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Event Notification Report for April 12, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/11/2001 - 04/12/2001

                              ** EVENT NUMBERS **

37672  37907  37908  37909  37910  37911  37912  37913  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   37672       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FROEDTERT MEMORIAL LUTHERAN HOSP     |NOTIFICATION DATE: 01/19/2001|
|LICENSEE:  FROEDTERT MEMORIAL LUTHERAN HOSP     |NOTIFICATION TIME: 16:59[EST]|
|    CITY:  MILWAUKEE                REGION:  3  |EVENT DATE:        01/17/2001|
|  COUNTY:                            STATE:  WI |EVENT TIME:        18:30[CST]|
|LICENSE#:  48-04193              AGREEMENT:  N  |LAST UPDATE DATE:  04/11/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROGER LANKSBURY      R3      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARCUM MARTZ                 |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION                                          |
|                                                                              |
| A patient being treated with a Leksell gamma system model 23004 type B       |
| received a treatment to the wrong site.  The intended dose or dose delivered |
| were not available.  The dose was delivered to the wrong location because    |
| the head frame had been installed in the wrong position.  The correct site   |
| was subsequently treated.  The hospital is in the process of informing the   |
| patient and the referring physician.  The attending physician did not        |
| believe the mistake would pose a problem to the patient.                     |
|                                                                              |
| ***** UPDATE AT 1439 EDT ON 04/11/01 FROM MARCUM MARTZ TO LEIGH TROCINE      |
| *****                                                                        |
|                                                                              |
| After discussions with the NRC Region 3 staff (Bob Gattone), it was          |
| determined that this event did not involve a medical misadministration.      |
| Therefore, the licensee is retracting this event notification.               |
|                                                                              |
| The NRC operations officer notified the R3DO (Wright) and NMSS EO (Smith).   |
|                                                                              |
| Call the NRC operations officer for a licensee contact telephone number.     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37907       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 05:55[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        04/10/2001|
+------------------------------------------------+EVENT TIME:        19:50[CDT]|
| NRC NOTIFIED BY:  SCOT MAGLIO                  |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK SHAFFER         R4      |
|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    |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SECURITY REPORT                                                              |
|                                                                              |
| Safeguards system degradation related to monitoring.  Immediate compensatory |
| measures taken upon discovery.                                               |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
|                                                                              |
| Refer to the HOO Log for additional details.                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37908       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [2] [3]               STATE:  SC |NOTIFICATION TIME: 11:17[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        10:35[EDT]|
| NRC NOTIFIED BY:  BRAMLETT                     |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MIKE ERNSTES         R2      |
|10 CFR SECTION:                                 |ED GOODWIN           NRR     |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       99       Power Operation  |99       Power Operation  |
|3     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SECURITY REPORT                                                              |
|                                                                              |
| Unescorted access granted inappropriately.  Immediate compensatory measures  |
| taken upon discovery.                                                        |
|                                                                              |
| Refer to the HOO Log for additional details.                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| See EN #37909.                                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37909       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CATAWBA                  REGION:  2  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [2] []                STATE:  SC |NOTIFICATION TIME: 11:30[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        03/31/1999|
+------------------------------------------------+EVENT TIME:             [EDT]|
| NRC NOTIFIED BY:  JIMMY BURGESS                |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MIKE ERNSTES         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          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SECURITY REPORT                                                              |
|                                                                              |
| Unescorted access granted inappropriately.  Immediate compensatory measures  |
| taken upon discovery.                                                        |
|                                                                              |
| Refer to the HOO Log for additional details.                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| See EN #37908.                                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37910       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK               REGION:  4  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [] []                 STATE:  KS |NOTIFICATION TIME: 11:37[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        04:50[CDT]|
| NRC NOTIFIED BY:  SIMS                         |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK SHAFFER         R4      |
|10 CFR SECTION:                                 |                             |
|*COM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| LOSS OF EMERGENCY PLAN SIRENS                                                |
|                                                                              |
| The site reported the loss of six emergency plan sirens which constitutes a  |
| major loss of emergency offsite communications for greater than one hour.    |
| This was caused by a loss of power due to high winds and downed power lines. |
| Power was restored to the sirens at 0807 CDST.                               |
|                                                                              |
