United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 1999

Event Notification Report for November 2, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/01/1999 - 11/02/1999

                              ** EVENT NUMBERS **

35790  36284  36372  36379  36380  36381  36382  36383  36384  

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35790       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 06/03/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 14:44[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        06/02/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        16:30[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  11/01/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |DAVID HILLS          R3      |
|  DOCKET:  0707001                              |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  THOMAS WHITE                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THREE SPRINKLER SYSTEMS DECLARED INOPERABLE DUE TO CORRODED HEADS (24-hour   |
| report)                                                                      |
|                                                                              |
| "On 06/02/99 at 1630 CDT, the Plant Shift Superintendent (PSS) was notified  |
| that numerous sprinkler heads were corroded, affecting 16 sprinkler systems  |
| in C-337 and one system in C-333, such that the ability of the sprinklers to |
| flow sufficient water was called into question.  Subsequently, these         |
| sprinkler systems were declared inoperable, and TSR-required actions         |
| establishing roving fire patrols were initiated.  This deficiency was        |
| detected during scheduled system inspections conducted by Fire Protection    |
| personnel.  Currently, functionality of the sprinkler heads has not been     |
| fully evaluated by Fire Protection personnel, and the remaining cascade      |
| buildings are currently being inspected, and if necessary, this report will  |
| be updated to identify any additional areas.  It has been determined that    |
| this event is reportable under 10CFR76.120(c)(2) as an event in which        |
| equipment is disabled or fails to function as designed."  The NRC resident   |
| inspector has been notified of this event.                                   |
|                                                                              |
| * * * UPDATE AT 1022 EDT ON 06/04/99 FROM CAGE TO TROCINE * * *              |
|                                                                              |
| "Two sprinkler heads on system D-1 in C-337 and two sprinkler heads on       |
| system 27 in C-335 were identified to also be corroded.  These were          |
| identified to the PSS on 06/03/99 at 1600 CDT and 1601 CDT, respectively,    |
| and determined to require an update to this report by the PSS.  It has been  |
| determined that this event is reportable under 10CFR76.120(c)(2) as an event |
| in which equipment is disabled or fails to function as designed."  Paducah   |
| personnel notified the NRC resident inspector of this update.  The NRC       |
| operations officer notified the R3DO (Hills) and NMSS EO (Combs).            |
|                                                                              |
| * * * UPDATE AT 2152 EDT ON 06/17/99 FROM WALKER TO POERTNER * * *           |
|                                                                              |
| "Three sprinkler heads on system C-15 and five sprinkler heads on system B-8 |
| in C-333 were identified to also be corroded.  The PSS was notified of this  |
| condition at 1300 CDT on 06/17/99 and determined that an update to this      |
| report was required.  It has been determined that this event is reportable   |
| under 10CFR76.120(c)(2) as an event in which equipment is disabled or fails  |
| to function as designed."  Paducah personnel notified the NRC resident       |
| inspector of this update.  The NRC operations officer notified the R3DO      |
| (Madera).                                                                    |
|                                                                              |
| * * * UPDATE 1440 EDT 6/18/1999 FROM UNDERWOOD TAKEN BY STRANSKY * * *       |
|                                                                              |
| "Two sprinkler heads on system C-15 and one sprinkler head on system B-8 in  |
| C-333 were identified to have corrosion.  The PSS was notified of this       |
| condition at 1350 CDT on 06/18/99.  The area of the fire patrol for system   |
| C-15 was expanded to include the two heads identified as corroded.  The one  |
| head on system B-8 was in the area already being patrolled.  The PSS         |
| determined that an update to this report was required."  The NRC resident    |
| inspector has been informed of this update.  Notified R3DO (Madera).         |
|                                                                              |
| * * * UPDATE 1315 EDT 6/25/1999 FROM WALKER TAKEN BY STRANSKY * * *          |
|                                                                              |
| "Two sprinkler heads on system D-8 and three sprinkler heads on system D-7   |
| in C-337 were identified to have corrosion.  The PSS was notified of the     |
| condition on system D-8 at 0125 CDT on 06/25/99 and at 1019 CDT on 06/25/99  |
