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Event Notification Report for February 28, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/27/2002 - 02/28/2002

                              ** EVENT NUMBERS **

38727  38728  38729  38730  38731  38732  38733  

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|General Information or Other                     |Event Number:   38727       |
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| REP ORG:  RI DEPT OF RADIOLOGICAL HEALTH       |NOTIFICATION DATE: 02/27/2002|
|LICENSEE:  RHODE ISLAND HOSPITAL                |NOTIFICATION TIME: 09:47[EST]|
|    CITY:  PROVIDENCE               REGION:  1  |EVENT DATE:        01/28/2002|
|  COUNTY:  PROVIDENCE                STATE:  RI |EVENT TIME:        15:00[EST]|
|LICENSE#:  7D-051-01             AGREEMENT:  Y  |LAST UPDATE DATE:  02/27/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES LINVILLE       R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JACK FERRUOLO                |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING POSSIBLE MISADMINISTRATION                  |
|                                                                              |
| "Event description: Cordis Checkmate IVBT system was used to treat a         |
| coronary artery on 1/28/02.  On 1/31/02 dosimetry and physicist records were |
| being reviewed by licensee physics staff and it was discovered that the      |
| 'diameter' of the vessel was used in the calculation instead of the          |
| 'radius'.  Agency was contacted by phone on 14 February 2002 to inform       |
| Agency of possible misadministration.  At this time the actual increase in   |
| dose had not been determined.  On 14 February 2002 the Agency was notified   |
| by FAX that, in fact, a misadministration had occurred.  Estimated dose      |
| received by the outer portion of the coronary artery was 14.6 Gy rather than |
| the intended 8 Gy.  Patient and physician were notified."                    |
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|Fuel Cycle Facility                              |Event Number:   38728       |
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| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION    |NOTIFICATION DATE:
02/27/2002|
|   RXTYPE: URANIUM FUEL FABRICATION             |NOTIFICATION TIME: 11:59[EST]|
| COMMENTS: LEU CONVERSION (UF6 to UO2)          |EVENT DATE:        02/26/2002|
|           COMMERCIAL LWR FUEL                  |EVENT TIME:        15:00[EST]|
|                                                |LAST UPDATE DATE:  02/27/2002|
|    CITY:  COLUMBIA                 REGION:  2  +-----------------------------+
|  COUNTY:  RICHLAND                  STATE:  SC |PERSON          ORGANIZATION |
|LICENSE#:  SNM-1107              AGREEMENT:  Y  |CAUDLE JULIAN        R2      |
|  DOCKET:  07001151                             |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID WILLIAMS               |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01 RESPONSE INVOLVING A C4 DISSOLVER ACID WASH PUMPOUT    
  |
| (24-Hour Report)                                                             |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "Facility -- Westinghouse Electric Company, Commercial Fuel Fabrication      |
| Facility, Columbia SC, low enriched (<=5.0 wt. % U-235) PWR fuel fabricator  |
| for commercial light water reactors.  License:  SNM-1107."                   |
|                                                                              |
| "Time and Date of Event -- Approx. 15:00 hours, Tuesday, February 26,        |
| 2002."                                                                       |
|                                                                              |
| "Reason for Notification -- During an internal procedure review by           |
| Operations, it was discovered that a current Process Information Form (PIF)  |
| for flushing and pumping out the lines of the C4 dissolvers did not contain  |
| all the required criticality controls.  The operating procedure for pumpout  |
| of UN product to non-favorable geometry bulk storage requires sampling for   |
| grams U-235 per liter, pH, and % free acid.  The PIF required only % free    |
| acid."                                                                       |
|                                                                              |
| "Summary of Process -- During normal processing, uranium is recovered from   |
| scrap materials in the favorable geometry C4 dissolvers system.  The         |
| resulting uranyl nitrate (UN) is sampled and released.  It is then pumped    |
| through gamma monitors, an active engineered control, to the non-favorable   |
| geometry UN bulk storage tanks."                                             |
|                                                                              |
| "When needed for uranium accountability purposes, the C4 dissolver system    |
| tanks are filled with water to the 40% level and then with water and acid to |
| the 43% level (approximately 102.3 gallons total) to flush the system."      |
|                                                                              |
| "As-Found Condition -- A summary of the as found conditions is as follows:   |
| *  The condition was found during an internal procedure review - not during  |