| The NRC Resident Inspector was notified.   The licensee will make a press    |
| release to the news media.                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37911       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 12:06[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        11:18[EDT]|
| NRC NOTIFIED BY:  DON SHEEHAN                  |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES LINVILLE       R1      |
|10 CFR SECTION:                                 |                             |
|*PRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NATIONAL WEATHER SERVICE TONE-ALERT RADIOS OUT OF SERVICE FOR PLANNED        |
| MAINTENANCE                                                                  |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "[The] Emergency Planning Department at Nine Mile Point [Unit 1 was]         |
| notified by Jim Holman of [the] Oswego County Emergency Planning Department  |
| that the tone-alert radios for the National  Weather Service (NWS) were out  |
| of service (OOS) as of 1118 on 04/11/01 and are expected to be returned to   |
| service (RTS) at 1400 on 04/11/01.  The system was taken OOS for planned     |
| maintenance.  [The] Sheriff's Department [is] prepared to perform route      |
| alerts if necessary per procedure EPIP-EPP-30 (Prompt Notification System    |
| Problem Response).  [The] control room [was] notified [of the event] at 1125 |
| on 04/11/01."                                                                |
|                                                                              |
| "(10 CFR 50.72(b) and 10 CFR 50.72(a)(2) apply.)"                            |
|                                                                              |
| The licensee notified the NRC resident inspector and county sheriff.  The    |
| licensee also plans to notify applicable local and state agencies.           |
|                                                                              |
| (Refer to event #37912 for a similar event notification from Fitzpatrick.)   |
|                                                                              |
| * * * UPDATE ON 4/11/01 AT 1523 BY SHEEHAN TO GOULD * * *                    |
|                                                                              |
| The radio was back in service at 1515.                                       |
|                                                                              |
| The NRC Resident Inspector will be notified.    Reg 1 RDO(Linville) was      |
| notified                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37912       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FITZPATRICK              REGION:  1  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 12:24[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        11:18[EDT]|
| NRC NOTIFIED BY:  NICHOLAS AVRAKOTOS           |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES LINVILLE       R1      |
|10 CFR SECTION:                                 |                             |
|*PRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| NATIONAL WEATHER SERVICE TONE-ALERT RADIOS OUT OF SERVICE FOR PLANNED        |
| MAINTENANCE                                                                  |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "[The] Control Room [and] Emergency Planning Department [were] notified (via |
| [the] Nine Mile Point Unit 1 Control Room) by Jim Holman of [the] Oswego     |
| [County] Emergency Management Office that the tone-alert radios for the      |
| National  Weather Service (NWS) were out of service (OOS) as of 1118 on      |
| 04/11/01 and are expected to be returned to service (RTS) at 1400 on         |
| 04/11/01.  The system was taken OOS for planned maintenance.  [The] Oswego   |
| Sheriff's Department is prepared to perform route alerts if necessary."      |
|                                                                              |
| "Review - 10 CFR 50.72(b) [and] 10 CFR 50.72(a)(2)"                          |
|                                                                              |
| The licensee notified the NRC resident inspector and plans to notify         |
| applicable local and state agencies.                                         |
|                                                                              |
| (Refer to event #37911 for a similar event notification from Nine Mile       |
| Point.)                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37913       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MONTICELLO               REGION:  3  |NOTIFICATION DATE: 04/11/2001|
|    UNIT:  [1] [] []                 STATE:  MN |NOTIFICATION TIME: 19:01[EDT]|
|   RXTYPE: [1] GE-3                             |EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        17:15[CDT]|
| NRC NOTIFIED BY:  TIM WITSCHEN                 |LAST UPDATE DATE:  04/11/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GEOFFREY WRIGHT      R3      |
|10 CFR SECTION:                                 |                             |
|*INC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|*IND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| FAILURE OF STANDBY GAS TREATMENT SYSTEM CHARCOAL FILTERS TO PASS A TECHNICAL |
| SPECIFICATION REQUIRED SURVEILLANCE                                          |
|                                                                              |
| The licensee reported that the 'A' train of standby gas treatment did not    |
| pass a test involving an in-place charcoal absorber test with halogenated    |
| hydrocarbon tracer (freon).  This technical specification required           |
| surveillance test is performed approximately every 18-months.                |
|                                                                              |
| The unit was placed in a 7-day limiting condition for operation for the 'A'  |
| train of standby gas treatment prior to the test.  The unit remains in that  |
| LCO as a result of this test.  The 'B' train is currently operable.          |
|                                                                              |
| The licensee's investigation is in progress.  At this time, the licensee     |
| believes that the problem is the result of bypass leakage.  The licensee     |
| plans to verify the root cause and retest the system tomorrow.               |
|                                                                              |
| This event was reported as an event or condition that at the time of         |
| discovery could have prevented the fulfillment of the safety function of     |
| structures or systems that are needed to control the release of radioactive  |
| material and mitigate the consequences of an accident.                       |
|                                                                              |
| The licensee notified the NRC resident inspector and plans to notify state   |
| and local officials.                                                         |
+------------------------------------------------------------------------------+