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Event Notification Report for May 6, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/03/2002 - 05/06/2002

                              ** EVENT NUMBERS **

38883  38884  38895  38896  38897  38898  38899  38900  

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|General Information or Other                     |Event Number:   38883       |
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| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  TULANE UNIVERSITY                    |NOTIFICATION TIME: 11:03[EDT]|
|    CITY:  NEW ORLEANS              REGION:  4  |EVENT DATE:        04/22/2002|
|  COUNTY:                            STATE:  LA |EVENT TIME:        10:25[CDT]|
|LICENSE#:  LA-0004-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BLAIR SPITZBERG      R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT BLACKWELL              |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| The following event description is taken from a facsimile:                   |
|                                                                              |
| "On April 22, 2002, the technologist injected a patient with a syringe       |
| labeled Tc-99m MAG 3 in order to image the kidneys. The gamma camera showed  |
| uptake in the liver-kidney indicating a sulfur colloid dose. The patient was |
| prescribed a 4.5 mCi dose of Tc-99m MAG 3, but received a 4.5 mCi dose of    |
| Tc-99m Sulfur Colloid. The patient and the pharmacy were notified of the     |
| error. The dose for a patient receiving 5 mCi of Tc-99m Sulfur Colloid is    |
| estimated as the following:  Liver - 12.15 Rad, Spleen - 7.65 Rad, Bone      |
| Marrow - 0.05 Rad, Testes - 0.02 Rad, Ovaries - 0.2 Rad, and Total Body -    |
| 0.675 Rad."                                                                  |
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|General Information or Other                     |Event Number:   38884       |
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| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  LONGVIEW INSPECTION                  |NOTIFICATION TIME: 15:05[EDT]|
|    CITY:  CHANNAHON                REGION:  3  |EVENT DATE:        06/01/2000|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+PAUL LOHAUS          STP     |
| NRC NOTIFIED BY:  JOSEPH KLINGER               |TIM MCGINTY          IRO     |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT OF RADIOGRAPHER OVEREXPOSURE FROM TWO
YEARS AGO       |
|                                                                              |
| "On April 29, 2002, the department completed its investigation into a        |
| reported radiography incident that may have occurred in June 2000. After a   |
| review of all available information, the department cannot definitively      |
| eliminate the possibility that an industrial radiographer received a         |
| radiation burn while performing industrial radiography at a temporary        |
| jobsite near Channahon, Illinois. The radiographer was using an 81.2 Ci      |
| lr-192 source while performing radiographs on 8-inch pipe welds. The         |
| radiographer alleges that after cranking the source back in, he approached   |
| the area without looking at his survey meter. He set the meter behind the    |
| camera and knelt down in front of the camera, He changed out the film and    |
| then changed out the band and numbers for the next shot. He then             |
| disconnected the guide tube and saw 4-6 inches of the drive cable. He looked |
| over at the survey meter and saw that it was pegged. He then immediately     |
| went to the controls and cranked the source fully into the camera. He        |
| performed a survey of the area and saw that the source was shielded          |
| properly. He looked at his alarming rate meter and saw that the battery      |
| indicator showed low battery. His self-reading pocket dosimeter showed       |
| off-scale. What happened after that is even more unclear but the             |
| radiographer continued working for the rest of the day. The radiographer did |
| not report the incident to the RSO nor did the other radiographer on the two |
| certified radiographer team. In fact, the other radiographer denies knowing  |
| anything about the reported incident. The allegedly overexposed radiographer |
| states that after one or two weeks, he noticed a red area, about the size of |
| a nickel, on his leg. He stated that it was a red area with what appeared to |
| be white scar tissue in the center. It was not until May or June of 2001     |
| that he realized that it may have been a radiation burn. During August or    |
| September 2001 his condition apparently worsened and the area would not      |
| heal. In early January 2002 the Radiation Safety Officer finally became      |
| aware of this matter, and notified the department on January 15, 2002. In    |
| early January 2002 the radiographer was apparently examined by a physician.  |
| The radiographer stated that the physician took a biopsy and the diagnosis   |
| was either sarcoma or radiodermatitis. A preliminary report was provided to  |
| the department by the licensee on January 16, 2002. The department           |
| recommended the licensee seek assistance from the REAC/TS Center in Oak      |
| Ridge, which they did. The information pertaining to this incident was       |
| provided to REAC/TS by the licensee and REAC/TS concluded that the medical   |
| condition could be attributed to the event in June 2000. After thoroughly    |
| reviewing all the information available and scheduling interviews for        |
| involved out of state personnel, the department conducted interviews and     |
| time in motion studies on February 25, 2002. Subsequent to the interviews    |
