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Event Notification Report for August 6, 2002

                                     U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/05/2002 - 08/06/2002

                              ** EVENT NUMBERS **

39096  39110  39111  
.
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|General Information or Other                     |Event Number:   39096       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/26/2002|
|LICENSEE:  ST. MARY'S HOSPITAL                  |NOTIFICATION TIME: 19:30[EDT]|
|    CITY:  GRAND JUNCTION           REGION:  4  |EVENT DATE:        07/26/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:        16:45[MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  08/05/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |MELVYN LEACH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  P. V. EGIDI                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - MISSING I-125 SEEDS                                 |
|                                                                              |
| The following is from a facsimile report:                                    |
|                                                                              |
| "At approximately 4:45 PM Friday July 26, 2002, I [Colorado Department of    |
| Health and Environment] received a call from ..., RSO and Medical Physicist  |
| at St. Mary's Hospital in Grand Junction, Colorado.                          |
|                                                                              |
| "[RSO] informed us he is missing 3, I-125 prostrate seeds (approx. 0.36 mCi  |
| [millicuries] each). He was made aware of the loss late this morning.        |
| Surveys were conducted in all suspect areas of the hospital to no avail. It  |
| is possible that either the seeds never arrived due to poor inventory        |
| control of the supplier, or that the seeds went to the trash, which left the |
| hospital around 7:00 A.M. Since the seeds are shielded, they would probably  |
| not be detected at the landfill."                                            |
|                                                                              |
| * * * UPDATED AT 1800 EDT ON 8/5/02 BY TIME BONZER TO FANGIE JONES * * *     |
|                                                                              |
| The final report is that the seeds were not found, it is indeterminate       |
| whether the seeds actually made it to the hospital.  The hospital will take  |
| additional steps to insure that they actually receive the seeds they are     |
| suppose to receive.                                                          |
|                                                                              |
| The hospitals action plan is as follows:                                     |
|                                                                              |
| "We are revising our QA processes. We will return to performing our own      |
| source counts and not be dependent on others so we do not go looking for     |
| something we may have never received. We also will increase our needle-prep  |
| area monitoring to include a more thorough area survey Including removing    |
| the lead shielding"                                                          |
|                                                                              |
| Notified the R4DO (Chuck Cain) and NMSS EO (E. William Brach).               |
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|Hospital                                         |Event Number:   39110       |
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| REP ORG:  BENEFIS HEALTH CARE                  |NOTIFICATION DATE: 08/05/2002|
|LICENSEE:  BENEFIS HEALTH CARE                  |NOTIFICATION TIME: 17:36[EDT]|
|    CITY:  GREAT FALLS              REGION:  4  |EVENT DATE:        08/05/2002|
|  COUNTY:                            STATE:  MT |EVENT TIME:             [MDT]|
|LICENSE#:  25-12710-01           AGREEMENT:  N  |LAST UPDATE DATE:  08/05/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHUCK CAIN           R4      |
|                                                |E. WILLIAM BRACH     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KARI CANN                    |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33               MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION - DOSE GIVEN APPROXIMATELY 22% LESS THAN          
|
| PRESCRIBED                                                                   |
|                                                                              |
| This report is made due to failure to provide test per NRC Notification      |
| Notice 2002-19.    A review of the administration records indicate that 6    |
| patients received palliative doses of samarium since 12/99 that were about   |
| 22% low.  Benifis Health Care does not use unit dose vials, they receive     |
| multidose vials and withdraw a dose out into a plastic syringe.  After       |
| receipt of a calibration source, the RSO determined that radiation readings  |
| for a dose in a plastic syringe was 21.6% higher than in a glass syringe.  A |
| correction factor has been put in place for plastic syringes to insure       |
| proper dosages in the future.  The patients have been determined to have no  |
| adverse affects, they all had relief of pain even with the lower dose.  The  |
| patients and attending physicians have not been informed at this time.       |
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|Power Reactor                                    |Event Number:   39111       |
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| FACILITY: DUANE ARNOLD             REGION:  3  |NOTIFICATION DATE: 08/06/2002|
|    UNIT:  [1] [] []                 STATE:  IA |NOTIFICATION TIME: 04:34[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        08/05/2002|
+------------------------------------------------+EVENT TIME:        23:33[CDT]|
| NRC NOTIFIED BY:  BRIAN HUPKE                  |LAST UPDATE DATE:  08/06/2002|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |                             |
|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       94       Power Operation  |94       Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| LOSS OF RESIDUAL HEAT REMOVAL (RHR)  HEAT REMOVAL CAPABILITY.                |
|                                                                              |
| "At 23:33 on 8/5/02 both loops of RHRSW (Residual Heat Removal Service       |
| Water) were declared inoperable due to experiencing high differential        |
| pressure greater than 12 psid across the 'A' loop RHRSW strainer and the 'B' |
| loop RHRSW strainer.                                                         |
|                                                                              |
| "On 8/4/02 while running a surveillance for the 'B' RHRSW pump a high        |
| strainer differential pressure annunciator was received, which comes in a 6  |
| psid.  'B' pump flow at the time was 2400 GPM.  The in plant operator was    |
| sent locally to investigate the local differential pressure indication and   |
| discovered the instrument was pegged high at > (greater than ) 15 psid.  The |
| pump was secured and the corresponding Limiting Condition of Operation of 7  |
| days was entered for the 'B' RHRSW loop.  Maintenance was immediately        |
| planned and begun to clean the 'B' RHRSW strainer.  At the time plans were   |
| also made to inspect the 'B' RHRSW/ESW (Emergency Service Water) pit and     |
| Stilling Basin.                                                              |
|                                                                              |
| "On 8/5/02 after inspections of the Stilling basin found algae growth, plans |
| were made to run the 'A' side RHRSW pumps to determine operability of the    |
| 'A' loop of RHRSW.  At that time the Stilling basin cleaning also began.     |
| After the completion of stilling basin cleaning on 8/5/02, the 'A' RHRSW     |
| pump was started and strainer differential was between 2.5 - 4.5 psid at a   |
| pump flow of 2400 GPM which was held for 15 minutes.  At this time the 'C'   |
| RHRSW pump was started and flow raised to 4100 GPM at which time strainer    |
| differential pressure was steady at 5.5 - 6.0 psid.  As flow was raised to   |
| 5000 GPM Strainer differential pressure pegged high at > (greater than) 15   |
| psid within 3 minutes.  The 'A' RHRSW pump was then secured and flow lowered |
| to 2100 GPM where strainer differential pressure remained at 10 - 12 psid    |
| and then pegged high at greater than 15 psid.  The 'C' RHRSW pump was then   |
| secured and the 'A' RHRSW loop was declared inoperable at 23:33 on 8/5/02.   |
| The LCO for both loops of RHRSW inoperable was then entered at 23:33 on      |
| 8/5/02.                                                                      |
|                                                                              |
| "This report is being made under 50.72(b)(3)(v)(B) 'Any event or condition   |
| that at the time of discovery could have prevented the fulfillment of the    |
| safety function of structures or systems that are needed to remove residual  |
| heat.' "                                                                     |
|                                                                              |
|                                                                              |
| All other Emergency Core Cooling Systems are fully operable if needed.       |
|                                                                              |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
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