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Event Notification Report for December 17, 2001

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           12/14/2001 - 12/17/2001

                              ** EVENT NUMBERS **

38513  38562  38563  38564  38565  38566  38567  38568  38569  38570  38571  38572 
38573  38574  38575  38576  
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38513       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 11/23/2001|
|    UNIT:  [1] [] []                 STATE:  FL |NOTIFICATION TIME: 12:30[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        11/23/2001|
+------------------------------------------------+EVENT TIME:        12:10[EST]|
| NRC NOTIFIED BY:  CHARLIE PIKE                 |LAST UPDATE DATE:  12/15/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CAUDLE JULIAN        R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO FLORIDA STATE INVOLVING RECOVERED SEA TURTLE
FROM    |
| UNIT 1 INTAKE STRUCTURE                                                      |
|                                                                              |
| "A sea turtle with no external injuries but appearing to be distressed was   |
| recovered from the Unit 1 Intake Structure.  The State Stranding Coordinator |
| for sea turtles has been contacted."                                         |
|                                                                              |
| * * * UPDATE 11/23/01 AT 1255EST FROM CHARLIE PIKE TO S. SANDIN * * *        |
|                                                                              |
| "Turtle has died."                                                           |
|                                                                              |
| The licensee informed both the State of Florida and the NRC Resident         |
| Inspector.                                                                   |
|                                                                              |
| * * * UPDATE 1413EST ON 12/3/01 FROM JACK BREEN TO FANGIE JONES * * *        |
|                                                                              |
| At approximately 1215 EST on 12/3/01, a report was made to the Florida       |
| Department of Fish and Wildlife concerning the recovery of an injured sea    |
| turtle from the plant's intake canal.  The turtle was a green sea turtle in  |
| the intake canal that appeared distressed and looked to have a wound from a  |
| boat motor on its back.  It will be transferred to the State for             |
| rehabilitation.                                                              |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.  Notified           |
| R2DO(MacAlpine).                                                             |
|                                                                              |
| * * * UPDATE 1333EST ON 12/15/01 FROM JACK BREEN TO JOHN MACKINNON * * *     |
|                                                                              |
| At approximately 1215 EST on 12/15/01, a report was made to the Florida      |
| Department of Fish and Wildlife Conservation Commission to pick up a Green   |
| Turtle for rehabilitation. The Green Turtle was taken from the plant's       |
| intake canal, and the turtle appears to have shark bites.                    |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.  Notified R2DO      |
| (Chuck Ogle).                                                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38562       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 12/14/2001|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 08:57[EST]|
|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        12/14/2001|
+------------------------------------------------+EVENT TIME:        06:45[CST]|
| NRC NOTIFIED BY:  KEVIN HUJET                  |LAST UPDATE DATE:  12/14/2001|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE MARIE STONE     R3      |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       95       Power Operation  |95       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PLANT COMPUTER AND SAFETY PARAMETERS DISPLAY SYSTEM INOPERABLE              
|
|                                                                              |
| The unit suffered a failure of the plant computer at 1452 CST on 12/13/01    |
| and repairs are ongoing.  The plant computer is expected to be down greater  |
| than 24 hours.  The plant computer feeds the Safety Parameter Display System |
| (SPDS), which is inoperable also.  The licensee has made a decision to make  |
| this report under a major loss of emergency assessment capabilities per 10   |
| CFR 50.72(b)(3)(xiii) as a conservative measure.  The control board          |
| indicators are operable and are used by the operators normally in an         |
| emergency.  The Shift Technical Advisor will perform a manual review of      |
| safety parameters in the case of an emergency, using the control board       |
| indications.                                                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38563       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ELKHART HOSPITAL                     |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  ELKHART HOSPITAL                     |NOTIFICATION TIME: 12:17[EST]|
|    CITY:  ELKHART                  REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        00:00[CST]|
|LICENSE#:  13-18879-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GARETH WILLIAMS              |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATIONS:  UNDERDOSES OF SAMARIUM-153             |
|                                                                              |
| Elkhart Hospital was notified today by the RSO for Spectrum Pharmaceuticals  |
| that Sa-153 quadramet doses total activity shipped to them was incorrectly   |
| calibrated.  Spectrum Pharmaceuticals informed the Hospital that they had    |
| made an error in the attenuation calculation for the beta factor in the      |
| samarium-153 total activity and that this error may have been made more than |
