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Event Notification Report for June 1, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/31/2001 - 06/01/2001

                              ** EVENT NUMBERS **

38026  38039  38040  38041  38042  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38026       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FT CALHOUN               REGION:  4  |NOTIFICATION DATE: 05/23/2001|
|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 16:19[EDT]|
|   RXTYPE: [1] CE                               |EVENT DATE:        05/23/2001|
+------------------------------------------------+EVENT TIME:        14:45[CDT]|
| NRC NOTIFIED BY:  MATZKE                       |LAST UPDATE DATE:  05/31/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF CRIMINAL ACT INVOLVING INDIVIDUAL GRANTED ACCESS TO THE SITE.   |
|                                                                              |
| COMPENSATORY MEASURES NOT FULLY IMPLEMENTED                                  |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED                                  |
|                                                                              |
| CONTACT NRC HEADQUARTERS OPERATIONS OFFICER FOR ADDITIONAL INFORMATION       |
|                                                                              |
| * * * RETRACTED AT 1600 EDT ON 5/31/01 BY ERICK MATZKE TO FANGIE JONES * *   |
| *                                                                            |
|                                                                              |
| Further investigation of the issue determined that the event notification    |
| was not reportable and retracts the notification of event #38026.            |
|                                                                              |
| The licensee notified the NRC Resident Inspector.  R4DO (Dale Powers) was    |
| notified.                                                                    |
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|Fuel Cycle Facility                              |Event Number:   38039       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 05/31/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 10:17[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/30/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        11:00[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/31/2001|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |MARK RING            R3      |
|  DOCKET:  0707001                              |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  M. C. PITTMAN                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FIRE PROOF COVER OVER A PROCESS OPENING  COULD NOT PERFORM ITS INTENDED      |
| FUNCTION.                                                                    |
|                                                                              |
|                                                                              |
| NRC BULLETIN 91-01 24 HOUR NOTIFICATION                                      |
|                                                                              |
|                                                                              |
| At 1400, 05/30/01 the Plant Shift Superintendent (PSS) was notified that the |
| Zetex material used as a fire proof cover on the # 3 low speed purge and     |
| evacuation pump has deteriorated to the point of failure such that it could  |
| not perform its intended function.  The material was being used according to |
| CP2-CO-CN2030, as a fire proof cover over a process opening.  The material   |
| has become brittle and failed to the point of leaving openings to the        |
| process system.  NCSA GEN-10, Removal and Handling of Contaminated Equipment |
| from the Cascade at PGDP, requires fire proof covers to be installed on      |
| cascade system openings to prevent the introduction of moderation from a     |
| sprinkler activation, lube oil leak, or RCW leak.  Double contingency for    |
| this scenario is established by implementing two controls on moderation.     |
| One leg of double contingency is based on the fire proof cover preventing a  |
| moderator release from entering the open process system.  Since the fire     |
| proof cover deteriorated to the point of leaving openings to the process     |
| system, the ability to prevent introduction of moderator was lost.  This     |
| control was violated and double contingency was not maintained.              |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
| A material credited to perform a criticality safety related function was not |
| able to perform its function.                                                |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED [BRIEF SCENARIO(S) OF HOW            |
| CRITICALITY COULD OCCUR]:                                                    |
|                                                                              |
| In order for criticality to be possible, greater than 10 kg of a moderator   |
| would have to enter the open process system and interact with a uranium      |
| deposit greater than the minimum critical mass in a geometry favorable for a |
| criticality.                                                                 |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| Double contingency for this scenario is established by implementing two      |
| controls on moderation.                                                      |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):                                       |
|                                                                              |
| Maximum assay of 1.08 wt.% U235.                                             |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| The first leg of double contingency is based on the unlikelihood of a        |
| moderator release (Sprinkler, RCW, oil) into the open process system during  |
| the time the system is open.  Since there was no moderator release into the  |
| system, this leg of double contingency was maintained.                       |
|                                                                              |
| The second leg of double contingency is based on the fire proof cover        |
| preventing a moderator release from entering the open process system. Since  |
| the fire proof cover deteriorated to the point of leaving openings in the    |
| process system, the ability to prevent introduction of moderator was lost.   |
| The control was violated and double contingency was not maintained.          |
|                                                                              |
| Since double contingency is based on two controls on moderation, double      |
| contingency was not maintained.                                              |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:  |
|                                                                              |
| The degraded Zetex fire proof material was replaced with an approved AQ-NCS  |
| aluminum cover. Other cascade openings using Zetex material are being        |
| inspected for signs of degradation and will be replaced as necessary.  The   |
| use of Zetex material as a fire proof cover will be re-evaluated.            |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the certificate     |
