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Event Notification Report for November 5, 2002


                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/04/2002 - 11/05/2002

                              ** EVENT NUMBERS **

39287  39334  39335  39342  39343  

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|General Information or Other                     |Event Number:   39287       |
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| REP ORG:  ALTECH CORPORATION                   |NOTIFICATION DATE: 10/15/2002|
|LICENSEE:  ALTECH CORPORATION                   |NOTIFICATION TIME: 15:52[EDT]|
|    CITY:  POCATELLO                REGION:  4  |EVENT DATE:        10/15/2002|
|  COUNTY:  BANNOCK                   STATE:  ID |EVENT TIME:        11:30[MDT]|
|LICENSE#:  11-27657-01           AGREEMENT:  N  |LAST UPDATE DATE:  11/04/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BILLY BERRY                  |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| LOST OR STOLEN TROXLER MOISTURE DENSITY GAUGES                               |
|                                                                              |
| The licensee reported that two (2) Troxler moisture density gauges model     |
| number #2401 were missing from their storage area. The two gauges were       |
| serial number 2813 and 2744. Both gauges contain an 8.2 millicurie Cs-137    |
| and 50 millicurie Am-241:Be source. The gauges are inventoried every six     |
| months and were verified in storage in March 2002. The cases (storage boxes) |
| were verified again in August 2002. The licensee has notified local and      |
| county police of the missing gauges. Additionally, the licensee has          |
| contacted NRC Region 4 to inform them of this event.                         |
|                                                                              |
| * * * * * UPDATE BY LICENSEE TO MIKE RIPLEY 1210 EST 11/4/02 * * *           |
| The licensee reported that both Troxler moisture density gauges were found   |
| and returned to the licensee.  The gauges were found in the Portneauf River  |
| on 10/13/2002 by two hunters in the Blaze Creek Area near Lava Hot Springs,  |
| ID.  The licensee stated that the Idaho State Police at Boise, ID, are       |
| continuing to investigate the lost gauges.  Notified R4DO (C. Marschall) and |
| NMSS EO (F. Brown).                                                          |
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|General Information or Other                     |Event Number:   39334       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 10/31/2002|
|LICENSEE:  KUMAR AND ASSOCIATES, INC            |NOTIFICATION TIME: 12:10[EST]|
|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        10/30/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MST]|
|LICENSE#:  778-01                AGREEMENT:  Y  |LAST UPDATE DATE:  11/04/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ED STROUD                    |                             |
|  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 A STOLEN TROXLER GAUGE                      |
|                                                                              |
| Licensee reported that a Troxler gauge, was stolen from the open bed of a    |
| pickup truck parked in front of a private residence, sometime during the     |
| night of 10/30/02. The gauge, model #3440 serial #16911, contained           |
| approximately 44 millicuries of Am-241:Be, and approximately 9 millicuries   |
| of Cs-137.  The gauge was locked and the chain was cut. The licensee will be |
| notifying the Denver police department of the theft.                         |
|                                                                              |
| * * * * * UPDATE 1800 EST 11/4/2002 TO MIKE RIPLEY FROM COLORADO DEPARTMENT  |
| OF PUBLIC HEALTH AND ENVIRONMENT (received via fax)   * * * *                |
|                                                                              |
| "The police recovered a Troxler moisture-density gauge that was reported     |
| stolen last week.  Kumar and Associates, a Colorado licensee, reported the   |
| gauge stolen on 10/31/02 (sec preliminary report 39334). Later that same     |
| night, police were called to a Denver location because of a suspicious       |
| package that was left by a dumpster. The package was labeled with, a         |
| radioactive sticker. The Denver Fire Department's Haz-mat team checked the   |
| package and removed it to a safe storage location. Today, 11/4/02, the       |
| package was positively identified as the stolen gauge, and returned to the   |
| licensee. The licensee reported that the gauge was intact and that the       |
| sources appeared undisturbed."                                               |
|                                                                              |
| Notified R4 DO (C. Marschall) and NMSS EO (P. Holahan)                       |
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|General Information or Other                     |Event Number:   39335       |
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| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE: 10/31/2002|
|LICENSEE:  BAYFRONT MEDICAL CENTER              |NOTIFICATION TIME: 16:45[EST]|
|    CITY:  ST. PETERSBURG           REGION:  2  |EVENT DATE:        10/31/2002|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EST]|
|LICENSE#:  0023-2                AGREEMENT:  Y  |LAST UPDATE DATE:  10/31/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHARLES ADAMS(email)         |                             |
|  HQ OPS OFFICER:  ARLON COSTA                  |                             |
+------------------------------------------------+                             |
|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 EVENT                             |
|                                                                              |
| "Manufacturer's employee changed the Gamma Knife's printer on 2 Aug 02 and   |
| during the process the calibration parameters for the Gamma Knife instrument |
| were reset from 3.52 c/gray (on 6-02) to 3.5 c/gray (on 1-99). Licensee was  |
| not aware of the change. Ten patients were treated with this instrument from |
| 26 Aug-30 Oct 02. The area treated was the brain and the overexposure was as |
| much as 60% above the prescribed dose of 12-24 grays. The physicians and     |
| patients involved are being notified. The error was discovered during a      |
| recalibration on 10-30-02. The instrument has been removed from service.     |
| Florida is investigating."                                                   |
|                                                                              |
| The isotope used by the Gamma Knife Model C S/N 4189C is Co-60 (Activity     |
| 5.72 Ci).                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39342       |
+------------------------------------------------------------------------------+
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| FACILITY: MCGUIRE                  REGION:  2  |NOTIFICATION DATE: 11/04/2002|
|    UNIT:  [] [2] []                 STATE:  NC |NOTIFICATION TIME: 11:48[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        11/04/2002|
+------------------------------------------------+EVENT TIME:        11:08[EST]|
| NRC NOTIFIED BY:  STEVE BUSHNELL               |LAST UPDATE DATE:  11/04/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNUSUAL EVENT         |KERRY LANDIS         R2      |
|10 CFR SECTION:                                 |TERRY REIS           NRR     |
|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |JERRY DOZIER         NRR     |
|                                                |RICHARD WESSMAN      IRO     |
|                                                |RENE ZAPATA          FEMA    |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| UNUSUAL EVENT DECLARED DUE TO PRIMARY SYSTEM UNIDENTIFIED LEAKAGE GREATER    |
| THAN 10 GPM                                                                  |
|                                                                              |
| "Primary system unidentified leakage >10 gpm.  Leakage occurred during       |
| planned maintenance activity on a NV [Chemical volume and Control System]    |
| system demineralizer.  The leakage has been isolated at 1108.  We are        |
| running an NC [primary] system leakage calculation at present prior to       |
| terminating the event.  All primary system parameters were normal during the |
| event"                                                                       |
|                                                                              |
| The leakage was 11 gpm and was indicated by VCT level dropping.              |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
|                                                                              |
| * * * * UPDATE TO MIKE RIPLEY AT 1315 EST 11/04/02 * * * *                   |
|                                                                              |
| At 1315 EST 11/04/02 Licensee reported  termination of the unusual event  at |
| 1302 EST based on recalculation of primary system leakage: Total leakage =   |
| 0.094 gpm.  Identified leakage = 0.017 gpm.  Unidentified leakage = 0.077    |
| gpm.  Leakage was caused by leak by through isolation valves onto the floor  |
| and down a floor drain in the auxiliary building. Notified NRR EO (Reis),    |
| R2DO (Landis), IRO (Wessman), AND FEMA (Zapata).                             |
+------------------------------------------------------------------------------+