| acid wash pumpout.                                                           |
| *  The PIF was approved for use on February 14, 2002.                        |
| *  The PIF required only sampling for free acid.                             |
| *  The gamma monitors were functioning properly."                            |
|                                                                              |
| "Double Contingency Protection -- Double contingency protection for this     |
| situation is based on concentration control, that is (1) preventing          |
| solutions with >10 grams U-235 per liter from being transferred into the UN  |
| bulk storage tanks, and (2) detecting any increasing concentration of U-235  |
| in the tanks and taking corrective actions.  It was determined, however,     |
| that documented double contingency protection was lost because sampling for  |
| pH was not required on the PIF.  Double contingency protection was           |
| immediately restored by withdrawing the PIF.  Therefore, the incident        |
| requires notification in accordance with Westinghouse Operating License      |
| (SNM-1107), paragraph 3.7.3(c.5), in which less than previously documented   |
| double contingency protection remains in an analyzed system, but less than   |
| safe mass is involved."                                                      |
|                                                                              |
| "Summary of Activity --                                                      |
| *  The PIF was immediately withdrawn.                                        |
| *  Immediate instructions were given to Operations to ensure that all        |
| required sampling was performed.                                             |
| *  A causal analysis will be performed to determine corrective actions       |
| needed to prevent recurrence."                                               |
|                                                                              |
| "Conclusions --                                                              |
| *  Loss of documented double contingency protection did occur, but was       |
| immediately restored.                                                        |
| *  At no time was criticality possible because the gamma monitors ensure     |
| that the concentration remains <5 grams U-235 per liter.                     |
| *  At no time was there any risk to the health or safety of any employee or  |
| member of the public. No exposure to hazardous material was involved.        |
| *  It has been determined that this is a safety significant incident in      |
| accordance with governing procedures.  A root cause analysis will be         |
| performed."                                                                  |
|                                                                              |
| The licensee notified the NRC Region 2 office (David Ayres) and NMSS (Dennis |
| Morey).                                                                      |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
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|Other Nuclear Material                           |Event Number:   38729       |
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| REP ORG:  UNIV OF MICHIGAN                     |NOTIFICATION DATE: 02/27/2002|
|LICENSEE:  UNIV OF MICHIGAN                     |NOTIFICATION TIME: 12:00[EST]|
|    CITY:  ANN ARBOR                REGION:  3  |EVENT DATE:        02/27/2002|
|  COUNTY:  WASHTENAW                 STATE:  MI |EVENT TIME:        08:30[EST]|
|LICENSE#:  21-00215-04           AGREEMENT:  N  |LAST UPDATE DATE:  02/27/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHRISTINE LIPA       R3      |
|                                                |ALEXANDER ADAMS/PM   NRR     |
+------------------------------------------------+DON COOL             NMSS    |
| NRC NOTIFIED BY:  MARK DRISCOLL                |JOSEPH HOLONICH      IRO     |
|  HQ OPS OFFICER:  LEIGH TROCINE                |IMOB Office via fax  NMSS    |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 10 CFR PART 21 NOTIFICATION REGARDING FAILURE OF A J.L. SHEPHERD &           |
| ASSOCIATES, MARK-1, MODEL-25, IRRADIATOR, DOOR INTERLOCK                     |
|                                                                              |
| During the performance of a pre-operations inspection, an operator           |
| discovered that an irradiator door interlock could be defeated and that the  |
| door could be raised and expose the source.  The irradiator involved is a    |
| J.L. Shepherd & Associates, Mark 1, Model 25, irradiator which contains 780  |
| curies of cesium-137, and it is used for irradiating biological specimens.   |
|                                                                              |
| The university has been contacted.  The licensee notified the NRC Region 3   |
| office (Darryl Weideman), and the licensee plans to notify the vendor.       |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
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|Power Reactor                                    |Event Number:   38730       |
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| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 02/27/2002|
