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Event Notification Report for June 25, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           06/24/1999 - 06/25/1999

                              ** EVENT NUMBERS **

35855  35856  35857  35858  35859  

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|Fuel Cycle Facility                              |Event Number:   35855       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 06/24/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 05:18[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        06/23/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        20:50[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  06/24/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |MIKE JORDAN          R3      |
|  DOCKET:  0707001                              |ROBERT PIERSON       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MATT MAURER                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 24 HOUR REPORT - SAFETY SYSTEM ACTUATION                                     |
|                                                                              |
| "At 2050 CDT on 6/23/99, C-333A Autoclave Position 1 North received a High   |
| Autoclave Steam Pressure Alarm while in Technical Specification Requirement  |
| mode 5.  The Autoclave Steam Pressure Control System is required to be       |
| operable while in mode 5 per LCO 2.2,3.3.  An Increase in autoclave steam    |
| pressure was observed by the Autoclave Steam Pressure Control System and the |
| system isolated the steam from the autoclave as designed.  The autoclave was |
| placed in mode 2 and the cause of the safety system actuation is being       |
| investigated."                                                               |
|                                                                              |
| The NRC Resident Inspector has been notified of this event.                  |
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|Hospital                                         |Event Number:   35856       |
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| REP ORG:  U.S. VETERANS ADMINISTRATION         |NOTIFICATION DATE: 06/24/1999|
|LICENSEE:  DURHAM VA HOSPITAL                   |NOTIFICATION TIME: 15:00[EDT]|
|    CITY:  DURHAM                   REGION:  2  |EVENT DATE:        05/28/1999|
|  COUNTY:                            STATE:  NC |EVENT TIME:        12:00[EDT]|
|LICENSE#:  32-01134-01           AGREEMENT:  Y  |LAST UPDATE DATE:  06/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |AL BELISLE           R2      |
|                                                |FRED COMBS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  LYNNE McGUIRE                |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| LOSS OF IODINE-125 SEEDS INTO SANITARY SEWER                                 |
|                                                                              |
| "On May 28, 1999, two I-125 sources, with a combined activity of 0.584 mCi,  |
| were lost from the Medical Center.  The seeds had been implanted into a      |
| patient's prostate earlier in the day.  The patient had been instructed to   |
| save his urine so that any seeds passed in the urine could be recovered.  An |
| instruction sheet was posted on the door, directing that all urine, trash    |
| and linen be saved, and nurses had been trained for the procedure.  A nurse  |
| called nuclear medicine to report that two seeds were in the urine           |
| container.  When nuclear medicine personnel arrived to recover the seeds,    |
| the urine had been flushed into the sanitary sewer by another staff member   |
| on the floor.                                                                |
|                                                                              |
| "The toilet and urine container were surveyed with a portable low-energy     |
| gamma detector, and no residual activity was detected.  The sources are      |
| presumed to have gone into the sewer, and assuming the seeds remain covered  |
| by water, no significant exposure is expected to any individual member of    |
| the public.  On June 1, 1999, the loss of the sources was reported by phone  |
| to the VA National Health Physics Program.                                   |
|                                                                              |
| "In order to prevent recurrence of this type of incident, the nurses on ward |
| 7A have been retrained in the proper procedures.  In the future, implant     |
| patient rooms will be posted with larger signs saying 'hold urine, trash,    |
| linen'."                                                                     |
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|Power Reactor                                    |Event Number:   35857       |
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| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 06/24/1999|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 17:05[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        06/24/1999|
+------------------------------------------------+EVENT TIME:        15:41[EDT]|
| NRC NOTIFIED BY:  ROY GREEN                    |LAST UPDATE DATE:  06/24/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GLENN MEYER          R1      |
|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     A/R        Y       100      Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| AUTOMATIC REACTOR SCRAM WITH PARTIAL LOSS OF OFFSITE POWER                   |
|                                                                              |
| An automatic reactor scram occurred due to low reactor vessel water level.   |
| The low level condition was caused by the failure of a feedwater level       |
| controller.  All control rods inserted following the scram.  Offsite power   |
| line #5 failed to transfer following the scram, causing the following ESF    |
