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Event Notification Report for May 8, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/07/2001 - 05/08/2001

                              ** EVENT NUMBERS **

37966  37969  37970  37971  

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|Other Nuclear Material                           |Event Number:   37966       |
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| REP ORG:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION DATE: 05/05/2001|
|LICENSEE:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION TIME: 11:51[EDT]|
|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        05/04/2001|
|  COUNTY:  PHILADELPHIA              STATE:  PA |EVENT TIME:        16:30[EDT]|
|LICENSE#:  37-00118-07           AGREEMENT:  N  |LAST UPDATE DATE:  05/07/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |HAROLD GRAY          R1      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT FORREST               |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| DISCOVERY OF A BRACYTHERAPY MISADMINISTRATION INVOLVING A LEAKING IODINE-125 |
| SOURCE AT THE UNIVERSITY OF PENNSYLVANIA IN PHILADELPHIA                     |
|                                                                              |
| At approximately 1000 on 05/04/01, the licensee administered a prostate      |
| implant involving the 94 iodine-125 seeds on the order of about 1/2          |
| millicurie per seed.  (It is currently believed that the intended dosage for |
| the patient was approximately 47 millicuries.  The licensee reported that    |
| the intended dose is received from decay of the seeds which remain in the    |
| patient after treatment.)                                                    |
|                                                                              |
| Surveys were performed after the administration, and one of the implant      |
| needles had readings that were higher than expected.  At that time, it was   |
| assumed that a source was stuck in the applicable needle (a more likely      |
| scenario).  However, at approximately 1630, removable contamination (due to  |
| a leaking source) was discovered on the applicable needle.  It is currently  |
| believed that one of the seeds may have been damaged during the needle       |
| loading process, and that the damaged seed was implanted into the patient    |
| during treatment administration.                                             |
|                                                                              |
| At this time, there is only [one]complication that is expected as a result   |
| of the leaking iodine-125 source.  It was reported that the activity from    |
| the leaking source could get into the blood stream and that the thyroid      |
| would filter the radio-iodine.  Therefore, the patient may receive an        |
| unintended thyroid dose.                                                     |
|                                                                              |
| The authorized user was notified, and the patient was informed.  The patient |
| was also prescribed Lugols solution (a potassium iodide solution) to         |
| minimize the unintended iodine-125 thyroid uptake from the leaking seed.     |
| Initial estimates indicate a thyroid activity measurement of 73 nanocuries.  |
| [Based on normal thyroid turnover, a dose of about 320 millirem is           |
| calculated to the thyroid.]                                                  |
|                                                                              |
| The licensee plans to notify the referring physician.                        |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
|                                                                              |
| * * * UPDATE ON 5/7/01 @ 1059 FROM FORREST TO GOULD * * *                    |
|                                                                              |
| This update was to make the event clear.  The changes appear in the          |
| brackets[ ].                                                                 |
| Notified Reg 1 RDO(Cook) and NMSS EO(Frant)                                  |
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|Power Reactor                                    |Event Number:   37969       |
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| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 05/07/2001|
|    UNIT:  [] [2] []                 STATE:  CT |NOTIFICATION TIME: 15:23[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        05/07/2001|
+------------------------------------------------+EVENT TIME:        14:43[EDT]|
| NRC NOTIFIED BY:  STEPHEN BAKER                |LAST UPDATE DATE:  05/07/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |WILLIAM COOK         R1      |
|10 CFR SECTION:                                 |                             |
|*RPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       97       Power Operation  |0        Hot Standby      |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| MANUAL REACTOR TRIP - LOSS OF CIRCULATING WATER PUMP                         |
|                                                                              |
| Operators manually inserted a reactor trip when a circulating water  pump    |
| tripped.  The "A" pump was out for maintenance with divers in the water bay. |
| As a precaution for the safety of the divers, the travelling screens on the  |
| "B" water bay were stopped and tagged.  Kelp started building up on the "B"  |
| traveling screens and the licensee pulled the divers from the water and      |
| restarted the "B" screens.  As the screens started to move an increase in    |
| pressure across the screens and led to the pump trip.                        |
|                                                                              |
| The plant response to the trip was normal all control rods fully inserted.   |
| The plant is stable in mode three.  Reactor coolant pumps are running and    |
| decay is being removed by dumping steam to the main condenser (two           |
| circulating water pumps are still running).                                  |
|                                                                              |
| The licensee notified the NRC resident inspector, the State DEP and the town |
| of Waterford.  A press release is planned.                                   |
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|Other Nuclear Material                           |Event Number:   37970       |
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| REP ORG:  NEB DIV OF RADIOACTIVE MATERIALS     |NOTIFICATION DATE: 05/07/2001|
|LICENSEE:  NEB PUBLIC POWER DISTRICT            |NOTIFICATION TIME: 16:22[EDT]|
|    CITY:  SUTHERLAND               REGION:  4  |EVENT DATE:        05/01/2001|
|  COUNTY:                            STATE:  NE |EVENT TIME:             [CDT]|
|LICENSE#:  NE-10-03-03           AGREEMENT:  Y  |LAST UPDATE DATE:  05/07/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JEFF SHACKELFORD     R4      |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+SUSAN FRANT          NMSS    |
| NRC NOTIFIED BY:  JOHN FASSELL                 |                             |
|  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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| AGREEMENT STATE REPORT                                                       |
|                                                                              |
| The event took place at a coal plant where a nuclear gauge is installed on a |
| coal chute.  Not following established maintenance procedures led to workers |
| entering the chute with the source exposed.  A field of approximately 450    |
| mr/hr was created.  Whole body exposure was calculated based on a five hour  |
| stay time resulting in an estimate of 2.25 Rem for the most exposed          |
| individual.   Two other individuals were involved with lower total exposure. |
|                                                                              |
|                                                                              |
| The source involved is believed to be Cs-137 with an activity between 100    |
| and 200 mCi.                                                                 |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37971       |
+------------------------------------------------------------------------------+
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| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 05/08/2001|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 01:52[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        05/08/2001|
+------------------------------------------------+EVENT TIME:        00:09[EDT]|
| NRC NOTIFIED BY:  VEITCH                       |LAST UPDATE DATE:  05/08/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE JORGENSEN      R3      |
|10 CFR SECTION:                                 |                             |
|*RPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     M/R        Y       22       Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
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| REACTOR WAS MANUALLY SCRAMMED FROM 22% POWER DUE TO FAILURE OF RECIRC PUMP   |
| TO RESTART                                                                   |
|                                                                              |
| A manual scram was inserted at 0009 on 5/8/01.  The scram was conducted in   |
| accordance with plant procedures, IOI-8 "Manual Scram," due to a failure of  |
| the reactor recirculation pump "A" to restart during a downshift from fast   |
| to slow speed operation.  Plant response to the manual scram was as          |
| anticipated, all rods fully inserted, no ECCS actuations occurred and no     |
| SRVs opened.  Reactor vessel water level reached Level 3 (177.7 inches) and  |
| operators entered the Plant Emergency Instructions.  At 0016 the Plant       |
| Emergency Instructions were exited.  The cause of the "A" recirculation pump |
| failure to restart is being investigated.                                    |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
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