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|Power Reactor                                    |Event Number:   39343       |
+------------------------------------------------------------------------------+
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| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 11/04/2002|
|    UNIT:  [] [2] []                 STATE:  CA |NOTIFICATION TIME: 22:15[EST]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        11/04/2002|
+------------------------------------------------+EVENT TIME:        16:44[PST]|
| NRC NOTIFIED BY:  DOUG KNUDSON                 |LAST UPDATE DATE:  11/04/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       18       Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MANUAL REACTOR TRIP DUE TO DECREASING PRIMARY SYSTEM PRESSURE                |
|                                                                              |
| Licensee reported that PZR spray valve ZPV-100A failed to 46.5% open and     |
| mechanically bound. Unsuccessful attempts were made to close the valve       |
| manually (from controller) and by isolating instrument air to containment.   |
| RCS pressure slowly decreased and a manual reactor trip (all rods fully      |
| inserted) was performed at 2005 psig .  RCS pressure continued to drop to a  |
| low of approximately 1840 psig (1740 psig is automatic trip setpoint). Two   |
| reactor coolant pumps were secured in accordance with Emergency Operating    |
| Instructions and RCS pressure recovered to 2250 psig (NOP) over a 1.5 hour   |
| time frame.  A containment entry was performed and the spray valve shut      |
| while it was being isolated by manually shutting it's associated isolation   |
| valves.  Decay heat is being removed by dumping steam to condenser and there |
| is no indication of primary to secondary leakage.                            |
|                                                                              |
| The Licensee has notified the NRC Resident Inspector.                        |
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