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Event Notification Report for August 9, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/06/1999 - 08/09/1999

                              ** EVENT NUMBERS **

35996  35997  35998  35999  36000  36001  36002  36003  36004  36005  36006  36007 
36008  

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   35996       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  U.S. AIR FORCE                       |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  U.S. AIR FORCE                       |NOTIFICATION TIME: 09:36[EDT]|
|    CITY:  CANNON AFB               REGION:  4  |EVENT DATE:        07/08/1999|
|  COUNTY:  CURRY                     STATE:  NM |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  08/06/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TOM STETKA           R4      |
|                                                |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  LOYD UTTERBACK (fax)         |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MISSING TRITIUM EXIT SIGNS                                                   |
|                                                                              |
| In a letter dated 23 July 1999, the Commander of Cannon Air Force Base       |
| summarized that two (2) exit signs, each containing 20 Curies of tritium (in |
| 1997), were missing.  These signs were manufactured by SBS Technologies,     |
| Inc. located in Winston-Salem, NC (model #B-100 Luminexit or Betalux         |
| Self-Luminous Exit Signs).  The report includes corrective actions and       |
| further details.                                                             |
|                                                                              |
| HOO NOTE:  Refer to event #35907 which describes a similar occurrence.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35997       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 08/06/1999|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 10:03[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        08/06/1999|
+------------------------------------------------+EVENT TIME:        09:11[EDT]|
| NRC NOTIFIED BY:  DAVID T. WALSH               |LAST UPDATE DATE:  08/06/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD BARKLEY      R1      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| 1-HOUR SAFEGUARDS REPORT                                                     |
|                                                                              |
| DISCOVERY OF POTENTIAL COMPROMISE OF SAFEGUARDS INFORMATION.  COMPENSATORY   |
| MEASURES NOT FULLY IMPLEMENTED.  THE LICENSEE INFORMED THE NRC RESIDENT      |
| INSPECTOR.  CONTACT THE HEADQUARTERS OPERATIONS CENTER FOR ADDITIONAL        |
| DETAILS.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35998       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  SENTARA NORFOLK HOSPITAL             |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  SENTARA NORFOLK HOSPITAL             |NOTIFICATION TIME: 10:34[EDT]|
|    CITY:  NORFOLK                  REGION:  2  |EVENT DATE:        08/06/1999|
|  COUNTY:  NORFOLK                   STATE:  VA |EVENT TIME:        08:58[EDT]|
|LICENSE#:  45-00131-02           AGREEMENT:  N  |LAST UPDATE DATE:  08/06/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PAUL FREDRICKSON     R2      |
|                                                |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID WEIMER                 |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|IBBF 30.50(b)(2)(ii)     EQUIP DISABLED/FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STUCK SOURCE IN HDR AFTERLOADER DURING TESTING                               |
|                                                                              |
| AT 0858 EDT ON 8/6/99, A HIGH DOSE REMOTE (HDR) AFTERLOADER SOURCE STUCK IN  |
| THE EXTENDED POSITION DURING PHANTOM VISUAL STEP INDICATOR TESTING.  THE HDR |
| IS A GAMMA MED 12I CONTAINING A 4.5-CURIE IRIDIUM-192 SOURCE LOCATED IN THE  |
| RADIATION ONCOLOGY  4-MeV VAULT.  THREE HOSPITAL STAFF ENTERED THE VAULT     |
| FOR APPROXIMATELY 1-1/2 MINUTES EACH IN ORDER TO MANUALLY CRANK THE SOURCE   |
| BACK INTO THE STOWED POSITION.  THE RSO ESTIMATES THAT THE BRIEF EXPOSURE    |
| TIME IN THE 200 MILLIREM/HR FIELD RESULTED IN APPROXIMATELY 5-10 MILLIREM    |
| DOSE TO EACH INDIVIDUAL.  THE PERSONNEL FILM BADGES WILL BE PROCESSED TO     |
| CONFIRM THIS ESTIMATE.  THE SERVICE COMPANY IN RICHMOND, VIRGINIA, HAS       |
| DISPATCHED A TECHNICIAN TO RETURN THE SOURCE TO THE STOWED POSITION.  THIS   |
| PARTICULAR DEVICE WAS SCHEDULED FOR A SOURCE CHANGEOUT ON MONDAY WHICH WILL  |
| BE COMPLETED TODAY.  THE LICENSEE NOTIFIED THEIR REGION 2 INSPECTOR PRIOR TO |
| CONTACTING THE HEADQUARTERS OPERATIONS CENTER.                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35999       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DIABLO CANYON            REGION:  4  |NOTIFICATION DATE: 08/06/1999|
|    UNIT:  [1] [2] []                STATE:  CA |NOTIFICATION TIME: 11:20[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        08/06/1999|
