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Event Notification Report for December 11, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           12/10/2002 - 12/11/2002

                              ** EVENT NUMBERS **

39426  39430  39432  39433  39434  39435  39436  39437  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39426       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 12/06/2002|
|LICENSEE:  NORTHWEST COMMUNITY HOSPITAL         |NOTIFICATION TIME: 13:13[EST]|
|    CITY:  ARLINGTON HEIGHTS        REGION:  3  |EVENT DATE:        12/05/2002|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CST]|
|LICENSE#:  IL-01094-01           AGREEMENT:  Y  |LAST UPDATE DATE:  12/06/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KENNETH RIEMER       R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOE KLINGER                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL EVENT, DOSE GREATER THAN 20% LARGER THAN    |
| PRESCRIBED                                                                   |
|                                                                              |
| "On December 5, 2002, the RSO at Northwest Community Hospital, Arlington     |
| Heights IL, notified the department of a 'reportable'  (misadministration)   |
| event that occurred involving Intravascular Brachytherapy.   The treatment   |
| was for a 52 mm lesion using 85 mCi [millicuries] of  P-32 (GDT source) in a |
| Guidant Corporation Galileo device.  The prescribed dose was 20 gray.  Using |
| a three step automated system, as  the 1st step was completed, the           |
| authorized user intervened and repositioned the markers for the system to    |
| intentionally deliver an  additional dose to this area of the lesion.  After |
| completing the treatment. The calculated dose to the lesion was determined   |
| to be 24.6  gray.  This is greater than 20% over the prescribed dose for     |
| this treatment and thus a reportable event. The RSO reported that the        |
| clinical  range for this treatment is 15-26 gray so no adverse health        |
| effects are anticipated with this event.  The RSO stated that a written      |
| report would be filed with the department within the required 15 day         |
| period.                                                                      |
|                                                                              |
| "Event Date  12/05/2002  License No:  IL-01094-01 Licensee: Northwest        |
| Community Hospital                                                           |
| City: Arlington Heights    State: IL  Event Class:  MD2 - MEDICAL EVENT      |
| Medical Event Information:  Patient Number: 1                                |
| % Overexposed: 23                                                            |
| Procedure:  BRACHY, REMOTE AFTERLOADER,                                      |
| Dose in RAD:  2460  Organ:  HEART   Study:  CARDIOVASCULAR SYSTEM            |
| Radionuclide:  P-32                                                          |
| Administered By:  PHYSICIAN  Keywords:  INTRAVASCULAR BRACHYTHERAPY"         |
|                                                                              |
| Item Number:  IL020074                                                       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39430       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: ZION                     REGION:  3  |NOTIFICATION DATE: 12/09/2002|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 12:42[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        12/09/2002|
+------------------------------------------------+EVENT TIME:        10:20[CST]|
| NRC NOTIFIED BY:  MARK BITTMANN                |LAST UPDATE DATE:  12/10/2002|
|  HQ OPS OFFICER:  ERIC THOMAS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |KENNETH REIMER       R3      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Decommissioned   |0        Decommissioned   |
|2     N          N       0        Decommissioned   |0        Decommissioned   |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF ENS AND COMMERCIAL TELEPHONE LINES                                   |
|                                                                              |
| At 10:20 CST on 12/9/2002, experienced a major loss of offsite               |
| communications ability on the ENS, NARS, and commercial telephone systems.   |
| Repair personnel have been dispatched to the site by Ameritech.  The         |
| licensee is continually manning a cell phone until the lines are restored.   |
|                                                                              |
| Internal communications on site are still available, as well as microwave    |
| communications to the EOF.                                                   |
|                                                                              |
| A trouble ticket was generated for the FTS lines, ticket number 3612.        |
|                                                                              |
| The licensee notified the State and stated that the NRC Resident Inspector   |
| will be notified.                                                            |
|                                                                              |
| * * * * UPDATE FROM ZION TO MIKE RIPLEY AT 2325 EST 12/9/02 * * *            |
|                                                                              |
| Repair crews have pinpointed the telephone line problem and anticipate       |
| completing repairs by mid-day Tuesday, 12/10/02.  The licensee continues to  |
| man a cell phone until the lines are restored.                               |
|                                                                              |
| Notified the R3 DO (P. Hiland)                                               |
|                                                                              |
| ***UPDATE FROM ZION TO HOWIE CROUCH AT 0509 EST ON 12/10/02 ***              |
|                                                                              |
| Licensee reported that all commercial and ENS lines have been repaired and   |
| returned to service.                                                         |
|                                                                              |
| Notified the R3 DO (P. Hiland)                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   39432       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 12/10/2002|
|LICENSEE:  LAREDO REGIONAL MEDICAL CENTER       |NOTIFICATION TIME: 10:13[EST]|
