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Event Notification Report for May 22, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/21/2002 - 05/22/2002

                              ** EVENT NUMBERS **

38922  38923  38933  38934  

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|General Information or Other                     |Event Number:   38922       |
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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE:
05/16/2002|
|LICENSEE:  HUNTINGTON MEMORIAL HOSPITAL         |NOTIFICATION TIME: 17:25[EDT]|
|    CITY:  PASADENA                 REGION:  4  |EVENT DATE:        05/15/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:        11:00[PDT]|
|LICENSE#:  0239-19               AGREEMENT:  Y  |LAST UPDATE DATE:  05/16/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |C.W. (BILL) REAMER   NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BARBARA HAMRICK              |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING THEFT OF LICENSED MATERIAL >1000 TIMES 
    |
|                                                                              |
| "At 11:00 am PDT on May 15, 2002, four packages were stolen from an          |
| unsecured Airborne Express truck parked at 39 Congress Avenue, Pasadena, Ca. |
| Due to a mix-up by the driver, it was not known that one of the packages     |
| contained radioactive material until the next day, when Huntington Memorial  |
| Hospital's Radiation Safety Officer[ ], realized that they had not received  |
| one of the packages of Palladium-103 seeds that they were expecting. [The    |
| RSO] reported the loss to the California Radiologic Health Branch at 12:15   |
| PM PDT on May 16, 2002.                                                      |
|                                                                              |
| "The package was supposed to have contained 72 seeds at 1.54 mCi/seed, or a  |
| total of 110 mCi of Pd-103, which would produce a field of about 230 mR/hr   |
| at one foot from the unshielded material.                                    |
|                                                                              |
| "Los Angeles County personnel took the initial call from the hospital, and   |
| is following up on this incident. Los Angeles County is a Contract County in |
| California's Agreement State Program. The L.A. County inspector talked to    |
| the hospital about issuing a press release, and they are currently preparing |
| one. The inspector will also obtain information on the package dose-rates,   |
| when it was shipped by Imagyn in TX, and the calibration dates for the       |
| seeds.. The seeds were purchased from Theragenics, shipped to Imagyn for     |
| some preparation, then shipped to the California licensee in two packages.   |
| The first package was received in tact. The second was stolen from the       |
| Airborne Express truck. There has been no indication by any of the parties   |
| that the other three packages stolen contained any radioactive material."    |
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|General Information or Other                     |Event Number:   38923       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 05/16/2002|
|LICENSEE:  LUTHERAN MEDICAL CENTER              |NOTIFICATION TIME: 18:29[EDT]|
|    CITY:                           REGION:  4  |EVENT DATE:        05/16/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  05/16/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |C.W. (BILL) REAMER   NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIM G. BONZER (fax)          |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT ON MEDICAL MISADMINISTRATION                          |
|                                                                              |
| "[ ]Med. Physicist called on the date of this memo. It was regarding the     |
| placing of 111 seeds [of I-125] when the prescribed dose was 110 seeds. Per  |
| the physicist he could not see the additional seed because of the blood.     |
| After doing a source count he believes the additional seed was implanted     |
| into the patient. The additional seeds activity was 0.33 mCi. Additional     |
| information will follow."                                                    |
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|Power Reactor                                    |Event Number:   38933       |
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| FACILITY: SALEM                    REGION:  1  |NOTIFICATION DATE: 05/21/2002|
|    UNIT:  [] [2] []                 STATE:  NJ |NOTIFICATION TIME: 15:52[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        05/20/2002|
+------------------------------------------------+EVENT TIME:        15:30[EDT]|
| NRC NOTIFIED BY:  BRAIN BONNER                 |LAST UPDATE DATE:  05/21/2002|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |FRANK COSTELLO       R1      |
|10 CFR SECTION:                                 |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       98       Power Operation  |98       Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| FIRE PROTECTION CARBON DIOXIDE IN SAFETY RELATED AREAS                       |
|                                                                              |
| REPORTED UNDER FIRE PROTECTION LICENSE CONDITION 2.C.X                       |
|                                                                              |
|                                                                              |
|                                                                              |
| Tracer gas testing was being performed for the following fire areas at Salem |
| Unit 1 and Unit 2:                                                           |
|                                                                              |
| (1) Unit 1 EL. 78 Lower Electrical Penetration Area                          |
| (2) Unit 1 EL. 64  4160V Switchgear Room                                     |
| (3) Unit 2 EL. 78  Lower Electrical Penetration Area                         |
|                                                                              |
