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Event Notification Report for March 18, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/15/2002 - 03/18/2002

                              ** EVENT NUMBERS **

38770  38771  38772  38773  38774  38775  

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|Hospital                                         |Event Number:   38770       |
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| REP ORG:  FOX CHASE CANCER CENTER              |NOTIFICATION DATE: 03/15/2002|
|LICENSEE:  FOX CHASE CANCER CENTER              |NOTIFICATION TIME: 10:23[EST]|
|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        03/15/2002|
|  COUNTY:                            STATE:  PA |EVENT TIME:             [EST]|
|LICENSE#:  37-02766-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/15/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID LEW            R1      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KAREN SHEEHAN                |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|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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| P-32 SOURCE USED IN RESEARCH DISCOVERED MISSING                              |
|                                                                              |
| The following preliminary information was provided by the licensee:          |
|                                                                              |
| "This is to inform you of an incident that occurred at our facility          |
| involving a recent shipment of 250 microcuries of phosphorous-32 [P-32]      |
| deoxyguanosine 5 triphosphate. The shipment was delivered to our facility    |
| (License # 37-02766-01) on March 8, 2002 as an excepted package, limited     |
| quantity [49 CFR173.421]. The package was delivered to the recipient lab and |
| the blue plastic container was placed in a freezer that was locked for       |
| storage of the material. On March 11, 2002 when the freezer was unlocked and |
| the blue container was removed for use there was no vial of P-32 inside. The |
| lab worker immediately reported the situation to her Principal Investigator. |
| Initially the assumption was simply that the facility was shortchanged a     |
| vial and indeed that is our conclusion after investigation of the incident.  |
| The Radiation Safety Officer [RSO] was notified via e-mail at or about the   |
| time the purchasing department was notified.                                 |
|                                                                              |
| "The RSO immediately began an investigation of the incident. It was          |
| determined that the initial recipient did not follow the facilities          |
| procedure for opening packages of radioactive material and failed to monitor |
| the surface of the package or look inside and verify the contents. The       |
| shipper, Perkin Elmer, was notified and asked to investigate the matter. The |
| distribution coordinator at Perkin Elmer indicated that there might have     |
| been other incidents where primary vials have been omitted from a shipment.  |
| She declined to give further details until they finish their investigation.  |
| The RSO was informed that each package is not routinely surveyed by Parker   |
| Elmer even though  an exposure rate was indicated on the packing slip.       |
|                                                                              |
| "Physical inventories of the laboratory concerned and an adjacent laboratory |
| were conducted and there were no discrepancies. Hospital security has been   |
| notified and they are conducting an investigation. A radiation survey using  |
| a Ludlum Model 3 survey meter with a 44-9 probe was performed of the lab in  |
| question, as well as the tissue culture room where the material was stored,  |
| and the Principal Investigator's Office. The shelves, drawers, cabinets,     |
| sinks, trashcans were surveyed in these areas with no positive results. A    |
| water cooler in the vicinity was swipe tested on the advice of our           |
| consultant. The water cooler showed no evidence of P-32 contamination. All   |
| the bottles next to the water cooler were also surveyed via a meter and no   |
| levels were found.                                                           |
|                                                                              |
| "The Principal Investigator [ ] was interviewed by the RSO.  She indicated   |
| that she was not aware of any personal conflicts within her lab nor any      |
| other labs at the facility.  She indicated that not only is their            |
| radioactive material kept locked within a freezer dedicated to radioactive   |
| materials storage, but that the tissue culture room is kept locked when not  |
| in use.                                                                      |
|                                                                              |
| "Access to the building requires an access card and there is a record of all |
| personnel who entered the building during the period March 8-11. They are in |
| the process of interviewing those personnel on the list.                     |
|                                                                              |
| "Shipping and Receiving was checked for other shipments from Perkin Elmer    |
| but none were received on March 8.                                           |
