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Event Notification Report for June 20, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           06/19/2002 - 06/20/2002

                              ** EVENT NUMBERS **

38994  39003  

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|General Information or Other                     |Event Number:   38994       |
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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE:
06/14/2002|
|LICENSEE:  CITY OF HOPE NATIONAL MEDICAL CENTER |NOTIFICATION TIME:
17:28[EDT]|
|    CITY:  DUARTE                   REGION:  4  |EVENT DATE:        06/13/2002|
|  COUNTY:  LOS ANGELES               STATE:  CA |EVENT TIME:        14:30[PDT]|
|LICENSE#:  0307-19               AGREEMENT:  Y  |LAST UPDATE DATE:  06/14/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANTHONY GODY         R4      |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GREGER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| STATE LICENSEE REPORTED THAT THREE OF TEN I-125 SEEDS WERE LOST IN THE
SEWER |
| DRAIN                                                                        |
|                                                                              |
| At 2:30pm on June 13, 2002 the radiation safety officer (RSO) for City of    |
| Hope National Medical Center reported that during the course of an           |
| iodine-125 prostate permanent implant procedure, three of the ten seeds were |
| lost down the autoclave sink located in the operating room.                  |
|                                                                              |
| The initial report from the preliminary investigation was that the operating |
| room technician wanted to wash off the three seeds prior to autoclaving      |
| them.  They were not going to be used in the procedure.  During this process |
| they ended up being washed down the drain of the autoclave sink.   Although  |
| this occurred at approximately 5:00pm on June 12, 2002, the RSO was not      |
| notified until approximately noon on June 13, 2002.   They requested the RSO |
| investigate the reason(s) for the delay in reporting the incident.  The      |
| activity of the iodine -125 seeds was 0.344 mCi each (for a total of 1.032   |
| mCi) at 5:00pm on June 12, 2002.   At noon on June 13, 2002 the activity was |
| 0.340 mCi (for a total of 1.02 mCi).                                         |
|                                                                              |
| On June 14, 2002 a request was made to remove the sink trap and piping in an |
| effort to locate the seeds.  At approximately 10:00am it was reported that   |
| the seeds were not located, even with the use of a NaI probe and visual      |
| examination.  This information was forwarded to ICE Supervisor for reporting |
| to the NRC.                                                                  |
|                                                                              |
| Investigation # 061402                                                       |
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|Power Reactor                                    |Event Number:   39003       |
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| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 06/19/2002|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 16:30[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        06/19/2002|
+------------------------------------------------+EVENT TIME:        14:30[CDT]|
| NRC NOTIFIED BY:  EUMAR HENSON                 |LAST UPDATE DATE:  06/19/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|AINA 50.72(b)(3)(v)(A)   POT UNABLE TO SAFE SD  |                             |
|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |
|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       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| POTENTIAL FOR HOT-SHORT CAUSING THE RWST TO DRAIN                            |
|                                                                              |
| "On 6/7/02, Wolf Creek Nuclear Operation Corporation notified Callaway Plant |
| of a potential hot short issue involving the possibility to drain the        |
| Refueling Water Storage Tank to the containment recirculation sump during a  |
| fire. Initial evaluations indicate a potential for this issue to be          |
| applicable to Callaway Plant.                                                |
|                                                                              |
| "The issue discovered was that control cables for 2 redundant motor operated |
| valves are routed in the same electrical raceway. The 2 valves are on the    |
| same electrical separation group, but are redundant in their function of     |
| conserving water inventory in the RWST. Further investigation determined     |
| that the other electrical separation group has the same configuration. The   |
| licensee has implemented an hourly fire watch as a compensatory action.      |
| Engineering analyses are being conducted to determine if further             |
| modifications are necessary. Appropriate changes or compensations will be    |
| instituted into the corrective action system as identified."                 |
|                                                                              |
| The licensee informed the NRC Resident Inspection.                           |
|                                                                              |
| Related Event #38970 at Wolf Creek                                           |
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