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Event Notification Report for October 5, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           10/04/2001 - 10/05/2001

                              ** EVENT NUMBERS **

38346  38347  38348  38349  38350  38351  38352  

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|General Information or Other                     |Event Number:   38346       |
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| REP ORG:  NV DIV OF RAD HEALTH                 |NOTIFICATION DATE: 10/04/2001|
|LICENSEE:  LAS VALLEY WATER DISTRICT            |NOTIFICATION TIME: 14:11[EDT]|
|    CITY:  LAS VEGAS                REGION:  4  |EVENT DATE:        10/04/2001|
|  COUNTY:                            STATE:  NV |EVENT TIME:             [PDT]|
|LICENSE#:  00-11-0196-01         AGREEMENT:  Y  |LAST UPDATE DATE:  10/04/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STAN MARSHALL                |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - DAMAGED GAUGE                                       |
|                                                                              |
| 1. Event Report ID No.:  NV-01-006                                           |
|                                                                              |
| 2. License No.:  00-11-0196-01                                               |
|                                                                              |
| 3. Licensee:  Las Valley Water District                                      |
|                                                                              |
| 4. Event time, date, location:  Las Vegas, NV, October 1, 2001               |
|                                                                              |
| 5. Event type (e.g. misadministration, lost source, overexposure, etc.):     |
| Slightly damaged portable gauge. Cause of the incident was lack of attention |
| to detail.                                                                   |
|                                                                              |
| 6. Any notifications i.e. other agencies, patient, press release, FBI, etc.: |
| N/A                                                                          |
|                                                                              |
| 7. Event description: release, isotope, activity, exposure(s), dose,         |
| contamination level, equipment malfunction model, serial No., etc.:  A       |
| portable gauge fell off the bed of a slow moving transporting pickup and was |
| slightly damaged. The gauge was not carried in it's shipping container at    |
| the time of the incident, The source was in the safe, shielded position at   |
| the time of the incident. The gauge has been surveyed and leak tested and    |
| has been shipped to the manufacturer for repair. The gauge was a Troxler     |
| Model 3440, s/n 22284 containing 10 mCi of Cs-137 and 40 mCi of Am-241 :Be.  |
|                                                                              |
| 8. Transport vehicle description, if known:  Company pickup.                 |
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|Power Reactor                                    |Event Number:   38347       |
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| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 10/04/2001|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 14:23[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        10/03/2001|
+------------------------------------------------+EVENT TIME:        23:28[EDT]|
| NRC NOTIFIED BY:  PETER ORPHANOS               |LAST UPDATE DATE:  10/04/2001|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD CONTE        R1      |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 24-HOUR REPORT IN ACCORDANCE WITH OPERATING LICENSE DUE TO POTENTIAL MAXIMUM |
| POWER LEVEL VIOLATION                                                        |
|                                                                              |
| "This report is being made in accordance with Limerick Generating Station    |
| Unit 2 Operating License Condition 2.E. as a potential violation of License  |
| Condition 2.C(1), Maximum Power Level                                        |
|                                                                              |
| "GE Report titled 'Impact of Steam Carryover Fraction on Process Computer    |
| Heat Balance Calculations', September 2001, documents a non-conservative     |
| assumption for the moisture carryover fraction used in the calculation of    |
| core thermal power. The assumed carryover fraction of 0.1% was discovered to |
| be potentially closer to zero and therefore non-conservative in later model  |
| GE BWRs.                                                                     |
|                                                                              |
| "A review of Limerick Unit 2 moisture carryover data from an ASME PTC 6 test |
| performed in October of 1999 found a moisture carryover value of 0.0277%,    |
| inducing an estimated bias of approximately 2.8 MWth. Similar testing on     |
| Limerick Unit 1 found a value of greater than 0.1%. Based on this data       |
| Limerick Unit 1 is not considered affected at this time.                     |
|                                                                              |
| "Based on this potential non-conservatism on Unit 2, indicated Maximum Power |
| Level shift average is being administratively controlled 3 MWth below the    |
