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Event Notification Report for August 9, 2002

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/08/2002 - 08/09/2002

                              ** EVENT NUMBERS **

38602  39113  39119  39120  

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|Power Reactor                                    |Event Number:   38602       |
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| FACILITY: CRYSTAL RIVER            REGION:  2  |NOTIFICATION DATE: 01/01/2002|
|    UNIT:  [3] [] []                 STATE:  FL |NOTIFICATION TIME: 10:08[EST]|
|   RXTYPE: [3] B&W-L-LP                         |EVENT DATE:        01/01/2002|
+------------------------------------------------+EVENT TIME:        09:19[EST]|
| NRC NOTIFIED BY:  BILL BANDHAUER               |LAST UPDATE DATE:  08/08/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE BOLAND          R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| OFFSITE NOTIFICATION DUE RESCUED SEA TURTLE                                  |
|                                                                              |
| EN #37902 started the biennial report period.                                |
|                                                                              |
| On January 1, 2002 at 0919, a rescued sea turtle was identified as a green   |
| sea turtle.  This is the 62nd rescue of a live sea turtle at Crystal River   |
| Unit 3 (CR-3) in this biennial period. Notification to the National Marine   |
| Fisheries Service and the Florida Fish and Wildlife Conservation Commission. |
|                                                                              |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
|                                                                              |
| * * *  UPDATE ON 1/05/02 @ 1002 BY RAWLS TO GOULD  * * *                     |
|                                                                              |
| On January 5, 2002, at 0720, a rescued sea turtle was identified as a        |
| Loggerhead Sea Turtle. This is the 63rd rescue of a live sea turtle at       |
| Crystal River Unit 3 (CR3) in this biennial period.  This is reportable as a |
| 4-hour report under 10 CFR 50.72(b)(2)(xi) as this event is related to the   |
| protection of the environment for which a notification to other government   |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife    |
| Conservation Commission) has been or will be made.                           |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| Reg 2 RDO (Decker) was notified.                                             |
|                                                                              |
| * * * UPDATE ON 01/09/02 @ 1107 EST BY ANDY BARNES TAKEN BY MACKINNON * * *  |
|                                                                              |
| On January 9, 2002, at 0838, a rescued sea turtle was identified as a Kemp's |
| Ridley Sea Turtle. This is the 64th rescue of a live turtle at Crystal River |
| Unit 3 (CR-3) in this biennial period. This is reportable as a 4-hour 10 CFR |
| 50.72(b)(2)(xi) as this event is related to the protection of the            |
| environment for which a notification to other government agencies (National  |
| Marine Fisheries Service and Florida Fish and Wildlife Conservation          |
| Commission) has been or will be made.                                        |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| Reg 2 (Brian Bonser) was notified.                                           |
|                                                                              |
| * * * UPDATE ON 02/17/02 at 0940 EST BY RICKY RAWLS TO FANGIE JONES * * *    |
|                                                                              |
| "On February 17, 2002 at 0820, a rescued injured sea turtle was identified   |
| as a Kemp's Ridley Sea Turtle. The injury will require transportation to     |
| Clearwater Marine Science Center or Florida Fish and Wildlife Conservation   |
| Refuge. The Injury appears to be from a boat propeller. This is the 65th     |
| rescue of a live sea turtle at Crystal River Unit 3 (CR-3) in this biennial  |
| period. This is Reportable as a 4-Hour Report under 10 CFR 50.72(b)(2)(xi)   |
| as this event is related to the protection of the environment for which a    |
| notification to other government agencies (National Marine Fisheries Service |
| and Florida Fish and Wildlife Conservation Commission) has been or will be   |
| made. This Is an update to event 38602."                                     |
|                                                                              |
| The NRC Resident Inspector will be notified.  R2DO (Stephen Cahill) has been |
| notified.                                                                    |
|                                                                              |
| * * * UPDATE ON 03/01/02 AT 1122 EST BY RICKY RAWLS TO GERRY WAIG * * *      |
|                                                                              |
| "On March 1, 2002 at 0952, a healthy rescued sea turtle was identified as a  |