+------------------------------------------------+EVENT TIME:        07:50[PDT]|
| NRC NOTIFIED BY:  DAVID PIERCE                 |LAST UPDATE DATE:  08/06/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |TOM STETKA           R4      |
|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          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| EMERGENCY SIREN COMPUTER INOPERABLE                                          |
|                                                                              |
| The shift supervisor was notified at 0750 PDT that the early warning siren   |
| (EWS) computer, located in the San Louis Obispo County Sheriff's office, had |
| failed at 0605 PDT. Licensee personnel transferred control of the emergency  |
| sirens to a computer located at the licensee's San Louis Obispo distribution |
| center at 0745 PDT. The NRC resident inspector will be informed of this      |
| notification by the licensee.                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36000       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  STATE OF CALIFORNIA                  |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  UNIVERSITY OF CALIFORNIA - IRVINE    |NOTIFICATION TIME: 11:59[EDT]|
|    CITY:  IRVINE                   REGION:  4  |EVENT DATE:        07/01/1999|
|  COUNTY:  ORANGE                    STATE:  CA |EVENT TIME:             [PDT]|
|LICENSE#:  1338-30               AGREEMENT:  Y  |LAST UPDATE DATE:  08/06/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TOM STETKA           R4      |
|                                                |CHARLES MILLER       IRO     |
+------------------------------------------------+DON COOL, NMSS       EO      |
| NRC NOTIFIED BY:  MARK SHAFFER (NRC REG 4)     |AARON A. DANIS, NMSS IAT     |
|  HQ OPS OFFICER:  LEIGH TROCINE                |KEN BROCKMAN, R4     IAT     |
+------------------------------------------------+DICK ROSANO, NRR     IAT     |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT REGARDING AN INTENTIONAL UNAUTHORIZED EXPOSURE OF AN  |
| INDIVIDUAL USING PHOSPHORUS-32                                               |
|                                                                              |
| The following text is a portion of a facsimile received in the NRC           |
| Operations Center from NRC Region 4:                                         |
|                                                                              |
| "The licensee determined that a researcher had placed approximately 15-30    |
| microcuries of phosphorus-32, less than 10% of the annual limit of intake    |
| (ALI), on a fellow researchers chair with the intention of exposing that     |
| individual to radiation."                                                    |
|                                                                              |
| "On July 2, 1999, during a routine survey of a laboratory and an adjacent    |
| office area by one of three researchers working in the laboratory, the       |
| researcher identified contamination on her office chair.  The contamination  |
| was significant enough that it met the criteria for reporting the incident   |
| to the licensee's Radiation Safety Office.  The Radiation Safety staff       |
| responded, performed additional surveys of the laboratory and adjacent       |
| office area, and ultimately bagged the chair and removed it to their         |
| radioactive waste storage area.  The only contamination found by the         |
| Radiation Safety staff was in the immediate vicinity of the fume hood and on |
| the researcher's chair.  A spill of P-32 had occurred in a fume hood in the  |
| laboratory on June 29 or 30.  Initially, it was assumed that this was the    |
| source of the contamination on the researcher's chair."                      |
|                                                                              |
| "On Tuesday, July 6, 1999, the Radiation Safety Officer contacted the        |
| Principal Investigator at the laboratory where the incident occurred to      |
| discuss the possible causes for the spill and to verify that the             |
| contamination had been removed.  At this time, the Principal Investigator    |
| told the Radiation Safety Officer that the contamination on the chair was    |
| intentionally placed there and that the researcher who was responsible had   |
| resigned. ..."                                                               |
|                                                                              |
| "The University of California - Irvine campus police have referred this case |
| to the Orange County District Attorney's Office, Environmental Protection    |
| Unit, for review. The Los Angeles [Federal Bureau of Investigation] Office   |
| [Weapons of Mass Destruction] Coordinator was contacted by [Radiologic       |
| Health Branch] at the request of NRC [Region 4] and was provided with the    |
| name of the Orange County District Attorney's Office contact for this        |
| case."                                                                       |