| for system D-7.  Both systems were immediately declared inoperable and LCO   |
| fire patrol actions were implemented.  It was determined that an update to   |
| this report was required."  The NRC resident inspector has been informed of  |
| this update.  Notified R3DO (Jordan).                                        |
|                                                                              |
| * * * UPDATE 2119 EDT 7/30/1999 FROM CAGE TAKEN BY STRANSKY * * *            |
|                                                                              |
| "Five sprinkler heads and one sprinkler piping tee on C-337 system D-7 were  |
| identified to have corrosion. The PSS was notified of these corroded system  |
| parts and declared the system inoperable at 0931 CDT on 07/30/99.  LCO       |
| required fire patrols of the affected area were initiated.  The PSS          |
| determined that an update to this event report was required."  The NRC       |
| resident inspector has been informed of this update.  Notified R3DO          |
| (Wright).                                                                    |
|                                                                              |
| * * * UPDATE 1655 EDT 7/31/1999 FROM WHITE TAKEN BY STRANSKY * * *           |
|                                                                              |
| "Two sprinkler heads on C-337 System D-1 were identified to have corrosion.  |
| The PSS was notified of these corroded system parts and declared the system  |
| inoperable at 1155 CDT on 7/31/99.  LCO required fire patrols of the         |
| affected area were initiated.  The PSS determined that an update to this     |
| report was required."  The NRC resident inspector has been informed of this  |
| update.  Notified R3DO (Wright).                                             |
|                                                                              |
| * * * UPDATE 1546 EDT 8/10/1999 FROM WHITE TAKEN BY STRANSKY * * *           |
|                                                                              |
| "Two sprinkler heads on C-337 system C-15 were identified to have corrosion. |
| The PSS was notified of these corroded system parts and declared the system  |
| inoperable at 1130 CDT on 8/10/99.  LCO required fire patrols of the         |
| affected area were initiated.  The PSS determined that an update to this     |
| report was required."  The NRC resident inspector has been informed of this  |
| update.  Notified R3DO (Burgess).                                            |
|                                                                              |
| * * * UPDATE AT 1154 EDT 8/22/99 FROM WALKER TO POERTNER * * *               |
|                                                                              |
| Four adjacent sprinkler heads on C-333 System B-1 were identified to have    |
| corrosion.  The PSS was notified of the corroded system parts and declared   |
| the system inoperable at 0918 CDT on 8/22/99.  LCO required fire patrols     |
| were initiated.  The PSS determined that an update to this report was        |
| required.  It has been determined that this event is reportable under        |
| 10CFR76.120(c)(2) as an event in which equipment is disabled or fails to     |
| function as designed.  The NRC resident inspector will be notified.  The NRC |
| operations officer notified the R3DO (Clayton).                              |
|                                                                              |
| * * * UPDATE 2015 EDT ON 8/28/99 FROM W. F. GAGE TO S. SANDIN * * *          |
|                                                                              |
| "Two adjacent sprinkler heads on C-337 System D-11 were identified to have   |
| corrosion.  The PSS was notified of these corroded system parts and declared |
| the system inoperable at 1420 CDT on 8/28/99.   LCO required fire patrols of |
| the affected area were initiated. The PSS determined that an update to this  |
| report was required."                                                        |
| Paducah personnel informed the NRC resident inspector.  The NRC operations   |
| officer notified the R3DO (Leach) and NMSS EO (Piccone).                     |
|                                                                              |
| * * * UPDATE 2037 EDT ON 8/29/99 FROM KEVIN BEASLEY TO S. SANDIN * * *       |
|                                                                              |
| "Two adjacent sprinkler heads on C-337 System D-15 were identified to have   |
| corrosion and the PSS declared the system inoperable at 0925 [CDT] on        |
| 8/29/99.  Also two adjacent heads on C-337 System D-10 were identified to    |
| have corrosion and the PSS declared the system inoperable at 1450.   LCO     |
| required fire patrols for both of the affected areas were initiated in the   |
| time frame required by TSR.  The PSS determined that an update to this       |
| report was required."  Paducah personnel informed the NRC resident           |
| inspector.  The NRC operations officer notified the R3DO (Leach) and NMSS EO |
| (Piccone).                                                                   |
|                                                                              |
