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Event Notification Report for August 16, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/15/2000 - 08/16/2000

                              ** EVENT NUMBERS **

37225  37226  37227  37228  37229  

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|Power Reactor                                    |Event Number:   37225       |
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| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 08/15/2000|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 01:45[EDT]|
|   RXTYPE: [1] GE-2                             |EVENT DATE:        08/15/2000|
+------------------------------------------------+EVENT TIME:        01:40[EDT]|
| NRC NOTIFIED BY:  JERE FREEMAN                 |LAST UPDATE DATE:  08/15/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       86       Power Operation  |78       Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF SECONDARY           |
| CONTAINMENT                                                                  |
|                                                                              |
| Two reactor building isolation valves (V-28-21 and V-28-22) are not          |
| performing their isolation function.  The plant is required to be in the     |
| shutdown mode by 0704 EDT on 8/15/00 and cold shutdown mode by 0904 EDT on   |
| 8/15/00.  The valves were discovered at 0304 EDT on 8/14/00 and the licensee |
| has been working on restoring their function.  The licensee is continuing to |
| try to restore their function and qualify other valves to perform their      |
| function.                                                                    |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| * * * UPDATE ON 08/15/00 AT 1241 ET BY WRONKA TAKEN BY MACKINNON * * *       |
|                                                                              |
| Correction:  This event notification corrects the above reported Oyster      |
| Creek Notification. The plant was required to be in shutdown mode by 0704 ET |
| today, 08/15/00.  A loss of Secondary Containment Integrity was discovered   |
| at 0304 ET on 08/14/00.  Subsequent troubleshooting determined at 1120 ET on |
| 08/14/00 that V-28-21 and V-28-22, Reactor Building Exhaust Valves, leak by  |
| when closed.  A 30 hour LCO, Cold Shutdown, was in effect at the time of the |
| initial notification which was determined to be not applicable and was       |
| exited at 0438 ET on 08/15/00.   R1DO (Cliff Anderson) notified.             |
|                                                                              |
| The NRC Resident Inspector was notified of this update by the licensee.      |
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|General Information or Other                     |Event Number:   37226       |
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| REP ORG:  TENNESSEE DIV OF RAD HEALTH          |NOTIFICATION DATE: 08/15/2000|
|LICENSEE:  CUMBERLAND MEDICAL CENTER            |NOTIFICATION TIME: 14:03[EDT]|
|    CITY:  CROSSVILLE               REGION:  2  |EVENT DATE:        08/14/2000|
|  COUNTY:                            STATE:  TN |EVENT TIME:        12:00[EDT]|
|LICENSE#:  R-18002               AGREEMENT:  Y  |LAST UPDATE DATE:  08/15/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE BOLAND          R2      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DEBRA SHULTS                 |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION                 |
|                                                                              |
| On 08/14/00, the Medical Physicist at Cumberland Medical Center called to    |
| report a therapy misadministration.  Two patients were treated for prostate  |
| cancer with I-125 implants.  The pre-plan called for patient 1 to be treated |
| with 78 seeds containing 0.326 millicurie per seed. The pre-plan called for  |
| patient 2 to be treated with 123 seeds containing 0.229 millicurie per seed. |
| During the post plan review, it was discovered that an error had occurred    |
| when ordering the seeds.  Patient 1 was treated with seeds containing 0.414  |
| mCi/seed and Patient 2 was treated with seeds containing 0.291 mCi/seed.     |
| The physicist has implemented measures to prevent reoccurrence.  The         |
| licensee will submit a written report within 15 days.                        |
|                                                                              |
| Tennessee event Report No. is TN-00-122.                                     |
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+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37227       |
+------------------------------------------------------------------------------+
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| REP ORG:  UNIVERSITY OF PITTSBURGH             |NOTIFICATION DATE: 08/15/2000|
|LICENSEE:  UNIVERSITY OF PITTSBURGH             |NOTIFICATION TIME: 16:20[EDT]|
|    CITY:  PITTSBURGH               REGION:  1  |EVENT DATE:        08/15/2000|
|  COUNTY:                            STATE:  PA |EVENT TIME:        14:00[EDT]|
|LICENSE#:  37-00245-02           AGREEMENT:  N  |LAST UPDATE DATE:  08/15/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLIFFORD ANDERSON    R1      |
|                                                |PHILIP TING          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  M SHEETZ                     |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION INVOLVING YTTRIUM-90 (Y-90).              |
|                                                                              |
| This event occurred at the University of Pittsburgh Presbyterian Hospital    |
| located at 200 Lothrop St, Pittsburgh, PA.                                   |
|                                                                              |
| A patient  was to have received 80 millicuries of Y-90 for cancer treatment. |
| The Y-90 was contained in glass microspheres which were to be transferred to |
| the patient cancer site via a catheter. The Thera Sphere delivery device     |
| made by Nordion did not delivery most of the microspheres to the patient and |
| at this time it is unknown how much of the 80 millicuries of Y-90 is still   |
| in the catheter.  The caller, a Health Physicist, did not know what caused   |
| the Nordion Thera Sphere delivery device to fail.  No one was contaminated   |
| or overexposed by this incident.  The patients physician was notified of the |
| potential Medical Misadministration.  NRC Region 1 Jim Dwyer was notified of |
| this event by the licensee.  Half Life of Y-90 is 64 hours.                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37228       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 08/15/2000|
|LICENSEE:  SAIC, INC.                           |NOTIFICATION TIME: 17:12[EDT]|
|    CITY:  SAN DIEGO                REGION:  4  |EVENT DATE:        08/14/2000|
|  COUNTY:                            STATE:  CA |EVENT TIME:        18:00[PDT]|
|LICENSE#:  2290-037              AGREEMENT:  Y  |LAST UPDATE DATE:  08/15/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHUCK PAULK          R4      |
|                                                |PHILIP TING          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  D. BUNN                      |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT CONCERNING MISSING AMERICIUM-241 CALIBRATION SOURCE.  |
|                                                                              |
| State of California Department of Health was notified today by SAIC, Inc.,   |
| located in San Diego, that a 14 millicurie Americium-241 calibration source  |
| has been missing since yesterday evening.  The lab in which the calibration  |
| source was located has been surveyed and now other rooms are being surveyed  |
| to locate the missing  source.                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37229       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HATCH                    REGION:  2  |NOTIFICATION DATE: 08/16/2000|
|    UNIT:  [1] [] []                 STATE:  GA |NOTIFICATION TIME: 02:15[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        08/16/2000|
+------------------------------------------------+EVENT TIME:        00:30[EDT]|
| NRC NOTIFIED BY:  PAUL UNDERWOOD               |LAST UPDATE DATE:  08/16/2000|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PAUL FREDRICKSON     R2      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 1 DECLARED HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE DUE TO A   |
| FAILURE DURING SURVEILLANCE TESTING                                          |
|                                                                              |
| "While performing weekly exercise per Operating Order 00-01-0200S, High      |
| Pressure Coolant Injection turbine stop valve failed to close when trip      |
| solenoid pushbutton was depressed.                                           |
|                                                                              |
| "High Pressure Coolant Injection was declared inoperable.                    |
|                                                                              |
| "Cause of turbine stop valve failure to close is under investigation."       |
|                                                                              |
| With HPCI inoperable, Unit 1 entered a 14 day LCO Action Statement.  Both    |
| Maintenance and Engineering are evaluating corrective actions.  The licensee |
| will inform the NRC Resident Inspector.                                      |
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