|                                                                              |
| "We have completed the following corrective actions. A review of package     |
| receipt procedures including survey of the package and inspection of the     |
| primary vial was done with the personnel in the lab that received the        |
| shipment. The lab in question also developed a procedure checklist that      |
| includes not only the above but also the step of matching the lot number on  |
| the vial with that on the shipping papers. A memo has been sent to all of    |
| the other research labs reminding them of the procedures for receiving       |
| packages include a survey of the surface of the package even though          |
| regulations do not require that for an exempt quantity package and an email  |
| send as urgent went to all research areas, Nuclear Medicine and Radiation    |
| Oncology. A review of the incident and package receipt procedures will be    |
| included in annual inservices and information conveyed during routine        |
| inspections of radioactive materials laboratories.                           |
|                                                                              |
| "We have concluded that the primary vial was probably not shipped, because   |
| the material was secured within the building, the tissue culture room, and   |
| within the freezer from the time delivered until the attempt to use it. No   |
| evidence of any irregularity resulted from the investigations conducted by   |
| the RSO and Security. But since we cannot rule out that the vial was shipped |
| we are notifying the Nuclear Regulatory Commission. Security has always been |
| a priority at Fox Chase Cancer Center and we are aware of the heightened     |
| concerns due to the terrorist attacks of September 11".                      |
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|Fuel Cycle Facility                              |Event Number:   38771       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE:
03/15/2002|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 12:55[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        03/14/2002|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:00[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  03/15/2002|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MONTE PHILLIPS       R3      |
|  DOCKET:  0707002                              |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC SPAETH                  |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 24-HOUR NRC BULLETIN 91-01 REPORT                                            |
|                                                                              |
| "During Field-testing of the west annex floor, the floor failed to maintain  |
| the solution in a safe slab by allowing water to seep in cracks along the    |
| wall. This is a violation of NCSA- 0705_076 (inadvertent containers)         |
| administrative controls on potential inadvertent containers. While an unsafe |
| amount of solution was NOT lost in this event, the cracks represent a loss   |
| of one leg of double contingency control as defined in NCSE- 0705_076.       |
|                                                                              |
| "Background information: On March 6, a low level probe for the storage       |
| columns in the West Annex developed a leak and allowed uranium-bearing       |
| solution to accumulate on the floor. The amount of spilled solution on the   |
| floor was estimated at that time to be no more than 18.4 liters. The spill   |
| amount did not meet the definition of an unsafe amount of uranium bearing    |
| material, the process conditions credited for meeting double contingency in  |
| the NCSE's were maintained.                                                  |
|                                                                              |
| "On March 14, after completing repairs to the low level probe, the solution  |
| level in the West Annex storage columns was remeasured. The solution volume  |
| lost, calculated from the system sight glasses was calculated to be          |
| approximately 97.5 liters. Given the known assay and concentration of        |
| uranium, the spilled solution still did not represent an unsafe amount of    |
| uranium bearing material even when the volume was increased from 18.4 liters |
| to 97.5 liters.                                                              |
|                                                                              |
| "On March 14, an NCS engineer and Operations personnel investigated the      |
| difference between the amount of solution observed on the floor and the      |
| amount estimated by the level of the sight glass. A field test was conducted |
| where as water was observed to seep into cracks between the floor and the    |
| wall.                                                                        |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:  Low. The solution in question could not     |
| support a criticality in any geometry. Less than a safe mass amount of       |
| solution was involved.                                                       |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR):                                                    |
| For a criticality to occur, the following events are required. The West      |
