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Event Notification Report for April 4, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/03/2002 - 04/04/2002

                              ** EVENT NUMBERS **

38758  38790  38825  38826  38827  38828  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38758       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
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| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 03/09/2002|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 05:32[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        03/09/2002|
+------------------------------------------------+EVENT TIME:        01:00[EST]|
| NRC NOTIFIED BY:  GORDON ROBINSON              |LAST UPDATE DATE:  04/03/2002|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MOHAMED SHANBAKY     R1      |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| LOCAL LEAK RATE TEST FAILURE                                                 |
|                                                                              |
| Appendix J Local Leak Rate Testing of Containment Penetration for Drywell    |
| Sprays failed Tech Spec Acceptance Criteria for Secondary Containment Bypass |
| Leakage.  The leakage limit is 9 standard cubic feet per hour and the test   |
| results were 10.5 standard cubic feet per hour.  The identified degraded     |
| condition is reportable as a condition of the nuclear power plant,           |
| including its principle safety barriers being seriously degraded per         |
| 10CFR50.72(b)(3)(ii)                                                         |
|                                                                              |
| The NRC Resident Inspector will be notified of this event by the licensee.   |
|                                                                              |
| ***UPDATE (RETRACTION) ON 4/3/02 at 1147 EST FROM ROBERT BOESCH TO RICH      |
| LAURA***                                                                     |
|                                                                              |
| "On 03/09/02, Appendix J Local Leak Rate Testing (LLRT) of a primary         |
| containment penetration for Drywell Sprays failed Tech Spec Acceptance       |
| Criteria for Secondary Containment Bypass Leakage. The test results were     |
| attributed to the tested Containment Isolation Valve (CIV), HV151FO16A. The  |
| identified condition was reported in EN#38758 as a Degraded Condition per 10 |
| CFR 50.72(b)(3)(ii)(A).                                                      |
|                                                                              |
| "As a result of observations made during the testing, one of the test        |
| boundary valves, HV151FO21A, was refurbished. Significant valve seat         |
| degradation was noted after the test boundary valve was disassembled. After  |
| the refurbishment of the test boundary valve, the Appendix J LLRT was        |
| repeated for the tested CIV, HV151FOl 6A, with acceptable results. Since no  |
| significant maintenance was performed on the tested CIV that would affect    |
| its leak-tightness, the subsequent test results are valid for as-found       |
| leakage of the tested CIV. The total As-Found Secondary Containment Bypass   |
| Leakage was less than the Tech Spec limit. Based on this evaluation, ENS     |
| Notification ENS38758 is retracted."                                         |
|                                                                              |
| The NRC Resident  Inspector was notified.  The R1DO (G. Meyer) was notified. |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38790       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 03/20/2002|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 22:56[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        03/20/2002|
+------------------------------------------------+EVENT TIME:        15:43[EST]|
| NRC NOTIFIED BY:  PETER A. GARDNER             |LAST UPDATE DATE:  04/03/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD CONTE        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          Y       2        Startup          |2        Startup          |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT-1 HPCI SYSTEM FAILED TO MEET REQUIRED RESPONSE TIME DURING
SURVEILLANCE |
| TESTING                                                                      |
|                                                                              |
| "On 3/20/02 at 15:43 the Unit-1 HPCI system failed to meet required system   |
| response time during surveillance testing. Testing was being performed to    |
| establish HPCI operability during reactor startup with reactor steam dome    |
| pressure at 204 psig. The HPCI system failed to achieve rated system flow    |
| within the required time from system initiation. Troubleshooting is          |
| currently in progress and a determination is underway to determine if this   |
| problem was related to maintenance activities performed during the refueling |
| outage.                                                                      |
|                                                                              |
| "This report is being made in pursuant to 10CFR50.72(b)(3)(v)(D) for failure |