| 6 months ago.  Spectrum Pharmaceuticals believes that the Sa-153 total       |
| activity is actually less by 20 to 30%.  At this time, Elkhart Hospital does |
| not know how many patients have received an underdose of Sa-153.             |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38564       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GOSHEN GENERAL HOSPITAL              |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  GOSHEN GENERAL HOSPITAL              |NOTIFICATION TIME: 12:18[EST]|
|    CITY:  GOSHEN                   REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        00:00[CST]|
|LICENSE#:  13-18845-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  Dr. SHEPERD                  |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATIONS:  UNDERDOSES OF SAMARIUM-153             |
|                                                                              |
| Goshen General Hospital was notified today by the RSO for Spectrum           |
| Pharmaceuticals that Sa-153 quadramet, used for pain relief in bone cancer   |
| patients, beta attenuation were incorrectly calculated.  This attenuation    |
| calculation error made by Spectrum Pharmaceuticals has resulted in patient's |
| given Sa-153 at Goshen General Hospital being underdosed between 20 to 30%.  |
| The attenuation error may have existed for greater than 6 months. Three      |
| patients have been given a possible underdose of Sa-153.                     |
|                                                                              |
| NRC Region 3 personnel have been notified of this event by the licensee.     |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38565       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  HOME HOSPITAL                        |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  HOME HOSPITAL                        |NOTIFICATION TIME: 13:17[EST]|
|    CITY:  LAFAYETTE                REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:             [CST]|
|LICENSE#:  13-09788-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DUNSEATH                     |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION:  UNDERDOSE OF SAMARIUM-153              |
|                                                                              |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30%     |
| less than labeled due to an error in the attenuation calculation for the     |
| beta factor in the Sa-153 total activity calculation.  This calculation      |
| error may have existed for greater than 6 months.  The licensee is aware of  |
| one patient who was treated during this period and is reviewing treatment    |
| records to determine whether any others may be affected.                     |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38566       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST. JOSEPH'S REGIONAL MEDICAL CENTR  |NOTIFICATION DATE:
12/14/2001|
|LICENSEE:  ST. JOSEPH'S REGIONAL MEDICAL CENTR. |NOTIFICATION TIME:
14:13[EST]|
|    CITY:  SOUTH BEND               REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:             [CST]|
|LICENSE#:  13-02650-02           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  Dr. JOHN SCHEU               |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATIONS:  UNDERDOSES OF SAMARIUM-153           
|
|                                                                              |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30%     |
| less than labeled due to an error in the attenuation calculation for the     |
| beta factor in the Sa-153 total activity calculation.  This calculation      |
| error may have existed greater than 6 months.  The licensee is aware of two  |
| patients who were treated during this period.                                |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38567       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 12/14/2001|
|    UNIT:  [1] [2] []                STATE:  MI |NOTIFICATION TIME: 14:30[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        12/14/2001|
+------------------------------------------------+EVENT TIME:        11:27[EST]|
| NRC NOTIFIED BY:  STEVE COSAR                  |LAST UPDATE DATE:  12/14/2001|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE MARIE STONE     R3      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY REPORT                                                      |
|                                                                              |
| A contract supervisor tested positive for illegal drug use during a random   |
| test. The individual did not have access to vital areas, and his site access |
| has been terminated. The NRC resident inspector has been informed of this    |
| event by the licensee.                                                       |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38568       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  BORGESS MEDICAL CENTER               |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  BORGESS MEDICAL CENTER               |NOTIFICATION TIME: 14:44[EST]|
|    CITY:  KALAMAZOO                REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  MI |EVENT TIME:             [EST]|
|LICENSE#:  21-12275-02           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC RAMSAY                  |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION:  UNDERDOSE OF SAMARIUM-153               |
|                                                                              |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30%     |
| less than labeled due to an error in the attenuation calculation for the     |
| beta factor in the Sa-153 total activity calculation.  This calculation      |
| error may have existed for greater than 6 months.  The licensee does not     |
| know how many patients have been treated and is looking through records to   |