| licensed power level of 3458 MWth.                                           |
|                                                                              |
| "Exelon staff is continuing to evaluate the effect of the moisture carryover |
| term in the heat balance calculation."                                       |
|                                                                              |
| The NRC resident has been notified.                                          |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38348       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CRYSTAL RIVER            REGION:  2  |NOTIFICATION DATE: 10/04/2001|
|    UNIT:  [3] [] []                 STATE:  FL |NOTIFICATION TIME: 15:59[EDT]|
|   RXTYPE: [3] B&W-L-LP                         |EVENT DATE:        10/04/2001|
+------------------------------------------------+EVENT TIME:             [EDT]|
| NRC NOTIFIED BY:  RICKY RAWLS                  |LAST UPDATE DATE:  10/04/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES CASTO        R2DO    |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(3)(ii)(A)  DEGRADED CONDITION     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SMALL PRESSURE BOUNDARY LEAK IDENTIFIED WHILE SHUTDOWN                       |
|                                                                              |
| "At 0809 on October 4, 2001, Crystal River Unit 3 (CR-3) was in MODE 6       |
| shutdown for refueling operation. CR-3 has identified a small defect in the  |
| reactor coolant system (RCS) pressure boundary. An RCS leak was suspected    |
| due to elevated radioactivity levels detected in the nuclear services closed |
| cycle cooling water (SW) system since June 2001. Testing was conducted       |
| on-line in MODE 1 and could not determine the source of the leakage.         |
| Additional testing in MODE 6 has identified the seal area heat exchanger on  |
| the 1B reactor coolant pump (RCP-1B) as the most likely source of the        |
| leakage. The defect allowed a small amount of leakage to occur from the RCS  |
| to the SW system during the previous operating cycle. A definitive leak      |
| location could not be identified due to the extremely small size of the      |
| leak. However, since all components in the RCP heat exchanger are included   |
| as part of the class 1 RCS pressure boundary, this defect is reportable      |
| under 10 CFR 50.72(b)(3)(ii)(A). CR-3 was shutdown in MODE 6 at the time of  |
| the discovery. The RCP heat exchanger will be repaired prior to returning to |
| power operation."                                                            |
|                                                                              |
| The leak rate has been determined to be 0.02 gpm which exceeds the Technical |
| Specification limit of 'No Pressure Boundary Leakage' and it appears to be a |
| long term development.                                                       |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38349       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: RIVER BEND               REGION:  4  |NOTIFICATION DATE: 10/04/2001|
|    UNIT:  [1] [] []                 STATE:  LA |NOTIFICATION TIME: 16:10[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        10/04/2001|
+------------------------------------------------+EVENT TIME:        09:13[CDT]|
| NRC NOTIFIED BY:  DANNY WILLIAMSON             |LAST UPDATE DATE:  10/04/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLAUDE JOHNSON       R4      |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OPERATING LICENSE CONDITION VIOLATION (POTENTIAL MAXIMUM POWER LEVEL         |
| VIOLATION)                                                                   |
|                                                                              |
| "This report is being made as required by River Bend Station license         |
| condition 2.E. River Bend is reporting a potential violation of the maximum  |
| power level as authorized in license condition 2.C.1.                        |
|                                                                              |
| "This event is similar to event numbers 38337 and 38340 reported by two      |
| other BWR plants Based on the General Electric (GE) report titled, 'Impact   |
| of Steam Generator Carryover Fraction on Process Computer Heat Balance       |
| Calculations, September 2001.' It is possible that River Bend may have       |
| exceeded the maximum power level on some occasions in the past by            |
| approximately three megawatts thermal.                                       |
|                                                                              |
| "River Bend Station is currently in a refueling outage, so no immediate      |
| actions are necessary. This condition has been entered into the station's    |
| corrective action program to further evaluate the applicability of this      |
| condition and to develop an appropriate response before returning to power   |
| operations.                                                                  |
|                                                                              |
| "The licensee notified the NRC resident inspector."                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38350       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  RAPID CITY REGIONAL HOSPITAL         |NOTIFICATION DATE: 10/04/2001|
|LICENSEE:  RAPID CITY REGIONAL HOSPITAL         |NOTIFICATION TIME: 16:58[EDT]|