| and time in motion studies, careful review was performed as well as          |
| additional clarifying information was requested and reviewed. Finally on     |
| April 29, 2002, the department concluded that it could not definitively      |
| eliminate the possibility that this industrial radiographer received a       |
| radiation burn while performing industrial radiography at a temporary job    |
| site near Channahon, Illinois in June 2000. The radiographer underwent skin  |
| grafting on February 26, 2002, and was released after several days. The      |
| radiographer currently remains under medical surveillance and reports that   |
| the graft was less than successful. The licensee has been issued a Notice of |
| Violation and will take appropriate actions to prevent a recurrence. The     |
| radiographer may be subject to additional department enforcement action      |
| related to his industrial radiographer certification resulting from this     |
| event."                                                                      |
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|Power Reactor                                    |Event Number:   38895       |
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| FACILITY: FARLEY                   REGION:  2  |NOTIFICATION DATE: 05/03/2002|
|    UNIT:  [1] [] []                 STATE:  AL |NOTIFICATION TIME: 14:42[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        05/03/2002|
+------------------------------------------------+EVENT TIME:        13:21[CDT]|
| NRC NOTIFIED BY:  DANA WHITE                   |LAST UPDATE DATE:  05/03/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RUDOLPH BERNHARD     R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| AUTOMATIC REACTOR TRIP DUE TO INDICATED LOSS OF RCS FLOW                     |
|                                                                              |
| RPS indicated that there was a loss of RCS flow to 1 loop, which resulted in |
| an automatic reactor trip.  All three loops of RCS flow were in operation    |
| throughout the event.  All rods fully inserted, no ECCS systems actuated,    |
| and decay heat is being removed by the Auxiliary Feedwater system.  The      |
| Licensee indicated that the electrical grid was stable and that a post trip  |
| investigation is ongoing.                                                    |
|                                                                              |
| The NRC Resident Inspector will be notified.                                 |
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|General Information or Other                     |Event Number:   38896       |
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| REP ORG:  BOSTON SCIENTIFIC                    |NOTIFICATION DATE: 05/03/2002|
|LICENSEE:  BOSTON SCIENTIFIC                    |NOTIFICATION TIME: 15:25[EDT]|
|    CITY:  SPENCER                  REGION:  3  |EVENT DATE:        04/03/2002|
|  COUNTY:  OWEN                      STATE:  IN |EVENT TIME:             [CST]|
|LICENSE#:  GENERAL               AGREEMENT:  N  |LAST UPDATE DATE:  05/03/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DIMITRI KONEAS               |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 5 LOST AIR NOZZLE SOURCES                                                    |
|                                                                              |
| Licensee reports that 5 static eliminator Po-210 sources are missing.  All   |
| of the sources are 10 micro-curie, with the following serial numbers and     |
| dates:  #119686  19 Apr 00,  #104160  28 Jul 98,  #108071  18 Jan 99,        |
| #108072  Jan 18 99, and #111277  10 May 99.  The Licensee is still looking   |
| for the missing sources and has contacted the vendor which has indicated     |
| that the sources were never shipped back to the vendor.                      |
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|General Information or Other                     |Event Number:   38897       |
+------------------------------------------------------------------------------+
                         
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| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 05/03/2002|
|LICENSEE:  UNIVERSITY OF ALABAMA AT BIRMINHAM   |NOTIFICATION TIME:
17:07[EDT]|
|    CITY:  BIRMINGHAM               REGION:  2  |EVENT DATE:        05/03/2002|
|  COUNTY:                            STATE:  AL |EVENT TIME:        11:30[CDT]|
|LICENSE#:  266                   AGREEMENT:  Y  |LAST UPDATE DATE:  05/03/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RUDOLPH BERNHARD     R2      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID TURGERVILLE            |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT-SHIPMENT WITH LOOSE SURFACE CONTAMINATION
LEVELS >    |
| LIMITS                                                                       |
|                                                                              |
| "At 11:30 am on May 3, 2002, the writer was advised by [the], Assistant      |
| Radiation Safety Officer at the University of Alabama at Birmingham (UAB) in |
| Birmingham, Alabama that their nuclear medicine department had received a    |
| radiopharmaceutical package that was found to have removable radioactive     |
| contamination on the external surface of the package that exceeded 22,200    |
| disintegration's per minute (dpm) per 100 square centimeters. The package    |
| was received on the afternoon of May 2, 2002 from Central Pharmacy Services, |
| Inc., d/b/a as Birmingham Central Pharmacy in Birmingham, Alabama. Central   |
| Pharmacy Services, Inc. is authorized to prepare and distribute              |
| radiopharmaceuticals under Alabama Radioactive Material License No. 1168 and |
