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Event Notification Report for March 20, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/19/2002 - 03/20/2002

                              ** EVENT NUMBERS **

38680  38781  38782  38783  38784  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38680       |
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| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 02/07/2002|
|    UNIT:  [] [3] []                 STATE:  NY |NOTIFICATION TIME: 16:52[EST]|
|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        02/07/2002|
+------------------------------------------------+EVENT TIME:        16:00[EST]|
| NRC NOTIFIED BY:  ROGER YOUNG                  |LAST UPDATE DATE:  03/19/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |LAWRENCE DOERFLEIN   R1      |
|10 CFR SECTION:                                 |RICHARD ROSANO       IAT     |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |SUSIE BLACK          NRR     |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 1-HOUR SECURITY REPORT INVOLVING THE POTENTIAL LOSS OF SAFEGUARDS           
|
| INFORMATION                                                                  |
|                                                                              |
| Discovery of loss of classified document/safeguards information.  No         |
| compensatory measures available.  Licensee notified the NRC Resident         |
| Inspector.  Contact the Headquarters Operations Center for additional        |
| details.                                                                     |
|                                                                              |
| ***RETRACTED ON 3/19/02 AT 1110 EST FROM BRIAN ROKES TO RICH LAURA***        |
|                                                                              |
| The licensee is retracting this event after completing their investigation.  |
| The licensee informed the Resident Inspector.  Notified the RIDO (R. Conte). |
| Contact the HOO for details.                                                 |
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|General Information or Other                     |Event Number:   38781       |
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| REP ORG:  ABB INC                              |NOTIFICATION DATE: 03/19/2002|
|LICENSEE:  ABB INC                              |NOTIFICATION TIME: 12:53[EST]|
|    CITY:  CORAL SPRING             REGION:  2  |EVENT DATE:        03/18/2002|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EST]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  03/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAY HENSON           R2      |
|                                                |VERN HODGE           NRR     |
+------------------------------------------------+RICHARD CONTE        R1      |
| NRC NOTIFIED BY:  R. GONNAM/M. RUIZ            |PATRICK HILAND       R3      |
|  HQ OPS OFFICER:  GERRY WAIG                   |DALE POWERS          R4      |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| INITIAL NOTIFICATION OF POTENTIAL DEFECT CLASS 1E TYPE CV-2 AND CV-22        |
| RELAYS                                                                       |
|                                                                              |
| "This letter is the initial notification of a deviation concerning our Class |
| 1E type CV-2 and CV-22 relays.                                               |
|                                                                              |
| "One of our customers notified us that several of the CV-2 relays they had   |
| recently received did not have a particular assembly on the moving disc      |
| which other CV-2 relays on the same order did have. Discussions with this    |
| customer concluded they were speaking of a weight assembly that is used in   |
| balancing the moving disc and is required as a part of the completed relay.  |
|                                                                              |
| "Upon visual examination of the CV-2 relays returned to us for corrective    |
| action this deviation was confirmed. A preliminary investigation showed that |
| our manufacturing system allowed for the potential for this deviation to     |
| occur.                                                                       |
|                                                                              |
| "Details will be provided in our written notification forthcoming within the |
| next thirty days."                                                           |
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|Power Reactor                                    |Event Number:   38782       |
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| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 03/19/2002|
|    UNIT:  [] [2] []                 STATE:  WI |NOTIFICATION TIME: 14:15[EST]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        03/19/2002|
+------------------------------------------------+EVENT TIME:        10:56[CST]|
| NRC NOTIFIED BY:  MIKE MEYER                   |LAST UPDATE DATE:  03/19/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MONTE PHILLIPS       R3      |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(3)(ii)(A)  DEGRADED CONDITION     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |98       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF SPDS DEGRADES COMMUNICATION/ASSESSMENT/RESPONSE CAPABILITY    
      |
|                                                                              |
| "During the performance of a software update to the Primary Plant Process    |
| Computer System (PPCS) the Unit 2 PPCS servers failed rendering Reactor      |
| Thermal Output and Safety Parameter Display functions for Unit 2 inoperable. |
| At the time of the failure the software update was only being performed on   |
| Unit 2. Unit 1 PPCS was verified operable and was not affected because the   |
| software update was only being applied to the Unit 2 Servers.                |
|                                                                              |
| "Abnormal Operating Procedure AOP-21, PPCS Malfunction was entered and       |
| Reactor Power was reduced approximately 2% and is currently being controlled |
