Event Notification Report for April 7, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/06/2000 - 04/07/2000

                              ** EVENT NUMBERS **

36053  36868  36870  36871  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36053       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UNIVERSITY OF CT HEALTH CENTER       |NOTIFICATION DATE: 08/21/1999|
|LICENSEE:  UNIVERSITY OF CT HEALTH CENTER       |NOTIFICATION TIME: 14:31[EDT]|
|    CITY:  FARMINGTON               REGION:  1  |EVENT DATE:        08/20/1999|
|  COUNTY:                            STATE:  CT |EVENT TIME:        17:45[EDT]|
|LICENSE#:  0613022               AGREEMENT:  N  |LAST UPDATE DATE:  04/06/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PETER ESELGROTH      R1      |
|                                                |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KEN PRICE                    |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION                                           |
|                                                                              |
| On 8/20/99, a possible medical misadministration occurred at University of   |
| CT Health Center located in Farmington, Conn.  The physician prescribed a    |
| dose of 13 millicuries P-32 (Chromic Phosphate) for a lung cancer patient.   |
| After injection, it was determined that only 6.9 millicuries of P-32 had     |
| been injected.  The physician issued a revised written directive for 7       |
| millicuries of P-32 based on the patients condition.                         |
|                                                                              |
| (Call the NRC Operations Center for a licensee contact telephone number.)    |
|                                                                              |
| * * * RETRACTION REPORTED BY KEN PRICE ON 04/06/00 AT 1622 EDT TAKEN BY      |
| MACKINNON * * *                                                              |
|                                                                              |
| The licensee is retracting this event after discussions with NRC Region 1    |
| (David Dwyer).  The Physician changed the written directive for the amount   |
| of dose that the patient was to have received. Therefore, this event is not  |
| reportable and is being retracted.  NRC R1DO (Jack McFadden) and NMSS EO     |
| (John Hickey) notified.                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36868       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  U.S. NAVY                            |NOTIFICATION DATE: 04/05/2000|
|LICENSEE:  U.S. NAVY                            |NOTIFICATION TIME: 13:00[EDT]|
|    CITY:  YUMA                     REGION:  4  |EVENT DATE:        04/04/2000|
|  COUNTY:                            STATE:  AZ |EVENT TIME:        15:30[MST]|
|LICENSE#:  45-23645-01NA         AGREEMENT:  Y  |LAST UPDATE DATE:  04/06/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |STEVE CAHILL         R2      |
+------------------------------------------------+SCOTT MOORE          NMSS    |
| NRC NOTIFIED BY:  CDR. GARY HIGGINS            |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STRONTIUM/YTTRIUM SOURCE LOST TO LANDFILL                                    |
|                                                                              |
| A generally licensed strontium/yttrium source, 500 mCi, from an 'In Flight   |
| Blade Inspection System' was improperly placed in a dumpster which in turn   |
| was dumped at a regular land fill.  The U.S. Navy is investigating the       |
| incident and trying to determine where and how deep the source is in the     |
| land fill.                                                                   |
|                                                                              |
| The U.S. Navy notified NRC Region 2 (M. Fuller) and intends to notify the    |
| State of Arizona.                                                            |
|                                                                              |
| ****************** UPDATE AT 0814 ON 04/06/00 FROM GARY HIGGINS TO LEIGH     |
| TROCINE ******************                                                   |
|                                                                              |
| The licensee called to provide the following correction to the original      |
| report:                                                                      |
|                                                                              |
| The licensee reported that they were provided with an incorrect activity for |
| the missing source.  They were originally informed that the activity was 500 |
| mCi when in fact the actual activity was 500 �Ci.                            |
|                                                                              |
| The licensee notified the NRC Region 2 office (Mike Fuller).  The NRC        |
| operations officer notified the R2DO (Cahill), R4DO (Jones), and NMSS EO     |
| (Sturz).                                                                     |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36870       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HATCH                    REGION:  2  |NOTIFICATION DATE: 04/06/2000|
|    UNIT:  [] [2] []                 STATE:  GA |NOTIFICATION TIME: 12:38[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        04/06/2000|
+------------------------------------------------+EVENT TIME:        10:00[EDT]|
| NRC NOTIFIED BY:  BARRY COLEMAN                |LAST UPDATE DATE:  04/06/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |STEVE CAHILL         R2      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| GROUP 1 ISOLATION OCCURRED DURING MAIN TURBINE CONTROL TESTING WHICH CAUSED  |
| THE REACTOR COOLANT SAMPLE VALVES TO CLOSE.                                  |
|                                                                              |
| During performance of Main Turbine Control testing, a Group 1 isolation      |
| occurred which caused Reactor Coolant sample valves 2B31 F019 & F020 (0.75"  |
| line; 1.0" valves) to close.  One of the jumpers installed during the Main   |
| Turbine Control test made the Main Turbine Logic think that the generator    |
| was tied to the line.  This caused the Main Turbine speed control to go to   |
| 1800 RPM because the main turbine speed control was selected to 1800 RPM     |
| instead of all valves closed.   When the operator reset the Main Turbine,    |
| all 4 Main Turbine Stop Valves opened as a result of the speed control being |
| selected to 1800 RPM.  A Group 1 isolation occurred due to the Main Turbine  |
| stop valves opening coincident with a low Main Condenser Vacuum.  Only the   |
| Reactor Coolant Sample Valves closed.  Main Steam Isolation valves and the   |
| Main Steam line drain valves remained closed during the Group 1 isolation.   |
| The licensee is continuing the Main Turbine Control Test.                    |
|                                                                              |
|                                                                              |
| The NRC Resident Inspector was notified of the event by the licensee.        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36871       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 04/06/2000|
|    UNIT:  [2] [] []                 STATE:  NY |NOTIFICATION TIME: 14:02[EDT]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        04/06/2000|
+------------------------------------------------+EVENT TIME:        12:05[EDT]|
| NRC NOTIFIED BY:  JOHN LAMB                    |LAST UPDATE DATE:  04/06/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JACK MCFADDEN        R1      |
|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        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SPENT FUEL POOL STORAGE RACKS BORAFLEX  DEGRADING.                           |
|                                                                              |
|                                                                              |
| An evaluation of a preliminary report on the Spent Fuel Pool storage racks   |
| Boraflex testing determined that degradation is occurring.  Some racks might |
| not be able to receive fuel and ensure the Technical Specification           |
| requirement of maintaining Keff <= to 0.95 with un-borated water could be    |
| assured.  Administrative controls will ensure that Keff is maintained <= to  |
| 0.95.  The design of the fuel racks was to allow full core off-loads for the |
| term of the license.                                                         |
|                                                                              |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
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