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Event Notification Report for April 25, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/24/2000 - 04/25/2000

                              ** EVENT NUMBERS **

36922  36923  36924  36925  36926  

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|General Information or Other                     |Event Number:   36922       |
+------------------------------------------------------------------------------+
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| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 04/24/2000|
|LICENSEE:  ST JAMES HOSPTIAL & HEALTH CENTER    |NOTIFICATION TIME: 15:23[EDT]|
|    CITY:  CHICAGO HEIGHTS          REGION:  3  |EVENT DATE:        04/20/2000|
|  COUNTY:                            STATE:  IL |EVENT TIME:        12:00[CDT]|
|LICENSE#:  IL-01289-01           AGREEMENT:  Y  |LAST UPDATE DATE:  04/24/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GARY SHEAR           R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOESPH KLINGER               |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PROJECTED DOSES TO A PATIENT MAY BE OFF BY GREATER THAN 20 PERCENT           |
|                                                                              |
| ST. JAMES HOSPITAL CALLED THE ILLINOIS DEPARTMENT OF NUCLEAR SAFETY  TO      |
| REPORT A MEDICAL THERAPY EVENT. FOUR IRIDIUM-192 SEEDS (APPROX. 5mCi each)   |
| WERE INSERTED THROUGH A PATIENTS NOSE TO TREAT THE BILE DUCT ON TUESDAY.     |
| THE PHYSICIAN HAD MARKED THE TUBE AT THE NOSE AS A REFERENCE POINT.  ON      |
| THURSDAY THE PHYSICIAN NOTICED THAT THE REFERENCE POINT HAD MOVED.  ST.      |
| JAMES HOSPITAL PERFORMED AN X-RAY AND NOTICED THAT THE SOURCES WERE NO       |
| LONGER AT THE TREATMENT SITE. THE LICENSEE BELIEVES THAT THE  DOSE TO THE    |
| INTENDED AREA WILL BE OUTSIDE THE RANGE OF THE 20% LIMIT.  THE LICENSEE      |
| BELIEVES THE TREATMENT WENT AS PLANNED FOR THE FIRST 24 HOURS AND THAT THE   |
| SEEDS MOVED SOMETIME DURING THE SECOND 24 HOURS.  TOTAL TREATMENT TIME WAS   |
| SUPPOSED TO HAVE BEEN 70 HOURS.                                              |
|                                                                              |
| THE LICENSEE IS PERFORMING A DOSE ASSESSMENT NOW AND WILL FORWARD A WRITTEN  |
| REPORT TO THE ILLINOIS DEPARTMENT OF NUCLEAR SAFETY WITHIN 15 DAYS.  THE     |
| LICENSEE PLANS TO CONTINUE THE TREATMENT ONCE THEY HAVE A BETTER ESTIMATE OF |
| DOSES TO THE TREATMENT SITE.                                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36923       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  SYNCOR INTERNATIONAL CORP            |NOTIFICATION DATE: 04/24/2000|
|LICENSEE:  SYNCOR INTERNATIONAL CORP            |NOTIFICATION TIME: 15:26[EDT]|
|    CITY:  STAMFORD                 REGION:  1  |EVENT DATE:        04/24/2000|
|  COUNTY:                            STATE:  CT |EVENT TIME:        05:00[EDT]|
|LICENSE#:  04-26507-01MD         AGREEMENT:  N  |LAST UPDATE DATE:  04/24/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN WHITE           R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+PHIL HARRELL         R4      |
| NRC NOTIFIED BY:  DAVID PELLICCIARINI          |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAAA 20.1906(d)           SURFACE CONT/ EXT RAD |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SURFACE CONTAMINATION FOUND ON PACKAGE DELIVERED TO SYNCOR STAMFORD, CT      |
| PHARMACY.                                                                    |
|                                                                              |
| A PACKAGE DELIVERED TO THE SYNCOR STAMFORD, CT. PHARMACY FACILITY FROM       |
| NORTHERN WESTCHESTER HOSPITAL, MOUNT KISCO, NY., WAS FOUND TO HAVE OUTSIDE   |
| SURFACE CONTAMINATION LEVEL OF 645,000 DPM/100 SQUARE CENTIMETER.  THE       |
| SURFACE CONTAMINATION OF THE PACKAGE WAS LIMITED TO THE TOP CORNER OF THE    |
| PACKAGE.  THE HIGHEST SURFACE CONTACT RADIATION LEVEL ON THE PACKAGE WAS     |
| 0.5MR/HR  (TOP CORNER OF THE PACKAGE).  THE SURFACE CONTAMINATION WAS FROM   |
| Tc-99m (145KeV GAMMA EMITTER, HALF LIFE OF ABOUT 6 HOURS).  THE PACKAGE WAS  |
| OPENED AND NO SURFACE CONTAMINATION WAS FOUND INSIDE THE PACKAGE.  THE       |
| DRIVER OF THE VEHICLE AND THE INSIDE OF THE VEHICLE THAT TRANSPORTED THE     |
| PACKAGE WERE SURVEYED AND NO CONTAMINATION WAS FOUND.  NORTHERN WESTCHESTER  |
| HOSPITAL WAS NOTIFIED BY SYNCOR OF THIS EVENT.  SYNCOR NOTIFIED NRC REGION 4 |
| (JEFF CRUZ) OF THIS EVENT.                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36924       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FARLEY                   REGION:  2  |NOTIFICATION DATE: 04/24/2000|
|    UNIT:  [1] [] []                 STATE:  AL |NOTIFICATION TIME: 16:26[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        04/24/2000|