|    UNIT:  [] [] [3]                 STATE:  CA |NOTIFICATION TIME: 14:54[EST]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        02/27/2002|
+------------------------------------------------+EVENT TIME:        10:43[PST]|
| NRC NOTIFIED BY:  DOUG KNUDSON                 |LAST UPDATE DATE:  02/27/2002|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID GRAVES         R4      |
|10 CFR SECTION:                                 |TOM KOSHY            NRR     |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|JOSEPH HOLONICH      IRO     |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     A/R        Y       100      Power Operation  |0        Hot Standby      |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
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| AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO A LOSS OF OFFSITE POWER ON
UNIT 3 |
| DURING THE PERFORMANCE OF SWITCHYARD MAINTENANCE                             |
|                                                                              |
|                                                                              |
| Prior to this transient, the 220-kV, switchyard, section-B, west bus was     |
| de-energized to facilitate the performance of maintenance activities.        |
| During the performance of local breaker failure backup testing on the        |
| switchyard, section-B, west bus; the switchyard section-B east bus tripped   |
| at 1043 PST resulting in a loss of offsite power on Unit 3.  The loss of     |
| offsite power in turn caused a turbine trip/reactor trip signal to be        |
| generated.  All rods fully inserted.  An emergency feedwater actuation       |
| signal (EFAS) initiated as expected on steam generator shrinkage, and a      |
| containment cooling actuation signal (CCAS) was manually initiated.  The     |
| loss of offsite power also resulted in a loss of all non-1E power.  The      |
| reactor coolant pumps remained running because their power supply            |
| automatically transferred to Unit 2, and the Unit 3, 1E, 4-kV buses remained |
| energized from Unit 2.  The emergency diesel generators automatically        |
| started but did not load due to the automatic power supply transfers to Unit |
| 2.  Preliminary indications revealed that the primary safety valves remained |
| closed.  The licensee stated that all systems functioned as required and     |
| that there was no impact on Unit 2.                                          |
|                                                                              |
| Unit 3 is currently stable in Hot Standby with emergency feedwater supplying |
| water to the steam generators and secondary steam being dumped to atmosphere |
| via the atmospheric dump valves (due to a loss of condenser vacuum).  The    |
| licensee reported that there was no steam generator tube leakage.            |
| Containment parameters remain normal.                                        |
|                                                                              |
| The Unit 3 east and west switchyard buses have been re-energized, and all    |
| non-1E power was restored to the 4-kV buses at 1120 PST.  The emergency      |
| diesel generators have been secured.  The licensee currently plans to        |
| perform secondary equipment inspections, and the event evaluation is         |
| ongoing.                                                                     |
|                                                                              |
| The licensee notified the NRC resident inspector and may make a press        |
| release.                                                                     |
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|Other Nuclear Material                           |Event Number:   38731       |
+------------------------------------------------------------------------------+
                         
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| REP ORG:  CANBERRA INDUSTRIES, INC.            |NOTIFICATION DATE: 02/27/2002|
|LICENSEE:  CANBERRA INDUSTRIES, INC.            |NOTIFICATION TIME: 15:13[EST]|
|    CITY:  WARRINGTON               REGION:  1  |EVENT DATE:        01/28/2002|
|  COUNTY:                            STATE:  PA |EVENT TIME:        13:00[EST]|
|LICENSE#:  37-02401-01           AGREEMENT:  N  |LAST UPDATE DATE:  02/27/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES LINVILLE       R1      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY SCHWAGER               |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF LICENSED NUCLEAR MATERIAL                                            |
|                                                                              |
| On 1/28/02 at 1300, it was discovered that 13 Cl-36 sources were missing.    |
| The sources were 10 microcuries each and were manufactured on Nov 1995.  The |
| sources were 1 inch diameter, flat disc with mylar window, and assembled     |
| with an ion chamber instrument.  Each source was individually packaged in a  |
| 2ft x 1ft x 1ft cardboard box.  The assemblies were packaged for shipment on |
| 1/28/02 and stored on a shelf prior to shipment.  A clean up had been        |
| performed recently and it is believed by the Licensee, that these materials  |
| had been thrown into a waste dumpster for disposal.                          |
