
| 3 lube oil cooler outlet valves were inspected and found to be in the        |
| correct position.                                                            |
|                                                                              |
| "Engineering personnel have since evaluated the impact of the mispositioned  |
| outlet valves on the essential chiller and determined that the mispositioned |
| valves could have caused the chillers to trip in approximately 6-1/2 hours.  |
| Therefore, in the event of a loss of coolant accident concurrent with a loss |
| of power, the essential chillers could not have performed their intended     |
| design basis function, and this event is reportable in accordance with       |
| 10CFR50.72(b)(2)(iii).  Reportability was determined at approximately 1445   |
| MST on February 24, 1999."                                                   |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| * * * RETRACTED ON 3/26/99 AT 1820 EST BY DAN MARKS TO FANGIE JONES * * *    |
|                                                                              |
| "On February 9, 1999 the Unit 1 Essential Chillers 1MECAE01 and 1MECRE01     |
| were running when the temperatures of the oil reservoirs were found to be    |
| elevated above the normal band.  It was initially thought that the chillers  |
| would have tripped, within 6.5 hours from the start of the chillers at 0510  |
| MST, on high compressor bearing oil temperature.                             |
|                                                                              |
| "Investigation of the event following the ENS notification has concluded     |
| that both chillers would have continued to operate and would not have        |
| tripped.  The chillers' oil temperatures had stabilized at elevated          |
| temperatures with enough margin from the trip setpoint to ensure their       |
| continued operation."                                                        |
|                                                                              |
| The licensee notified the NRC Resident Inspector.  The Headquarters          |
| Operations Officer notified the R4DO (Charles Cain).                         |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35506       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: GRAND GULF               REGION:  4  |NOTIFICATION DATE: 03/25/1999|
|    UNIT:  [1] [] []                 STATE:  MS |NOTIFICATION TIME: 00:18[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        03/24/1999|
+------------------------------------------------+EVENT TIME:        21:00[CST]|
| NRC NOTIFIED BY:  DAVID H. HANKS               |LAST UPDATE DATE:  03/26/1999|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES CAIN         R4      |
|10 CFR SECTION:                                 |                             |
|AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD  |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|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                                   
+------------------------------------------------------------------------------+
| High Pressure Core Spray (HPCS) Division 3 Diesel Generator declared         |
| inoperable.                                                                  |
|                                                                              |
| HPCS (Division 3) EDG oil level was discovered to be out of specification    |
| low during normal rounds.  The Division 3 EDG was conservatively declared    |
| inoperable until further evaluations can be performed to determine final     |
| disposition of oil leakage from its inspection cover.  The licensee entered  |
| Technical Specification 3.8.1 (72 hour limiting conditioning of operation).  |
| All Emergency Core Cooling systems including HPCS are fully operable.        |
| Earlier in the day an undervoltage spike on the electrical grid caused the   |
| Division 3 EDG to start. The diesel was properly secured.                    |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
|                                                                              |
| * * * RETRACTED ON 3/26/99 AT 1215 EST BY JAMES OWENS TO FANGIE JONES * * *  |
|                                                                              |
| After further evaluation, the licensee determined that the oil leak was      |
| minor and there was no need to declare the HPCS EDG inoperable.  The low oil |
| level was discovered on routine operator rounds at the lower end of its      |
| allowed band.  If there was any increase in leakage, it would have been      |
| noted on the operator rounds and further action could have been taken.       |
| Therefore, the conservative measure of declaring the HPCS EDG inoperable was |
| not necessary and the event notification is retracted.                       |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.  The Headquarters |
| Operations Officer notified the R4DO (Charles Cain).                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35516       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 03/26/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 16:08[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        03/26/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:56[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  03/26/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MELVYN LEACH         R3      |
