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Event Notification Report for July 16, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/13/2001 - 07/16/2001

                              ** EVENT NUMBERS **

38123  38137  38138  38139  38140  38141  38142  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38123       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CLINTON                  REGION:  3  |NOTIFICATION DATE: 07/09/2001|
|    UNIT:  [1] [] []                 STATE:  IL |NOTIFICATION TIME: 13:07[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        07/09/2001|
+------------------------------------------------+EVENT TIME:        09:00[CDT]|
| NRC NOTIFIED BY:  JAMIE BARTSCH                |LAST UPDATE DATE:  07/13/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID HILLS          R3      |
|10 CFR SECTION:                                 |                             |
|AIND 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                                   
+------------------------------------------------------------------------------+
| CONTROL ROOM VENTILATION SYSTEM DECLARED INOPERABLE                          |
|                                                                              |
| The Division 2 Main Control Room Ventilation System was declared inoperable  |
| at 0900 CDT on 7/9/2001 because it was not maintaining the required positive |
| pressure while running in the High Radiation Mode of operation.  The system  |
| was declared operable at 0913 CDT when the required positive pressure was    |
| restored.  During the 13 minute period Division 2 was inoperable, Division 1 |
| Main Control Room Ventilation System was inoperable due to a scheduled       |
| maintenance outage.  Therefore, with both systems inoperable, a condition    |
| existed which could have prevented the fulfillment of the safety function of |
| the Main Control Room Ventilation System needed to mitigate the consequences |
| of an accident.  The cause of the perturbation in control room pressure is   |
| being investigated.                                                          |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| *** RETRACTION FROM STEVEN STRICKLAN RECEIVED BY LEIGH TROCINE AT 0451 EDT   |
| ON 07/13/01 ***                                                              |
|                                                                              |
| The licensee is retracting this event notification.  The following text is a |
| portion of a facsimile received from the licensee:                           |
|                                                                              |
| "On 07/09/01, at approximately 0900 [CDT], the Clinton Power Station (CPS)   |
| experienced a transient situation where, for a period of 13 minutes, the     |
| positive pressure in the Main Control Room (MCR) was compromised.  Based on  |
| this condition, an ENS notification (#38123) was made in accordance with the |
| requirements of 10CFR50.72(b)(3)(v), any 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:                                    |
| (A)  shut down the reactor and maintain it in a safe shutdown condition;     |
| (B)  remove residual heat;                                                   |
| (C)  control the release of radioactive material; or                         |
| (D)  mitigate the consequences of an accident."                              |
|                                                                              |
| "An evaluation of the conditions present at the time positive pressurization |
| of the MCR was temporarily interrupted has been performed.  The evaluation   |
| results indicated that the conditions that potentially existed during this   |
| event were bounded by the design basis analysis performed for the [MCR].     |
| The calculated MCR operator thyroid dose for this event was determined to be |
| approximately 23.185 Rem, which is less than the USAR calculated dose of 25  |
| Rem.  The USAR dose is calculated based on a 20-minute time delay in         |
| starting the system in the high radiation mode.  For this event, the high    |
| radiation mode was already in operation.  Whole body and Beta dose for this  |
| event are not governing."                                                    |
|                                                                              |
| "It [has] therefore been demonstrated that, in the event of a design basis   |
| event, time dose impact of the condition as it existed would be bounded by   |
| the current analyses of record.  As such, the safety function would be       |
| fulfilled, and the ENS notification is retracted."                           |
|                                                                              |
| "Although it has been demonstrated that the safety function would be         |
| fulfilled, the situation represented a condition prohibited by Technical     |
| Specifications, and this event continues to be evaluated for reportability   |
| as a Licensee Event Report under 10CFR50.73(a)(2)(i)(B)."                    |
|                                                                              |
| The licensee notified the NRC resident inspector.  The NRC operations center |
| notified the R3DO (Hills).                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   38137       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  BURLINGTON INDUSTRIES                |NOTIFICATION DATE: 07/13/2001|
|LICENSEE:  BURLINGTON INDUSTRIES                |NOTIFICATION TIME: 14:07[EDT]|
|    CITY:  HURT                     REGION:  2  |EVENT DATE:        07/13/2001|
|  COUNTY:                            STATE:  VA |EVENT TIME:             [EDT]|
|LICENSE#:  20-07181-04G          AGREEMENT:  N  |LAST UPDATE DATE:  07/13/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PAUL FREDRICKSON     R2      |
|                                                |DONALD COOL          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHARLES CROCKER              |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOST AM-241 SOURCE                                                           |
