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Event Notification Report for August 27, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/24/2001 - 08/27/2001

                              ** EVENT NUMBERS **

38230  38231  38232  38233  38234  

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|Power Reactor                                    |Event Number:   38230       |
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| FACILITY: PEACH BOTTOM             REGION:  1  |NOTIFICATION DATE: 08/24/2001|
|    UNIT:  [2] [3] []                STATE:  PA |NOTIFICATION TIME: 02:29[EDT]|
|   RXTYPE: [2] GE-4,[3] GE-4                    |EVENT DATE:        08/23/2001|
+------------------------------------------------+EVENT TIME:        21:43[EDT]|
| NRC NOTIFIED BY:  NILS BAHLIN                  |LAST UPDATE DATE:  08/24/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES NOGGLE         R1      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|3     N          Y       80       Power Operation  |80       Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| LOSS OF ELECTRICAL POWER TO THE TECHNICAL SUPPORT CENTER                     |
|                                                                              |
| An unexpected electrical breaker trip has caused a loss of power to the      |
| Technical Support Center (TSC).                                              |
|                                                                              |
| On 08/23/01 at 21:43  the main control room was notified that the TSC, which |
| is located in a building adjacent to the protected area, was without power.  |
| Communications were verified available from the TSC.                         |
|                                                                              |
| An investigation revealed that an offsite breaker controlled by the power    |
| system director had tripped.  Further investigation is in progress to        |
| identify and repair any deficiencies.                                        |
|                                                                              |
| The station procedures for contingency  actions were put in place if an      |
| event requiring the TSC were to occur during the loss of power.  Power was   |
| restored to the TSC at 0130 EDT on 08/24/01 from an alternate offsite        |
| source.                                                                      |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
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|General Information or Other                     |Event Number:   38231       |
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| REP ORG:  ROSEMOUNT NUCLEAR INSTRUMENTS INC    |NOTIFICATION DATE: 08/24/2001|
|LICENSEE:  ROSEMOUNT NUCLEAR INSTRUMENTS INC    |NOTIFICATION TIME: 12:46[EDT]|
|    CITY:  EDEN PRAIRIE             REGION:  3  |EVENT DATE:        08/24/2001|
|  COUNTY:                            STATE:  MN |EVENT TIME:             [CDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  08/24/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RONALD GARDNER       R3      |
|                                                |BILL JONES           R4      |
+------------------------------------------------+VERN HODGE           NRR     |
| NRC NOTIFIED BY:  CLEVELAND                    |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| PART 21 FOR A POTENTIAL NONCONFORMANCE RELATED TO REMOTE DIAPHRAGM SEALS     |
|                                                                              |
| Pursuant to 10CFR Part 21 Paragraph 21.21(b), Rosemount Nuclear Instruments, |
| Inc. (RNII) is writing to inform you of a potential nonconformance related   |
| to two model 1159 remote diaphragm seals. The two remote diaphragm seals are |
| connected to a single Rosemount nuclear qualified transmitter with serial    |
| number 0521038.  The two remote diaphragm seals are used to measure          |
| differential process pressure or liquid level while preventing the process   |
| fluid from contacting the transmitter diaphragm. The remote seals contain    |
| discrepant fill fluid screws.  The fill fluid screws are part of the         |
| pressure boundary of the remote seal system.  The nonconformance was due to  |
| an oversight during assembly, which has been corrected.                      |
|                                                                              |
| The material specification for the qualified fill screws is 416 SST.  The    |
| unqualified fill screws are 416 SST with a ball tip that is AISA E52100.     |
| The ball tip allows multiple insertions.  The qualified screw does not       |
| possess the bearing feature.                                                 |
|                                                                              |
| 1.0   Affected customer - Grand Gulf                                         |
|                                                                              |
| 2.0   Identification of items supplied - Model 1159 Remote Diaphragm Seals   |
|                                                                              |
| 3.0   Identification of firm supplying the Item - Rosemount Nuclear          |
| Instruments, Inc.                                                            |
|                                                                              |
| 4.0   Nature of the failure and potential safety hazard:                     |
|                                                                              |
| This notification relates to two Model 1159 Remote Diaphragm Seals, which    |
| contain discrepant fill fluid seal screws. These screws are part of the      |
| pressure boundary of the remote diaphragm seal system.                       |
|                                                                              |
| This notification is not applicable to other remote diaphragm seal systems.  |
|                                                                              |
| RNII has determined that there is no safety impact related to plant          |
| applications.  RNII does not feel Licensees with installed Model 1159 Remote |
| Diaphragm Seals need to address this issue.                                  |
|                                                                              |
| 5.0  The corrective action which is taken, the name of the individual or     |
| organization responsible for that action and the length of time taken to     |
| complete that action:                                                        |
|                                                                              |
| RNII immediately contacted the affected customer, and the nonconforming      |