| determine number of patients treated with Sa-153.                            |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38569       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  BRONSON METHODIST HOSPITAL           |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  BRONSON METHODIST HOSPITAL           |NOTIFICATION TIME: 14:48[EST]|
|    CITY:  KALAMAZOO                REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  MI |EVENT TIME:             [EST]|
|LICENSE#:  21-13125-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARK WATTS                   |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE MEDICAL MISADMINISTRATION:  UNDERDOSE OF SAMARIUM-153               |
|                                                                              |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30%     |
| less than labeled due to an error in the attenuation calculation for the     |
| beta factor in the Sa-153 total activity calculation.  This calculation      |
| error may have existed for greater than 6 months.  The licensee is aware of  |
| one patient treated in the last year.                                        |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38570       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST. LUKES HOSPITAL                   |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  ST. LUKES HOSPITAL                   |NOTIFICATION TIME: 15:07[EST]|
|    CITY:  BETHLAHAM                REGION:  1  |EVENT DATE:        12/12/2001|
|  COUNTY:                            STATE:  PA |EVENT TIME:        07:00[EST]|
|LICENSE#:  37-07939-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLIFFORD ANDERSON    R1      |
|                                                |PAUL BONNETT         R1      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KATHY SANDERS                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAA1 20.1906(d)(1)        SURFACE CONTAM LEVELS |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SURFACE CONTAMINATION                                                        |
|                                                                              |
| IBA out of New Jersey delivered a metal case, ammo case, which contained     |
| less than 21 millicuries of fluorine-18, to St. Lukes North outpatient       |
| facility on 12/12/01 before 0700 hours.  Swipes taken of the outside and     |
| inside of the ammo case found technetium-99m contamination.  Outside and     |
| inside swipes both indicated contamination level around 6800 cpm. The ammo   |
| case was decontaminated and placed in St. Lukes Hot Lab.  St. Lukes          |
| contacted IBA and informed them of the contamination.                        |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38571       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  BAYOU TESTERS                        |NOTIFICATION TIME: 15:20[EST]|
|    CITY:                           REGION:  4  |EVENT DATE:        12/12/2001|
|  COUNTY:                            STATE:  LA |EVENT TIME:        00:00[CST]|
|LICENSE#:  LA-7112-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |FED BROWN            NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT BLACKWELL              |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| EXCESSIVE EXPOSURE                                                           |
|                                                                              |
| "The monthly personnel badges showed an excessive exposure for three         |
| employees.  [One individual] had 5136 mRem, [another individual] had 5095    |
| mRem, and [a third individual] had 5200 mRem for the year as of November 10, |
| 2001.  Once the facility received the badge report, the facility notified    |
| [the] DEQ.  The facility is also sending a written report to [the] DEQ.      |
| These three individuals have been removed from radiation work."              |
|                                                                              |
| Event Report No.:  LA010017                                                  |
|                                                                              |
| (Call the NRC operation officer for contact information and for the names of |
| the individuals involved.)                                                   |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38572       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST. JOSEPH'S HOSPITAL                |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  ST. JOSEPH'S HOSPITAL                |NOTIFICATION TIME: 15:27[EST]|
|    CITY:  KOKOMO                   REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        00:00[CST]|
|LICENSE#:  13-11385-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TODD REYBURN                 |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION:  UNDERDOSE OF SAMARIUM-153              |
|                                                                              |
| The licensee was notified today by the RSO for Spectrum Pharmaceuticals that |
| the total activity of Sa-153 quadramet doses may be approximately 20-30%     |
| less than labeled due to an error in the attenuation calculation for the     |
| beta factor in the Sa-153 total activity calculation.  This condition may    |
| have existed for greater than 1 year.  The licensee found one patient who    |
| was treated with Sa-153 and that was on 10/05/00.                            |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38573       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MEMORIAL HOSPITAL                    |NOTIFICATION DATE: 12/14/2001|
|LICENSEE:  MEMORIAL HOSPITAL                    |NOTIFICATION TIME: 15:43[EST]|
|    CITY:  SOUTH BEND               REGION:  3  |EVENT DATE:        12/14/2001|
|  COUNTY:                            STATE:  IN |EVENT TIME:        00:00[CST]|
|LICENSE#:  13-18881-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/14/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANNE MARIE STONE     R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RICHARD SELLE                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATIONS:  UNDERDOSES OF SAMARIUM-153           
|