| holder.                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38040       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UNIVERSITY OF PITTSBURGH MED. CENT.  |NOTIFICATION DATE: 05/31/2001|
|LICENSEE:  UNIVERSITY OF PITTSBURGH             |NOTIFICATION TIME: 11:24[EDT]|
|    CITY:  PITTSBURGH               REGION:  1  |EVENT DATE:        09/03/1996|
|  COUNTY:                            STATE:  PA |EVENT TIME:        18:00[EDT]|
|LICENSE#:  37-00245-02           AGREEMENT:  N  |LAST UPDATE DATE:  05/31/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ERIC REBER           R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JERRY ROSEN                  |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| The following is taken from a faxed report:                                  |
|                                                                              |
| The following event is being reported as a medical misadministration in      |
| accordance with the May 22, 2001, directive of NRC Region I                  |
| representatives.                                                             |
|                                                                              |
| At 6:00 PM on September 3,1996, a patient was implanted with six ribbons,    |
| each containing four Iridium-192 seeds. The seeds each contained 1.01        |
| millicuries (total activity of 24.2 millicuries). The ribbons were placed in |
| catheters implanted into the patient's right jaw and secured by crimping a   |
| metal button around the catheter. The corresponding written directive        |
| prescribed a treatment time of 47 hours. At 4:45 PM on September 5, 1996,    |
| the radiation oncologist arrived to remove the sources and determined that   |
| one ribbon was missing from the treatment site. The Radiation Safety Office  |
| (RSO) was notified. The five remaining ribbons were removed from the patient |
| and a survey was done of the patient, the patient's room and surroundings.   |
| The missing ribbon was located on the floor in front of a laundry bin. The   |
| ribbon was secured and returned to storage.                                  |
|                                                                              |
| The RSO investigated this event and determined that all six ribbons were in  |
| place at 8:00 AM on September 5th when the day nurse checked the patient and |
| documented the status of the brachytherapy implant in the patient's record.  |
| (Note: Prior to this event nurses were required to evaluate and document the |
| status of brachytherapy implants at the beginning of each work shift.) At    |
| approximately 9:30 AM the patient complained of discomfort and experienced   |
| significant vomiting. This condition persisted through the remainder of the  |
| day. A Patient Service Technician (PST) reported that she changed the        |
| patient's gown and bed linens at approximately 2:30 PM. Staff physicians,    |
| nurses and residents evaluated the patient throughout that day as documented |
| in the patient's record. However, such documentation does not include an     |
| indication or the status of the implant.                                     |
|                                                                              |
| The licensee concluded that the brachytherapy ribbon likely became dislodged |
| from the treatment site due to the patient's vomiting and/or                 |
| self-intervention sometime between 9:30 AM and 2:30 PM on September 5th. The |
| ribbon was apparently entangled in the patient's bed linens until the linens |
| were changed by the PST at 2:30 PM; whereupon the ribbon dropped from the    |
| soiled linens when they were placed in the linen storage bin. It is also     |
| possible that the ribbon may have become dislodged at the time (2:30 PM) the |
| patient's gown was being changed.                                            |
|                                                                              |
| Assuming the worst case that the brachytherapy ribbon became dislodged at    |
| 9:30 AM, the deviation from the total prescribed treatment dose due to the   |
| single ribbon missing for 7.5 hours is 2.7 percent, The possible localized   |
| radiation dose outside the treatment Site was also evaluated. If it is       |
| assumed that with patient movement the average location of the ribbon would  |
| be 10 cm from the patient's body. then the closest area of the body exposed  |
| would receive a radiation dose of less than one rad. This radiation dose is  |
| no more than the lower extremities would receive from the prescribed         |
| brachytherapy implant procedure and substantially less than that which would |
| be received by the upper torso and head in areas near the implant site. If   |
| the ribbon became dislodged when the patient's gown was being changed, there |
| would be no significant radiation dose to any portion of the patient's body  |
| since the source had been removed from the bed at that time.                 |
|                                                                              |
| Based on its review of the circumstances surrounding this event and the      |
| possible associated radiation exposures, the licensee concluded that the     |
| event did not constitute a misadministration or recordable event. However,   |
| in consideration of the possible ramifications of a future such event, the   |
| licensee implemented a policy requiring that documented checks of the        |
| implant site be performed at four hour intervals by nursing personnel.       |
| (Note: The NRC's regulations and guidance are silent on the issue of         |
| frequency of monitoring implants.)                                           |
|                                                                              |
| Elmer Cano, M.D., the Radiation Oncologist, did not feel that this event     |
| would impact on the well being of the patient. The patient's referring       |
| physician was verbally notified of this event at the time of its             |
| occurrence.                                                                  |
|                                                                              |
| Full details of the event were documented and placed in the incident file to |
| be reviewed during the next NRC inspection.                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   38041       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 05/31/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 16:52[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/31/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        13:30[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/31/2001|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MARK RING            R3      |
|  DOCKET:  0707002                              |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BULLETIN 91-01 - 24 HOUR REPORT                                              |
|                                                                              |
| The licensee, during a review of the plant surveillance program, discovered  |
| a surveillance that was suppose to be done every 6 months was missed the     |
| last time and is about 6 months overdue.                                     |
|                                                                              |
| The following is taken from a faxed report:                                  |
|                                                                              |
