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Event Notification Report for October 15, 2001

                    *** NOT FOR PUBLIC DISTRIBUTION***
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           10/12/2001 - 10/15/2001

                              ** EVENT NUMBERS **

38381  38382  38383  38384  38385  38386  
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|Hospital                                         |Event Number:   38381       |
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| REP ORG:  WASHINGTON HOSPITAL CENTER           |NOTIFICATION DATE: 10/12/2001|
|LICENSEE:  WASHINGTON HOSPITAL CENTER           |NOTIFICATION TIME: 14:45[EDT]|
|    CITY:  WASHINGTON               REGION:  1  |EVENT DATE:        10/12/2001|
|  COUNTY:                            STATE:  DC |EVENT TIME:        12:30[EDT]|
|LICENSE#:  0803604-03            AGREEMENT:  N  |LAST UPDATE DATE:  10/12/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |R1 IRC TEAM MANAGER  R1      |
|                                                |LINDA HOWELL         R4      |
+------------------------------------------------+JOHN HICKEY          NMSS    |
| NRC NOTIFIED BY:  GLENN                        |ANITA TURNER         NMSS    |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAA2 20.1906(d)(2)        EXTERNAL RAD LEVELS > |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| PACKAGE CONTAINING PHOSPHOROUS-32 WITH EXTERNAL RAD LEVELS GREATER
THAN      |
| LIMITS                                                                       |
|                                                                              |
| The Washington Hospital Center received a package from Isotex Diagnostics    |
| Incorporated(Texas lic # L02999) of Friendswood, Texas that measured on      |
| surface contact 48 Rads/hr using an ion chamber with the beta shield off.    |
| This was over a small area of the package.  At one meter with the beta       |
| shield off it measured 77 millirads/hr.  Both the shipper and the            |
| carrier(FedEx) have been notified.  The package contained 92.8 millicuries   |
| of phosphorous-32 with packing label yellow-2 and transport index 0.6.       |
| There was no contamination detected.  They are holding the package for       |
| inspection by the shipper.                                                   |
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|Fuel Cycle Facility                              |Event Number:   38382       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 10/12/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 15:32[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        10/11/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        14:44[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  10/12/2001|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |MICHAEL PARKER       R3      |
|  DOCKET:  0707001                              |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  WALKER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
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| 24 HOUR 91-01 BULLETIN RESPONSE                                              |
|                                                                              |
| Four waste drums were discovered to be incorrectly characterized based on    |
| incorrect laboratory analysis results. The incorrect analysis resulted from  |
| failure to follow a step in the procedure and violated the single point      |
| failure prevention arguments for sample characterization in NCSA 1493-33.    |
| The purpose of preventing a single point failure is to maintain double       |
| contingency for the case in which independent sample results are used to     |
| characterize and classify waste drums as "NCS Spacing Exempt."               |
|                                                                              |
| The samples were later re-analyzed for both assay and U-235 content.  The    |
| re-analysis results demonstrated that three of the four drums in question    |
| are in fact non-fissile and have been handled conservatively.  The remaining |
| drum is greater than 1%, but the U-235 mass is less than the limit for       |
| spacing exemption.                                                           |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROLS INVOLVED AND THEIR IMPACT ON
DOUBLE      |
| CONTINGENCY                                                                  |
|                                                                              |
| Double contingency is maintained by implementing controls to ensure the      |
| samples are analyzed correctly, without common mode failures.                |
|                                                                              |
| The first leg of double contingency is based on correctly analyzing the      |
| sample for U-235 loading.  Since the procedure was violated the analysis     |
| result should not have been relied upon for NCS purposes. The control was    |
| violated.  Since there are two controls on one parameter, double contingency |
| was not maintained.                                                          |
|                                                                              |
| The second leg of double contingency is based on independently analyzing the |
| sample correctly for U-235 loading. Since the procedure was violated the     |
| independent analysis result should not have been relied upon for NCS         |
| purposes. The control was violated.  Since there are two controls on one     |
| parameter, double contingency was not maintained.                            |
|                                                                              |
| Since double contingency is based on two controls on one parameter, double   |