| Green Sea Turtle. This is the 66th rescue of a live sea turtle at Crystal    |
| River Unit 3 (CR-3) in this biennial period. This is Reportable as a 4-Hour  |
| Report under 10 CFR 50.72(b)(2)(xi) as this event is related to the          |
| protection of the environment for which a notification to other government   |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife    |
| Conservation Commission) has been or will be made. This is an update to      |
| event 38602."                                                                |
|                                                                              |
| The NRC Resident Inspector was notified. R2DO (Julian) was notified.         |
|                                                                              |
| * * * UPDATE ON 03/07/02 AT 1114 EST BY CHUCK MORRIS TO MIKE NORRIS * * *    |
|                                                                              |
| "On March 7, 2002 at 0835, two healthy sea turtles rescued at CR#3 were      |
| identified as Green Sea Turtles. These are the 67th and 68th live sea turtle |
| rescues at the Crystal River Energy Complex in this biennial period. This is |
| Reportable as a 4-Hour Report under 10 CFR 50.72(b)(2)(xi) as this event is  |
| related to the protection of the environment for which a notification to     |
| other government agencies (National Marine Fisheries Service and Florida     |
| Fish and Wildlife Conservation Commission) has been or will be made. This is |
| an update to event 38602."                                                   |
|                                                                              |
| The NRC Resident Inspector was notified. R2DO (Henson) was notified.         |
|                                                                              |
| * * * UPDATE ON 04/02/02 at 0408 EST BY RICKY RAWLS TO FANGIE JONES * * *    |
|                                                                              |
| "On April 2, 2002 at 0236, two sea turtles previously rescued at CR#3 intake |
| area were identified by FPC Mariculture staff as Kemp Ridley Sea Turtles.    |
| One of the turtles appears to be in distress and may require transportation  |
| to Clearwater Marine Science Center of Florida Fish and Wildlife             |
| Conservation Refuge. These are the 69th and 70th live sea turtle rescues at  |
| the Crystal River Energy Complex in this biennial period. This is Reportable |
| as a 4-Hour Report under 10 CFR 50.72(b)(2)(xi) as this event is related to  |
| the protection of the environment for which a notification to other          |
| government agencies (National Marine Fisheries Service and Florida Fish and  |
| Wildlife Conservation Commission) has been or will be made. This is an       |
| update to event 38602."                                                      |
|                                                                              |
| The NRC Resident Inspector will be notified.  The R2DO (Carolyn Evans) was   |
| notified.                                                                    |
|                                                                              |
| ***** UPDATE AT 1023 EDT ON 05/19/02 FROM PELLERIN TO LEIGH TROCINE *****    |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On May 19, 2002, at 0916, a sea turtle previously rescued at CR#3 intake    |
| area was identified by FPC Mariculture staff as Green Sea Turtle.  This is   |
| the 71st live sea turtle rescue at the Crystal River Energy Complex in this  |
| biennial period.  This is Reportable as a 4-Hour Report under 10 CFR         |
| 50.72(b)(2)(xi) as this event is related to the protection of the            |
| environment for which a notification to other government agencies (National  |
| Marine Fisheries Service and Florida Fish and Wildlife Conservation          |
| Commission) has been or will be made.  This is an update to event 38602."    |
|                                                                              |
| The licensee plans to notify the National Marine Fisheries Service and       |
| Florida Fish and Wildlife Conservation Commission and the NRC resident       |
| inspector.  The NRC operations officer notified the R2DO (Paul               |
| Fredrickson).                                                                |
|                                                                              |
| * * * UPDATE 1816 EDT ON 5/28/02 FROM BERRY FOSTER TO S. SANDIN * * *        |
|                                                                              |
| "On May 28, 2002 at 1700, a sea turtle previously rescued at CR#3 intake     |
| area was identified by FPC Mariculture staff as a Green Sea Turtle. This is  |
| the 72nd live sea turtle rescue at the Crystal River Energy Complex in this  |
| biennial period. The turtle is being transported to the Clearwater Marine    |
| Science Center. This is Reportable as a 4-Hour Report under 10 CFR 50.72 (b) |
| (2) (xi) as this event is related to the protection of the environment for   |
