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Event Notification Report for April 19, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/18/2000 - 04/19/2000

                              ** EVENT NUMBERS **

36712  36883  36903  

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|Fuel Cycle Facility                              |Event Number:   36712       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 02/21/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 12:22[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        02/21/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        10:00[CST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  04/18/2000|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |BRUCE JORGENSEN      R3      |
|  DOCKET:  0707001                              |ROBERT PIERSON       NMSS    |
+------------------------------------------------+JOSEPH GIITTER       IRO     |
| NRC NOTIFIED BY:  CALVIN PITTMAN               |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01, 4 HOUR REPORT -                                          |
|                                                                              |
| Material storage areas transferred from DOE to USEC contain uncharacterized  |
| potentially fissile material that does not comply with USEC NCS program      |
| requirements. The stored material also does not meet DOE NCS requirements.   |
| Responsibility for the storage areas was transferred to USEC for more rapid  |
| remediation of the non-conforming conditions, in part to support the Seismic |
| Upgrade Project in C-331 and C-335, and to improve overall site safety.      |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:  The DOE material storage areas were located  |
| within the boundaries of USEC leased space. Transfer to USEC control allows  |
| more timely remediation to establish double contingency controls on the      |
| material.  Timely remediation will improve overall site safety.  The         |
| material is in a stable condition and double contingency will be established |
| using USEC procedures.  These procedures ensure that safety is not degraded  |
| during the remediation actions.                                              |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED [BRIEF SCEANARIO(S) OF HOW           |
| CRITICALITY COULD OCCUR]:  In order for a criticality to be possible, more   |
| than a critical mass would need to be accumulated in an unsafe geometry.     |
| The stored material is primarily equipment items in which the fissile        |
| material is deposited in small quantities widely dispersed over large        |
| surface areas.                                                               |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY CONCENTRATION, etc):       |
| Since no NCS controls were applied to the equipment, double contingency can  |
| not be demonstrated.                                                         |
|                                                                              |
| ESTIMATED AMOUNT,  ENRICHMENT,  FORM OF LICENSED MATERIAL (INCLUDE PROCESS   |
| LIMIT AND %  WORST CASE CRITCAL MASS):  Unknown due to DOE previously        |
| controlling areas.                                                           |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:  No NCS controls (other than providing 10   |
| feet buffer zone) where in place.                                            |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:  |
| Areas are to be remediated in accordance with NCS program requirements.      |
|                                                                              |
| The NRC Resident Inspector has been notified of this event.                  |
|                                                                              |
| PGDP Problem Report No. ATRC-OO-1009:  PGDP Event Report No. PAD-2000-017.   |
|                                                                              |
| * * * UPDATE 1232 4/18/2000 FROM PITTMAN TAKEN BY STRANSKY * * *             |
|                                                                              |
| An additional area, DMSA 30 in C-337, was transferred from DOE to USEC on    |
| 4/18/2000 at 1000 CST. The NRC resident inspector has been informed of this  |
| update. Notified  R3DO (Ring), NMSS (Sturz).                                 |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   36883       |
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| FACILITY: BROWNS FERRY             REGION:  2  |NOTIFICATION DATE: 04/12/2000|
|    UNIT:  [] [2] []                 STATE:  AL |NOTIFICATION TIME: 17:57[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4           |EVENT DATE:        04/12/2000|
+------------------------------------------------+EVENT TIME:        14:10[CDT]|
| NRC NOTIFIED BY:  RAY SWAFFORD                 |LAST UPDATE DATE:  04/18/2000|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHRIS CHRISTENSEN    R2      |
|10 CFR SECTION:                                 |                             |
|AINB 50.72(b)(2)(iii)(B) POT RHR INOP           |                             |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL    |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| LEAK IN THE HPCI TEST RETURN HEADER TO THE CONDENSATE STORAGE TANK           |
|                                                                              |
| On 4/12/2000, at 14:10 while performing 2-SR-3.5.1 .7, HPCI Main and Booster |
| Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure, the    |
| Unit Operator (UO)observed unstable HPCI suction pressure, followed by an    |
| auto swap of the suction from the Condensate Storage Supply to the           |
| Suppression Pool. The UO then observed annunciator, 'HPCI PUMP SUCT          |
| CONDENSATE HDR LEVEL LOW'.  HPCI was tripped and declared inoperable.        |
| Subsequently a leak was discovered on the HPCI Test Return header to the     |
| CST.  The leak has been isolated. Unit conditions are stable.                |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
|                                                                              |
| * * * RETRACTION 1815 4/18/2000 FROM TIM GOLDEN TAKEN BY BOB STRANSKY * * *  |
|                                                                              |
| "TVA is retracting this report. Subsequent investigation into the cause of   |
| this event determined that the source of the leak was a separated weld in a  |
| non-safety related portion of the test return flowpath to the condensate     |
| storage tank. Testing and engineering analyses performed after the event     |
| demonstrated that the conditions which caused the event would not have       |
| prevented HPCI from performing it's safety function if required.             |
| Specifically, if HPCI had been called upon to mitigate an actual event,      |
| automatic closure of the test return control valve would have isolated the   |
| leak, thereby establishing a safety injection flow path to the reactor       |
| vessel. Therefore, this event is not reportable with respect to              |
| 10CFR50.72(b)(2)(iii) and is hereby retracted. The senior NRC resident       |
| inspector has been informed."                                                |
|                                                                              |
| Notified R2DO (Boland).                                                      |
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|Hospital                                         |Event Number:   36903       |
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| REP ORG:  ST. LUKE'S REGIONAL MEDICAL CENTER   |NOTIFICATION DATE: 04/18/2000|
|LICENSEE:  ST. LUKE'S REGIONAL MEDICAL CENTER   |NOTIFICATION TIME: 12:21[EDT]|
|    CITY:  BOISE                    REGION:  4  |EVENT DATE:        02/25/2000|
|  COUNTY:                            STATE:  ID |EVENT TIME:             [MDT]|
|LICENSE#:  11-27312-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/18/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DALE POWERS          R4      |
|                                                |FRITZ STURZ          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ETHAN FAIRBANKS              |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| On 2/25/2000, an individual was implanted with 58 I-125 seeds for prostate   |
| treatment. However, the activity of the seeds implanted (0.354 mCi/seed) was |
| higher than prescribed (0.27 mCi/seed). The licensee reported that, although |
| the actual dose to the prostate was similar to the planned treatment dose,   |
| since the activity of the implanted seeds exceeded the prescribed activity   |
| by more than 20%, this occurrence was being treated as a misadministration.  |
|                                                                              |
| The misadministration was discovered during a review performed on 4/17/2000. |
| The licensee reported that an error occurred when the seeds were being       |
| ordered, and that additional steps would be added to the procedure to        |
| prevent recurrence. The radiation oncologist has been notified, and he will  |
| inform the patient of the incident.                                          |
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