| At 1330 hrs. the Plant Shift Superintendent was notified that a required     |
| surveillance for NCSA 705_040 was not performed in the required periodicity. |
| This surveillance is necessary to ensure that uranium bearing material is    |
| not accumulating in the piping due to either precipitating out or through    |
| bonding with oil-bearing material which then layers out in the piping. By    |
| not performing this surveillance one of the barriers for maintaining double  |
| contingency was lost for this operation thus making this a reportable        |
| event.                                                                       |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:                                               |
|                                                                              |
| The surveillance required to perform non-destructive analysis (NDA) on       |
| piping of the 705 geometrically safe overhead storage (GSS) was not          |
| performed. However, based on the historic evidence as discussed in sections  |
| 4.3 and 4.5 of analysis performed for this system it is highly unlikely that |
| material is accumulating in the piping and thus the safety significance of   |
| this event is low.                                                           |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR):                                                    |
|                                                                              |
| Without measuring a significant amount of material could accumulate in GSS   |
| piping and result in an unsafe condition.                                    |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| The parameter which was violated during this upset was maintaining the       |
| concentration of material in the GSS piping to a safe level through periodic |
| NDA surveillance of various piping in the GSS. It should be noted that the   |
| physical integrity of the piping in question (i.e., that containing the      |
| uranium-bearing material) was maintained.                                    |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF:                                                   |
|                                                                              |
| Based on the most recent sampling of solution contained in the GSS the       |
| amount of uranium involved is small (approximately 0.0002 grams              |
| uranium/liter)                                                               |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| Did not perform the required surveillance within the allotted time period.   |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
|                                                                              |
| Isolated the GSS from other influents at 1335 hrs. Will commence NDA         |
| measurements 06/01/01.                                                       |
|                                                                              |
| The licensee notified the NRC Resident Inspector and the local DOE           |
| representative.                                                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38042       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 05/31/2001|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 17:03[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        04/11/2001|
+------------------------------------------------+EVENT TIME:        00:05[EDT]|
| NRC NOTIFIED BY:  BRIAN THOMAS                 |LAST UPDATE DATE:  05/31/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ERIC REBER           R1      |
|10 CFR SECTION:                                 |                             |
|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| INADVERTENT LOSS OF 'A' RPS BUS                                              |
|                                                                              |
| The following is taken from a faxed report:                                  |
|                                                                              |
| This 60-day optional report in accordance with 10CFR50.73(a)(1), is being    |
| made under the reporting requirement of 10CFR50.73(a)(2)(iv)(A) to describe  |
| an invalid actuation of the Containment Isolation System.                    |
|                                                                              |
| On April 11, 2001, at 0005 hours, the control room received an alarm for     |
| loss of the 'A' Reactor Protection System (RPS) bus. As a result of the loss |
| of the 'A' RPS bus the following actuations occurred: an A1 & A2 RPS half    |
| scram, a Nuclear Steam Supply System Shutoff (NSSSS) logic A & C trip,       |
| tripping of the 'A' and 'B' Reactor Water Clean Up (RWCU) pumps due to       |
| closure of the inboard isolation valve BG-HV-F001, recirculation sampling    |
| isolation, and closure of the inboard Main Steam Line Drain valve            |
| AB-HV-F016                                                                   |
|                                                                              |
| The 'A' RPS bus was shifted to the alternate feed at 0023 and the RPS A1 &   |
| A2, the NSSSS, and the primary containment isolation signals (PCIS) were     |
| reset. At 0036, recirculation sampling was restored. Valve, BG-HV-F001 and   |
| AB-HV-F016 were reopened at 0039 hours.                                      |
|                                                                              |
| The above actuations and isolations were expected as a result of the loss of |
| the 'A' RPS bus. These actions and isolations were due to an invalid signal  |
| resulting from the inadvertent de-energization of the 'A' RPS bus.           |
|                                                                              |
| Fire Protection Operators were performing testing of the smoke detectors in  |
| the RPS motor-generator (MG) set room using a test pole. When the Fire       |
| Protection Operator in the overhead was handing the test pole to the Fire    |
| Protection Operator on the floor, the pole slipped and struck breaker switch |
| for H1SB-1AN410 (A RPS EPA breaker), causing the breaker to open. Opening of |
| the breaker lead to the loss of the 'A' RPS bus.                             |
|                                                                              |
| After determining that no damage occurred to breaker H1SB-1AN410, the 'A'    |
| RPS was restored to the normal power source.                                 |
|                                                                              |
| The impact on the plant safety from this event was minimal.  The isolations  |
| and equipment losses during the event caused only a minor plant transient    |
| and the equipment performed as expected. After the plant was stabilized and  |
| the cause of the loss of the 'A' RPS was identified, the half scram was      |
| reset.                                                                       |
|                                                                              |
| This event has been entered into the corrective action program.              |
|                                                                              |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
+------------------------------------------------------------------------------+