| of a single train accident mitigation system."                               |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| ***UPDATE (EVENT RETRACTION) 4/3/02 at 1533 from Stan Gamble to Rich         |
| Laura***                                                                     |
|                                                                              |
| "This is a retraction of the event notification made on 3/20/02 at 22:56     |
| hours. This event (#38790) was initially reported as a safety system         |
| functional failure under the requirement of 1OCFR5O.72(b)(3)(v)(D). Unit 1   |
| High Pressure Coolant Injection (HPCI) failed to meet the required system    |
| maximum response time during surveillance testing. Testing was being         |
| performed during reactor startup with reactor steam dome pressure at 204     |
| psig.                                                                        |
|                                                                              |
| "Rated flow was not achieved within the 59-second maximum response time      |
| specified in the test due to motor operated valve (MOV) and flow controller  |
| manipulations performed during the unsatisfactory testing. The test was      |
| re-performed successfully and the system was declared operable on 2/21/02 at |
| 02:15 hours. System repair was not required.                                 |
|                                                                              |
| "The system response was verified to be as designed considering the test     |
| conditions. A condition did not exist at the time of discovery that could    |
| have prevented the fulfillment of the safety function."                      |
|                                                                              |
| Notified R1DO (G. Meyer)                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38825       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: ARKANSAS NUCLEAR         REGION:  4  |NOTIFICATION DATE: 04/03/2002|
|    UNIT:  [1] [2] []                STATE:  AR |NOTIFICATION TIME: 11:34[EST]|
|   RXTYPE: [1] B&W-L-LP,[2] CE                  |EVENT DATE:        04/03/2002|
+------------------------------------------------+EVENT TIME:        08:27[CST]|
| NRC NOTIFIED BY:  TOM SCOTT                    |LAST UPDATE DATE:  04/03/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BILL JONES           R4      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FITNESS FOR DUTY REPORT INVOLVING CONTRACT SUPERVISOR                        |
|                                                                              |
| A non-licensed contractor supervisor tested positive for alcohol during a    |
| for-cause fitness for duty test. The individual's site unescorted access has |
| been removed. Contact the Headquarters Operations Officer for additional     |
| information.                                                                 |
|                                                                              |
| The NRC Resident Inspector was notified of the event by the licensee.        |
|                                                                              |
| The licensee also notified NRC Region 4 (Dennis Schaefer) of the event.      |
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|Fuel Cycle Facility                              |Event Number:   38826       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: FRAMATOME ANP RICHLAND               |NOTIFICATION DATE: 04/03/2002|
|   RXTYPE: URANIUM FUEL FABRICATION             |NOTIFICATION TIME: 17:05[EST]|
| COMMENTS: LEU CONVERSION                       |EVENT DATE:        04/03/2002|
|           FABRICATION & SCRAP RECOVERY         |EVENT TIME:             [PST]|
|           COMMERCIAL LWR FUEL                  |LAST UPDATE DATE:  04/03/2002|
|    CITY:  RICHLAND                 REGION:  4  +-----------------------------+
|  COUNTY:  BENTON                    STATE:  WA |PERSON          ORGANIZATION |
|LICENSE#:  SNM-1227              AGREEMENT:  Y  |BILL JONES           R4      |
|  DOCKET:  07001257                             |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CALVIN MANNING               |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01 (CRITICALITY CONTROLS) ISSUE AT FRAMATONE ANP RICHLAND 
  |
|                                                                              |
| "Background: FRA-ANP routinely uses 45-gallon drums that contain a neutron   |
| absorbing spider assembly for processing and storing unmoderated urania      |
| powder.  The spider assembly is inserted into the drum and bolted to the     |
| drum bottom. This spider assembly is designed such that it will prevent      |
| criticality in a single drum even if the drum is accidentally filled with an |
| optimum mixture of UO2 and water and is also fully reflected by water.       |
| Accidental disassembly is prevented by the spider assembly design.  However, |
| when a drum reaches the end of useful service, or if the drum will no longer |
| be used for dirty or Gd contaminated powder, the neutron absorbing spider    |
| assembly is removed and reused with a new 45-gallon drum.  The old drum sans |
| insert is then destroyed.                                                    |
|                                                                              |
| "Event Description: On swing shift April 2, 2002 process operators removed   |