|                                                                              |
| "This information has been reviewed by the licensee and is current as of 3   |
| p.m. PDT on August 5, 1999."                                                 |
|                                                                              |
| Contact the NRC operations officer for additional information.               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36001       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 08/06/1999|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 13:37[EDT]|
|   RXTYPE: [3] CE                               |EVENT DATE:        07/27/1999|
+------------------------------------------------+EVENT TIME:        08:12[CDT]|
| NRC NOTIFIED BY:  ARTHUR E. WEMETT             |LAST UPDATE DATE:  08/06/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |TOM STETKA           R4      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FIRE PROTECTION ISSUE                                                        |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "During evaluation of the design bases for the plant sprinkler systems and   |
| to revise the sprinkler system specifications, it was identified on July 27, |
| 1999, that a fire area that contains essential cables was not in complete    |
| compliance with the requirements of 10 CFR Part 50, Appendix 'R.'   The      |
| requirement is that safe shutdown equipment is located in an area where      |
| there is 1) fire detection and automatic fire suppression equipment          |
| installed in the area and 2) separation of at least 20 feet with no          |
| intervening combustibles or adequate fire barriers.  It was determined       |
| [that] the sprinkler and detection systems did not provide coverage of the   |
| entire area.  It was also determined [that] though the essential cables are  |
| separated by at least [20] feet, there are intervening combustibles and no   |
| rated fire barriers between the cables.  Contingency actions (fire watches   |
| established in the effected zone) were implemented to address the            |
| non-conformance at the time of discovery.  Upon further review by licensing  |
| personnel, it was determined to be reportable in accordance with             |
| 10CFR50.72."                                                                 |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36002       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PRAIRIE ISLAND           REGION:  3  |NOTIFICATION DATE: 08/06/1999|
|    UNIT:  [1] [2] []                STATE:  MN |NOTIFICATION TIME: 15:20[EDT]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        08/06/1999|
+------------------------------------------------+EVENT TIME:        13:30[CDT]|
| NRC NOTIFIED BY:  BRAD ELLISON                 |LAST UPDATE DATE:  08/06/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK RING            R3      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF A DOOR CONFIGURATION THAT DID NOT MEET THE ACCEPTANCE CRITERIA  |
| FOR THE STRUCTURAL ANALYSIS OF THE DESIGN BASIS HIGH ENERGY LINE BREAK       |
| (HELB)                                                                       |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "During performance of monthly equipment walkdowns, it was discovered that a |
| door assumed to open as a vent path in the HELB analysis was jammed closed.  |
| The door is one of two doors in a double door assembly.  The analysis        |
| assumes that both doors open in order for room pressurization to meet the    |
| acceptance criteria for the structural analysis of the design basis HELB.    |
| The door was returned to an operable configuration.  The door was disabled   |
| for 20 minutes from the time of discovery."                                  |
|                                                                              |
| The length of time the door was in this configuration prior to discovery is  |
| not currently known.  The units are not in any limiting conditions for       |
| operation as a result of this issue.                                         |
|                                                                              |
| The door involved is door #182.  It is an Auxiliary Building door on the     |
| 735' level, and it goes to the Fuel Handling Area which is part of a special |
| vent zone.  It is also an HELB analysis door.                                |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36003       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  HERMANN HOSPITAL                     |NOTIFICATION TIME: 16:09[EDT]|
|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        08/04/1999|
|  COUNTY:                            STATE:  TX |EVENT TIME:        10:40[CDT]|
|LICENSE#:  L00650                AGREEMENT:  Y  |LAST UPDATE DATE:  08/06/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TOM STETKA           R4      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  HELEN WATKINS (facsimile)    |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT HERMANN HOSPITAL IN |
