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Event Notification Report for October 8, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           10/07/1999 - 10/08/1999

                              ** EVENT NUMBERS **

36268  36269  36270  36271  36272  

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|Fuel Cycle Facility                              |Event Number:   36268       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 10/06/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 18:30[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        10/06/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        17:03[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  10/07/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |JOHN JACOBSON        R3      |
|  DOCKET:  0707002                              |JOHN GREEVES         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KEITH WILLIAMSON             |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| INFORMATION REPORT ON RUPTURE OF CIRCULATING WATER HEADER FOLLOWED BY AN     |
| OFFSITE NOTIFICATION (4-HOUR NOTIFICATION)                                   |
|                                                                              |
| The plant suffered a rupture in a 6-inch header on the plant circulating     |
| water header that does not affect present plant operation.  Work is in       |
| progress to isolate the leak.  Several thousand gallons of water have been   |
| released on site, and environmental sampling of the site outfalls is         |
| underway to determine if any release offsite of chlorine (water additive)    |
| has taken place.                                                             |
|                                                                              |
| Portsmouth personnel have notified the NRC resident inspector.               |
|                                                                              |
| (Call the NRC operations officer for a contact telephone number.)            |
|                                                                              |
| ******************** UPDATE AT 0103 ON 10/07/99 FROM ERIC SPAETH TO LEIGH    |
| TROCINE ********************                                                 |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth:     |
|                                                                              |
| "At approximately 1703 hrs on 10/06/99, a recirculating cooling water line   |
| rupture occurred on the plant.  A 6-inch line rupture caused a significant   |
| increase in flow through an NPDES outfall.  Monitoring has not determined a  |
| permitted limit exceedance or impact to local water tributaries.  However,   |
| [at 0008 hrs on 10/07/99,] a courtesy notification to [the Ohio              |
| Environmental Protection Agency (OEPA)] was made to advise of this upset     |
| condition."                                                                  |
|                                                                              |
| "[This is a 4-hour] notification to the NRC due to [the] plant notifying     |
| [another] government agency [ ... ]."                                        |
|                                                                              |
| "There was no loss of hazardous/radioactive material or                      |
| radioactive/radiological contamination exposure as a result of this event."  |
|                                                                              |
| Portsmouth personnel plan to notify the NRC resident inspector and the       |
| Department of Energy site representative.  The NRC operations center         |
| notified the R3DO (Jacobson), NMSS EO (Hickey), and IRO (Miller).            |
|                                                                              |
| * * * UPDATE 1601 10/7/1999 FROM LARSON TAKEN BY STRANSKY * * *              |
|                                                                              |
| "At 1205 hours on 10/7/99 Environmental Management personnel notified the    |
| Ohio Dept. of Natural Resources of an observed fish kill in a local          |
| tributary (Little Beaver Creek) that was attributed to the recirculating     |
| cooling water line rupture that occurred on 10/6/99. Additionally, the Ohio  |
| EPA was notified at 1240 hours on 10/7/99. A press release was also issued   |
| at 1600 hours on 10/7/99."                                                   |
|                                                                              |
| Notified R3DO (Shear).                                                       |
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|General Information or Other                     |Event Number:   36269       |
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| REP ORG:  STATE OF ILLINOIS                    |NOTIFICATION DATE: 10/07/1999|
|LICENSEE:  RUSH-PRES-ST. LUKE'S MEDICAL CENTER  |NOTIFICATION TIME: 00:43[EDT]|
|    CITY:                           REGION:  3  |EVENT DATE:        10/05/1999|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|
|LICENSE#:  IL-01766-01           AGREEMENT:  Y  |LAST UPDATE DATE:  10/07/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN JACOBSON        R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  PATRICIA LARKINS (NRC)       |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF A NOVOSTE CORPORATION BETA-CATHETER TREATMENT      |
| DEVICE DRIVE MECHANISM FAILURE AT ST. LUKE'S MEDICAL CENTER  (The facility's |
| location was not provided.)                                                  |
|                                                                              |
| The following text is a portion of an E-mail sent to the NRC operations      |