| by Control Board Delta-T. The Safety Parameter Display System was also       |
| rendered inoperable and is the bases for making this Notification.           |
|                                                                              |
| "Presently the Unit 2 PPCS servers are being re-booted, and it is expected   |
| that PPCS will be available in about 2 hours. It is not known what the exact |
| failure mechanisms for Unit 2, only that it is either the software or the    |
| procedure that caused the PPCS failure to unit 2."                           |
|                                                                              |
| The licensee also notified the NRC Resident Inspector.                       |
|                                                                              |
| * * * UPDATE ON 3/19/02 @1732 BY HARRSCH TO GOULD * * *                      |
|                                                                              |
| As of 1534 CST, the PPCS system was returned to service for Unit 2.  All     |
| required functions were verified operable, including Reactor Thermal Output  |
| (RTO) and the Safety Parameter Display System (SPDS).  The initial failure   |
| was related to the installation of a software upgrade and the problem has    |
| been corrected.   With the RTO function now Operable, Unit 2 will be         |
| returning to full power from 98%.                                            |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| Reg 3 RDO(Phillips) was informed                                             |
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|Hospital                                         |Event Number:   38783       |
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| REP ORG:  ST FRANCIS HOSPITAL & HEALTH CTR     |NOTIFICATION DATE: 03/19/2002|
|LICENSEE:  ST FRANCIS HOSPITAL & HEALTH CTR     |NOTIFICATION TIME: 17:31[EST]|
|    CITY:  BEECH GROVE              REGION:  3  |EVENT DATE:        02/28/2002|
|  COUNTY:  MARION                    STATE:  IN |EVENT TIME:             [CST]|
|LICENSE#:  13-02128-03           AGREEMENT:  N  |LAST UPDATE DATE:  03/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MONTE PHILLIPS       R3      |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BERRY STEWART (RSO)          |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|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 DURING STENT RESTENOSIS IRRADIATION                |
|                                                                              |
| "On 02/28/02, patient was scheduled for irradiation of an in stent           |
| restenosis using the Novoste Beta-Cath system, specifically 30 mm serial     |
| number 88746.                                                                |
|                                                                              |
| "The cardiologist stated the reference vessel diameter was 2.7 mm            |
|                                                                              |
| "The standard dose for a reference diameter of 2.7 mm is 18.4 Gy delivered   |
| in 3'22".                                                                    |
|                                                                              |
| "The patient was identified, and pre-procedure patient survey was performed. |
| The novoste unit was prepped, placed in sterile bag and catheter attached,   |
| by the authorized user, system was pressurized to verify water flow through  |
| the system. The sources were sent to the treatment position in the catheter  |
| and verified visually by authorized user and medical physicist that the      |
| sources were in the proper location within the catheter. The sources were    |
| returned to the source holding area with a green light indicating they were  |
| in the safe position.                                                        |
|                                                                              |
| "The authorized user took the Novoste system to the patient and the          |
| cardiologist inserted the treatment catheter through the arrow sheath        |
| protector and forwarded the treatment catheter to the desired treatment      |
| location, verified via fluoroscopy.                                          |
|                                                                              |
| "When the treatment catheter was in place, the cardiologist indicated the    |
| location to be correct, the authorized user indicated he was ready to send   |
| the sources, and upon acknowledgement the sources were sent to treatment     |
| location under fluoroscopy. The distal marker was visualized but the         |
| proximal marker wasn't seen. The cardiologist rotated the C-arm to change    |
| the perspective of the image. The proximal marker still wasn't visualized.   |
|                                                                              |
| "The authorized user then attempted to return the sources to the safe        |
| position in the Novoste device. There was no indication of the sources       |
| returning to safe position. The catheter was immediately removed from the    |
| patient and taken to the safety box. The medical physicist then attempted to |
| return the sources to the safe position and verify their location. This      |
| attempt was unsuccessful.                                                    |
|                                                                              |
| "The patient was surveyed and found to be at background.                     |
|                                                                              |
| "Utilizing multiple wet gauze pads, the catheter was wiped clean in an       |
| attempt to locate the sources visually. The sources were not seen. The       |
| catheter was then passed over the survey meter, with the unit in the box to  |
| determine if the sources were in the catheter. There were no sources in the  |
| catheter,                                                                    |
|                                                                              |
| "At this time, the cardiologist was asked if he wanted to change systems and |
| continue the treatment. The authorized user and cardiologist decided to      |
| abort the procedure. The patient was notified of the decision by the         |