| the neutron absorbing spider assemblies from three 45-gallon drums per       |
| standard operating procedure (SOP). Operators moved these three drums to the |
| old waste area.                                                              |
|                                                                              |
| "Around midnight, a process operator retrieved one of the 45-gallon drums in |
| the old waste area instead of going to the powder storage area to retrieve a |
| 45-gallon drum.  He transferred it to a nearby utility hood and used it to   |
| prepare a blend of unmoderated dirty urania powder for subsequent            |
| dissolution.  The process operator failed to perform a required visual       |
| inspection of the interior of the 45-gallon drum prior to transferring 250   |
| kg of urania powder enriched to 2.7 wt.% 235U into it.  The same process     |
| operator secured the lid and transferred it per SOP to another process       |
| enclosure where the drum lid is removed and a drum tumbling lid is           |
| installed.  When the process operator removed the drum lid at about 0230, he |
| noticed the drum did not have a neutron absorbing spider assembly and        |
| contacted supervision.  Supervision immediately contacted Criticality        |
| Safety.                                                                      |
|                                                                              |
| "Safety Significance of Event: The safety significance of this event is low. |
| The urania powder placed in this drum was known in advance to contain less   |
| than 1 wt.% moisture equivalent hydrogen.  Two process operators had         |
| previously verified the material had acceptable laboratory analysis results  |
| and that the correct material had been selected for the blend.               |
|                                                                              |
| "A sphere of 250 kg UO2 powder enriched to 5 wt.% 235U, with a bulk density  |
| of 4 g/cc, and  containing 10 wt.% water that is fully reflected by water    |
| has a keff of 0.95.  Therefore, the material in the drum would have to have  |
| more than 10 times the limit before criticality could occur in the drum.     |
|                                                                              |
| "Potential Criticality Pathways Involved (Brief Scenario(s) Of How           |
| Criticality Could Occur): Criticality could only occur if moderation control |
| on the material placed in the drum is lost.  This could hypothetically occur |
| if powder containing over 10 times the allowed limit were placed into the    |
| drum or if a similar amount liquid water entered a drum from an external     |
| source.                                                                      |
|                                                                              |
| "Controlled Parameters (Mass, Moderation, Geometry, Concentration, Etc.):    |
| The process parameter controlled in this portion of the process is           |
| moderation.  An additional design control is the neutron absorbing insert.   |
| When installed, this insert will keep the drum sub-critical even if          |
| moderation control is completely lost in a single drum.                      |
|                                                                              |
| "Estimated Amount, Enrichment, Form of Licensed Material ( Include Process   |
| Limit and % Worst Case Critical Mass):                                       |
| The amount of material involved is 250 kg of urania powder enriched to 2.7   |
| wt.% 235U.  The material contained <0.2 wt.% moisture.  The process limit is |
| 1.0 wt.% moisture.  More than 10 wt.% water and a full water reflector is    |
| required for keff to exceed 0.95 at 5.0 wt.% 235U.                           |
|                                                                              |
| "The minimum critical mass for optimally moderated urania powder enriched to |
| 2.75 wt.% 235U with full water reflection is about 124 kg.                   |
|                                                                              |
| "Nuclear Criticality Safety Control(s) or Control System(s) and Description  |
| of the Failures or Deficiencies:                                             |
| The moderator control system requires that any material placed into a        |
| 45-gallon drum have at least on assurance that the material contains less    |
| than 1.0 wt.% moisture.  The moderation control system includes two          |
| operators verifying that acceptable lab analysis results have been obtained  |
| and that the correct material has been selected for being dumping into a     |
| 45-gallon drum.  These operators are also aided by a computer controlled     |
| inventory system that also checks for acceptable moisture results on each    |
| item being placed on a blend make up list.                                   |
|                                                                              |
| "In addition to moderation control, the neutron adsorbing spider assemblies  |
| will keep the drum subcritical even if it is filled with optimally moderated |
| UO2.  This control failed because a drum without the required insert was     |
| inadvertently used in the process.  This occurred because the process        |
| operator failed to perform a required visual inspection prior to filling the |