|  DOCKET:  0707002                              |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KEITH VANDERPOOL             |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01, 24 HOUR  REPORT                                          |
|                                                                              |
| On March 25, 1999 at 0958, during a building NCS self assessment, an NCS     |
| Engineer discovered that a Nuclear                                           |
| Criticality Safety Approval (NCSA) requirement was not being maintained in   |
| the X-330 ACR 2 Small Diameter                                               |
| Container Storage Area.  NCSA-Plant025.A00 requirement #11 states that, "A   |
| minimum spacing of 23 inches center-to-center shall be maintained between    |
| small diameter containers within a storage area."  An F-can and GP can were  |
| discovered to be spaced 22" center-to-center, in violation of this           |
| requirement.                                                                 |
|                                                                              |
| All other controls were maintained during this event.  The spacing control   |
| was restored under direction of the NCS staff.                               |
|                                                                              |
| The facility personnel notified the NRC Resident Inspector and the DOE site  |
| representative.                                                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35517       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 03/27/1999|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 07:04[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        03/27/1999|
+------------------------------------------------+EVENT TIME:        06:05[EST]|
| NRC NOTIFIED BY:  ALAN RABENOLD                |LAST UPDATE DATE:  03/27/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MELVYN LEACH         R3      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Hot Shutdown     |0        Hot Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RHR PUMP FAILS TO START                                                      |
|                                                                              |
| While attempting to place the unit onto RHR shutdown cooling, the 'A' RHR    |
| pump failed to start. The unit is currently in Condition 3 at 227F, and the |
| main condenser is being used to remove decay heat. The licensee suspects     |
| that the failure of the pump to start may be due to a problem with a pump    |
| interlock. The licensee is currently troubleshooting the pump.               |
|                                                                              |
| The licensee entered Technical Specification Action Statement 3.0.3 due to   |
| the unavailability of shutdown cooling loop 'A'. The unit was shut down      |
| overnight in order to commence a refueling outage. The licensee will inform  |
| the NRC resident inspector of this report.                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   35518       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  HONOLULU RESOURCE RECOVERY VENTURE   |NOTIFICATION DATE: 03/27/1999|
|LICENSEE:  HONOLULU RESOURCE RECOVERY VENTURE   |NOTIFICATION TIME: 16:06[EST]|
|    CITY:  HONOLULU                 REGION:  4  |EVENT DATE:        03/27/1999|
|  COUNTY:                            STATE:  HI |EVENT TIME:        08:40[HST]|
|LICENSE#:  53-23291-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/28/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHARLES CAIN         R4      |
|                                                |ROBERT PIERSON       NMSS    |
+------------------------------------------------+JOSEPHINE PICCONE    NMSS    |
| NRC NOTIFIED BY:  GLENN MURATA                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAE1 20.2202(b)(1)       PERS OVEREXPOSURE      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL RADIATION EXPOSURE TO UNMONITORED PERSONNEL                        |
|                                                                              |
| A potential overexposure condition was discovered when a shredder line at    |
| the site was being put back in service.  When the level detector was         |
| energized the expected alarm was not received.  Investigation found that the |
| shutter on a KayRay Model 7062-BP sealed source (serial number 26139-D) was  |
| stuck open.  The source contains 50 millicuries of Cs-137.  A survey of the  |
| area measured 150-200 mR/Hr at 2-4 inches and about 20 mR/Hr at 1 meter.     |
| The radiation officer initial investigation has identified three potential   |
| unmonitored exposures with the following estimations of time and field for   |
| each:                                                                        |
|                                                                              |
| 1.  For 30 minutes with a whole body exposure rate of 50 mR/Hr and up to 200 |