|                                                                              |
| The  tracer gas test,  along with a door fan test were being performed to    |
| determine actual field conditions for inclusion in a re-analysis of the      |
| carbon dioxide fire suppression system for these areas.  At 1730 hours on    |
| 05/20/02,  preliminary results were obtained for tests 1 and 2 above that    |
| indicated a significant amount of leakage through the ventilation control    |
| dampers in these areas that would prevent the carbon dioxide system from     |
| achieving the required concentration of 50% and a hold time of 20 minutes as |
| required by NFPA-12.  The results for Test 3 have not been completed but     |
| identify a similar condition for the Unit 2 Lower Electrical Penetration     |
| Area.                                                                        |
|                                                                              |
| The problem with leakage from these fires areas appears to be from a high    |
| differential pressure across the ventilation dampers that close on a carbon  |
| dioxide discharge, however, the ventilation fans continue to operate.  Based |
| on this information, the Unit 2 4160 VAC Switchgear Room, the Unit 1 460 VAC |
| Switchgear Room and the Unit 2 460 VAC Switchgear Room have a similar        |
| configuration on carbon dioxide actuation and will most likely not meet the  |
| 50% concentration requirement.  As a result, the carbon dioxide system for   |
| all six areas above were impaired and continuous fire watches were           |
| established.                                                                 |
|                                                                              |
| Although air leakage from the ventilation supply and exhaust dampers affects |
| the ability to achieve or maintain the carbon dioxide design concentration   |
| in accordance with NFPA-12, the carbon dioxide discharge into the room still |
| provides a fire suppression function.  Automatic early warning (ionization)  |
| fire detection will alert the dedicated onsite fire brigade, who will        |
| respond and extinguish any fire using manual fire suppression methods.  The  |
| fire brigade can manually activate an additional carbon dioxide system       |
| discharge.  Based on the above, there is reasonable assurance that the plant |
| can achieve and maintain safe shutdown.                                      |
|                                                                              |
| Failure to meet the carbon dioxide concentration in all six of these areas   |
| is a violation of the Fire Protection Program License Condition 2.C.5 (Unit  |
| 1) and 2.C.10 (Unit 2). Failure to meet Unit 2 License condition 2.C.10      |
| requires a 24-hour report accordance with Unit 2 License Condition 2I and a  |
| follow-up 14 day special report.                                             |
|                                                                              |
| The NRC Resident inspector will be notified of this event by the licensee.   |
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|Power Reactor                                    |Event Number:   38934       |
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| FACILITY: COLUMBIA GENERATING STATIREGION:  4  |NOTIFICATION DATE: 05/21/2002|
|    UNIT:  [2] [] []                 STATE:  WA |NOTIFICATION TIME: 18:59[EDT]|
|   RXTYPE: [2] GE-5                             |EVENT DATE:        05/03/2002|
+------------------------------------------------+EVENT TIME:        15:40[PDT]|
| NRC NOTIFIED BY:  BOB BROWNLEE                 |LAST UPDATE DATE:  05/21/2002|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |LINDA SMITH          R4      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| UNANALYZED CONDITION THAT SIGNIFICANTLY DEGRADED PLANT SAFETY                |
|                                                                              |
| On May 3, 2002, approximately 20 gallons of water was spilled on the floor   |
| of the cable spreading room (CSR).  Some of the water leaked down into rooms |
| below the CSR floor, resulting in an electrical ground on the on the 125-VAC |
| Division 2 battery bus S1-2.  The S1-2 bus remained operable.  It has since  |
| been determined that the pathway for leakage through the floor of the CSR    |
| was cracks in the concrete due to abandoned concrete anchors, and through    |
| shrinkage cracks in the reinforced concrete floor slab.  Shrinkage cracks    |
| are also located in the 525' elevation floor above the Control Room.  These  |
| two floors are considered essential fire rated assemblies and are required   |
| to be "leak tight". These floors have not had a qualified paint/sealant      |
| applied that would render them "leaktight".  Other floors that are fire      |
| rated assemblies are believed to have had the appropriate paint/sealant      |
| applied, but this is being verified.  Should a fire system actuate, or       |
| develop a leak in either the CSR or the room above the Control Room, there   |
| is the potential for leakage through the floors to impact Division 1 or 2    |
| safety-related equipment in the rooms below.  A barrier impairment has been  |
| initiated for the CSR on May 6, 2002 and for the 525' elevation above the    |
| Control Room on May 7, 2002 with compensatory action to include these areas  |
| on an hourly fire/flood tour. With the hourly fire/flood tours in place, the |
| floors of the CSR and the room above the Control Room have been declared     |
| "operable but degraded" per formal assessment of operability, and no longer  |
| represent an unanalyzed condition that significantly degrades plant safety.  |
| The cracks associated with the abandoned anchor bolts have been sealed.      |
| Hourly fire/flood tours remain in effect until both floors have been         |
| properly sealed.                                                             |
|                                                                              |
| The NRC Resident Inspector has been notified of this event.                  |
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