| HOUSTON, TEXAS  (ABNORMAL OCCURRENCE)                                        |
|                                                                              |
| The following text is a portion of a facsimile received from the Texas       |
| Department of Health Bureau of Radiation Control:                            |
|                                                                              |
| "Incident 7492 - Texas Licensee 650 - Texas is investigating.  [Abnormal     |
| Occurrence] criteria applies."                                               |
|                                                                              |
| "INITIAL NOTIFICATION OF THERAPY MISADMINISTRATION:  License L00650"         |
|                                                                              |
| "Hermann Hospital herewith notifies the Agency of a Misadministration of     |
| Radioactive Materials in a therapy procedure."                               |
|                                                                              |
| "Specifically, approximately 27.3 mCi of I-131 was administered to the wrong |
| patient at approximately 1040 a.m. [CDT] on August 4, 1999.  The error was   |
| discovered at 1315 [CDT] on August 4, 1999."                                 |
|                                                                              |
| "The patients involved were both outpatients, female Oriental's, with        |
| English as a secondary language.  Patient One (for whom the therapy was      |
| intended) is approximately 55 years old, while Patient Two (who received the |
| dose inadvertently) is approximately 64 years old."                          |
|                                                                              |
| "Patient Two had completed a scheduled bone density scan and [was] still in  |
| the Nuclear Medicine area.  At that time, she was mis-identified by the      |
| technologist who was to administer the I-131 dose.  Patient One was later    |
| discovered in the waiting area still needing to be dosed.  She later         |
| received the prescribed I-131 dose and returned home."                       |
|                                                                              |
| "The nuclear medicine physicians conferred with the Patient Two's personal   |
| care physician and with Hermann Hospital's Risk Management Office.  The      |
| patient was finally located at about 1600 [CDT] on August 4, 1999.  The      |
| Chief Nuclear Medicine Physician, the Nuclear Pharmacy Manager and the       |
| Radiation Safety Officer proceeded to Patient Two's Home and discussed the   |
| event with her and her husband.  With their consent, we initiated the        |
| administration of supersaturated Potassium Iodide (1 ml three times per day) |
| and Furosemide (Lasix) at an initial dosage of 40 mg/day at approximately    |
| 1720 [CDT] on August 4, 1999."                                               |
|                                                                              |
| "We are, of course, continuing our assessment of the events leading up to    |
| this misadministration and will prepare the reports required by TAC          |
| 289.252(f)(4)."                                                              |
|                                                                              |
| (Call the NRC operations officer for state and licensee contact              |
| information.)                                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36004       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WASHINGTON HOSPITAL CENTER           |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  WASHINGTON HOSPITAL CENTER           |NOTIFICATION TIME: 16:41[EDT]|
|    CITY:  Washington               REGION:  1  |EVENT DATE:        08/05/1999|
|  COUNTY:                            STATE:  DC |EVENT TIME:        17:00[EDT]|
|LICENSE#:  SNM-1446              AGREEMENT:  N  |LAST UPDATE DATE:  08/06/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RICHARD BARKLEY      R1      |
|                                                |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. BASS, JOHN GLENN         |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NCAR                     CARDIAC PACEMAKER      |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| EXPLANT OF AN IMPLANTED NUCLEAR-POWERED CARDIAC PACEMAKER FOLLOWING DEATH OF |
| A PATIENT                                                                    |
|                                                                              |
| A representative from the Washington Hospital Center located in Washington   |
| D.C. reported the explant of an implanted nuclear-powered cardiac pacemaker  |
| due to death of the patient at Georgetown Medical Center located in          |
| Washington D.C.  The patient passed away on 08/05/99, and Washington         |
| Hospital Center was notified at approximately 1700 on 08/06/99.  The cause   |
| of death was unknown, but it was reported that the pacemaker was not the     |