|                                                                              |
| A source purchased from Panametrics (under general license 20-07181-04G) and |
| delivered to the facility in 1977 was inadvertently placed in a scrap metal  |
| bin and picked up by a scrap metal dealer in 1997. The device contained a 10 |
| mCi Am-241 source. The scrap metal dealer was contacted, but the whereabouts |
| of the material are unknown.                                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38138       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 07/13/2001|
|    UNIT:  [] [2] []                 STATE:  AZ |NOTIFICATION TIME: 14:51[EDT]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        07/13/2001|
+------------------------------------------------+EVENT TIME:        08:21[MST]|
| NRC NOTIFIED BY:  DONALD STRAKA                |LAST UPDATE DATE:  07/13/2001|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHUCK CAIN           R4      |
|10 CFR SECTION:                                 |                             |
|ARPS 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     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP                                                       |
|                                                                              |
| "On July 13, 2001, at approximately 08:21 MST Palo Verde Unit 2 experienced  |
| an automatic reactor trip (RPS actuation) from approximately 100% rated      |
| thermal power due to low Departure from Nucleate Boiling Ratio (DNBR) trip   |
| generated by the Core Protection Calculators (CPCs). The DNBR trip resulted  |
| from the closure of 3 of the 4 main steam isolation valves (MSIVs). Unit 2   |
| was at normal temperature and pressure prior to the trip. All CEAs inserted  |
| fully into the reactor core. No ESF actuations occurred and none were        |
| required. An investigation of this event has been commenced to determine why |
| the MSIVs closed.                                                            |
|                                                                              |
| "Due to the MSIV closures, two of twenty main steam safety valves (MSSVs)    |
| lifted to relieve secondary pressure. Operators restored reactor coolant     |
| system heat removal using atmospheric dump valves and feedwater to the steam |
| generators is being supplied by the B train main feedwater pump.             |
|                                                                              |
| "Safety related buses remained energized during and following the reactor    |
| trip. The offsite power grid is stable. No significant LCOs have been        |
| entered as a result of this event. No major equipment was inoperable prior   |
| to the event that contributed to the event.                                  |
|                                                                              |
| "Unit 2 is stable at normal operating temperature and pressure in Mode 3.    |
| The event did not result in any challenges to fission product barriers and   |
| there were no adverse safety consequences as a result of this event. The     |
| event did not adversely affect the safe operation of the plant or the health |
| and safety of the public."                                                   |
|                                                                              |
| The NRC resident inspector has been informed of this event by the licensee.  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38139       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 07/13/2001|
|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 14:52[EDT]|
|   RXTYPE: [1] GE-3                             |EVENT DATE:        07/13/2001|
+------------------------------------------------+EVENT TIME:        08:55[EDT]|
| NRC NOTIFIED BY:  JOHN MacDONALD               |LAST UPDATE DATE:  07/13/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANTHONY DIMITRIADIS  R1      |
|10 CFR SECTION:                                 |                             |
|AINA 50.72(b)(3)(v)(A)   POT UNABLE TO SAFE SD  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| APRM FLOW-BIASED SCRAM SETPOINTS SET NONCONSERVATIVELY                       |
|                                                                              |
| "On July 13, 2001 at 0855 hrs, with the reactor at 100% core thermal power,  |
| Pilgrim Station determined the Average Power Range Monitoring (APRM) system  |
| flow-biased reactor scram setpoints were non-conservative and potentially    |
| exceeded Core Operating Limit Report (COLR) analyses. Programmed Flow        |
| Control Trip Reference (FCTR) cards establish the APRM flow-biased scram     |
| setpoints. The FCTR cards are a plant enhancement in response to the BWR     |
| stability issue. During core flow mapping for FCTR card calibration in       |
| accordance with station procedure (9.17.1), it was determined by reactor     |
| engineering personnel that the input setting for the FCTR card DIP switches  |
| was non-conservative. In response to this event, the APRMs were declared     |
| inoperable and Technical Specification 3.1 and the Actions of Table 3.1.1    |
| were initiated. TS Table 3.1.1 requires that reactor trip capability for the |
| given trip function be restored within 1 hour or initiate insertion of       |
| operable control rods and complete insertion of all operable control rods    |
| within 4 hours. However, Instrumentation and Controls personnel completed    |
| FCTR card DIP switch adjustments in accordance with station procedure        |
| (3.M.2-5.4.s) within approximately 45 minutes. All APRM RPS functions were   |
| declared operable at 0946 hours and TS 3.1 was exited. The reactor remained  |
| at 100% core thermal power throughout the event and there were no plant      |
| transients as a result of the event.                                         |