| Annex blending system would have to be operating and processing solution     |
| with a high concentration of uranium and assay. Then a leak would have to    |
| occur such that an unsafe amount of solution would collect on the floor. The |
| solution would then flow into the cracks on the floor into an unsafe         |
| geometry. Depending on the amount of solution collected some reflection      |
| would be required to maintain a critical chain reaction.                     |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION,
ETC.):    |
| N/A.  Volume or Geometry                                                     |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE
PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS): Based upon the amount of solution  |
| that leaked on the floor, 51 grams U235. This represents 3% of the required  |
| amount of solution                                                           |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND
DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES: Cracks between the floor and the wall could |
| allow solution to enter an unknown unfavorable geometry in the event of a    |
| spill.                                                                       |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS
IMPLEMENTED:  |
| The PSS directed remaining in an anomalous condition until the repairs to    |
| the cracks can be made."                                                     |
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|General Information or Other                     |Event Number:   38772       |
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| REP ORG:  WV RADIOLOGICAL HEALTH PROGRAM       |NOTIFICATION DATE:
03/15/2002|
|LICENSEE:  WEIRTON MEDICAL CENTER               |NOTIFICATION TIME: 17:37[EST]|
|    CITY:  WEIRTON                  REGION:  2  |EVENT DATE:        03/02/2002|
|  COUNTY:                            STATE:  WV |EVENT TIME:             [EST]|
|LICENSE#:  47-17567-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/15/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK LESSER          R2      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAN HILL                     |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| COURTESY NOTIFICATION                                                        |
|                                                                              |
| The West Virginia Radiological Health Program was notified by the Ohio       |
| Bureau of Radiation Protection that a shipment of medical waste from the     |
| Weirton Medical Center activated a radiation detector at the Stericycle      |
| medical waste incineration facility in Ohio. The dose rate at the surface of |
| the package was greater than 500 microR/hr (as of 3/15/02, it was 200        |
| microR/hr). The incinerator facility is holding the package in a secure      |
| location until the Weirton Medical Center is able to retrieve it.            |
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|Power Reactor                                    |Event Number:   38773       |
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| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 03/16/2002|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 06:59[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        03/16/2002|
+------------------------------------------------+EVENT TIME:        02:40[EST]|
| NRC NOTIFIED BY:  ROBERT BOESCH                |LAST UPDATE DATE:  03/16/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVID LEW            R1      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| UNIT 2 ENTERED TS 3.0.3 AFTER DECLARING ESS BUSES INOPERABLE DUE TO
ERROR IN |
| CLEARANCE                                                                    |
|                                                                              |
| "On 3/16/02 at 0240 hours, a field operator was directed to remove a         |
| clearance and rack in 4 Kv breakers for the Unit 1 A & B Control Rod Drive   |
| system. The system had been out of service for maintenance during the refuel |
| outage. Upon arrival at the load center, the operator found both breakers    |
| racked out but not secured with the required seismic restraints. According   |
| to plant procedures, this renders the associated bus inoperable. Shift       |
| supervision was notified and the Unit 1 'A' and 'D' ESS Busses were declared |
| inoperable. The immediate effects were for Unit 2 to enter TS 3.0.3 which    |
| was exited 30 minutes later, once the breakers were returned to their        |
| racked-in position. In review of the Loss of Safety Function, it was         |
| discovered that, with the 'A' and 'D' ESS Busses inoperable, the Control     |
| Structure chillers were inoperable resulting in an event or condition that   |
| could have prevented fulfillment of a Safety Function required to Mitigate   |
| the consequences of an accident. In accordance with 10CFR50.72(b)(3)(,v)(D)  |
| this loss of safety function requires an 8 hour ENS Notification."           |
|                                                                              |
| The 4 Kv breakers were racked out 8 days ago.  Due to an oversight in        |
| preparation of the clearance, the procedure requiring installation of the    |
| seismic restraints was not referenced.  The licensee informed the NRC        |
| Resident Inspector.                                                          |