|                                                                              |
| The licensee was notified today by the RSO of Spectrum Pharmaceuticals that  |
| the total activity of Sa-153 quadramet does may be approximately 20-30% less |
| than labeled due to an error in the attenuation calculation for beta factor  |
| in the Sa-153 total activity.  The licensee believes that he has treated two |
| patients since 1998 with Sa-153.                                             |
|                                                                              |
| NRC Region 3 has been notified of this event.                                |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38574       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 12/15/2001|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 23:00[EST]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        12/15/2001|
+------------------------------------------------+EVENT TIME:        19:00[EST]|
| NRC NOTIFIED BY:  TOM RESTUCCIO                |LAST UPDATE DATE:  12/15/2001|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       60       Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MANUAL REACTOR SCRAM FROM 60% POWER DUE TO UNIDENTIFIED LEAK RATE
EXCEEDING  |
| 5 GPM                                                                        |
|                                                                              |
| At 0431 on December 15, 2001, Unit 2 noted a step increase in unidentified   |
| drywell leakage from 0.2 gpm (normal) to 0.4 gpm.  Coincident with this step |
| increase, containment atmosphere radiation levels rose and alarmed on the    |
| particulate channels.  Throughout the day, investigation continued into      |
| possible causes, and the trend in leakage showed no appreciable increase.    |
| At 1658, containment atmosphere radiation levels rose again, and a large     |
| step increase in leakage was noted from approximately 0.5 gpm to 1.7 gpm.    |
| The technical specification limit is less than 5 gpm unidentified leakage    |
| and less than a 2-gpm rise in unidentified leakage during the previous the   |
| 24 hours.  At 1745, plant management ordered an orderly plant shutdown to    |
| identify the source of leakage in the drywell.  At 1900, a normal reactor    |
| shutdown was commenced, original reactor power was 100%, in preparation for  |
| repairing the leak in the drywell.  At 1919, drywell unidentified leakage    |
| rose to 2.27 gpm, and the technical specification action statement was       |
| entered for greater than a 2-gpm rise in unidentified leakage during the     |
| previous 24 hours.                                                           |
|                                                                              |
| At 2040, the drywell unidentified leak rate exceeded 5 gpm (5.87 gpm), and   |
| the decision was made to scram the plant.  At 2046, the reactor mode switch  |
| was placed in shutdown, all systems functioned as required, all rods fully   |
| inserted into the core.  The scram signal received was Average Power Range   |
| Monitor (APRM) neutron upscale due to setpoint setdown with the mode switch  |
| out of run.  A secondary scram signal was received when reactor water level  |
| dropped to less than 159.3" (Level 3) (expected due to level shrink on the   |
| scram).  Level 3 also provided a Primary Containment Isolation System (PCIS) |
| signal to group 4 (Residual Heat Removal System, [RHS] sampling valves) and  |
| group 5 (RHS shutdown cooling valves).  At the time of the signal, all group |
| 4 and 5 valves were closed.  At 2043, technical specification action         |
| statement associated with exceeding 5 gpm was exited.  At 2149, technical    |
| specification action statement associated with greater than 2 gpm rise over  |
| the previous 24 hours was exited.                                            |
|                                                                              |
| At this time, drywell unidentified leakage 1.5 gpm and lowering, plant       |
| pressure is being reduced.   Reactor water level is being maintained with    |
| condensate/feedwater.  Reactor pressure control is being maintained via      |
| turbine bypass valves with cooldown in progress.  All Emergency Core Cooling |
| Systems and the Emergency Diesel Generator are fully operable, and the       |
| electrical grid is stable.                                                   |
|                                                                              |
| The NRC resident inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38575       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 12/16/2001|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 00:30[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        12/15/2001|
+------------------------------------------------+EVENT TIME:        22:28[EST]|
| NRC NOTIFIED BY:  ALAN RABENOLD                |LAST UPDATE DATE:  12/16/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE MARIE STONE     R3      |
|10 CFR SECTION:                                 |                             |
|ACCS 50.72(b)(2)(iv)(A)  ECCS INJECTION         |                             |
|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 Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE REACTOR RECIRCULATION PUMPS DOWN SHIFTED TO SLOW SPEED FOR
UNKNOWN       |
| REASONS RESULTING IN AN AUTOMATIC REACTOR SCRAM, BALANCE-OF-PLANT          
 |
| ISOLATIONS, AND EMERGENCY CORE COOLING SYSTEM ACTUATIONS.                    |
|                                                                              |
| At 2228 EST on 12/15/01, the reactor recirculation pumps down shifted to     |
| slow speed for unknown reasons.  This caused reactor pressure vessel (RPV)   |
| water level to swell, and an automatic reactor scram from 100% power         |
| occurred when Level 8 was reached.  All control rods fully inserted.         |
| Following the scram, RPV water level started to decrease because the         |
| feedwater pumps also tripped (as designed) when Level 8 was reached.  When   |
