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Event Notification Report for November 1, 2002


                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           10/31/2002 - 11/01/2002

                              ** EVENT NUMBERS **

39235  39323  39325  39327  39328  39329  39333  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   39235       |
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| FACILITY: WOLF CREEK               REGION:  4  |NOTIFICATION DATE: 10/01/2002|
|    UNIT:  [1] [] []                 STATE:  KS |NOTIFICATION TIME: 17:44[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        10/01/2002|
+------------------------------------------------+EVENT TIME:        08:45[CDT]|
| NRC NOTIFIED BY:  STEVEN A. HENRY              |LAST UPDATE DATE:  10/31/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |KRISS KENNEDY        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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| UNANALYZED CONDITION RELATING TO CONTROL ROOM EVACUATION                     |
|                                                                              |
| "On October 1 2002, conditions were discovered that if an evacuation of the  |
| Wolf Creek Generation Station (WCGS) control room were required, due to a    |
| fire, necessary steps could not be completed within committed time           |
| requirements. The station is in Mode 1, at 100% power.                       |
|                                                                              |
| "During a timed walk down of procedure OFN RP-017, 'Control Room             |
| Evacuation,' it was identified that operators did not complete Phase A       |
| actions of the procedure in the committed five minutes. Phase A provides     |
| that control of the plant will be established at the Auxiliary Shutdown      |
| Panel (ASP) and isolation of required instrumentation and other devices on   |
| the ASP will be accomplished. Phase A was performed in approximately 8       |
| minutes. This does not meet our commitment to 10 CFR 50 Appendix R as        |
| reflected in the WCGS Fire Protection Plan. The effect of additional time to |
| complete Phase A of the control room evacuation is being further analyzed to |
| determine the safety significance.                                           |
|                                                                              |
| "Based on the guidance provided in NUREG 1022 Revision 2, this situation     |
| meets the criterion of 10CFR50.72(b)(3)(ii)(B) for an 8-hour ENS             |
| notification, as it relates to being in an unanalyzed condition."            |
|                                                                              |
| The Licensee has implemented compensatory measures at 1900 CDT, 10/1/02.     |
|                                                                              |
| The licensee has notified the NRC Resident Inspector                         |
|                                                                              |
| ****RETRACTION JEFF ISCH TO MIKE NORRIS 1429 ET 10/31/02****                 |
|                                                                              |
| "BASIS FOR RETRACTION:                                                       |
|                                                                              |
| "A safety significance evaluation was performed for the condition described  |
| above and it was determined that the circumstances do not constitute a       |
| significant reduction in plant safety. This conclusion is based on the       |
| results of simulator exercises that concluded that the 5 minute completion   |
| time was conservative and that the actions needed to place the plant in a    |
| safe condition could be performed within 8 minutes. The evaluation provides  |
| reasonable assurance that operator activities taken to complete Phase A      |
| actions within a 7 to 8 minute period does not result in consequences of     |
| safety significance. This conclusion is further validated by comparing the   |
| results with bounding conditions contained in a Westinghouse WCAP report for |
| a similar condition involving a failed open power operated relief valve      |
| (PORV), as well as an engineering evaluation previously performed for both   |
| PORVs spuriously opening due to a fire. Therefore, per NUREG 1022, this      |
| condition is not an unanalyzed condition that significantly degrades plant   |
| safety and is not required to be reported in accordance with                 |
| 10CFR50.72(b)(3)(ii)(B)."                                                    |
|                                                                              |
| The Licensee has notified the NRC Resident Inspector.                        |
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|General Information or Other                     |Event Number:   39323       |
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| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 10/28/2002|
|LICENSEE:  CONSTRUCTION TESTING LAB             |NOTIFICATION TIME: 15:23[EST]|
|    CITY:  METAIRIE                 REGION:  4  |EVENT DATE:        09/20/2002|
|  COUNTY:                            STATE:  LA |EVENT TIME:             [CDT]|
|LICENSE#:  LA-6427-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  10/28/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |MELVYN LEACH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT BLACKWELL              |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| LOUISIANA DEPT OF ENVIRONMENTAL QUALITY AGREEMENT STATE REPORT RE: STOLEN    |
| MOISTURE/DENSITY GAUGE                                                       |
|                                                                              |