| * * * UPDATE AT 0930 EDT ON 9/1/99  BY ERIC WALKER TO FANGIE JONES * * *     |
|                                                                              |
| Add two adjacent sprinkler heads on C-337 D-14.  Paducah personnel informed  |
| the NRC Resident Inspector.  The NRC operations officer notified the R3DO    |
| (David Hills) and NMSS (Robert Pierson).                                     |
|                                                                              |
| * * * UPDATE AT 1133 EDT ON 9/8/99  BY TOM WHITE TO FANGIE JONES * * *       |
|                                                                              |
| Add two adjacent sprinkler heads on C-331 System 26, system declared         |
| inoperable at 2155 CDT on 9/7/99.  An LCO required fire patrol for the       |
| affected area was initiated in the time frame required by the TSR.  Paducah  |
| personnel informed the NRC Resident Inspector.  The NRC operations officer   |
| notified the R3DO (Monte Phillips) and NMSS (Josie Piccone).                 |
|                                                                              |
| * * * UPDATE AT 0948 ON 9/30/99 BY ERIC WALKER TO DOUG WEAVER * * *          |
|                                                                              |
| Add two adjacent sprinkler heads on C-333  System B-15 were identified to    |
| have corrosion and the PSS declared the system inoperable at 0815 CDT on     |
| 9/30/99.  An LCO required fire patrol for the affected area was initiated in |
| the time frame required by the TSR.  The PSS determined that an update to    |
| this report was required.                                                    |
| Paducah personnel informed the NRC resident inspector.   The NRC operations  |
| officer notified the R3DO (Vegel) and NMSS (Cool).                           |
|                                                                              |
| * * * UPDATE AT 1600 ON 10/13/99 BY WALKER TO GOULD * * *                    |
|                                                                              |
| Two adjacent sprinkler heads on C-333 System A-11 were Identified to have    |
| corrosion and the PSS declared the system inoperable at 1307 CDT on          |
| 10/13/99.  An LCO required fire patrol for the affected area was initiated   |
| in the time frame required by the TSR,  The PSS determined that an update to |
| this report was required.  Paducah personnel informed the NRC resident       |
| inspector.   The NRC operations officer notified the R3DO (Madera) and NMSS  |
| (Moore).                                                                     |
|                                                                              |
| * * * UPDATE AT 1520 ON 10/19/99 FROM UNDERWOOD TAKEN BY STRANSKY * * *      |
|                                                                              |
| Six sprinkler heads on C-337 System D-16 were identified to have corrosion   |
| and the PSS declared the system inoperable at 1052 CDT on 10/19/99.  An LCO  |
| required fire patrol for the affected area was initiated in the time frame   |
| required by the TSR.  The PSS determined that an update to this report was   |
| required.  The NRC resident inspector has been informed of this update.  The |
| NRC Operations Officer notified R3DO (Jorgensen).                            |
|                                                                              |
| * * * UPDATE AT 2140 ON 10/19/99 FROM WALKER TAKEN BY STRANSKY * * *         |
|                                                                              |
| Seven sprinkler heads on C-337 System A-7 were identified to have corrosion, |
| and another four had been painted over.  In addition, three adjacent         |
| sprinkler heads on C-337 System A-8 were identified to have corrosion.  The  |
| PSS declared the systems inoperable at 1900 CDT on 10/19/99.  An LCO         |
| required fire patrols for the affected areas were initiated in the time      |
| frame required by the TSR.  The PSS determined that an update to this report |
| was required.  The NRC resident inspector has been informed of this update.  |
| The NRC Operations Officer notified R3DO (Wright).                           |
|                                                                              |
| * * * UPDATE AT 1713 ON 10/21/99 FROM CAGE TAKEN BY JOLLIFFE * * *           |
|                                                                              |
| Four sprinkler heads on C-337 System A-5, twelve sprinkler heads on C-337    |
| System A-8, three sprinkler heads on C-337 System A-9, and six sprinkler     |
| heads on C-337 System B-8 were identified to have corrosion.  On 10/21/99,   |
| the PSS declared System A-5 and A-9 inoperable at 1028 CDT, System A-8       |
| inoperable at 1227 CDT and System B-8 inoperable at 1406 CDT.   An LCO       |
| required fire patrol for the affected areas was initiated in the time frame  |
| required by the TSR..  The PSS determined that an update to this report was  |
| required.  The NRC Resident Inspector has been informed of this update.  The |
| NRC Operations Officer notified the R3DO Bruce Jorgensen.                    |
|                                                                              |