| seals were returned to RNII prior to installation into the customer's        |
| facility.  The unit will be reworked to conform to the qualification         |
| requirements.                                                                |
|                                                                              |
| RNII internal corrective actions:                                            |
|                                                                              |
| 1. Revised the non-standard filling procedure for remote seals to ensure     |
| that qualified fill screws are installed during the filling process.         |
|                                                                              |
| 2. Training of engineering, manufacturing and quality personnel involved in  |
| the preparation, review and approval of non-standard procedures and          |
| processes to reemphasize the need to specifically address the material       |
| requirements.                                                                |
|                                                                              |
| 6.0  Any advice related to the potential failure of the item:                |
|                                                                              |
| This notification applies to a single transmitter with two Model 1159C20A    |
| Remote Diaphragm Seals.  This unit was returned to RNII prior to             |
| installation; therefore, does not pose a potential failure.                  |
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|Hospital                                         |Event Number:   38232       |
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| REP ORG:  PROVIDENCE HOSPITAL                  |NOTIFICATION DATE: 08/24/2001|
|LICENSEE:  PROVIDENCE HOSPITAL                  |NOTIFICATION TIME: 15:03[EDT]|
|    CITY:  WASHINGTON               REGION:  1  |EVENT DATE:        08/24/2001|
|  COUNTY:                            STATE:  DC |EVENT TIME:             [EDT]|
|LICENSE#:  08-01728-01           AGREEMENT:  N  |LAST UPDATE DATE:  08/24/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES NOGGLE         R1      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  PAUL SMITH                   |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| PROVIDENCE HOSPITAL REPORTED MEDICAL MISADMINISTRATIONS  OCCURRING  BETWEEN  |
| 1996 AND 2000                                                                |
|                                                                              |
| The hospital reported that during the period from 8/7/96 to 10/18/00         |
| fourteen medical misadministrations of strontium-90 occurred during clinical |
| procedures using a strontium-90 eye applicator.  The same ophthalmologist    |
| was the operator of the applicator during all fourteen incidences.  It       |
| appears that there was a misinterpretation of what the affect the shield had |
| on the radiation reaching the eye.  There was a supposition that the use of  |
| the shield reduced the radiation to the eye by a minimum of 50% and up to    |
| 80%.  Therefore, the amount of administration time for the procedures was    |
| doubled.  The amount of radiation given(in the range of 3,000 rads) was well |
| within the therapeutic range for the procedure, but it was not what the      |
| physician had written.  The amount of rads given was doubled of what was     |
| prescribed.                                                                  |
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|Power Reactor                                    |Event Number:   38233       |
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| FACILITY: COLUMBIA GENERATING STATIREGION:  4  |NOTIFICATION DATE: 08/24/2001|
|    UNIT:  [2] [] []                 STATE:  WA |NOTIFICATION TIME: 17:05[EDT]|
|   RXTYPE: [2] GE-5                             |EVENT DATE:        08/24/2001|
+------------------------------------------------+EVENT TIME:        13:05[PDT]|
| NRC NOTIFIED BY:  FISHER                       |LAST UPDATE DATE:  08/24/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BILL JONES           R4      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
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| SAFEGUARDS SYSTEM DEGRADATION RELATED TO AREA BOUNDARY                       |
|                                                                              |
| IMMEDIATE COMPENSATORY MEASURES TAKEN UPON TO DISCOVERY                      |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED                                  |
|                                                                              |
| CONTACT THE HEADQUARTERS OPERATION CENTER FOR ADDITIONAL DETAILS.            |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38234       |
+------------------------------------------------------------------------------+
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| FACILITY: VOGTLE                   REGION:  2  |NOTIFICATION DATE: 08/25/2001|
|    UNIT:  [1] [] []                 STATE:  GA |NOTIFICATION TIME: 00:34[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        08/24/2001|
+------------------------------------------------+EVENT TIME:        23:07[EDT]|
| NRC NOTIFIED BY:  ROBERT DORMAN                |LAST UPDATE DATE:  08/25/2001|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |EDWARD MCALPINE      R2      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF EXCITATION TO THE MAIN GENERATOR RESULTS IN A REACTOR TRIP.          |
|                                                                              |
| Unit 1 was operating at approximately 100% power.  While the main generator  |
| rectifier bank # 1 was being placed back in service after repairs when the   |
| main generator had a loss of excitation to the generator resulting in a      |
| generator trip, turbine trip and reactor trip.  All rods fully inserted into |
| the core.  An investigation is in progress to determine when excitation was  |
| lost when attempting to place main generator rectifier bank # 1 back in      |
| service.  An Auxiliary Feedwater  Actuation Signal was generated on Lo-Lo    |
| Steam Generator Water Levels and AMSAC.  Both Motor Driven Feedwater Pumps   |
| and the Turbine Driven Auxiliary Feedwater Pump started.  The plant is       |
| currently stable in mode 3 (Hot Standby).  An evaluation is in progress to   |
| determine what work will be done with the unit shut down and to develop a    |
| schedule for returning to power operation.                                   |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
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