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Event Notification Report for July 19, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/18/2001 - 07/19/2001

                              ** EVENT NUMBERS **

38148  38149  38150  38151  38152  

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|Power Reactor                                    |Event Number:   38148       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COMANCHE PEAK            REGION:  4  |NOTIFICATION DATE: 07/18/2001|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 10:42[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/18/2001|
+------------------------------------------------+EVENT TIME:        07:59[CDT]|
| NRC NOTIFIED BY:  RAUL MARTINEZ                |LAST UPDATE DATE:  07/18/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |WILLIAM JOHNSON      R4      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|AESF 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      |
|                                                   |                          |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP ON TURBINE TRIP DURING RESTORATION OF AMSAC ALARM     |
|                                                                              |
| "During restoration of AMSAC [Accident Mitigation System Actuation           |
| Circuitry] to restore a trouble alarm, a spurious turbine trip signal was    |
| generated, causing a reactor trip from 100% power.  AFW [Auxiliary           |
| Feedwater] actuation followed the reactor trip and the MSIV's [Main Steam    |
| Isolation Vales] were closed for temperature control."                       |
|                                                                              |
| All control rods fully inserted.  Unit 2 is currently stable at normal       |
| operating pressure and temperature (NOP, NOT) using the Atmospheric Dumps    |
| and both motor-driven AFW pumps for decay heat removal.  There is no known   |
| primary-to-secondary tube leakage and samples confirm less than minimum      |
| detectable activity (less than MDA).  Operators are in the process of        |
| re-opening the MSIV's to place the main condenser back in service.           |
| All electrical buses remained energized throughout the event.                |
|                                                                              |
| The licensee notified the NRC resident inspector and does not plan a press   |
| release.                                                                     |
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+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   38149       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 07/18/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 13:05[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        07/17/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:30[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/18/2001|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |BRUCE JORGENSEN      R3      |
|  DOCKET:  0707002                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SALYERS                      |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)        SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| HIGH PRESSURE FIRE WATER SPRINKLER SYSTEM DECLARED INOPERABLE                |
|                                                                              |
| On 7/17/01 at approximately 1530 hrs, the Plant Shift Superintendent (PSS)   |
| was notified that during a Fire Protection Engineering assessment/inspection |
| that High Pressure Fire Water (HPFW) sprinkler system #165 in the X-333      |
| Building contained five adjacent sprinkler heads with visible corrosion      |
| deposits.  Previous engineering reviews have concluded that the system under |
| this condition would not be capable of meeting the Technical Safety          |
| Requirements (TSR) to maintain operability.                                  |
|                                                                              |
| The PSS declared the affected sprinkler system inoperable and TSR required   |
| actions were implemented.                                                    |
|                                                                              |
| The NRC Resident Inspector was notified along with the DOE Representative.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38150       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MATHY CONSTRUCTION CO                |NOTIFICATION DATE: 07/18/2001|
|LICENSEE:  MATHY CONSTRUCTION CO                |NOTIFICATION TIME: 15:11[EDT]|
|    CITY:  ONALASKA                 REGION:  3  |EVENT DATE:        07/18/2001|
|  COUNTY:                            STATE:  WI |EVENT TIME:        12:00[CDT]|
|LICENSE#:  4818722-01            AGREEMENT:  N  |LAST UPDATE DATE:  07/18/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE JORGENSEN      R3      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DUKATZ                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE LICENSEE REPORTED THEIR TROXLER GAUGE WAS STOLEN                         |
|                                                                              |
| The licensee reported that a Troxler moisture density gauge model 3440       |
| serial #26689 containing 8 millicuries of Cs and 40 millicuries of Am/Be was |
| stolen from the back of a truck in Barabo, WI.  This occurred within 5-10    |
| minutes when the driver entered a store to use the bathroom and buy some     |
| ice.  The licensee will notify the local police and the State.               |
|                                                                              |
| * * * UPDATE ON 7/18/01 @ 1553 FROM DUKATZ TO GOULD * * *                    |
|                                                                              |
| The local police contacted the licensee @ 1550 to inform them the gauge was  |
| located.  There was no damage and the gauge was intact.  Licensee has sent a |
| technician to retrieve the gauge.                                            |
|                                                                              |
| Regon 3 (Darrel Wiedeman) and NMSS (Susan Frant) have been informed.         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38151       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/18/2001|
|LICENSEE:  BOLDER COMMUNITY HOSPITAL            |NOTIFICATION TIME: 15:30[EDT]|
|    CITY:  BOLDER                   REGION:  4  |EVENT DATE:        06/09/2001|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:  262-01                AGREEMENT:  Y  |LAST UPDATE DATE:  07/18/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID GRAVES         R4      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JACOBI (BY FAX)              |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT -  LEAKING SEALED SOURCE                              |
|                                                                              |
| The following is taken from a faxed report:                                  |
|                                                                              |
| "We have recently experienced an incident resulting in the compromising of   |
| the shielding around an Iodine-125 prostate implant seed (sealed source).    |