| cause of death.    The pacemaker has been explanted and has been in secure   |
| storage at Washington Hospital Center since this afternoon (08/06/99).       |
|                                                                              |
| The pacemaker contains 2.8 curies of Plutonium-238 (approximately 175        |
| milligrams).  It was manufactured by Cordis model OMNI Stancor (model #184A, |
| serial #586).                                                                |
|                                                                              |
| The licensee has contacted the manufacturer and plans to ship the pacemaker  |
| to the manufacturer for proper disposal.  The licensee also notified the NRC |
| Region 1 office (Jim Dwyer).                                                 |
|                                                                              |
| (Call the NRC operations officer for a site contact telephone number and     |
| address.)                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36005       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 08/06/1999|
|    UNIT:  [2] [] []                 STATE:  NY |NOTIFICATION TIME: 16:42[EDT]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        08/06/1999|
+------------------------------------------------+EVENT TIME:        14:00[EDT]|
| NRC NOTIFIED BY:  MIKE VASELY                  |LAST UPDATE DATE:  08/09/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD BARKLEY      R1      |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       99       Power Operation  |99       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| VOLUNTARY NOTIFICATION REGARDING POTENTIAL FOR CONTROL ROOM VENTILATION      |
| SYSTEM RECIRCULATION DUE TO SMOKE FROM FIRES ON THE OTHER SIDE OF THE HUDSON |
| RIVER                                                                        |
|                                                                              |
| Brush fires are currently burning along the west side of the Hudson River    |
| across from the Indian Point facility.  The fires pose no threat to          |
| operation of the facility or personnel because they are on the opposite side |
| of the river.  Recent changes in wind direction have caused the smoke plum   |
| to reach the site.  Control room personnel have begun to notice the odor but |
| are not currently adversely affected.  The control room ventilation system   |
| is currently in its normal configuration with outside air makeup.  The       |
| licensee may decide to place the system in its incident mode (full internal  |
| recirculation) in the future to maintain the comfort level should the        |
| condition persist.  This evolution will be performed using normal operating  |
| procedures, and as such, the licensee does not consider this to be an        |
| engineered safety feature actuation.                                         |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
|                                                                              |
| *** UPDATE AT 0403 ON 8/9/99 DURING MORNING STATUS CALL BY POERTNER ***      |
|                                                                              |
| The control room ventilation system was not placed in its incident mode.     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36006       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  IDAHO NAT ENGR & ENVIRONMENTAL LAB   |NOTIFICATION DATE: 08/06/1999|
|LICENSEE:  IDAHO NAL ENGR & ENVIRONMENTAL LAB   |NOTIFICATION TIME: 19:34[EDT]|
|    CITY:  IDAHO FALLS              REGION:  4  |EVENT DATE:        08/06/1999|
|  COUNTY:                            STATE:  ID |EVENT TIME:        16:00[MDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  08/07/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TOM STETKA           R4      |
|                                                |SUSAN SHANKMAN       NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  BOB TOONE, ED BROWN          |BILL BEECHER         PAO     |
|  HQ OPS OFFICER:  LEIGH TROCINE                |R. REAPE/D. SULLIVAN FEMA    |
+------------------------------------------------+RON GRAHAM           USDA    |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| COURTESY NOTIFICATION OF A DEPARTMENT OF ENERGY (DOE) IDAHO ALERT DECLARED   |
| DUE TO A FIRE IN THE DESERT ON DOE CONTROLLED PROPERTY                       |
|                                                                              |
| This event was classified as an Alert at 1600 MDT in accordance with DOE     |
| procedures.  This is not a classification driven by the Three Mile Island    |
| Independent Spent Fuel Storage Facility (ISFSI) Emergency Plan.  This is a   |
| courtesy notification.                                                       |
|                                                                              |
| A fire occurred that covers approximately 7 acres of DOE controlled          |
| property.  The Idaho Nuclear Engineering and Environmental Laboratory        |
| (INEEL) fire department and Bureau of Land Management (BLM) are fighting the |