| * * * UPDATE AT 2128 ON 10/22/99 FROM ERIC WALKER TAKEN BY JOLLIFFE * * *    |
|                                                                              |
| At 1400 CDT on 10/22/99, the PSS was notified that numerous corroded         |
| sprinkler heads were discovered in C-337 on sprinkler systems B-1, B-3, B-5, |
| B-6, B-7, B-11 and D-17.  Due to the number of systems called into question, |
| the PSS declared all of the sprinkler systems in C-337 on the cell floor (a  |
| total of 66 systems) inoperable and TSR required actions establishing roving |
| fire patrols were initiated within the required time frame.  The PSS         |
| determined that an update to this report was required.  It has been          |
| determined that this event Is reportable under 10CFR76.120(c)(2) as an event |
| in which equipment is disabled or fails to function as designed.             |
| The NRC Resident lnspector has been informed of this update.  The NRC        |
| Operations Officer notified the R3DO Bruce Jorgensen.                        |
|                                                                              |
| * * * UPDATE AT 1239 ON 10/24/99 FROM TOM WHITE TAKEN BY JOLLIFFE * * *      |
|                                                                              |
| At 1200 CDT on 10/23/99, the PSS was notified that numerous corroded         |
| sprinkler heads were discovered in C-337 on sprinkler systems B-13 and B-14  |
| on the ground floor,  The PSS declared these systems inoperable and TSR      |
| required actions establishing roving fire patrols were initiated within the  |
| required time frame.  At 1600 CDT on 10/23/99, the PSS  was notified that    |
| numerous corroded sprinkler heads were discovered in C-337 on sprinkler      |
| systems A-16, B-12, C-8, C-12, C-15, D-5 and D-8 on the cell floor,  These   |
| systems have already been declared inoperable and fire patrols are already   |
| being performed.  The PSS determined that an update to this report was       |
| required.  It has been determined that this event is reportable under        |
| I0CFR76.120(c)(2) as an event in which equipment is disabled or fails to     |
| function as designed.  The NRC resident inspector has been informed of this  |
| update.  The NRC Operations Officer notified the R3DO Bruce Jorgensen.       |
|                                                                              |
| * * * UPDATE AT 1117 ON 10/25/99 FROM W. F. CAGE TAKEN BY SANDIN * * *       |
|                                                                              |
| At 1940 CDT on 10/24/99, the PSS was notified that numerous corroded         |
| sprinkler heads had been discovered on High Pressure Fire Water systems C-4, |
| C-5, C-6 and C-8, located in the C-337 building.  These systems had          |
| previously been declared inoperable, and fire patrols were already being     |
| performed at the time of discovery.  The PSS determined that an update to    |
| this report was required.  It has been determined that this event is         |
| reportable under 10CFR76.120(c)(2) as an event in which equipment is         |
| disabled or fails to function as designed.                                   |
| The NRC Resident Inspector has been notified of this update.  The NRC        |
| Operations Officer notified R3DO (Lanksbury) and NMSS (Brain Smith).         |
|                                                                              |
| * * * UPDATE AT 2235 ON 10/27/99 BY WHITE TAKEN BY MACKINNON * * *           |
|                                                                              |
| At 1517 CDT on 10/27/99, the PSS was notified that 9 corroded sprinkler      |
| heads had been discovered on High Pressure Fire Water System A-12 located in |
| the C-333 building.  This system has been declared inoperable and fire       |
| patrols have been initiated.  The PSS determined that an update to this      |
| report was required.  The NRC Resident Inspector has been notified of this   |
| update.  The NRC Operations Officer notified R3DO (Jordan) and NMSS EO       |
| (Hickey).                                                                    |
|                                                                              |
| * * * UPDATE AT 2150 ON 10/30/99 BY UNDERWOOD TAKEN BY WEAVER * * *          |
|                                                                              |
| At 1950 CDT on 10/30/99, the PSS was notified that numerous corroded         |
| sprinkler heads had been discovered on High Pressure Fire Water Systems A-5, |
| A-9, A-11, C-5, and C-7 in the C-333 building.  Reference ATR-1 1999-6699    |
| and 6702.  These systems have been declared inoperable and fire patrols have |
| been initiated.  Also, due to the number of inoperable sprinkler heads, the  |
| remaining systems on the cell floor of C-333 were called into question and   |
| declared inoperable.  Fire patrols for the entire cell floor have been       |
| initialed.  The PSS determined that an update to this report was required.   |
| The NRC Resident Inspector has been notified of this update.  The NRC        |
| Operations Officer notified R3DO (Jordan) and NMSS EO (Hickey).              |
|                                                                              |
| * * * UPDATE AT 2111 ON 10/31/99 BY UNDERWOOD TAKEN BY WEAVER * * *          |