| This report is filed per the requirements of RH 458                          |
|                                                                              |
| "On June 5, 2001, during the course of an I-125 seed implant of a patient's  |
| prostate gland an Iodine-125 seed which was thought to have been implanted   |
| was instead withdrawn with the implant plunger back into a position partly   |
| in the implant applicator and partly in the seed cartridge. This seed        |
| position will not allow the cartridge to be removed normally from the        |
| implant applicator.  A GM counter (thin end window) survey was performed     |
| over that section of the implant applicator but the presence of the seed was |
| not detected. The cartridge was then forcefully removed from the applicator. |
| The applicator was rinsed into a stainless steel basin to remove blood clots |
| that were present.  The routine survey at the end of the procedure indicated |
| that a seed was present in this washbasin.   A bent seed was found in a      |
| blood clot.  When the seed was removed from the basin, a survey of the basin |
| indicated that the water was also contaminated.   It was concluded that the  |
| shielding around the seed had been compromised.                              |
|                                                                              |
| "The contents of the rinse basin were poured into a plastic container that   |
| could be sealed.  All equipment, which had come in contact with the seeds,   |
| was surveyed and cleaned until wipe tests demonstrated that removable        |
| contamination had been reduced to less than 200 dpm.  The sealed plastic     |
| container containing the contaminated liquid, and all of the cleaning        |
| materials were placed in our long-term waste storage facility for decay.     |
| Absorbent material was added to this container on July 11th to soak up any   |
| remaining liquid and eliminate any potential spill hazard over the two years |
| (10 half-lives) this container will be in storage.                           |
|                                                                              |
| "The two individuals most closely involved in extracting the seed cartridge  |
| and performing the cleanup were given thyroid bioassay exams in the week     |
| immediately following the incident.  Those exams were negative. The patient  |
| was given the same exam approximately one month following the procedure that |
| indicated an uptake of 0.2 ▒ 0.09 ÁCi corrected to the day of the implant.   |
| If this uptake is real and not the result of radiation scatter from his      |
| active prostate seed implant (87 seeds, 22.3 mCi on the day of the thyroid   |
| scan), this would result in a radiation dose to the thyroid of not more that |
| 0.8 cGy. This radiation dose has no clinical significance.                   |
|                                                                              |
| "Corrective Actions: This incident occurred because the applicator plunger,  |
| which most likely had a blood clot adhering at the point normally in contact |
| with the iodine-125 seed, extracted the seed previously pushed into the      |
| prostate gland.  The seed, believed to have been implanted, instead came to  |
| rest across the space between the applicator body and the seed cartridge. A  |
| GM survey of the applicator body and cartridge combination failed to detect  |
| the presence of the seed. The seed was damaged when the cartridge was        |
| forcefully withdrawn.                                                        |
|                                                                              |
| "This incident could have been averted using the following procedure:        |
|                                                                              |
| 1. Assume that any cartridge jam is caused by an unaccounted for I-125       |
| seed.                                                                        |
| 2. Remove the implant needle from the applicator body. (If there is believed |
| to be only one seed involved in the jam, the applicator body may be surveyed |
| by directing the sensitive portion of the GM detector down the barrel of the |
| applicator previously occupied by the implant needle.  The GM detector may   |
| not be sensitive enough to detect radiation though the sides of the          |
| applicator body.)                                                            |
| 3. Place the body of the applicator with the cartridge still in place, into  |
| the rinse pan.                                                               |
| 4. Advance the plunger slowly through the seed cartridge until the seed is   |
| visible and can be rinsed away from the body of the applicator. (This may    |
| requite lifting the cartridge plunger to allow the applicator plunger past   |
| such that it can traverse the full extent of the cartridge.)  If the         |
| cartridge is not empty the seed causing the jam will be pushed out by        |
| another seed so two seeds will deposit in the rinse basin.                   |
| 5. Withdraw the applicator plunger completely and remove the seed cartridge  |
| normally.                                                                    |
| 6. NEVER forcefully remove a seed cartridge!                                 |
|                                                                              |
| "All individuals involved In this incident have reviewed this procedure."    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38152       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 07/19/2001|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 05:16[EDT]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        07/19/2001|
+------------------------------------------------+EVENT TIME:        03:00[CDT]|
| NRC NOTIFIED BY:  RYAN RODE                    |LAST UPDATE DATE:  07/19/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRUCE JORGENSEN      R3      |
|10 CFR SECTION:                                 |                             |
|ASHU 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  |90       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                  
+------------------------------------------------------------------------------+
| TECH SPEC REQUIRED SHUTDOWN DUE TO TIME LIMIT ON NON-SAFETY POWER TO         |
| INSTRUMENT BUS                                                               |
|                                                                              |
| The licensee entered Technical Specification 15.3.7(b)(1)(j) at 1900 CDT on  |
| 7/18/2001, which allowed 8 hours to restore electrical power from a safety   |
| powered bus to the Unit 1 instrument bus.  Non-safety power was provided     |
| when a problem caused an automatic transfer.  At 0300 CDT on 7/19/2001 a     |
| Technical Specification required shutdown was commenced.  The plant has 6    |
| hours to reach Hot Shutdown and another 44 hours to reach Cold Shutdown.     |
| The licensee has been and continues to research the problem and does not     |
| know when safety power will be restored to the instrument bus.               |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
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