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Event Notification Report for February 20, 2002

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

                              Event Reports For
                           02/19/2002 - 02/20/2002

                              ** EVENT NUMBERS **

38707  38708  38709  

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|Power Reactor                                    |Event Number:   38707       |
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| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 02/19/2002|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 01:27[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        02/18/2002|
+------------------------------------------------+EVENT TIME:        18:15[EST]|
| NRC NOTIFIED BY:  JAMES WITTER                 |LAST UPDATE DATE:  02/19/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES TRAPP          R1      |
|10 CFR SECTION:                                 |                             |
|AINA 50.72(b)(3)(v)(A)   POT UNABLE TO SAFE SD  |                             |
|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          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| BOTH EMERGENCY DIESEL GENERATORS INADVERTENTLY MADE INOPERABLE               |
|                                                                              |
| "On 02/18/02, at 1815 hours, the licensee discovered that the Beaver Valley  |
| Unit 2 #1 Emergency Diesel Generator had been rendered inoperable            |
| inadvertently, by the posting of a clearance at 1408 hours on 2/14/02. The   |
| #2 Emergency Diesel Generator had previously been removed from service for   |
| maintenance activities. Upon discovery that the #1 Emergency Diesel          |
| Generator was inoperable, action was immediately initiated to restore the #1 |
| Emergency Diesel Generator to Operable status. These actions were completed  |
| and the #1 Emergency Diesel Generator was restored to Operable status at     |
| 1830 hrs on 02/18/02.                                                        |
|                                                                              |
| "The #1 Diesel Generator was rendered inoperable at 1406 hrs on 02/14/02.    |
| During the period of inoperability, the licensee conducted core alterations  |
| including core reload during the ongoing ninth refueling outage. During the  |
| affected period, there were no challenges to the offsite power sources, and  |
| core cooling was maintained. Investigation into this event is ongoing.       |
|                                                                              |
| "This event is being reported under 10CFR50.72(v)(A) and 10CFR50.72(v)(B) as |
| a loss of Safe Shutdown Capability, and RHR Capability, respectively. There  |
| were no radiological releases associated with this event,"                   |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   38708       |
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| REP ORG:  UNIVERSITY OF WISCONSIN AT MADISON   |NOTIFICATION DATE: 02/19/2002|
|LICENSEE:  UNIVERSITY OF WISCONSIN AT MADISON   |NOTIFICATION TIME: 08:12[EST]|
|    CITY:  MADISON                  REGION:  3  |EVENT DATE:        02/15/2002|
|  COUNTY:                            STATE:  WI |EVENT TIME:             [CST]|
|LICENSE#:  4809843-18            AGREEMENT:  N  |LAST UPDATE DATE:  02/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANTON VEGEL          R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BEN-ZIKRI                    |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION DUE TO AN EQUIPMENT MALFUNCTION                    |
|                                                                              |
| A BetaCath Systems device containing strontium-90 produced by Novoste was    |
| being used to treat a patient.  On sending the active sources to the target  |
| area, a fluid leak occurred which slowed the movement of the seeds into the  |
| target vessel/position (Left Anterior Descending Artery). Not able to see    |
| the active seeds on the fluoroscopy monitors, a decision to have the active  |
| seeds returned to the holding device was made.   A total time of 17 seconds  |
| elapsed from the time of delivery until the active seeds were returned to    |
| the holding device.                                                          |
|                                                                              |
| On close inspection of the treatment catheter/device, one of the sealing     |
| O-rings was found to be ruptured.  This was the ultimate cause of the fluid  |
| leak and consequently the slow movement of the active seeds to the target    |
| position.                                                                    |
|                                                                              |
| With a dose rate of 0.095 Gy/s at 2 mm, the artery wall along the            |
| approximately 1 m track over which the source traveled out and back for its  |
| 17 sec would be calculated as:                                               |
|                                                                              |
| Speed equals 2 * (100 cm)/17 s = 11.8 cm/s                                   |
|                                                                              |
| Time wall was exposed to the 4 cm source = 4 cm / 11.8 cm/s = 0.34 s, but    |
| this time is doubled since it is exposed coming and going, to 0.68 s.        |
|                                                                              |
| Dose to the wall = 0.68 s * 0.095 Gy/s = 0.0646 Gy = 6.5 rads.               |
|                                                                              |
| The normal dose to the wall (assuming an 8 s round trip) would be 3.0 rads.  |
|                                                                              |
| A new catheter was tested with the non-active device and the treatment was   |
| continued.  The treatment was timed, checked for the return of the active    |
| sources and surveyed the patient/room post treatment.   No problems were     |
| encountered with the new treatment catheter.                                 |
|                                                                              |
| * * * UPDATE 1745EST ON 2/19/02 FROM ABDUL BEN-ZIKRI TO S. SANDIN VIA E-MAIL |
| * * *                                                                        |
|                                                                              |
| The following is a portion of an e-mail received at hoo1@nrc.gov:            |
|                                                                              |
| "I am retracting my event report (Event # 38708).  I took a conservative     |
| action and reported this event based on preliminary written information.     |
|                                                                              |
| "Our Hospital staff followed all standard operating & emergency procedures,  |
| and retracted the source when they realized that they did not arrive to the  |
| area of clinical interest as indicated in  the report below.  Based on the   |
| investigation analysis, we conclude that there was no misadministration to   |
| report."                                                                     |
|                                                                              |
| Notified R3DO(Jorgensen) and NMSS(Brach).                                    |
| .                                                                            |
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|Other Nuclear Material                           |Event Number:   38709       |
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| REP ORG:  PRINCETON UNIVERSITY                 |NOTIFICATION DATE: 02/19/2002|
|LICENSEE:  PRINCETON UNIVERSITY                 |NOTIFICATION TIME: 11:35[EST]|
|    CITY:  PRINCETON                REGION:  1  |EVENT DATE:        01/23/2002|
|  COUNTY:                            STATE:  NJ |EVENT TIME:             [EST]|
|LICENSE#:  290518524             AGREEMENT:  N  |LAST UPDATE DATE:  02/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MICHAEL MODES        R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SUE DUPRE                    |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MISSING RAT CARCASSES CONTAMINATED WITH TRITIUM                              |
|                                                                              |
| On 1/23/02 the Radiation Safety Officer was informed that 15 rat carcasses   |
| contaminated with 14 mCi of tritium were missing from the freezer.  This was |
| discovered on 1/21/02 when a scheduled pickup for disposal was made and the  |
| 2 bags of rat carcasses were not located.  A thorough search of the          |
| laboratories and freezers was made.  It is believed that the 2 bags were     |
| mistakenly picked up on 11/7/01 when a scheduled pickup for disposal of      |
| non-contaminated rat carcasses was made.  The 2 bags were last seen in       |
| October when the bags were placed in the freezer.                            |
|                                                                              |
| New procedures have been put in place to prevent this event from being       |
| repeated.  A written report will be submitted within 30 days.                |
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