|                                                                              |
| At 1412 CDT on 10/31/99, the PSS was notified that five corroded sprinkler   |
| heads had been discovered on High Pressure Fire Water System 9 in the C-335  |
| building.  There were two adjacent corroded heads discovered in two separate |
| locations and a third individual head at a different location.  The system   |
| was declared inoperable and fire patrols were initiated.  The corroded heads |
| have since been replaced and the system returned to operable status.   The   |
| NRC Resident Inspector was notified of this update.  The NRC Operations      |
| Officer notified R3DO (Jordan) and NMSS EO (Hickey).                         |
|                                                                              |
| * * * UPDATE AT 2121 ON 11/01/99 BY KEVIN BEASLEY TAKEN BY JOLLIFFE * * *    |
|                                                                              |
| At 0930 CST on 11/01/99, the PSS was notified that three corroded sprinkler  |
| heads had been discovered on the High Pressure Fire Water System B-4 in the  |
| C-337 building.  Two of these sprinkler heads are adjacent.  Two adjacent    |
| corroded sprinkler heads were also discovered on the High Pressure Fire      |
| Water System B-5 in the C-337 building.  These systems were declared         |
| inoperable and fire patrols were initiated.  Work has been initiated to      |
| replace the subject heads.  The NRC Resident Inspector has been notified of  |
| this update.  The NRC Operations Officer notified the R3DO Jim Creed.        |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36284       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 10/13/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 02:50[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        10/12/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        02:55[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  11/01/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |JOHN MADERA          R3      |
|  DOCKET:  0707001                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  J. UNDERWOOD                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 24 HOUR REPORT - VALID ALARM ON PRIMARY CONDENSATE, A SAFETY SYSTEM          |
|                                                                              |
| "At 0225 CDT on 10/12/99, the PSS office was notified that a Primary         |
| Condensate alarm was received on the C-360 position 3 autoclave Water        |
| Inventory Control System (WICS).  The WICS is required to be operable while  |
| heating in mode 5 according to TSR 2.1.4.3.  The autoclave was checked       |
| according to the alarm response procedure and subsequently removed from      |
| service and declared inoperable by the Plant Shift Superintendent.           |
| Troubleshooting was initiated and is continuing in order to determine the    |
| reason for the alarm.                                                        |
|                                                                              |
| "The safety system actuation is reportable to the NRC as required by Safety  |
| Analysis Report, section 6.9, table 1, criteria J.2, Safety System actuation |
| due to a valid signal as a 24-hour event notification."                      |
|                                                                              |
| The NRC Resident Inspector has been notified of this event.                  |
|                                                                              |
| * * * UPDATE AT 1551 ON 11/01/99 BY FRANK CAGE TO JOLLIFFE * * *             |
|                                                                              |
| "Troubleshooting and testing by System Engineering has determined that this  |
| actuation was caused by a short circuit of the primary condensate WICS       |
| wiring to its protective conduit.  Agitation of the conduit resulted in      |
| repeated false alarms on the WICS.  Given this finding and the fact that the |
| actuation occurred at a point in the heat cycle beyond the initial heatup    |
| and triple point when the maximum condensate is being produced, indicate     |
| that the actuation signal was not a result of water backed up in the drain   |
| line, which the WICS is designed to protect against.  Thus, this is an       |
| invalid signal.  Actuations caused by invalid signals are not reportable to  |
| the NRC."                                                                    |
|                                                                              |
| Therefore, this event is being retracted.                                    |
|                                                                              |
| The NRC Resident Inspector has been notified of this update.  The NRC        |
| Operations Officer notified the R3DO Jim Creed and the NMSS EO John Hickey.  |
|                                                                              |
| PGDP Problem Report #ATR-99-6175, PGDP Event Report #PAD-1999-112.           |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36372       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  LIBERTY HOSPITAL                     |NOTIFICATION DATE: 10/29/1999|