| which a notification to other government agencies (National Marine Fisheries |
| Service and Florida Fish and Wildlife Conservation Commission) has been or   |
| will be made. This is an update to event 38602."                             |
|                                                                              |
| The licensee will inform the NRC Resident Inspector.  Notified               |
| R2DO(Landis).                                                                |
|                                                                              |
| * * * UPDATE 1602 EDT ON 5/31/02 FROM BILL BANDHAUER TO MIKE NORRIS * * *    |
|                                                                              |
| "On May 30, 2002 at 1323, a sea turtle previously rescued at CR#3 intake     |
| area was identified by FPC Mariculture staff as a Kemp's Ridley Sea Turtle.  |
| This is the 72nd live sea turtle rescue at the Crystal River Energy Complex  |
| in this biennial period. (Note: The sequential numbering of the live sea     |
| turtle takes has been modified to reflect the actual live sea turtle takes,  |
| On 4/02/02, a live rescue of two turtles was reported, however, one of the   |
| turtles died and was reclassified as a non-causal mortality, which is        |
| non-reportable). This event is Reportable as a 4-Hour Report under 10 CFR    |
| 50.72(b) (2) (xi) as this event is related to the protection of the          |
| environment for which a notification to other government agencies (National  |
| Marine Fisheries Service and Florida Fish and Wildlife Conservation          |
| Commission) has been or will be made. This is an update to event 38602."     |
|                                                                              |
| The NRC Resident Inspector has been notified.  Notified R2DO (Landis).       |
|                                                                              |
| *****UPDATE AT 13:58 EDT ON 7/18/02 FROM SWEENEY TO LAURA*****               |
|                                                                              |
| An offsite notification to the State regarding a green sea turtle that was   |
| rescued from the CR#3 intake area by the FPC Mariculture staff.              |
|                                                                              |
| The NRC resident inspector was notified.  Notified R2DO (C. Payne).          |
|                                                                              |
| * * * UPDATE 1126 EDT ON 8/1/02 FROM BILL BANDHAUER TO FANGIE JONES * * *    |
|                                                                              |
| "At 0915 on August 1,2002, a dead sea turtle recovered at the CR#3 intake    |
| area was identified by FPC Mariculture staff as a Kemps Ridley Turtle. FPC   |
| determined that the cause of death was non-causally related to the operation |
| of CR3. This is the 7th dead Kemps Ridley Turtle recovery at the Crystal     |
| River Energy Complex in this biennial period. The threshold for reporting    |
| non-causal sea turtle deaths is 6 in a biennial period. This event is        |
| Reportable as a 4-Hour Report under 10 CFR 50.72 (b) (2) (xi) as this event  |
| is related to the protection of the environment for which a notification to  |
| other government agencies (National Marine Fisheries Service and Florida     |
| Fish and Wildlife Conservation Commission) will be made. This is an update   |
| to event 38602."                                                             |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.  The R2DO (Mike   |
| Ernstes) has been notified.                                                  |
|                                                                              |
| * * * UPDATE 1529 EDT ON 8/8/02 FROM DAN DeBOER TO GERRY WAIG * * *          |
|                                                                              |
| "At 1234 on August 8, 2002, FPC determined that the dead Kemps-Ridley sea    |
| turtle recovered at 1930 on May 11, 2002, at the Crystal River Unit 3 intake |
| area was reportable as a 4-Hour Report under 10 CFR 50.72 (b) (2) (xi). This |
| event is related to the protection of the environment for which a            |
| notification to other government agencies (National Marine Fisheries Service |
| and Florida Fish and Wildlife Conservation Commission) has been made. At     |
| 1347 on May 13, 2002 the FPC Mariculture Center determined that the cause of |
| death was non-causally related to the operation of Crystal River Unit 3.     |
| This was the 6th non-causal dead turtle recovery at the Crystal River Energy |
| Complex in this biennial period. The threshold for reporting non-causal sea  |
| turtle deaths is 6 in a biennial period. This is an update to event 38602."  |
|                                                                              |
| The licensee notified the NRC Resident Inspector. The R2DO (Claude Julian)   |
| has been notified.                                                           |
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|General Information or Other                     |Event Number:   39113       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 08/06/2002|