| drum.  Also, the operating procedure for disassembling 45-gallon drums with  |
| neutron absorbing spider assemblies did not require an out of service sign   |
| to be posted on the drum.                                                    |
|                                                                              |
| "Corrective Actions To Restore Safety Systems and When Each Was Implemented: |
| Manager of Criticality Safety convened an Incident Investigation Board at    |
| 0330.                                                                        |
|                                                                              |
| "The material involved was transferred to a drum containing a neutron        |
| absorbing spider assembly and handled per standard operating procedures.     |
| The transfer was completed by 0615.                                          |
|                                                                              |
| "All drums that do not contain neutron absorbing spider assemblies were      |
| tagged with out-of-service signs and then removed from the area and smashed. |
|                                                                              |
|                                                                              |
| "Drum disassembly, and blend make-up operations have been placed on hold     |
| pending completion of procedure revisions and training.                      |
|                                                                              |
| "Additional corrective actions are being evaluated."                         |
|                                                                              |
| Framatome notified Region 4 (B. SPITZBERG).                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   38827       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE:
04/03/2002|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 15:54[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        04/03/2002|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        11:59[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  04/03/2002|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |DAVID HILLS          R3      |
|  DOCKET:  0707002                              |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SEGMENTED GAMMA SCANNER (SGS) APPEARS TO GIVE  LOWER THAN ACTUAL
MASS VALUES |
| COMPARED WITH THE LOW DENSITY WASTE ASSAY MONITOR (LDWAM)  MASS
VALUES.      |
|                                                                              |
| NRC BULLETIN 91-01 4 HOUR NOTIFICATION                                       |
|                                                                              |
| "At 1159 hours today after Nuclear Materials Engineering completed a review  |
| of their databases for batched items stored in 55 gal. drums, it was         |
| discovered that 26 drums with questionable Segmented Gamma Scanner (SGS)     |
| values were located in the XT-847. The concern about the SGS not correctly   |
| counting the U-235 mass was identified earlier but at that time no drums     |
| were identified in the United States Enrichment Corporation (USEC) leased    |
| spaces. The mass counting error identified between the SCS and the Low       |
| Density Waste Assay Monitor (LDWAM) was at times off by a factor of 10 or    |
| more. Because of the questionable SGS measurements it could not be assured   |
| the 350 gram U-235 limit per batched drum was maintained. The governing NSCA |
| X-0847_ 001. A04 Operation of the XT-847 Facility in it's NCSE accounted for |
| an error of a factor of two in mass calculations, as a bounding condition.   |
| Thus with the loss of the bounding calculations and the potential error in   |
| mass calculations, this resulted in the loss of both legs of the double      |
| contingency basis (mass & the factor of two bounding error) for NCSA         |
| X-847_001.A04.  At the present time Waste Material handlers in the XT-847    |
| are moving all 26 drums from their storage area to another storage location  |
| within the building to allow for remeasurement of the drums. The guidance    |
| for moving and relocating these drums for remeasurement is covered by        |
| existing procedures and NCSAs.                                               |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS: The safety significance of this event is low |
| because the actual uranium mass content of the drums in question would not   |
| be expected to contain more than a safe amount of uranium bearing material.  |
| Other similar drums of trappIng material batched during the same period      |
| using LDWAM measurements contain considerably less than a safe mass of       |
| U-235. The uranium mass limits assume optimum moderation and 100%            |
| enrichment. The drums in question are known to contain less than 10%         |
| enrichment (based upon process knowledge or sampling) and the material       |
| stored in the XT-847 is dry trapping material (alumina, etc). Even with the  |
| maximum potential error in the SGS measurements, the total mass in any drum  |
| (or group) would be less than the safe mass of uranium at an H/U of 4 (wet   |
| air moderation of approximately 7.9 kg of U-235 (100% enrichment)            |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR):                                                    |