| mR/Hr to extremities (hands),                                                |
| 2.  For 5-10 minutes to the lower body an exposure rate of 5-10 mR/Hr, and   |
| 3.  For 5-10 minutes at 10 mR/Hr and 20 minutes at 50 mR/Hr to the whole     |
| body, 20 minutes at 150-200 mR/Hr to the upper extremities, and another 10   |
| minutes at 150-200 mR/Hr to the lower body and lower extremities.            |
|                                                                              |
| Further investigation will be carried out to determine if others may have    |
| been exposed.  The line was shut down on 3/12/99 and the shutter was closed, |
| this was the last known time it was closed.  The licensee has yet to         |
| determine when the shutter may have been opened.                             |
|                                                                              |
| The licensee will submit a written report within 30 days.                    |
|                                                                              |
| Refer to HOO Log for contact numbers.                                        |
|                                                                              |
| * * * UPDATE 1747EST ON 3/28/99 FROM RON FRICK TO S.SANDIN * * *             |
|                                                                              |
| Gamma Corporation acting as physics consultants for Honolulu Resource        |
| Recovery Venure contacted the NRC requesting instructions for moving the     |
| device to a storage area.  Established conference call with R4DO(Cain) and   |
| NMSS EO(Pierson).                                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35519       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: THREE MILE ISLAND        REGION:  1  |NOTIFICATION DATE: 03/28/1999|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 05:19[EST]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP            |EVENT DATE:        03/28/1999|
+------------------------------------------------+EVENT TIME:        05:05[EST]|
| NRC NOTIFIED BY:  DeHOFF                       |LAST UPDATE DATE:  03/28/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JACK MCFADDEN        R1      |
|10 CFR SECTION:                                 |JOHN ZWOLINSKI       NRR     |
|NINF                     INFORMATION ONLY       |ROBERT SKELTON       IAT     |
|                                                |ROBERTA WARREN       IAT     |
|                                                |GREG SMITH           IAT     |
|                                                |WILLIAM BEECHER      OPA     |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| TRESPASSERS ARRESTED OUTSIDE OF PROTECTED AREA                               |
|                                                                              |
| The Pennsylvania State Police arrested five individuals for trespassing onto |
| the licensee's property. The individuals were part of a group of             |
| approximately 125 people who gathered in a demonstration outside the North   |
| Gate to observe the anniversary of the Unit 2 accident. The licensee         |
| reported that the demonstration was peaceful.                                |
|                                                                              |
| The licensee will inform the NRC resident inspector of this report.          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Research Reactor                                 |Event Number:   35520       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: STATE UNIV OF NEW YORK AT BUFFALO    |NOTIFICATION DATE: 03/28/1999|
|   RXTYPE: 2000 KW PULSTAR                      |NOTIFICATION TIME: 12:32[EST]|
| COMMENTS:                                      |EVENT DATE:        03/28/1999|
|                                                |EVENT TIME:        01:45[EST]|
|                                                |LAST UPDATE DATE:  03/28/1999|
|    CITY:  BUFFALO                  REGION:  1  +-----------------------------+
|  COUNTY:  ERIE                      STATE:  NY |PERSON          ORGANIZATION |
|LICENSE#:  R-77                  AGREEMENT:  Y  |GREG SMITH           IAT     |
|  DOCKET:  05000057                             |ROBERTA WARREN       IAT     |
+------------------------------------------------+ROBERT SKELTON       IAT     |
| NRC NOTIFIED BY:  MARK ADAMS                   |JOHN ZWOLINSKI       NRR     |
|  HQ OPS OFFICER:  STEVE SANDIN                 |JOSEPH GIITTER       IRO     |
+------------------------------------------------+AL ADAMS             PM      |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SECURITY REPORT.                                                             |
|                                                                              |
| POSSIBLE ATTEMPTED ENTRY INTO AREA CONTAINING SPECIAL NUCLEAR MATERIAL.      |
| IMMEDIATE COMPENSATORY MEASURES TAKEN UPON DISCOVERY.  LICENSEE WILL NOTIFY  |
| NEW YORK DEPARTMENT OF PUBLIC SAFETY AND THE LOCAL FBI.  CONTACT THE         |
| HEADQUARTERS OPERATIONS OFFICER FOR ADDITIONAL DETAILS.                      |
+------------------------------------------------------------------------------+