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Event Notification Report for May 9, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/08/2001 - 05/09/2001

                              ** EVENT NUMBERS **

37970  37971  37972  37973  37974  37975  

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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:  05/08/2001|
|  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.                                                                 |
|                                                                              |
| * * * UPDATE ON 05/08/01 AT 1429 ET BY JOHN FASSELL TAKEN BY MACKINNON * *   |
| *                                                                            |
|                                                                              |
| Four workers were exposed instead of three and all four of the workers were  |
| radiation workers for the Neb Public Power District.  Calculated whole body  |
| radiation exposure to the four workers:  2250 mrem, 1361 mrem, 611 mrem, and |
| 450 mrem.  The whole body dose was based on total exposure time multiplied   |
| by the maximum measured rate at the beam port, 450 mrem/hr.  The individuals |
| were approximately one foot away from the beam port                          |
|                                                                              |
| The operations center informed the R4DO (Shackelford) and NMSS EO (Hickey).  |
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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     |
|                                                   |                          |
|                                                   |                          |
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                                   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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|Power Reactor                                    |Event Number:   37972       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 05/08/2001|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 12:44[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        05/08/2001|
+------------------------------------------------+EVENT TIME:        10:04[EDT]|
| NRC NOTIFIED BY:  JIM PRIEST                   |LAST UPDATE DATE:  05/08/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |WILLIAM COOK         R1      |
|10 CFR SECTION:                                 |                             |
|*SHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| TECH SPEC REQUIRED SHUTDOWN                                                  |
|                                                                              |
| On 5/8/01, at approximately 1004, the Hope Creek Generating Station          |
| initiated a unit shutdown to comply with the provisions of Technical         |
| Specification (TS) 3.0.3, TS 3.0.3 was entered at 0820 when both trains of   |
| the Main Steam Line Isolation Valve Sealing System (MSIVSS) were declared    |
| inoperable.  The 'B' MSIVSS had been inoperable since 5/4/01 due to a        |
| malfunctioning flow transmitter with the associated TS, 3.6.1.4 1 entered.   |
| On 5/8/01,  at 0508, a Potential Transformer fuse failure associated with    |
| the 'C' Class 1E 4.16kV bus tripped two of four channels of Loss of Voltage  |
| relay protection for that bus.   The tripped channels provide start          |
| permissives for the 'C' EDG and have actuated to the tripped condition to    |
| provide those permissives.   During subsequent investigation of the extent   |
| and consequences of the fuse failure, it was determined at 0820 hours that   |
| the fuse failure also affected the 'C' Emergency Diesel Generator (EDG)      |
| synchroscope rendering the 'C' EDG inoperable due to its inability to meet   |
| the surveillance requirement of TS 4.8.1.1.2.h.10  Since the 'C' EDG         |
| provides the 1E power to the 'A' MSIV Sealing System both trains of the MSIV |
| Sealing System were considered inoperable and TS 3.0.3 was entered.          |
|                                                                              |
| Investigation into the cause of the fuse failure is ongoing.  With the       |
| exception of the 'A' Control Room Emergency Filtration System, all other     |
| safety-related systems were operable at the time of the event.               |
|                                                                              |
| The licensee notified the NRC resident inspector, the State of New Jersey    |
| and Lower Alloways Creek Township.                                           |
+------------------------------------------------------------------------------+