| actuations to occur:  reactor building ventilation isolation, standby gas    |
| treatment system initiation, Division 1 and 3 emergency diesel generator     |
| (EDG) initiation, and control room special filter train initiation.  In      |
| addition, operators manually closed the main steam isolation valves (MSIVs)  |
| in response to decreasing condenser vacuum caused by a loss of power to the  |
| offgas system.  The unit is currently in Hot Shutdown, with reactor vessel   |
| water level being controlled by the reactor core isolation cooling (RCIC)    |
| system, and decay heat being removed via the safety/relief valves (SRVs).    |
| The licensee plans to take the unit to Cold Shutdown.                        |
|                                                                              |
| The licensee is currently troubleshooting the offsite power line #5 in order |
| to restore power to affected systems.                                        |
| The NRC resident inspector has been informed of this event.                  |
|                                                                              |
| * * * Update at 2244 on 06/24/99 from Trombley taken by Stransky * * *       |
|                                                                              |
| Scram recovery activities are continuing.  Offsite power line #5 has been    |
| restored, and the Division 1 EDG has been secured.  The licensee is          |
| currently in the process of securing the Division 3 EDG.  Operators          |
| experienced some problems with the RCIC flow controller and have taken       |
| manual control of the system [see related EN 35859].  The NRC Operations     |
| Officer notified R1DO (Glenn Meyer).                                         |
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|Hospital                                         |Event Number:   35858       |
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| REP ORG:  ALASKA REGIONAL HOSPITAL             |NOTIFICATION DATE: 06/24/1999|
|LICENSEE:  ALASKA REGIONAL HOSPITAL             |NOTIFICATION TIME: 19:27[EDT]|
|    CITY:  ANCHORAGE                REGION:  4  |EVENT DATE:        06/24/1999|
|  COUNTY:                            STATE:  AK |EVENT TIME:        12:00[YDT]|
|LICENSE#:  50-18244-01           AGREEMENT:  N  |LAST UPDATE DATE:  06/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOSEPH TAPIA         R4      |
|                                                |ROBERT PIERSON       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BRADLEY CRUZ                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATIONS CAUSED BY INCORRECT REPLACEMENT PART IN           |
| APPLICATOR                                                                   |
|                                                                              |
| The licensee reported that four medical misadministrations occurred due to   |
| the installation of an incorrect replacement part into an applicator that is |
| used in conjunction with a brachytherapy device.  The affected part is an    |
| insert for a "Duiclos mini ovoid" applicator (manufacturer unknown),         |
| purchased from the Radiation Products Design catalog.  The supplied          |
| replacement part looks similar to the original one, but is slightly shorter  |
| (the parts are not imprinted with any identification number). Due to the     |
| differing dimensions, treatments given using the applicator result in the    |
| source being placed at a slightly different axial location than intended,    |
| resulting in less than prescribed doses to the treatment area.  The          |
| misadministrations are characterized as follows:  (1) patient prescribed     |
| 3000 rads (cGy), received 1874 rads; (2) patient prescribed 3000 rads,       |
| received 2035 rads; (3) patient prescribed 2500 rads, received 1822 rads;    |
| (4) patient prescribed 3000 rads, received 2004 rads.  This condition was    |
| discovered when an x-ray indicated that the source was slightly out of       |
| position.                                                                    |
|                                                                              |
| The licensee plans to contact the vendor in order to obtain the correct      |
| insert for the applicator.                                                   |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35859       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 06/24/1999|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 22:44[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        06/24/1999|
+------------------------------------------------+EVENT TIME:        22:07[EDT]|
| NRC NOTIFIED BY:  WALT TROMBLEY                |LAST UPDATE DATE:  06/24/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GLENN MEYER          R1      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Hot Shutdown     |0        Hot Shutdown     |
|                                                   |                          |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RCIC SYSTEM DECLARED INOPERABLE                                              |
|                                                                              |
| The Unit 2 reactor core isolation cooling (RCIC) system was declared         |
| inoperable after operators noticed swings of 200-300 gpm in the system flow  |
| rate.  The system is currently being used to provide level control to the    |
| reactor vessel following a scram [see related EN 35857].  The system flow    |
| rate stabilized after operators placed the RCIC flow controller in manual,   |
| so the licensee considers the system to be inoperable but functional.  The   |
| licensee is continuing to cool down Unit 2.  The licensee plans to inform    |
| the NRC resident inspector of this report.                                   |
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