| center from the NRC Office of State Programs (Patricia Larkins) at 1650 on   |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce     |
| Sanza) to the NRC (Patricia Larkins) at 1409 on 10/05/99:                    |
|                                                                              |
| "FYI.  The license number is IL-01766-01"                                    |
|                                                                              |
| "-----Original Message-----  From: Gulczynski, Andy                          |
| Sent: Tuesday, October 05, 1999 12:05 PM                                     |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul                               |
| Cc: (ORS, Glen Ellyn DRM Staff)                                              |
| Subject: Reported Drive Mechanism Failure in Novoste Corporation             |
| Beta-Catheter Treatment Device "                                             |
|                                                                              |
| "Glenn Sullivan, RSO at Rush-Pres-St. Luke's Medical Center, [ ... ], just   |
| called me to report an event which occurred this morning."                   |
|                                                                              |
| "A patient was being treated with a Novoste Corporation Beta-Cath System     |
| (Model SRO.S03 using Novoste Source Train 139/99 in transfer device 7Z519).  |
| The device is used to treat arterial occlusions.   This system contains 56   |
| mCi of Sr-90 as of April 8, 1999, contained in 16 active seeds.  The source  |
| 'train' contains a total of 18 seeds, two of which are 'dummies', located at |
| the beginning and the end of the source train.  The sources are driven in to |
| and out of the catheter using saline solution (water pressure).  This system |
| is an 'all or nothing' system, meaning all the seeds are used in each        |
| treatment."                                                                  |
|                                                                              |
| "At the conclusion of today's treatment, the staff could not visually verify |
| the presence of all the sources within the machine.  They immediately        |
| removed the catheter from the patient; surveyed the patient, the catheter,   |
| and the room; and found no sources present.  They then connected the         |
| catheter to the machine and activated the drive mechanism.  Six active       |
| sources and one dummy source came out, which they placed into a shielded     |
| container.  They activated the drive mechanism again and 9 active sources,   |
| and one dummy source came out.  (This left one source unaccounted for.)      |
| They then surveyed the machine and confirmed the presence of the last source |
| within the machine, though they do not know exactly where it is located."    |
|                                                                              |
| "The patient suffered no adverse effects and received no unplanned exposure  |
| as a result of this event."                                                  |
|                                                                              |
| "Glenn Sullivan is preparing a written report, which will be sent to our     |
| Department."                                                                 |
|                                                                              |
| (Call the NRC operations officer for a licensee contact name and telephone   |
| number.)                                                                     |
|                                                                              |
| ******************** UPDATE AT 0044 ON 10/07/88 BY LEIGH TROCINE             |
| ********************                                                         |
|                                                                              |
| The following text is a portion of an E-mail sent to the NRC operations      |
| center from the NRC Office of State Programs (Patricia Larkins) at 1651 on   |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce     |
| Sanza) to the NRC (Patricia Larkins) at 1432 on 10/05/99:                    |
|                                                                              |
| "-----Original Message-----  From: Gulczynski, Andy                          |
| Sent: Tuesday, October 05, 1999 1:31 PM                                      |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul                               |
| Cc: (ORS, Glen Ellyn DRM Staff)                                              |
| Subject: Update to Novoste Corporation Beta Cath Event"                      |
|                                                                              |
| "Glenn Sullivan called again to inform us that a Novoste Corporation         |
| Representative will be at Rush-Pres-St. Luke's Medical Center tomorrow to    |
| investigate the cause of this event.  Glenn will keep us informed of any     |
| new                                                                          |
| developments. "                                                              |
|                                                                              |
| The NRC operations officer notified the R3DO (Jacobson) and NMSS EO          |
| (Hickey).                                                                    |
|                                                                              |
| ******************** UPDATE AT 0045 ON 10/07/88 BY LEIGH TROCINE             |
| ********************                                                         |
|                                                                              |