| the University of Alabama at Birmingham is authorized to receive radioactive |
| material under Alabama Radioactive Material License No. 266. The package as  |
| delivered contained unit doses of Tc-99m and a vial of I-131. These inside   |
| containers were found not to be contaminated. The actual contamination was   |
| found to be on a magnetic Department of Transportation transport label. The  |
| maximum amount of removable contamination was 150,000 dpm on a wipe sample   |
| of the magnetic label. Spectrum analysis indicate that the isotope was       |
| Tc-99m. The package was isolated.                                            |
|                                                                              |
| "Central Pharmacy Services, Inc. was notified of the incident. The cause of  |
| the incident is currently being investigated by this office."                |
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|Power Reactor                                    |Event Number:   38898       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: FERMI                    REGION:  3  |NOTIFICATION DATE: 05/03/2002|
|    UNIT:  [2] [] []                 STATE:  MI |NOTIFICATION TIME: 17:33[EDT]|
|   RXTYPE: [2] GE-4                             |EVENT DATE:        05/02/2002|
+------------------------------------------------+EVENT TIME:        18:34[EDT]|
| NRC NOTIFIED BY:  KEVIN DAHM                   |LAST UPDATE DATE:  05/03/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| ABILITY TO MEET 10 CFR 50 APPENDIX R III.G.3 NOT ANALYZED                    |
|                                                                              |
| "Operating License Condition 2.C(9) - Modification for Fire Protection (     |
| Section 9.5.1 SSER #5 and SSER #6)                                           |
|                                                                              |
| "On May 2, 2002 at 1834 hours, during a Fire Protection Self-Assessment      |
| field walk down of procedure 20.000.18, 'Shutdown From Outside The Control   |
| Room', a procedure step was identified that could not be performed as        |
| written.  Valve N2000F636, 'Condenser Hotwell Emergency Makeup Bypass Valve' |
| could not be manually operated without the use of a ladder. No ladders were  |
| staged for this purpose, and the requirement for a ladder was not specified  |
| in the procedure. The time required to procure a ladder and perform the      |
| required operation has not been analyzed for impact on the ability to meet   |
| safe shutdown requirements of 10CFR50 Appendix R III.G.3.                    |
|                                                                              |
| "The condition was documented in the corrective action program and a ladder  |
| has been staged at the valve. This condition is being reported as a          |
| potential non conformance with Operating License Condition 2.C(9)."          |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38899       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 05/03/2002|
|LICENSEE:  SOILS AND MATERIALS CONSULTANTS, INC |NOTIFICATION TIME:
18:51[EDT]|
|    CITY:                           REGION:  4  |EVENT DATE:        05/03/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:  595-01                AGREEMENT:  Y  |LAST UPDATE DATE:  05/03/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BLAIR SPITZBERG      R4      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIM BONZER (fax)             |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT-DAMAGED DENSITY GAUGE                                 |
|                                                                              |
| "RSO for the above licensee called on the date of this memo to report a CPN  |
| (model MC-1) was run over. The gauge was run over with the Cs-137 source in  |
| the ground, the user turned to get something out of his truck, which was     |
| near by and a roller ran over the gauge and then since people were waving at |
| him, backed over the gauge. Per the RSO, the CPN representative in Denver    |
| will take possession of the gauge and return [it]."                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38900       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 05/05/2002|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 13:53[EDT]|
|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        05/05/2002|
+------------------------------------------------+EVENT TIME:        11:43[CDT]|
| NRC NOTIFIED BY:  JERRY RISTE                  |LAST UPDATE DATE:  05/05/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION REQUIRED SHUTDOWN                                    |
|                                                                              |
| "At 1143 CDT, the Kewaunee Nuclear Power Plant commenced a plant shutdown.   |
| The plant shutdown was initiated due to an expected inability to restore the |
| Component Cooling (CC) heat exchanger 'A' to an operable status prior to     |
| exceeding it's 72 hour LCO action time.  The 72 LCO action time expires at   |
| 0934, Monday, May 6, 2002.  The CC heat exchanger was declared inoperable    |
| when it was removed from service to investigate CC system leakage of         |
| approximately 0.37 gpm.  With only one CC heat exchanger operable, Kewaunee  |
| T.S. require that after 72 hours, with one CC heat exchanger inoperable, a   |
| plant shutdown commences to < 350 F.  Current plans are to shut the plant    |
| down <350 F and repair the CC heat exchanger.  CC heat exchanger 'B'  has no |
| detectable leakage."                                                         |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
+------------------------------------------------------------------------------+