|                                                                              |
| There was no detectable radiation levels on the shipping container, and it   |
| is believed by the Licensee that there is no threat to the general           |
| population.                                                                  |
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|Power Reactor                                    |Event Number:   38732       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: DAVIS BESSE              REGION:  3  |NOTIFICATION DATE: 02/27/2002|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 15:42[EST]|
|   RXTYPE: [1] B&W-R-LP                         |EVENT DATE:        02/27/2002|
+------------------------------------------------+EVENT TIME:        13:30[EST]|
| NRC NOTIFIED BY:  DALE MILLER                  |LAST UPDATE DATE:  02/27/2002|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHRISTINE LIPA       R3      |
|10 CFR SECTION:                                 |TOM KOSHY            NRR     |
|ADEG 50.72(b)(3)(ii)(A)  DEGRADED CONDITION     |JOSEPH HOLONICH      IRO     |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| IDENTIFICATION OF AXIAL THROUGH-WELD INDICATIONS (REACTOR COOLANT
SYSTEM     |
| PRESSURE BOUNDARY LEAKAGE) ON ONE CONTROL ROD DRIVE MECHANISM
NOZZLE         |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On February 26, 2002, following shutdown for a scheduled refueling outage,  |
| the Davis-Besse Nuclear Power Station performed a qualified visual           |
| examination of the Reactor Vessel head per NRC Bulletin 2001-01.  This       |
| examination revealed evidence of boric acid build up around Control Rod      |
| Drive Mechanism (CRDM) nozzles but was inconclusive due to the previous      |
| known boric acid deposits.  At approximately 1330 hours on February 27,      |
| 2002, Ultrasonic Testing (UT) data identified axial through weld indications |
| on one CRDM.  Engineering evaluation of this data confirmed Reactor Coolant  |
| System pressure boundary leakage exists.  Technical Specification 3.4.6.2.a  |
| states that Reactor Coolant System leakage shall be limited to no pressure   |
| boundary leakage.  As a result this is being reported as a non-emergency,    |
| 8-hour report in accordance with 10CFR50.72(b)(3)(ii)(a), a condition that   |
| resulted in the nuclear power plant, including its principal safety barriers |
| being seriously degraded."                                                   |
|                                                                              |
| The licensee stated that UT inspections are continuing on other nozzles.     |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38733       |
+------------------------------------------------------------------------------+
                         
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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE:
02/27/2002|
|LICENSEE:  ACS ENGINEERING GROUP, CONSTRUCTION  |NOTIFICATION TIME:
16:01[EST]|
|    CITY:  TEMPE                    REGION:  4  |EVENT DATE:        02/26/2002|
|  COUNTY:                            STATE:  AZ |EVENT TIME:             [MST]|
|LICENSE#:  07-422                AGREEMENT:  Y  |LAST UPDATE DATE:  02/27/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID GRAVES         R4      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  NRC REGION 4                 |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT REGARDING THE LOSS OF CONTROL AND RECOVERY
OF AN ACS  |
| ENGINEERING GROUP, CONSTRUCTION, MOISTURE/DENSITY GAUGE IN TEMPE,
ARIZONA    |
|                                                                              |
| The following text is a portion of Preliminary Notification PNO-IV-02-013    |
| received from NRC Region 4:                                                  |
|                                                                              |
| "On February 26, 2002, the Arizona Radiation Regulatory Agency (ARRA)        |
| notified NRC Region IV by facsimile of the loss of control and recovery of a |
| portable gauge.  The ARRA was informed by the Gilbert, Arizona fire          |
| department on February 26, 2002, that a Troxler moisture/density gauge,      |
| Model 2401 (Serial No. MD91 005368) containing a 370 megabecquerel (10       |
| millicurie) source of americium-241/beryllium and a 1.48 gigabecquerel (40   |
| millicurie) cesium-137 source had been recovered by a motorist that saw the  |
| device fall off of a truck.  The motorist picked up the gauge and turned it  |
| into the local police department.  ARRA determined that the truck was        |
| operated by two employees of ACS Engineering Group, Construction, an Arizona |
| licensee.  The gauge was not damaged.  The licensee reclaimed the device on  |
| February 26, 2002.  ARRA will be investigating the event.  Media interest    |
| included reports by three local television stations."                        |
|                                                                              |
| "Region IV received notification of this occurrence by facsimile from ARRA   |
| at 2:35 p.m. (CT) on February 26, 2002.  Region IV has informed OEDO, NMSS,  |
| STP, and OPA."                                                               |
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