| The following text is a portion of an E-mail sent to the NRC operations      |
| center from the NRC Office of State Programs (Patricia Larkins) at 1653 on   |
| 10/06/99 which enclosed another E-mail from the State of Illinois (Bruce     |
| Sanza) to the NRC (Patricia Larkins) at 1436 on 10/06/99:                    |
|                                                                              |
| "-----Original Message-----  From: Gulczynski, Andy                          |
| Sent: Wednesday, October 06, 1999 1:35 PM                                    |
| To: Sanza, Bruce; Klinger, Joe; Eastvold, Paul                               |
| Cc: (ORS, Glen Ellyn DRM Staff); Merrihew, George                            |
| Subject: Update on Novoste Beta-Cath System"                                 |
|                                                                              |
| "Glenn Sullivan called me with an update to the Novoste Beta-Cath source     |
| drive mechanism failure:"                                                    |
|                                                                              |
| "Novoste service personnel were there today and dismantled the machine.      |
| They found the missing source in the 'belly' of the machine stuck to a       |
| magnet.  They don't know how or why yet.  They left the sources with Glenn   |
| and took the machine to their facility to perform tests on it, presumably to |
| figure out the root cause(s) of the failure."                                |
|                                                                              |
| "One of the sources involved in the event appeared to be damaged.  All of    |
| the sources were leak tested and none, including the damaged one, were       |
| leaking.  Glenn said that he would package the sources and ship them to the  |
| supplier."                                                                   |
|                                                                              |
| "A written report from Glenn Sullivan will be sent to our Department."       |
|                                                                              |
| The NRC operations officer notified the R3DO (Jacobson) and NMSS EO          |
| (Hickey).                                                                    |
+------------------------------------------------------------------------------+

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|Fuel Cycle Facility                              |Event Number:   36270       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 10/07/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 01:03[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        10/06/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        21:10[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  10/07/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |JOHN JACOBSON        R3      |
|  DOCKET:  0707002                              |JOHN HICKEY          NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  ERIC SPAETH                  |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01 RESPONSE (4-HOUR REPORT)                                  |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth:     |
|                                                                              |
| "On 10/06/99 at 2110 hrs, the Plant Shift Superintendent (PSS) was notified  |
| by NCS Engineering, that an Nuclear Criticality Safety Approval (NCSA)       |
| requirement was not being maintained in the X-333 process building during a  |
| maintenance evolution.  Maintenance personnel, while working on seal exhaust |
| pumps, removed the filter from the demister without prior non-destructive    |
| analysis (NDA) being completed."                                             |
|                                                                              |
| "Requirement #12 of NCSA-033_016.AO1 states in part [that] seal exhaust      |
| pumps/demisters shall be drained of oil then NDA measured for U-235 content  |
| prior to removal."                                                           |
|                                                                              |
| "At the direction of the [PSS,] the requirements for an NCS anomalous        |
| condition were initiated, and the area was boundaried off."                  |
|                                                                              |
| "There was no loss of hazardous/radioactive material or                      |
| radioactive/radiological contamination exposure as a result of this event."  |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:  An NDA measurement was not obtained;        |
| however, the demister was drained of oil.  Therefore, an unsafe mass is not  |
| anticipated.  The maximum enrichment for the seal exhaust is 3% U-235.       |
| Spacing was maintained; therefore, the overall safety [significance] is low. |
| (At the enrichment involved, the component is a favorable geometry)."        |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR):  In order for criticality to occur, a spacing      |
| violation would have to occur as well as a failure to NDA the equipment      |
| prior to removal."                                                           |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):    |
| Spacing [was] maintained.  Mass [was] assumed [to be] lost."                 |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS):  The equipment removed was only a  |
| part [of] the seal exhaust pump demister; therefore, a large mass is not     |
| anticipated.  The enrichment was at 3% in the form of UF4 with oil."         |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES:  NDA was not performed on seal demisters    |