| fire.  The fire is not threatening any site area.  It is located in the      |
| middle of a desert.  The fire fighters are currently in the "Mop Up Mode."   |
| There are no open flames, and the fire should be contained.  However, it is  |
| still windy.  The fire is believed to have been started due to a lightning   |
| strike during a wind storm and due to the ongoing dry weather.               |
|                                                                              |
| DOE Idaho made notifications per procedures to activate the Emergency        |
| Operations Center (EOC) and Emergency Control Center (ECC) to backup the     |
| INEEL and BLM firemen who are doing the actual fire fighting.  One offsite   |
| notification was made because BLM was assisting in fighting the fire.        |
|                                                                              |
| NRC assistance was not requested.                                            |
|                                                                              |
| (Call the NRC operations officer for a DOE contact telephone number.)        |
|                                                                              |
| *** UPDATE AT 0305 EDT ON 08/07/99 FROM BROWN TO POERTNER ***                |
|                                                                              |
| The DOE Alert was terminated at 0052 MDT on 08/07/99.  The fire was          |
| contained.  No facilities were threatened during the event.                  |
|                                                                              |
| The HOO notified the R4DO (Stetka), NMSS EO (Shankman), IRO (Miller), PAO    |
| (Gagner), FEMA (Sweetser), HHS-CDC (Wilson), EPA-NRC (Chancellor), and USDA  |
| (Graham).                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36007       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 08/08/1999|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 05:58[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        08/08/1999|
+------------------------------------------------+EVENT TIME:        03:40[EDT]|
| NRC NOTIFIED BY:  R. M. PEAL                   |LAST UPDATE DATE:  08/08/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RICHARD BARKLEY      R1      |
|10 CFR SECTION:                                 |                             |
|AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD  |                             |
|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                                   
+------------------------------------------------------------------------------+
| REACTOR CORE ISOLATION COOLING (RCIC) UNAVAILABLE                            |
|                                                                              |
| At 0340 EDT with Susquehanna Unit 1 operating at 100 percent power, the RCIC |
| leak detection logic 15-minute timer was energized when the "RCIC Leak       |
| Detection Logic 'B' Hi Temp" alarm energized.  The RCIC pipe routing area    |
| 15-minute timer was confirmed to be energized.  The Riley temperature module |
| for the RCIC pipe routing area was pegged up-scale.  Equipment room ambient  |
| temperature and RCIC pipe routing temperature both indicated 111 degrees     |
| Fahrenheit (Isolation setpoint 167 degrees).  No other high temperature      |
| alarms were noted.  An operator was dispatched to the RCIC pipe routing area |
| and verified no leak was present.  RCIC was manually isolated at 0346 EDT    |
| prior to the RCIC pipe routing area timer timing out, which would have       |
| caused an automatic isolation.  All other safety systems are operable.       |
|                                                                              |
| The NRC resident inspector has been notified.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36008       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 08/08/1999|
|    UNIT:  [] [2] [3]                STATE:  CA |NOTIFICATION TIME: 12:00[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        08/08/1999|
+------------------------------------------------+EVENT TIME:        08:10[PDT]|
| NRC NOTIFIED BY:  JACK WALLACE                 |LAST UPDATE DATE:  08/08/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |TOM STETKA           R4      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|3     N          Y       100      Power Operation  |100      Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY QUESTIONED DUE TO INATTENTIVENESS ON WATCH (1-Hour Security |
| Report)                                                                      |
|                                                                              |
| The fitness-for-duty of a security officer was questioned due to             |
| inattentiveness on watch.  Immediate compensatory measures were taken upon   |
| discovery.  (Call the NRC operations officer for additional details and for  |
| a site security contact telephone number.)                                   |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
+------------------------------------------------------------------------------+