| cardiologist at this time.                                                   |
|                                                                              |
| "The Novoste system was removed from the Cath lab in the safety box. Under   |
| visual inspection there appeared to be 6 source pellets and proximal marker  |
| in the source holding area of the Novoste unit. The remaining 6 source       |
| pellets and distal marker appeared to be in the base of the catheter that    |
| fits into the Novoste unit.                                                  |
|                                                                              |
| "All sources were visually accounted for, Novoste was called, and problem    |
| reported.                                                                    |
|                                                                              |
| "Novoste representative arrived within 2 hours of notification, and was able |
| to return all sources to the safe location, with the unit indicating the     |
| safe condition,                                                              |
|                                                                              |
| "Upon inspection, there was some type of material (black) in the source      |
| holding chamber. This material apparently restricted movement of the source  |
| pellets out of the source holding chamber,                                   |
|                                                                              |
| "The Novoste unit was immediately removed from service and it and the        |
| catheter was placed in the lead shield container to be returned to Novoste   |
| for evaluation.                                                              |
|                                                                              |
| "The time estimate for the time the distal marker was seen and the system    |
| removed from patient was approximately 30 seconds.                           |
|                                                                              |
| "The treatment was never actually started as the proximal marker was never   |
| visualized and that is the indication to start the timer, thus starting the  |
| treatment.                                                                   |
|                                                                              |
| "The only definite location of the sources is that the distal marker was at  |
| the proper location in the catheter.                                         |
|                                                                              |
| "If one assumes the six pellets were behind the distal marker for 20         |
| seconds, then the dose would be approximately 1.8 Gy to a length of 0.5 -    |
| 0.75 mm.                                                                     |
|                                                                              |
| "This would be a maximum dose estimate, as part of the time they were being  |
| remove from the patient, and in vessels that were much large than 2.7 mm     |
| diameter."                                                                   |
|                                                                              |
| The licensee stated that NRC Region 3 was notified of this event on 2/28/02. |
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|Power Reactor                                    |Event Number:   38784       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 03/19/2002|
|    UNIT:  [1] [] []                 STATE:  AZ |NOTIFICATION TIME: 19:02[EST]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        03/15/2002|
+------------------------------------------------+EVENT TIME:        06:30[MST]|
| NRC NOTIFIED BY:  DAN MARKS                    |LAST UPDATE DATE:  03/19/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DALE POWERS          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       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NON WORK RELATED FATALITY NOTIFICATION IN ACCORDANCE WITH 10CFR50.72        
|
|                                                                              |
| "At approximately 06:30 MST on March 15, 2002, a non-work related on-site    |
| fatality occurred at the Palo Verde Nuclear Generating Station. The fatality |
| was not related to the health and safety of the public or onsite personnel.  |
| Specifically, a contract carpenter was found by coworkers in the carpenter   |
| shop before work hours with no pulse or life signs. The individual was       |
| promptly attended by Palo Verde Emergency Medical Technicians (EMTs) and an  |
| air evacuation was completed. The individual was pronounced dead upon        |
| arrival at the hospital.                                                     |
|                                                                              |
| "The individual was outside of the Radiological Controlled Area and no       |
| radioactive material or contamination was involved. The work location was    |
| outside of the Protected Area.                                               |
|                                                                              |
| "Palo Verde has not observed any heightened public, media or government      |
| concern as a result of the fatality. Since the fatality is unrelated to Palo |
| Verde's industrial or radiological health and safety, no news release is     |
| planned.                                                                     |
|                                                                              |
| "Since the fatality was not work-related, nor the result of an accident, no  |
| notification to other government agencies was made at the time. However,     |
| Palo Verde is now making a notification to the Arizona Department of         |
| Occupational Safety and Health (ADOSH) due to a requirement to report any    |
| cardiac arrest on-site. Thus this ENS notification is in response to a       |
| notification to another government agency in accordance                      |
| with10CFR50.72(b)(2)(xi)."                                                   |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
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