| prior to removal.  The NDA is required to demonstrate that the component is  |
| less than a safe mass.  Spacing between components was maintained."          |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:  |
| At the direction of the [PSS,] the requirements for an NCS anomalous         |
| condition were initiated, and the [area was] boundaried off.  The filters    |
| removed will be scheduled to have NDA measurements performed."               |
|                                                                              |
| Portsmouth personnel stated that this event was a 4-hour notification        |
| because it involved a loss of one of two criticality controls without        |
| re-establishment within 4 hours.                                             |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector and the Department  |
| of Energy site representative.                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36271       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WEST VIRGINIA UNIVERSITY             |NOTIFICATION DATE: 10/07/1999|
|LICENSEE:  WEST VIRGINIA UNIVERSITY             |NOTIFICATION TIME: 14:22[EDT]|
|    CITY:  MORGANTOWN               REGION:  2  |EVENT DATE:        10/04/1999|
|  COUNTY:                            STATE:  WV |EVENT TIME:             [EDT]|
|LICENSE#:  47-23035-01           AGREEMENT:  N  |LAST UPDATE DATE:  10/07/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRIAN BONSER         R2      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+JOHN DAVIDSON        IAT     |
| NRC NOTIFIED BY:  KEN DOUGLASS                 |BARRY MANILLI        IAT     |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TRITIUM-FILLED EXIT SIGNS STOLEN FROM CREATIVE ARTS CENTER BUILDING          |
|                                                                              |
| On 10/4/1999, a University administrative assistant noticed that a           |
| tritium-filled exit sign had been stolen from a hallway in the creative arts |
| building. Upon further investigation, the licensee determined that up to     |
| five other signs were also missing from the building. The campus police were |
| notified, and a public safety report was filed. The licensee believes that   |
| the signs were stolen during the weekend of 10/2-3/1999. The licensee is     |
| currently researching specific information regarding the signs (model number |
| and activity).                                                               |
|                                                                              |
| The licensee may make a press release regarding this event.                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36272       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  COGEMA MINING INC.                   |NOTIFICATION DATE: 10/07/1999|
|LICENSEE:  COGEMA MINING INC.                   |NOTIFICATION TIME: 16:04[EDT]|
|    CITY:  MILLS                    REGION:  4  |EVENT DATE:        10/05/1999|
|  COUNTY:                            STATE:  WY |EVENT TIME:             [MDT]|
|LICENSE#:  SUA-1341              AGREEMENT:  N  |LAST UPDATE DATE:  10/07/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KRISS KENNEDY        R4      |
|                                                |JOHN GREEVES         NMSS    |
+------------------------------------------------+JOE HOLONICH         NMSS    |
| NRC NOTIFIED BY:  JOHN VASELIN                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MONITOR WELL PLACED IN EXCURSION STATUS                                      |
|                                                                              |
| "A routine biweekly water sample collected on October 5, 1999 from monitor   |
| well MW89, exceeded 2 of its 3 upper control limits (UCLs). A confirmation   |
| sample was collected on this date, which also exceeded 2 of its 3 UCLs.      |
| Monitor well MW89 has been placed on excursion status as per license Section |
| 11.2 and its sampling frequency is increased to weekly. MW89 is a perimeter  |
| ore zone monitor well located approximately 500 feet south of the Mine Unit  |
| 2 boundary, at the Christensen Mine, Campbell County Wyoming. The nearest    |
| community is Linch, Wyoming, approximately 15 miles to the southeast. Note   |
| that mining has been completed in Mine Unit 2 and it is currently on standby |
| status, awaiting for the second phase of groundwater restoration to begin."  |
|                                                                              |
| Data collected from the well, and the respective upper control limits are    |
| listed below:                                                                |
|                                                                              |
| Chloride      Conductivity         Alkalinity          Uranium               |
| Date                 mg/l           umhos/cm2            mg/l                |
| mg/l U3O8                                                                    |
|                                                                              |
| 10-5-99             17.5                   756                     123.6     |
| <0.4                                                                         |
| 10-7-99             17.1                   740                     121.9     |
| <0.4                                                                         |
|                                                                              |
| Limits -->          13.6                   823                     121.3     |
| none                                                                         |
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