|    CITY:  RAPID CITY               REGION:  4  |EVENT DATE:        10/04/2001|
|  COUNTY:                            STATE:  SD |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  10/04/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC HENDEE                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION - UNDERDOSE                                        |
|                                                                              |
| Today, 10/4/01, when the dose for a second treatment was being prepared, it  |
| was discovered that the first dose was not as large as prescribed.  The      |
| first dose administered on 9/27/01 should have been 750 centigray and was    |
| only  400 to 500 centigray.  The attending physician has been notified and   |
| the patient will be notified.  A correcting dose, an additional fraction,    |
| will be given to correct the underdose.  No adverse affects are expected by  |
| this misadministration.                                                      |
|                                                                              |
| The dosage is administered with a high dose rate machine, Nucletron          |
| Microselectron.                                                              |
|                                                                              |
| The Radiation Safety Officer contacted NRC Region 4 (Richard Leonardi).      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   38351       |
+------------------------------------------------------------------------------+
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| REP ORG:  US AIR FORCE                         |NOTIFICATION DATE: 10/04/2001|
|LICENSEE:  US AIR FORCE                         |NOTIFICATION TIME: 18:09[EDT]|
|    CITY:  CANNON AFB               REGION:  4  |EVENT DATE:        10/04/2001|
|  COUNTY:                            STATE:  NM |EVENT TIME:             [MDT]|
|LICENSE#:  42-23539-01AF         AGREEMENT:  Y  |LAST UPDATE DATE:  10/04/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CRAIG REFOSCO                |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REPORT OF 2 MISSING EXIT SIGNS CONTAINING TRITIUM AT CANNON AFB              |
|                                                                              |
| Two exit signs containing 20 curies of tritium each were discovered missing  |
| from building 1258 at Cannon Air Force Base, New Mexico.  The signs were in  |
| place on 9/26/01 during a previous inspection.  The signs are manufactured   |
| by SRB Technologies and the serial numbers are 192167 and 192168.  There     |
| will be a formal investigation conducted.                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38352       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 10/05/2001|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 04:30[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        10/05/2001|
+------------------------------------------------+EVENT TIME:        00:26[EDT]|
| NRC NOTIFIED BY:  J. A. WITTER                 |LAST UPDATE DATE:  10/05/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD CONTE        R1      |
|10 CFR SECTION:                                 |                             |
|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| UNIT 2 ENTERED TECH SPEC 3.0.3 DUE TO TWO TRAINS OF SERVICE WATER  DECLARED  |
| INOPERABLE                                                                   |
|                                                                              |
| "At 0026 hrs on October 5, 2001, Beaver Valley Power Station Unit 2          |
| experienced a trip of the 'A' Train Service Water (SWS) Pump. 2SWS-P21 C was |
| operating on the 'A' SWS header when the pump tripped on Motor Ground Over   |
| Current. Both A and B Train Emergency Service Water Pumps (SWE) auto started |
| as designed and Service Water header pressure returned to normal values. Due |
| to a piping class break, safety/non-safety, between the SWS and SWE systems, |
| the unit entered Technical Specification 3.0.3 due to two trains of Service  |
| Water being Inoperable. The unit entered and completed the Abnormal          |
| Operating Procedure for Loss of Service Water, and the Bravo Train of        |
| Service Water was restored Operable when 2SWE-P21 B was secured and isolated |
| from the 'B' SWS header. 25W5-P21 B continued to operate normally during     |
| this event. Technical Specification 3.0.3 was exited at 0037 hrs. The plant  |
| is currently stable and operating at 100% power. Technical Specification     |
| 3.7.4.1 for Service Water (72-hour action) is applicable, as the only        |
| operating pump on the 'A' SWS header is 2SWE-P21A. The Alpha Service Water   |
| Pump, 2SWS-P21 A is unavailable due to Intake Structure Bay cleaning.        |
| Currently efforts are under way to recover the Intake Bay and restore        |
| 2SWS-P21A Operable. It is expected that both trains of Service Water will be |
| Operable within 12 hours. The Non Safety Related Chiller units tripped due   |
| to the SWS low pressure conditions, and were recovered shortly there after.  |
| No additional failures or equipment challenges occurred as a result of this  |
| event."                                                                      |
|                                                                              |
| The licensee informed the NRC resident inspector.                            |
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