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Event Notification Report for April 20, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/19/2001 - 04/20/2001

                              ** EVENT NUMBERS **

37929  37930  37931  37932  37933  

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|General Information or Other                     |Event Number:   37929       |
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| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE: 04/19/2001|
|LICENSEE:  RADIATION ONCOLOGY OF PALM BEACH     |NOTIFICATION TIME: 11:53[EDT]|
|    CITY:  WEST PALM BEACH          REGION:  2  |EVENT DATE:        04/18/2001|
|  COUNTY:  PALM BEACH                STATE:  FL |EVENT TIME:             [EDT]|
|LICENSE#:  2842-1                AGREEMENT:  Y  |LAST UPDATE DATE:  04/19/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |DONALD COOL          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  FACSIMILE                    |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| The following is the text from a facsimile sent by the Florida Bureau of     |
| Radiation Control.                                                           |
|                                                                              |
| In November 2000, the licensee switched to metal needles requiring a         |
| new/different type of transfer tube for the Nucletron HDR unit which is used |
| to treat prostrate cancer patients. The new transfer tube was 1400mm long.   |
| The previous tube was 1200mm long.  Licensee physicist had a family          |
| emergency and left the country.  Replacement physicists were performing QA   |
| /QC on the HDR to treat a prostate patient when they noticed that the dwell  |
| position of the HDR unit was programmed to a 1200mm distance. Since November |
| it is possible that 18 prostrate patients may have essentially not been      |
| treated if the source really stopped 200 mm short.   Each patient received   |
| 3-4 HDR fractions and an external beam (linear accelerator dose).  Licensee  |
| has not yet been able to talk to their physicist and will not use the        |
| transfer tube until resolved.  Florida will conduct an on-site investigation |
| next week.                                                                   |
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|General Information or Other                     |Event Number:   37930       |
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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 04/19/2001|
|LICENSEE:  KLEINFELDER, INC.                    |NOTIFICATION TIME: 12:45[EDT]|
|    CITY:  TEMPE                    REGION:  4  |EVENT DATE:        04/19/2001|
|  COUNTY:                            STATE:  AZ |EVENT TIME:        05:00[MST]|
|LICENSE#:  7-409                 AGREEMENT:  Y  |LAST UPDATE DATE:  04/19/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHARLES MARSCHALL    R4      |
|                                                |DONALD COOL          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  FACSIMILE                    |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| THEFT OF MOISTURE/DENSITY GAUGE                                              |
|                                                                              |
| On 19 April 2001, the licensee reported the theft of a Campbell-Pacific      |
| moisture/density gauge, model CPN MC3, serial number M370403663, from the    |
| Foxtree Apartments, northwest corner of McKellips and Scottsdale Roads,      |
| Tempe, Arizona.  The gauge was locked in its transport container chained in  |
| the back of a 1999 Dodge Ram 1500, 2WD Quad Cab pickup, Arizona license CA   |
| 63664.  The truck itself was stolen early in the morning of 19 April.  The   |
| theft has been reported to the Tempe police.  A reward is being offered.     |
| The gauge contains approximately 8 millicuries of cesium 137 and 40          |
| millicuries of americium-beryllium.                                          |
|                                                                              |
| The State will notify the FBI, Mexico, and the states of Colorado, Nevada,   |
| Utah, New Mexico and California.                                             |
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|Power Reactor                                    |Event Number:   37931       |
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| FACILITY: MCGUIRE                  REGION:  2  |NOTIFICATION DATE: 04/19/2001|
|    UNIT:  [1] [2] []                STATE:  NC |NOTIFICATION TIME: 14:09[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/19/2001|
+------------------------------------------------+EVENT TIME:        12:30[EDT]|
| NRC NOTIFIED BY:  DON CRISP                    |LAST UPDATE DATE:  04/19/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |KERRY LANDIS         R2      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       80       Power Operation  |80       Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| A licensed employee was determined to be under the influence of alcohol      |
| during a for cause test.  The employee's access to the plant has been        |
| suspended.  NRC employees may contact the operations center for additional   |
| details.                                                                     |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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|Other Nuclear Material                           |Event Number:   37932       |
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| REP ORG:  U.S. ARMY                            |NOTIFICATION DATE: 04/19/2001|
|LICENSEE:  U.S. ARMY                            |NOTIFICATION TIME: 15:52[EDT]|
|    CITY:  ROCK ISLAND              REGION:  3  |EVENT DATE:        04/17/2001|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|
|LICENSE#:  12-00722-06           AGREEMENT:  Y  |LAST UPDATE DATE:  04/19/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RONALD GARDNER       R3      |
|                                                |CHARLES MARSCHALL    R4      |
+------------------------------------------------+JOSEPHINE PICCONE    NMSS    |
| NRC NOTIFIED BY:  JEFF HAVENER                 |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| LOST TRITIUM SOURCE                                                          |
|                                                                              |
| The U.S. Army reported the loss of a 1.6 Ci H-3 source.  The source is part  |
| of an M64A1 Sight.  The sight was undamaged and double bagged in plastic     |
| bags and then placed inside two cardboard boxes,  the outer box was          |
| unlabeled.  The sight was then transported to a local landfill in Jennings   |
| Parish, LA.   The licensee was unable to locate the sight at the landfill.   |
| The licensee will notify the State of Louisiana.                             |
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|Power Reactor                                    |Event Number:   37933       |
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| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 04/19/2001|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 17:24[EDT]|
|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        04/19/2001|
+------------------------------------------------+EVENT TIME:        14:40[CDT]|
| NRC NOTIFIED BY:  BRADLY MCMAHON               |LAST UPDATE DATE:  04/19/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RONALD GARDNER       R3      |
|10 CFR SECTION:                                 |                             |
|*UNA 50.72(b)(3)(ii)(B)  UNANALYZED COND OP     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       96       Power Operation  |96       Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| DEGRADED APPENDIX "R" FIRE BARRIER                                           |
|                                                                              |
| While conducting a walk down inspection of 10CFR50 Appendix R Barriers, two  |
| degraded gypsum walls were identified. The two walls are intended to serve   |
| as three hour rated Appendix R barriers.  The inspection of the walls        |
| revealed that a segment of the walls approximately 6 feet by 6 inches was    |
| not constructed as                                                           |
| required.  The two walls provide separation of safe shutdown equipment in    |
| the event of an Appendix R design basis fire.  The walls separate the        |
| charging pumps, a dedicated shutdown system component, from the safety       |
| injection pumps which are alternate shutdown system equipment.               |
|                                                                              |
| Although the walls are not constructed as designed, they appear to be        |
| completed to about 75% of design and are judged capable of providing some    |
| protection.  Nevertheless, the walls are declared inoperable and             |
| compensatory actions according to the Kewaunee Fire Plan have been           |
| initiated.  The walls are declared inoperable due to not having any          |
| documented analysis to support the design basis rating.                      |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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