|LICENSEE:  LIBERTY HOSPITAL                     |NOTIFICATION TIME: 10:37[EDT]|
|    CITY:  LIBERTY                  REGION:  3  |EVENT DATE:        10/27/1999|
|  COUNTY:                            STATE:  MO |EVENT TIME:             [CDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  11/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MIKE JORDAN          R3      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TOM BROWN                    |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| On 10/27/1999, a patient was to receive a dose of 120 Gy (12,000 rad) by way |
| of implanted palladium seeds. The seeds that were ordered and delivered to   |
| the hospital had an activity of 1.05 millicuries each, instead of 1.4        |
| millicuries, which would have been needed to obtain the prescribed dose. The |
| physicians treating the patient made a decision to implant the seeds anyway, |
| resulting in a dose of 90 Gy, and to supplement the dose by external beam.   |
| However, the written prescription kept in the hot lab was not annotated to   |
| include this change in treatment.                                            |
|                                                                              |
| Therefore, this condition is being reported as a medical misadministration,  |
| in that the actual dose was 25% less than that prescribed. The licensee will |
| contact the NRC Region III office regarding this issue.                      |
|                                                                              |
| * * * UPDATE AT 1601 ON 11/01/99 BY TOM BROWN TO JOLLIFFE * * *              |
|                                                                              |
| The licensee desires to retract this event since palladium is regulated by   |
| the state of Missouri and not the NRC.                                       |
|                                                                              |
| The NRC Operations Officer notified the R3DO Jim Creed and NMSS EO John      |
| Hickey.                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36379       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 11/01/1999|
|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 01:50[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        10/31/1999|
+------------------------------------------------+EVENT TIME:        20:30[EST]|
| NRC NOTIFIED BY:  MUTZ                         |LAST UPDATE DATE:  11/01/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MIKE JORDAN          R3      |
|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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SAFEGUARDS DEGRADATION RELATED TO MONITORING A CONTROL ACCESS                |
|                                                                              |
| COMPENSATORY MEASURES TAKEN.                                                 |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED.                                     |
|                                                                              |
| SEE HOO LOG FOR ADDITIONAL INFORMATION.                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36380       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CRMI                                 |NOTIFICATION DATE: 11/01/1999|
|LICENSEE:  LAS PIEDRAS CONSTRUCTION             |NOTIFICATION TIME: 08:55[EST]|
|    CITY:  UTUADO                   REGION:  2  |EVENT DATE:        10/30/1999|
|  COUNTY:                            STATE:  PR |EVENT TIME:        09:00[EST]|
|LICENSE#:  52-25125-01           AGREEMENT:  N  |LAST UPDATE DATE:  11/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK LESSER          R2      |
|                                                |FRITZ STURZ       EO NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RHOE (CONSULTANT)            |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STOLEN MOISTURE DENSITY GAUGE                                                |
|                                                                              |
| A CPN MODEL MC-3 SERIAL NUMBER M-351102935 CONTAINING 10 MILLICURIES OF      |
| CS-137 AND 50 MILLICURIES OF AM-241 WAS STOLEN FROM LAS PIEDRAS CONSTRUCTION |
| COMPANY'S FACILITIES IN UTUADO, PR.  THE LOCAL POLICE DEPARTMENT WAS         |
| NOTIFIED AND THERE WILL BE A PRESS RELEASE.                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36381       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FARLEY                   REGION:  2  |NOTIFICATION DATE: 11/01/1999|
|    UNIT:  [] [2] []                 STATE:  AL |NOTIFICATION TIME: 09:38[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        11/01/1999|
+------------------------------------------------+EVENT TIME:        06:30[CST]|
| NRC NOTIFIED BY:  WHITE                        |LAST UPDATE DATE:  11/01/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK LESSER          R2      |
|10 CFR SECTION:                                 |                             |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STEAM GENERATOR EDDY CURRENT INSPECTION DETECTED TUBE DEGRADATION            |
|                                                                              |
| DURING EDDY CURRENT INSPECTION, THE INSPECTION RESULTS FROM STEAM GENERATORS |