|LICENSEE:  CENTURA HEALTH PENRONSE ST. FRANCIS H|NOTIFICATION TIME: 13:30[EDT]|
|    CITY:  COLORADO SPRINGS         REGION:  4  |EVENT DATE:        08/02/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:  197-02                AGREEMENT:  Y  |LAST UPDATE DATE:  08/06/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHUCK CAIN           R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIMOTHY BONZER               |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION                 |
|                                                                              |
| "I received a call from Gerald White, of Colorado Associates in Medical      |
| Physics (CAMP) late on Friday August 2, 2002. He called to report a medical  |
| administration that occurred at Centura Health Penrose St. Francis Hospital  |
| in Colorado Springs (RML 197-02) earlier that day concerning a high dose     |
| rate afterloader (HDR) treatment.                                            |
|                                                                              |
| "Apparently, an incorrect catheter length was entered into the software for  |
| the HDR unit, resulting in the patient receiving zero therapy dose. Since    |
| the source left the housing, there was an exposure to the patient.           |
|                                                                              |
| "The physician is determining the path forward with respect to treatment. We |
| are awaiting more information from CAMP.  I sent them an e-mail yesterday    |
| evening (8/5/02) requesting more Information."                               |
|                                                                              |
| Colorado Department of Public Health and Environment, Laboratory and         |
| Radiation Services Division, Report Number M03-01.                           |
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|General Information or Other                     |Event Number:   39119       |
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| REP ORG:  ADVANCE TESTING CO                   |NOTIFICATION DATE: 08/08/2002|
|LICENSEE:  ADVANCE TESTING CO                   |NOTIFICATION TIME: 12:34[EDT]|
|    CITY:  FAIRFIELD                REGION:  1  |EVENT DATE:        08/06/2002|
|  COUNTY:  FAIRFIELD                 STATE:  CT |EVENT TIME:        14:30[EDT]|
|LICENSE#:  2434-3468 NY          AGREEMENT:  N  |LAST UPDATE DATE:  08/08/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DANIEL HOLODY        R1      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHRISTOPHER BROWER           |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| TROXLER MOISTURE DENSITY GAUGE DAMAGED                                       |
|                                                                              |
| During a paving job at the intersection of Route 95 and Route 7 in           |
| Fairfield, CT, a Troxler Moisture Density Gauge, Model # 3411B, Serial       |
| #16237, was run over by an asphalt roller. The gauge contains 8 millicuries  |
| of cesium 137 and 40 millicuries of Am-241/Be. The damaged Troxler Gauge was |
| removed from the asphalt and  placed in a secure container. The area was     |
| isolated and surveyed for contamination. No contamination was identified.    |
| The licensee notified the Connecticut Department of Transportation and NRC   |
| Region 1 of the event.                                                       |
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|Hospital                                         |Event Number:   39120       |
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| REP ORG:  FLETCHER ALLEN HEALTH CARE           |NOTIFICATION DATE: 08/08/2002|
|LICENSEE:  FLETCHER ALLEN HEALTH CARE           |NOTIFICATION TIME: 14:13[EDT]|
|    CITY:  BURLINGTON               REGION:  1  |EVENT DATE:        08/06/2002|
|  COUNTY:                            STATE:  VT |EVENT TIME:        14:00[EDT]|
|LICENSE#:  441018703             AGREEMENT:  N  |LAST UPDATE DATE:  08/08/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DANIEL HOLODY        R1      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MOORE                        |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33               MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION DUE TO EQUIPMENT PROBLEMS                          |
|                                                                              |
| A patient receiving brachytherapy treatment received partial treatment due   |
| to a fault error message for the guidance intervascular brachytherapy        |
| system.  This resulted in the wire being withdrawn too soon and the patient  |
| only receiving 76 centigrays when the prescribed treatment was 2000          |
| centigrays.   The patient and physician were notified and the patient was    |
| retreated.  NRC Region I was notified by the licensee on 8/6/02 by voice     |
| mail.                                                                        |
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