| "ON SEPTEMBER 20, 2002, A TROXLER 3411-B GAUGE WITH SERIAL NUMBER 4524 WAS   |
| STOLEN FROM THE BACK SEAT OF A GMC EXTRA CAB TRUCK.  THE GAUGE CONTAINED A   |
| 8.0 mCi (MILLICURIE)  SOURCE OF CS-137 AND A 40 mCi SOURCE OF AM241:BE.  THE |
| GAUGE WAS STOLEN BY BREAKING THE LOCK ON THE SIDE REAR WINDOW OF THE TRUCK.  |
| THE GAUGE WAS NOT CHAINED TO THE TRUCK.  THE FACILITY HAS CHANGE ITS         |
| PROCEDURES TO PREVENT THIS TYPE OF EVENT FROM OCCURRING AGAIN."              |
|                                                                              |
| "CONSTRUCTION TESTING LAB, 3008 5TH STREET, METAIRIE, LA"                    |
|                                                                              |
| "STOLEN FROM 1995 GMC EXTRA CAB TRUCK"                                       |
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|General Information or Other                     |Event Number:   39325       |
+------------------------------------------------------------------------------+
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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 10/28/2002|
|LICENSEE:  LITTLE COMPANY OF MARY HOSPITAL      |NOTIFICATION TIME: 23:33[EST]|
|    CITY:  TORRANCE                 REGION:  4  |EVENT DATE:        10/25/2002|
|  COUNTY:  LOS ANGELES               STATE:  CA |EVENT TIME:        14:30[PDT]|
|LICENSE#:  1258-19               AGREEMENT:  Y  |LAST UPDATE DATE:  10/28/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |MELVYN LEACH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT GREGER                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MISSING IODINE- 125 SEEDS                           |
|                                                                              |
| The Medical Physicist from Little Company of Mary Hospital called to report  |
| the loss of 5 Iodine-125 seeds of approximately 0.4 millicuries each.  The   |
| facility was doing an implant for the treatment of prostate cancer and had   |
| cut the strips in half (5 seeds each). After having implanted 9 strips they  |
| were unable to locate the tenth piece.  They surveyed the room and trash and |
| did not find the missing seeds.  The patient was fluoroscoped and x-rayed,   |
| the implanted seeds were counted and verified with what had been implanted.  |
| A representative from Amersham was present during the procedure and it was   |
| not determined if the tube shipped was half empty.                           |
|                                                                              |
| The seeds came in steel tubes of 10.  It is possible that one steel tube     |
| only had 5 when sent.  Implant performed at 11:00 on 10/24/02.  The tubes    |
| were counted, but not opened until the procedure (sterile) was initiated.    |
|                                                                              |
| The licensee kept looking for the missing Iodine-125 seeds and today,        |
| October 28, 2002,  concluded that the event was reportable and notified the  |
| State of CA today at 1458 hours PST.                                         |
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|General Information or Other                     |Event Number:   39327       |
+------------------------------------------------------------------------------+
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| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE: 10/29/2002|
|LICENSEE:  ROBERT BOISSONEAULT ONCOLOGY INSTITUT|NOTIFICATION TIME: 13:04[EST]|
|    CITY:  LACANTO                  REGION:  2  |EVENT DATE:        10/22/2002|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EDT]|
|LICENSE#:  2155-1                AGREEMENT:  Y  |LAST UPDATE DATE:  10/29/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHARLES ADAMS                |                             |
|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE - MEDICAL MISADMINISTRATION                                  |
|                                                                              |
| "On 10-22-02 the patient was undergoing the first of six fraction therapy    |
| using a HDR source in the cervix. The source was misplaced by approximately  |
| 2 centimeters. The dose received was 800 Rem instead of the prescribed dose  |
| of 500 Rem. On 10-28-02 the error was discovered during planning for the     |
| second fraction, and it was reported the same day. The patient and physician |
| have been notified. No long term health effect is expected and the           |
| prescribed treatment is continuing. Licensee will submit a letter of         |
| explanation within 15 days. Florida is continuing it's investigation."       |
|                                                                              |
| Florida Incident No.  FL02-161                                               |
| Isotope used was 9.961 Curies Ir-192.                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39328       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 10/29/2002|
|LICENSEE:  ALPHA TESTING, INC.                  |NOTIFICATION TIME: 13:44[EST]|
|    CITY:  DALLAS                   REGION:  4  |EVENT DATE:        10/28/2002|
|  COUNTY:                            STATE:  TX |EVENT TIME:        06:30[CDT]|
|LICENSE#:  L03411                AGREEMENT:  Y  |LAST UPDATE DATE:  10/29/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES H. OGDEN Jr.           |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - STOLEN NUCLEAR DENSITY GAUGE                        |
|                                                                              |
|                                                                              |
| "A company technician returned to the office at 6:30 a.m. after an extended  |