| contingency was not maintained.                                              |
|                                                                              |
| Potential Critical Pathways:                                                 |
|                                                                              |
| In order for a criticality to be possible, the mass in multiple waste drums  |
| would each have to be greater than the safe mass determined for that         |
| container size and these waste drums would have to be stored together or     |
| re-containerized into unfavorable geometry drums.                            |
|                                                                              |
|                                                                              |
| Safety Significance:                                                         |
|                                                                              |
| Double contingency for characterizing and storing "NCS Spacing Exempt" waste |
| are based on determination of U-235 mass in the drum.  Both of these         |
| controls were lost.  However, based on re-analysis results the drums are in  |
| fact non-fissile or spacing exempt.                                          |
|                                                                              |
| EXCLUSION ZONE AND POSTiNG:                                                  |
|                                                                              |
| Control the area around the drum and post as follows according to            |
| CP2-EG-N51031;                                                               |
|                                                                              |
| Do not move fissile/potentially fissile material into or within this area    |
| without NCS and PSS approval.                                                |
|                                                                              |
| NCS-INC-01 -025                                                              |
|                                                                              |
| CORRECTIVE ACTIONS:                                                          |
|                                                                              |
| 1.  Re-characterize the drum according to CP4-EW-WM2100 based upon the       |
| re-analysis results.                                                         |
|                                                                              |
| 2.  Remove the ropes and postings                                            |
|                                                                              |
| The NRC Resident Inspector was informed and the DOE Representative will be   |
| notified.                                                                    |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38383       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: THREE MILE ISLAND        REGION:  1  |NOTIFICATION DATE: 10/12/2001|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 16:32[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP            |EVENT DATE:        10/12/2001|
+------------------------------------------------+EVENT TIME:        12:30[EDT]|
| NRC NOTIFIED BY:  MILLER                       |LAST UPDATE DATE:  10/12/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |R1 IRC TEAM MANAGER  R1      |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling Shutdow|0        Refueling Shutdow|
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF A THROUGH-WALL LEAK AROUND 8 THERMOCOUPLE NOZZLES
(REACTOR      |
| COOLANT SYSTEM PRESSURE BOUNDARY LEAK)                                       |
|                                                                              |
| On October 11 and 12, 2001, following shutdown for a scheduled refueling     |
| outage, three Mile Island Unit 1 (TMI-1) performed a visual inspection of    |
| the Reactor Vessel (RV) Thermocouple (TC) nozzles per NRC Bulletin 2001-01.  |
| The inspection revealed evidence of boric acid buildup around all eight (8)  |
| TCs nozzles.   At approximately 1230 on October 12, 2001, Engineering        |
| evaluation of the visual inspection results confirmed that the boron         |
| deposits around the eight TCs indicate a Reactor Coolant System (RCS)        |
| pressure boundary leak.  This condition is consistent with industry          |
| experience with Primary Water Stress Corrosion Cracking (PWSCC) in reactor   |
| vessel head nozzles that have been evaluated as part of the NRC Generic      |
| Letter 97-01 and NRC Bulletin 2001-01.  TMI-1 plans to perform repairs       |
| during the current refueling outage.   Since the condition resulted in       |
| leakage through the RCS pressure boundary, it is being reported as a         |
| non-emergency [8-hour] report in accordance with 10 CFR 50.72(b)(3)(ii)(A)   |
| and 50.73(a)(2)(ii)(A).                                                      |
|                                                                              |
| Results from the CRDM nozzle inspection have not yet been submitted.         |
|                                                                              |
| The NRC resident inspector has been notified.                                |
+------------------------------------------------------------------------------+
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+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38384       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  PARK VIEW HOSPITAL                   |NOTIFICATION DATE: 10/12/2001|
|LICENSEE:  PARK VIEW HOSPITAL                   |NOTIFICATION TIME: 17:37[EDT]|
|    CITY:  Ft. WAYNE                REGION:  3  |EVENT DATE:        10/11/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        16:45[CST]|