| For a criticality to occur, the following events would be required: One or   |
| more drums must contain greater than a minimum critical mass of uranium (at  |
| this time, the measurement results are in question, but greater than a safe  |
| mass has not actually been measured in any drum), the contents of the drums  |
| would need to be moderated by water or oil (the material is dry trapping     |
| material), and some amount of reflection would be required (for the drums,   |
| or groups of drums, currently spaced 2 feet edge-to-edge apart).             |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY. CONCENTRATION,
ETC.):    |
| The drums were filled by batching small diameter containers of trapping      |
| material based upon NDA or sample measurements of the uranium mass present.  |
| The batching limits are 43.5% of the minimum critical mass assuming optimum  |
| moderation, concentration, geometry, reflection, etc. In the applicable      |
| NCSE, credit is taken for a double batch scenario bounding potential uranium |
| mass upsets; however, the potential error in the SGS measurements may be     |
| greater than a factor of two. Spacing is controlled for drums, or groups of  |
| drums, unless categorized as containing less than 15 grams U-235.            |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE
PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS): The contents of the drums are dry  |
| trapping material from the cascade buildings, and are known to be enriched   |
| to 10% or less.  At the time they were filled, the total mass was calculated |
| to be less than 350 grams U-235. However, the SGS used to measure source     |
| containers has been questioned. The variability of the SGS results indicate  |
| that the total uranium mass in containers batched into a drum could be       |
| non-conservative by a factor of 10 or more.                                  |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND
DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES: Recent NDA measurements performed on the    |
| Low Density Waste Assay Monitor (LDWAM) have identified discrepancies in the |
| gram quantity of U-235 when compared to the Segmented Gamma Scanner (SGS)    |
| measured values (see PR-PTS-02-01398). The SGS values are biased low which   |
| could have resulted in underestimatlng the total batch quantity for          |
| previously batched drums. Until confirmatory measurements of the drums are   |
| obtained, the potential mass content represents a loss of both legs of       |
| double contingency as described in the applicable NCSE.                      |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS
IMPLEMENTED:  |
| These drums are not safety systems but corrective actions to regain          |
| compliance was started at 1530 hours 4/2/02."                                |
|                                                                              |
| The NRC Resident Inspector was notified by the certificate holder.           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38828       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 04/03/2002|
|LICENSEE:  RUSH-PRESBYTERIAN-ST. LUKE'S MEDICAL |NOTIFICATION TIME:
16:05[EST]|
|    CITY:                           REGION:  3  |EVENT DATE:        10/17/2001|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CST]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  04/03/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVID HILLS          R3      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  THOMAS SEIF                  |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF MEDICAL MISADMINISTRATION                          |
|                                                                              |
| "On October 17, 2001 a patient was being treated with a P-32 impregnated     |
| balloon. This balloon is part of an FDA study sponsored by Radiance. This    |
| treatment is designed to be a sequence of inflations and deflations at the   |
| treatment site. During the record review on March 21, 2001, the patient was  |
| feeling significant discomfort, so the Doctor ordered for the balloon to be  |
| deflated. Since there was a deviation in protocol, all records were          |
| appropriately documented.                                                    |
|                                                                              |
| "During the record review on March 21, 2002, it was noted that the order for |
| the treatment to be given in the deflated state was approximately half of    |
| the original order. The order was supposed to be that the entire treatment   |
| time would be in the deflated stage, but unfortunately, only the deflated    |
| stage was administered. The dose was approximately 11 Gy (55%) of the        |
| original order of 20 Gy. No other deviations were noted.                     |
|                                                                              |
| "The patient and primary physician have been notified. Procedures are in the |
| process of being reviewed to ensure future compliance. The name and          |
| identification number of the patient involved has been attached on a         |
| separate sheet."                                                             |
+------------------------------------------------------------------------------+