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|Power Reactor                                    |Event Number:   38774       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: LASALLE                  REGION:  3  |NOTIFICATION DATE: 03/16/2002|
|    UNIT:  [] [2] []                 STATE:  IL |NOTIFICATION TIME: 13:55[EST]|
|   RXTYPE: [1] GE-5,[2] GE-5                    |EVENT DATE:        03/16/2002|
+------------------------------------------------+EVENT TIME:        12:15[CST]|
| NRC NOTIFIED BY:  MICHAEL FITZPATRICK          |LAST UPDATE DATE:  03/16/2002|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MONTE PHILLIPS       R3      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
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| PLANT SHUTDOWN IN ACCORDANCE WITH TECHNICAL SPECIFICATIONS                   |
|                                                                              |
| "This notification is being made pursuant to 10CFR50.72(b)(2)(i), and Exelon |
| Reportability Manual section SAF 1.2. At 1215 CST on 03/16/02, during Unit 2 |
| steady state operation at 100% power, a unit shutdown was initiated due to   |
| an increase in Reactor Coolant System Unidentified Leakage in excess of      |
| Technical Specification limits. RCS unidentified leakage has increased by    |
| 2.1 gallons per minute over a 24 hour period, from 0.9 gpm to 3.0 gpm, which |
| is above the Tech Spec limit of less than or equal to 2 gpm. On 3/16/02 at   |
| 0555 CST, a 12 hour timeclock was entered to be in Hot Shutdown by 1755 CST, |
| followed by Cold Shutdown on 3/17/02 at 1755 CST. Current plans are to enter |
| Cold Shutdown in order to enter the Primary Containment, and determine and   |
| correct the cause of the unidentified leakage."                              |
|                                                                              |
| The NRC resident inspector has been informed of this event by the licensee.  |
|                                                                              |
| * * * UPDATE 2214 EST 3/16/2002 FROM DANIEL COVEYOU TAKEN BY BOB STRANSKY * 
|
| * *                                                                          |
|                                                                              |
| "This notification provides an update of EN #38774 and is being made         |
| pursuant to 10CFR50.72(c)(2) and Exelon Reportability Manual section SAF     |
| 1.2.                                                                         |
|                                                                              |
| "As of 1540 CST, the indicated increase in the Unit 2 unidentified leakage   |
| rate over the previous 24 hr period has decreased to 1.7 gpm. As this value  |
| meets the LCO requirements of LaSalle Technical Specification 3.4.5 (<2 gpm  |
| increase within previous 24 hours), the plant shutdown initiated at 1215 CST |
| is no longer required.                                                       |
|                                                                              |
| "The increase (and subsequent decrease) in the indicated unidentified        |
| leakage rate is consistent with previously observed behaviors following      |
| primary containment cooling equipment lineup changes that induce containment |
| air temperature changes. Initial chemistry analyses of the primary           |
| containment environment (air and sump samples) indicate that there has been  |
| no increase in reactor coolant system leakage.                               |
|                                                                              |
| "The shutdown was terminated with the reactor operating at 69% power.        |
| Current plans are to return the unit to full power operation."               |
|                                                                              |
| The NRC resident inspector has been informed of this update by the licensee. |
| Notified R3DO (Phillips).                                                    |
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|Power Reactor                                    |Event Number:   38775       |
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| FACILITY: FT CALHOUN               REGION:  4  |NOTIFICATION DATE: 03/17/2002|
|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 17:03[EST]|
|   RXTYPE: [1] CE                               |EVENT DATE:        03/17/2002|
+------------------------------------------------+EVENT TIME:        15:25[CST]|
| NRC NOTIFIED BY:  ANTHONY CHRISTIANSON         |LAST UPDATE DATE:  03/17/2002|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |GAIL GOOD            R4      |
|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       98       Power Operation  |98       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION DUE TO BRUSH FIRE NEAR SITE                             |
|                                                                              |
| The licensee contacted the local volunteer fire department to respond to two |
| small brush fires burning under the plant access road bridge. The fire       |
| department responded at 1537 CST and both fires were extinguished by 1556    |
| CST. The licensee believes that the fires were caused by a passing train.    |
| The NRC resident inspector has been informed of this event by the licensee.  |
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