| RPV water level dropped to Level 2 (130 inches), balance-of-plant isolations |
| occurred, and all of the applicable valves properly isolated.  In addition,  |
| the high pressure core spray (HPCS) and reactor core isolation cooling       |
| (RCIC) systems automatically actuated when Level 2 was reached.  The HPCS    |
| and RCIC systems were utilized to restore RPV water level to the normal      |
| range.                                                                       |
|                                                                              |
| The unit is currently stable in Mode 3 with RPV pressure at 900 psi and RPV  |
| water level at 210 inches.  Normal feedwater is being utilized to maintain   |
| RPV water level within the proper band, and the HPCS and RCIC systems have   |
| been secured.  The main steam isolation valves remained open, and the        |
| condenser is being utilized as the heat sink.  Containment parameters are    |
| currently normal, the electrical grid is stable, and the emergency diesel    |
| generators are available.                                                    |
|                                                                              |
| The licensee stated that all systems functioned as required and that there   |
| was nothing unusual or misunderstood other than the cause of the initiating  |
| event (the recirculation pumps down shifting to slow speed).  The licensee's |
| investigation is underway.                                                   |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38576       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PEACH BOTTOM             REGION:  1  |NOTIFICATION DATE: 12/16/2001|
|    UNIT:  [] [3] []                 STATE:  PA |NOTIFICATION TIME: 21:39[EST]|
|   RXTYPE: [2] GE-4,[3] GE-4                    |EVENT DATE:        12/16/2001|
+------------------------------------------------+EVENT TIME:        16:45[EST]|
| NRC NOTIFIED BY:  JOHN McCLINTOCK              |LAST UPDATE DATE:  12/16/2001|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |                             |
|AINC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BOTH HIGH FLOW INSTRUMENTATION FOR REACTOR WATER CLEANUP (RWCU)
FOUND        |
| INOPERABLE.                                                                  |
|                                                                              |
| During performance of routine surveillance testing on the PBAPS Unit 3 RWCU  |
| system high flow isolation instrumentation, it was discovered that both      |
| channels of isolation instrumentation were simultaneously inoperable.  Both  |
| affected instruments were returned to operable status by 1828 hours on       |
| 12/16/01.                                                                    |
|                                                                              |
| The RWCU system is designed to automatically isolate upon detection of a     |
| high flow condition.  This isolation detection system utilizes two channels  |
| of differential pressure instrumentation for high flow detection.  An        |
| isolation of the RWCU system can be accomplished by actuation of either      |
| channel of the logic.  A single channel trip would result in either an       |
| inboard or outboard isolation.  A failure of both channels would result in a |
| failure of the system to isolate as required.                                |
|                                                                              |
| On 12/16/01 at 1111 hours, surveillance testing of the "A" channel high flow |
| instrument (DPIS 3-12-124A) determined that this instrument failed to trip   |
| due to entrapped air in the sensing line.  DPIS 3-12-124A was vented,        |
| retested, and returned to operable status at 1536 on 12/16/01.               |
|                                                                              |
| At 1645 hours, surveillance testing of the "B" channel RWCU high flow        |
| instrument (DPIS 3-12-124B) determined that this instrument failed to trip   |
| due to entrapped air in the sensing line.  DPIS 3-12-124B was vented,        |
| retested, and returned to operable status at 1828 on 12/16/01.               |
|                                                                              |
| At 1645 on 12/16/01, it was determined that both channels of Unit 3 RWCU     |
| system high flow isolation instrumentation were simultaneously inoperable    |
| since the system had been placed in service during refueling outage 3R13.    |
| Unit 3 entered Mode 2 on 10/08/01 at 2221 hours, requiring the Primary       |
| Containment Isolation (PCIS) function to be operable.                        |
|                                                                              |
| Based on the above, this event is reportable under 10 CFR                    |
| 50.72(b)(3)(v)(C).                                                           |
|                                                                              |
| The systems affected were the RWCU system isolation logic instruments, DPIS  |
| 3-12-124A and DPIS 3-12-124B.  These instruments actuate on high system flow |
| of 125%.  No plant effects or transient occurred as a result of this event.  |
| The RWCU system isolation capability, on high system flow, was inoperable.   |
| This isolation capability is required whenever the RWCU system is in service |
| with the reactor in Modes 1, 2, or 3.                                        |
|                                                                              |
| DPISs 3-12-124A and 3-12-124B were filled, vented, tested satisfactorily,    |
| and returned to operable status.                                             |
|                                                                              |
| A station investigation to determine the cause of the air entrapment is in   |
| progress.                                                                    |
|                                                                              |
| The NRC resident inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+
.