| "2A" AND "2C" WERE IDENTIFIED AS BEING IN THE C-3 INSPECTION CATEGORY PER    |
| TECHNICAL SPECIFICATIONS.  EDDY CURRENT INSPECTIONS ARE CONTINUING AND IT IS |
| ANTICIPATED THE "2B" WILL LATER BE IDENTIFIED AS BEING IN THE C-3 INJECTION  |
| CATEGORY.   THE TUBE DEGRADATION WILL REQUIRED TUBE PLUGGING.  STEAM         |
| GENERATORS MAY BE REPLACED DURING THE NEXT UNIT REFUELING.  TO DATE THE      |
| PERCENTAGE OF DEFECTIVE TUBES IN S/G "A" - 2.9%, S/G "B" - 0.3% AND S/G "C"  |
| - 2.3%.                                                                      |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36382       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MCGUIRE                  REGION:  2  |NOTIFICATION DATE: 11/01/1999|
|    UNIT:  [1] [2] []                STATE:  NC |NOTIFICATION TIME: 16:12[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        11/01/1999|
+------------------------------------------------+EVENT TIME:        15:41[EST]|
| NRC NOTIFIED BY:  CHUCK RARY                   |LAST UPDATE DATE:  11/01/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK LESSER          R2      |
|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          N       0        Cold Shutdown    |0        Cold Shutdown    |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - PLANT SECURITY EVENT -                                                     |
|                                                                              |
| Unescorted plant access granted inappropriately.  Compensatory measures were |
| immediately taken upon discovery.  The licensee plans to notify the NRC      |
| Resident Inspector.  Contact the NRC Operations Officer for additional       |
| details.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36383       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FORT BLISS, TEXAS                    |NOTIFICATION DATE: 11/01/1999|
|LICENSEE:  FORT BLISS, TEXAS                    |NOTIFICATION TIME: 16:31[EST]|
|    CITY:                           REGION:  4  |EVENT DATE:        11/01/1999|
|  COUNTY:                            STATE:  TX |EVENT TIME:        11:30[CST]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  11/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |JAMES CREED          R3      |
+------------------------------------------------+JOHN HICKEY          NMSS    |
| NRC NOTIFIED BY:  BRIAN BRENISER               |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAE1 20.2202(b)(1)       PERS OVEREXPOSURE      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - POTENTIAL CONTAMINATION EVENT -                                            |
|                                                                              |
| At 1130 CST on 11/01/99, a soldier opened and then closed four chemical      |
| agent detectors to determine the presence of their 250 millicurie            |
| Americium-241 sources.  After closing the fourth detector, the soldier       |
| complained of itching and burning of her skin.  She was sent to the fort     |
| medical hospital to determine if she was contaminated.                       |
|                                                                              |
| * * *  UPDATE AT 1921 ON 11/01/99 FROM MAJOR COOPER TO JOLLIFFE * * *        |
|                                                                              |
| Fort Bliss Hospital determined that the soldier was not contaminated.  The   |
| NRC Operations Officer notified Region 4 (Linda Howell) and R3DO (Jim        |
| Creed).                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36384       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MALLINCKRODT PHARMACY                |NOTIFICATION DATE: 11/01/1999|
|LICENSEE:  MALLINCKRODT PHARMACY                |NOTIFICATION TIME: 16:40[EST]|
|    CITY:  PINE BROOK               REGION:  1  |EVENT DATE:        11/01/1999|
|  COUNTY:                            STATE:  NJ |EVENT TIME:        15:30[EST]|
|LICENSE#:  24-04206-14MD         AGREEMENT:  N  |LAST UPDATE DATE:  11/01/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MOHAMED SHANBAKY     R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JASON WILLMAN                |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAE1 20.2202(b)(1)       PERS OVEREXPOSURE      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - HANDLES OF TRANSPORT PACKAGES CONTAMINATED -                               |
|                                                                              |
| Carlos Express Company transported two packages of limited quantities of     |
| technetium-99m from St Joseph Hospital and Medical Center in Patterson, NJ,  |
| to Mallinckrodt Pharmacy in Pine Brook, NJ.  An NRC Region 1 inspector       |
| surveyed the packages upon arrival in Pine Brook and found two hot spots on  |
| the packages (2 mR/hr on each package handle).  Wipe tests determined        |
| 130,000 DPM on one handle and 100,000 DPM on the second handle.  There was   |
| no radiation above background on the transport truck or the driver.  The     |
| licensee isolated the packages, notified Carlos Express and St Joseph        |
| Hospital and Medical Center, and is continuing to investigate this incident. |
+------------------------------------------------------------------------------+