| job in Brundidge, Alabama.  He was in the office to return to operations at  |
| the Dallas, office and was beginning to unload his truck and return his      |
| equipment to the office.  He unlocked his gauge (Troxler Model 3411B, Serial |
| # 6819) and placed it on the tailgate of the truck.  He walked into the      |
| office to get a chain and lock to secure the gauge in the company storage    |
| cabinet.  He walked back to the truck to get the gauge and discovered that   |
| the gauge and the concrete air meter were missing from the truck.  He        |
| contacted the dispatcher, who had not yet arrived at the office, to notify   |
| the company RSO.  Notifications were made to the Bureau of Radiation         |
| Control, the Dallas Police Department (Police Report # 823204L - a copy has  |
| not been received yet), and three local nuclear gauge repair centers         |
| (Richardson & Associated, Component Sales - Houston, and Troxler Labs,       |
| Arlington).  The gauge has not been located.  Source Serial #'s are: Cs-137, |
| 10 millicuries, S/N CC3975, and AmBE-241, 40 millicuries, S/N CCA3132.  The  |
| BRC is still investigating the incident."                                    |
|                                                                              |
| "Company truck with Logo, Texas Licensee # 5ND G59"                          |
|                                                                              |
| "Texas Incident No.: I-7945"                                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39329       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  OK DEQ RAD MANAGEMENT                |NOTIFICATION DATE: 10/29/2002|
|LICENSEE:  WOODWARD REGIONAL HOSPITAL           |NOTIFICATION TIME: 15:19[EST]|
|    CITY:  woodward                 REGION:  4  |EVENT DATE:        10/28/2002|
|  COUNTY:                            STATE:  OK |EVENT TIME:        15:00[CDT]|
|LICENSE#:  OK-21269-01           AGREEMENT:  Y  |LAST UPDATE DATE:  10/29/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  M. BRODERICK                 |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FOLLOW-UP PATIENT GIVEN INCORRECT PREP DRUG                                  |
|                                                                              |
|                                                                              |
| Woodward Regional Hospital was doing an Iodine-131 follow-up scan for        |
| residual Thyroid on cancer patient.  A nurse injected the patient with the   |
| incorrect prep drug, non radioactive drug, prior to the patient being        |
| administered 4 millicuries of Iodine-131.  The caller believes that the      |
| patient was given the incorrect prep drug on October 28, 2002 and today,     |
| October 29, 2002, was administered the 4 millicuries of Iodine-131 before    |
| given the scan. After the scan was performed it was discovered that the      |
| patient was given the incorrect prep drug for the scan. The State of         |
| Oklahoma is investigating this event.                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39333       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 10/31/2002|
|    UNIT:  [1] [] []                 STATE:  AZ |NOTIFICATION TIME: 11:04[EST]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        10/31/2002|
+------------------------------------------------+EVENT TIME:        05:45[MST]|
| NRC NOTIFIED BY:  DONALD STRAKA                |LAST UPDATE DATE:  10/31/2002|
|  HQ OPS OFFICER:  MIKE RIPLEY                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLAUDE JOHNSON       R4      |
|10 CFR SECTION:                                 |TERRY REIS           NRR     |
|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     M/R        Y       19       Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 1 MANUALLY TRIPPED DUE TO HIGH SULFATE CONCENTRATIONS IN THE STEAM      |
| GENERATORS                                                                   |
|                                                                              |
| "On October 31 2002, at approximately 05:45 MST Palo Verde Unit 1            |
| experienced a manual reactor trip from approximately 19% rated thermal power |
| due to high sulfate concentrations in the steam generators. Unit 1 was at    |
| normal temperature and pressure prior to the trip. All CEAs inserted fully   |
| into the reactor core. This was an uncomplicated reactor trip. No ESF        |
| actuations occurred and none were required. Safety related buses remained    |
| energized during and following the reactor trip. The offsite power grid is   |
| stable.  No significant LCOs have been entered as a result of this event. No |
| major equipment was inoperable prior to the event that contributed to the    |
| event.                                                                       |
|                                                                              |
| "Unit 1 is stable at normal operating temperature and pressure in Mode 3.    |
| The event did not result in any challenges to fission product barriers and   |
| there were no adverse safety consequences as a result of this event. The     |
| event did not adversely affect the safe operation of the plant or the health |
| and safety of the public."                                                   |
|                                                                              |
| The licensee stated that the trip was initiated at the recommendation of the |
| Chemistry Manager.  The licensee continues to investigate the reason for the |
| high sulfate concentration and an estimated restart date was not given.      |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
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