|LICENSE#:  13-01284-02           AGREEMENT:  N  |LAST UPDATE DATE:  10/12/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MICHAEL PARKER       R3      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  AGNEW                        |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PARK VIEW HOSPITAL REPORTED A MEDICAL MISADMINISTRATION                      |
|                                                                              |
| During an intravascular bracytherapy treatment with strontium-90 to a heart  |
| artery, a possible medical misadministration occurred at the completion of   |
| the treatment.   At the conclusion of this treatment, not all the sources    |
| returned to the Novoste applicator.  The sources were seen to have left the  |
| vessel and heart within the appropriate time(5 sec), but they did not all    |
| return to the device.   Another attempt to remove the sources was made, but  |
| was unsuccessful, so the entire treatment catheter was removed(within 18     |
| secs) from the patient as per their emergency procedures.   The physician    |
| and manufacturer of the device did not consider this as a medical            |
| misadministration, however an NRC inspector felt that it was for that        |
| additional 18 secs to remove the treatment catheter.  This incident occurred |
| 8/27/01.  It was decided not to notify the patient because of the patient's  |
| condition.                                                                   |
+------------------------------------------------------------------------------+
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38385       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 10/14/2001|
|    UNIT:  [] [2] []                 STATE:  CA |NOTIFICATION TIME: 12:14[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        10/14/2001|
+------------------------------------------------+EVENT TIME:        01:59[PDT]|
| NRC NOTIFIED BY:  KUNDSON                      |LAST UPDATE DATE:  10/14/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |LINDA HOWELL         R4      |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Hot Standby      |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE REACTOR COOLANT SYSTEM LEAKAGE                                      |
|                                                                              |
| During an inspection, while the plant was in shutdown mode 3, a dry white    |
| residue was discovered on a loop 2 hot leg spare thermowell plug.  Being     |
| conservative they looked at this condition as a possible RCS pressure        |
| boundary leakage while  in an operating mode.  However, there was no active  |
| leak from the spare thermowell plug.  The plant has 36 hours to be in mode   |
| 5.  They will determine the type of repair work necessary to remedy the      |
| problem.                                                                     |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38386       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY                    REGION:  2  |NOTIFICATION DATE: 10/14/2001|
|    UNIT:  [1] [] []                 STATE:  VA |NOTIFICATION TIME: 12:27[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        10/14/2001|
+------------------------------------------------+EVENT TIME:        11:45[EDT]|
| NRC NOTIFIED BY:  LOCASCIO/WOODZELL            |LAST UPDATE DATE:  10/14/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNUSUAL EVENT         |R2 IRC TEAM MANAGER  R2      |
|10 CFR SECTION:                                 |GENE IMBRO           NRR     |
|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |ZAPATA               FEMA    |
|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          N       0        Intermediate Shut|0        Intermediate Shut|
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REACTOR COOLANT SYSTEM BOUNDARY LEAKAGE                                      |
|                                                                              |
| During an inspection, while the plant was in intermediate shutdown (2235     |
| lbs. pressure), an unisolable leak at the "A" loop hot leg  temperature      |
| element was detected (at 0530 hrs) measuring 3 drops/min.  On the second     |
| entry (at 0940 hrs) when pressure was 400 lbs. no active leak was detected.  |
| The plant entered an NOUE at 1145 and TS action statement to be in cold      |
| shutdown within 30 hours was initiated.  Since the plant was already in      |
| intermediate shutdown, it should be in cold shutdown within 2-3 hours.       |
|                                                                              |
| The NRC Resident Inspector was notified along with State and local           |
| agencies.                                                                    |
|                                                                              |
|                                                                              |
| * * * UPDATE ON 10/14/01@ 1621 FROM LOCASCIO TO GOULD * * *                  |
|                                                                              |
| The plant went to below cold shutdown at 1620 at which time the NOUE was     |
| terminated.                                                                  |
|                                                                              |
| The NRC Resident Inspector was notified.  State and local agencies will be   |
| notified.                                                                    |
|                                                                              |
| Notified Reg 2 IRC Team manager, EO(Imbro) and FEMA(Ciboch)                  |
+------------------------------------------------------------------------------+
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