+------------------------------------------------+EVENT TIME:        12:53[CDT]|
| NRC NOTIFIED BY:  WES CUMBEE                   |LAST UPDATE DATE:  04/24/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ANN BOLAND           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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC START OF THE PENETRATION ROOM FILTRATION SYSTEM DURING MAINTENANCE |
| ACTIVITIES.                                                                  |
|                                                                              |
| Maintenance investigation of a  high vibration on "1B" Spent Fuel Pool       |
| Exhaust fan resulted in the trip of the Spent Fuel Pool ventilation and      |
| subsequent autostart of the Penetration Room Filtration System.  All systems |
| operated as required.                                                        |
|                                                                              |
| Operations restarted the Spent Fuel Pool ventilation and secured the         |
| Penetration Room Filtration System.                                          |
|                                                                              |
| An investigation into this event is in progress.                             |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36925       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BROWNS FERRY             REGION:  2  |NOTIFICATION DATE: 04/24/2000|
|    UNIT:  [] [2] [3]                STATE:  AL |NOTIFICATION TIME: 17:01[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4           |EVENT DATE:        04/23/2000|
+------------------------------------------------+EVENT TIME:        22:08[CDT]|
| NRC NOTIFIED BY:  JOE BENNETT                  |LAST UPDATE DATE:  04/24/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ANN BOLAND           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          Y       100      Power Operation  |100      Power Operation  |
|3     N          N       0        Refueling        |0        Refueling        |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| EMERGENCY DIESEL GENERATOR "3ED" RECEIVED AND AUTOMATIC START SIGNAL.        |
|                                                                              |
| On 04/21/00 at 2208, the "3ED" Emergency Diesel Generator received an        |
| automatic start signal due to degraded voltage as a result of testing        |
| activities associated with the "3ED" 4 kv Shutdown Board.  At the time the   |
| start was received, the Diesel Generator and the 4 kv Shutdown Board were    |
| considered inoperable for their Technical Specification functions, therefore |
| the event was not deemed reportable as an Engineered Safety Feature (ESF)    |
| actuation.  Further review of the event by the plant staff along with the    |
| Senior Resident Inspector concluded that this event should have been         |
| considered an ESF actuation, since the automatic start was not preplanned,   |
| and the Diesel Generator started as the result of a valid initiation         |
| signal.                                                                      |
|                                                                              |
| The NRC Resident will be notified of this event notification by the          |
| licensee.                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36926       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 04/24/2000|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 17:06[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        04/24/2000|
+------------------------------------------------+EVENT TIME:        14:03[EDT]|
| NRC NOTIFIED BY:  ARDIE KISSINGER              |LAST UPDATE DATE:  04/24/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOHN WHITE           R1      |
|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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| INVALID ISOLATED SIGNAL WAS GENERATED                                        |
|                                                                              |
| During operation of Unit 2 at 100% power, it has been determined that the    |
| inboard Primary Containment Isolation Valves associated with the Containment |
| Radiation Monitors (CRMs) received an invalid isolation signal.  During      |
| maintenance activities in the panel to change out a previously failed relay  |
| for the "A" CRM, the relay for automatic isolation was disturbed and an      |
| invalid signal was generated.  The relay inputs a close signal to the        |
| inboard valves of both CRM's, and the invalid signal caused the "B" CRM to   |
| isolate.  The licensee is investigating this event.                          |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+