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|Hospital                                         |Event Number:   37973       |
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| REP ORG:  HENRY FORD HOSPITAL                  |NOTIFICATION DATE: 05/08/2001|
|LICENSEE:  HENRY FORD HOSPITAL                  |NOTIFICATION TIME: 14:10[EDT]|
|    CITY:  DETROIT                  REGION:  3  |EVENT DATE:        04/20/2000|
|  COUNTY:                            STATE:  MI |EVENT TIME:        12:00[EDT]|
|LICENSE#:  21-04109-16           AGREEMENT:  N  |LAST UPDATE DATE:  05/08/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE JORGENSEN      R3      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ALAN JACKSON                 |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| Unintended deviation from a written directive in the use of an               |
| investigational temporary brachytherapy implantation device on 04/20/00.     |
| Device is the Proxima Therapeutics, GliaSite RTS (a 2-4 cm balloon           |
| catheter).  The device is being investigated under the NABTT # 9801          |
| Multi-center open label clinical study to evaluate the performance of the    |
| Proxima GliaSite RTS in patients with recurrent brain tumors undergoing      |
| surgical resection.                                                          |
|                                                                              |
| In this study, the GliaSite RTS is implanted in the tumor resection bed at   |
| the time of surgery.  Two weeks following surgery, a solution of lotrex and  |
| saline is infused into he balloon catheter in order to deliver the radiation |
| dose.  Following a specified dwell time, the lotrex is removed from the      |
| balloon and the balloon is then surgically removed from the patient's brain. |
| Prior to therapy, radiographic contrast media is infused into the balloon to |
| verify the balloon placement.  This contrast media is removed just prior to  |
| the infusion to the lotrex.  All fluid volumes are tracked to determine the  |
| exact volume of fluid in the balloon at all times.                           |
|                                                                              |
| In the specific treatment plan where the deviation from the written          |
| directive occurred, was prescribed by a Radiation Oncologist and infused     |
| into a balloon by a Nuclear Medicine Physician with a dwell time of 70       |
| hours.                                                                       |
|                                                                              |
| Following the prescribed dwell time the lotrex was removed and an initial    |
| assay of the retrieved lotrex demonstrated a 60% apparent reduction in       |
| retrieved activity as compared to the administered activity.  The reduced    |
| activity measured in the retrieval fluid was to be due to a mixture of       |
| contrast media with the lotrex in the fluid.  By diluting  the retrieved     |
| fluid, to remove attenuation characteristics of the contrast media, the      |
| total administered activity was measured.                                    |
|                                                                              |
| Since the contrast media was causing attenuation of the radioactivity in the |
| retrieved fluid, resulting in a reduction of the Dose Calibrator readings,   |
| it is assumed the radiation dose to the tissue surrounding the balloon was   |
| also reduced.  The absorbed dose to the tissue cannot be determined          |
| accurately due to the uncertainty in the homogeneity of the iodine-125 and   |
| contrast media in the GliaSite RTS during the therapy.  Therefore, the       |
| attenuation characteristics and absorbed energy within the tissue cannot be  |
| accurately modeled.                                                          |
|                                                                              |
| During the investigation of this incident, all steps contained  within the   |
| Henry Ford Hospital and NABTT #9801 Quality Management Programs were         |
| followed.  This incident notification of the patient, physicians and all     |
| attending staff within 4 hours following the retrieval of the lotrex that an |
| apparent discrepancy in the activity retrieved existed.  In addition, all    |
| trash and urine were verified to have been retrained and surveys of these    |
| waste showed negligible readings.  All room surveys also showed no           |
| contamination.   The patient, as well as fluid retrained from the surgical   |
| site and the GliaSite RTS all demonstrated no contamination.  The patient    |
| was not harmed by the event.                                                 |
|                                                                              |
| To prevent contrast contamination during this therapy in the future an       |
| additional flushing of all fluid from the balloon prior to infusion of the   |
| lotrex will be done.                                                         |
|                                                                              |
| The NABTT #9801 study is intended as a Phase 1 device trail rather than a    |
| clinical efficacy trail.                                                     |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37974       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DUANE ARNOLD             REGION:  3  |NOTIFICATION DATE: 05/08/2001|
|    UNIT:  [1] [] []                 STATE:  IA |NOTIFICATION TIME: 18:56[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        05/08/2001|
+------------------------------------------------+EVENT TIME:        16:28[CDT]|
| NRC NOTIFIED BY:  BILL CLARK                   |LAST UPDATE DATE:  05/08/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE JORGENSEN      R3      |
|10 CFR SECTION:                                 |                             |
|*ESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     A          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SPECIFIED SYSTEM ACTUATION                                                   |
|                                                                              |
| "With the plant in a refueling outage, during restoration of the CRD system, |
| ongoing maintenance prevented restoring and opening the scram discharge      |
| volume vents and drains.  Leakage slowly filled the scram discharge volume.  |
| At 1628, level reached the trip setpoint and initiated a RPS trip signal.    |
| This is considered a valid initiation signal.  All systems responded as      |
| expected.  No control rod movement occurred and no refueling operations were |
| in progress.  Scram has not been reset due to ongoing maintenance."          |
|                                                                              |
| The licensee informed the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37975       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS              REGION:  4  |NOTIFICATION DATE: 05/08/2001|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 19:24[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        05/08/2001|
+------------------------------------------------+EVENT TIME:        15:28[CDT]|
| NRC NOTIFIED BY:  RICK NANCE                   |LAST UPDATE DATE:  05/08/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JEFF SHACKELFORD     R4      |
|10 CFR SECTION:                                 |                             |
|*RPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|*ESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REACTOR TRIP - LOW STEAM GENERATOR LEVEL                                     |
|                                                                              |
| On 05/08/2001,  Unit 2 experienced a automatic Reactor Trip due to low water |
| level in the 2A Steam Generator.  Prior to the reactor trip, Instrument and  |
| Control Technicians were tuning the 2A Main Feed Water Regulating Valve      |
| digital control system. The 2A Main Feed Water Regulating Valve went fully   |
| closed, and the Control Room Staff was unable to reopen the valve.           |
|                                                                              |
| At the same time as the Reactor Trip, the Auxiliary Feed Water System        |
| actuated due to low water level in the 2A Steam Generator.  After the        |
| Reactor Trip all Control Rods Fully inserted into the core, all automatic    |
| systems operated as designed, and no primary to secondary leakage was        |
| detected.                                                                    |
|                                                                              |
| The plant is stable in Mode 3, reactor coolant pumps are running and decay   |
| heat is being removed by using the main turbine bypass valves.  Steam        |
| generator water level has been restored and main feed is being used to feed  |
| the steam generators.                                                        |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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