|                                                                              |
| "The cause of the event appears to [be] a lack of administrative controls to |
| ensure the FCTR card flow mapping be performed when steady-state 100% core   |
| thermal power is achieved following refueling outages or significant power   |
| maneuvers."                                                                  |
|                                                                              |
| The licensee informed the NRC resident inspector and will inform the         |
| Commonwealth of Massachusetts.                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38140       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION DATE: 07/13/2001|
|LICENSEE:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION TIME: 15:12[EDT]|
|    CITY:  ROYAL OAK                REGION:  3  |EVENT DATE:        07/12/2001|
|  COUNTY:                            STATE:  MI |EVENT TIME:        19:00[EDT]|
|LICENSE#:  21-01333-01           AGREEMENT:  N  |LAST UPDATE DATE:  07/13/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID HILLS          R3      |
|                                                |DONALD COOL          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SHERYL SCHULTZ               |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| An individual prescribed a dose of 2.8 - 3.46 GBq (75.6 - 93.5 mCi) of Y-90  |
| only received 1.1 GBq (29.7 mCi) due to a procedural error. The Y-90 was in  |
| the form of insoluble glass microspheres and was being injected into the     |
| liver in a saline solution. The procedure was being performed under an FDA   |
| approved humanitarian device exemption. During the treatment, the seal on    |
| the vial containing the microspheres was not properly pierced, causing       |
| backpressure to develop in the delivery lines and forcing some of the        |
| microspheres to back up into the treatment device. The licensee is           |
| implementing additional controls to prevent recurrence of this type of       |
| event. In addition, the device vendor (MDS Nordion) will continue with       |
| onsite proctoring of dose administrations until all treatment staff are      |
| fully trained.                                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   38141       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  McDOWELL AND ASSOCIATES              |NOTIFICATION DATE: 07/13/2001|
|LICENSEE:  McDOWELL AND ASSOCIATES              |NOTIFICATION TIME: 16:24[EDT]|
|    CITY:  FERNDALE                 REGION:  3  |EVENT DATE:        07/13/2001|
|  COUNTY:                            STATE:  MI |EVENT TIME:        07:30[EDT]|
|LICENSE#:  21-18724-01           AGREEMENT:  N  |LAST UPDATE DATE:  07/13/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID HILLS          R3      |
|                                                |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARY JARDINE                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| STOLEN MOISTURE/DENSITY GAUGE                                                |
|                                                                              |
| A Troxler Model 3440A moisture/density gauge (S/N 14786) was stolen from its |
| locked storage case. The gauge and case were chained to the bed of a pickup  |
| truck that was parked in Shelby Township, MI. The licensee has contacted     |
| local law enforcement agencies and has already contacted NRC Region III      |
| regarding this matter.                                                       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38142       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 07/15/2001|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 23:32[EDT]|
|   RXTYPE: [3] CE                               |EVENT DATE:        07/15/2001|
+------------------------------------------------+EVENT TIME:        21:58[CDT]|
| NRC NOTIFIED BY:  RAY PELLEGRIN                |LAST UPDATE DATE:  07/16/2001|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          ALERT                 |CHUCK CAIN           R4      |
|10 CFR SECTION:                                 |TAD MARSH            NRR     |
|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |NADER MAMISH         IRO     |
|                                                |SAM COLLINS          NRR     |
|                                                |JIM MULLINS          EPA     |
|                                                |CANUPP               FEMA    |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ALERT DECLARED DUE TO TOXIC GAS RELEASE NEAR PLANT SITE                      |
|                                                                              |
| The licensee declared an Alert (EAL EP-4-010 "Toxic Chemical Contingency")   |
| due to an anhydrous ammonia release at the Occidental Chemical facility      |
| located near the site.  The licensee reported that no ammonia has been       |
| detected onsite; however, personnel sheltering has been implemented. The     |
| release is ongoing and the chemical facility cannot estimate when the        |
| release will be secured. The NRC entered Monitoring at 0012EDT on 7/16/01.   |
|                                                                              |
| * * * UPDATE 0300EDT ON 7/16/01 FROM LICENSEE COMMUNICATOR TO S.SANDIN * *   |
| *                                                                            |
|                                                                              |
| The licensee terminated the Alert at 0200CDT after verifying that all        |
| exiting conditions were satisfied.  The licensee informed the NRC resident   |
| inspector and will inform state/local agencies.  The NRC exited Monitoring   |
| at 0315EDT on 7/16/01.  Notified FEMA(Canupp), DOE(Stambaugh),               |
| EPA-DOT(Loreck), USDA(Conley) and HHS-CDC(Cruz).                             |
+------------------------------------------------------------------------------+