|    CITY:  LAREDO                   REGION:  4  |EVENT DATE:        11/26/2002|
|  COUNTY:                            STATE:  TX |EVENT TIME:             [CST]|
|LICENSE#:  L02192-001            AGREEMENT:  Y  |LAST UPDATE DATE:  12/10/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KRISS KENNEDY        R4      |
|                                                |DANIEL GILLEN        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES H. OGDEN, JR.          |                             |
|  HQ OPS OFFICER:  JASON FLEMMING               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT ON AN I-131 SPILL  AT A TEXAS HOSPITAL                |
|                                                                              |
| "Patient was administered an I-131 capsule for ablation therapy on November  |
| 26, 2002. A fragment was dropped on the floor. The fragment was measured to  |
| contain 13 millicuries of I-131.  A contamination survey of the room         |
| determined that an area by the sink and an area by the imaging table         |
| revealed contamination. The room was sealed off, contamination by the sink   |
| was determined to have contamination in the amount of 2 millirem/hour near   |
| the sink and 1.6 millirem /hour near the imaging table. After                |
| decontamination the room was re-surveyed with the result of 1.6              |
| millirem/hour near the sink and 0.8 millirem/hour. Wipe tests were sent to   |
| the nuclear pharmacy for analysis. Results of the analysis indicated 87,313  |
| dpm near the sink and 1,229 dpm near the imaging table. With readings still  |
| above the action limits for contamination the facility closed the room for   |
| four (4) weeks. At that time additional wipe tests will be conducted and     |
| submitted to the nuclear pharmacy for analysis. Bioassay of personnel        |
| performing decontamination were conducted 24-hours after the clean-up with   |
| no action required for the clean-up crew. The fragment of the capsule was    |
| packaged in a lead container and returned to the nuclear pharmacy for        |
| disposal."                                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39433       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FARLEY                   REGION:  2  |NOTIFICATION DATE: 12/10/2002|
|    UNIT:  [1] [] []                 STATE:  AL |NOTIFICATION TIME: 10:39[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        12/10/2002|
+------------------------------------------------+EVENT TIME:        08:25[CST]|
| NRC NOTIFIED BY:  HUNTER                       |LAST UPDATE DATE:  12/10/2002|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRIAN BONSER         R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|AESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     M/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MANUAL TRIP FROM 100% POWER DUE TO STEAM GENERATOR LEVELS APPROACHING LOW    |
| LEVEL TRIP POINT                                                             |
|                                                                              |
| The unit was manually tripped from 100% power due to steam generator levels  |
| approaching the low level trip setpoint.  The motor driven auxiliary         |
| feedwater pumps auto started as a result of a trip of both main feedwater    |
| pumps and the turbine driven auxiliary feedwater pump autostarted due to low |
| steam generator levels.  The main feed pumps trip was a result of loss of    |
| power to the control systems.  An unintentional impact to the power supply   |
| for the control systems by plant facilities personnel resulted in the loss   |
| of power.  All rods fully inserted, no ECCS actuation occurred and no relief |
| valves lifted.  The unit is currently in mode 3 and all plant systems        |
| responded as designed.                                                       |
|                                                                              |
| The NRC Resident inspector was notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39434       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BRAIDWOOD                REGION:  3  |NOTIFICATION DATE: 12/10/2002|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 12:20[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        12/10/2002|
+------------------------------------------------+EVENT TIME:        11:20[CST]|
| NRC NOTIFIED BY:  CARL MOORE                   |LAST UPDATE DATE:  12/10/2002|
|  HQ OPS OFFICER:  ARLON COSTA                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |PATRICK HILAND       R3      |
|10 CFR SECTION:                                 |CHRISTOPHER GRIMES   NRR     |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |NADER MAMISH         IRO     |
|                                                |ELIZABETH HAYDEN     OPA     |
|                                                |SCOTT MORRIS         EDO     |
|                                                |JAN STRASMA          R3      |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION DUE TO SUSPICIOUS INDIVIDUAL                            |
|                                                                              |
| The licensee is issuing the following press release:                         |
|                                                                              |
| "BRACEVILLE, IL -  About 11:30 p.m. Monday, a man driving a compact vehicle  |
| failed to stop at the Braidwood Nuclear Station's initial security           |
| checkpoint in violation of station security policies. The unidentified male, |
| who was in the plant's parking lot briefly, refused to obey the security     |
| officers' instructions, drove through the station parking lot and left the   |
| site. He did not threaten the safety of the plant. At no time was the health |
| and safety of the public threatened. The man left the site after a few       |
| minutes and was detained in a short period of time by officers from the      |
| Wilmington Police Department, who had been notified by the Braidwood Police  |
| Department.                                                                  |
|                                                                              |
| "After the man entered the station property, Braidwood security officers     |
| used a direct communications link to immediately contact local authorities,  |
| who subsequently notified the FBI. Exelon is working with the FBI's Chicago  |
| office and local authorities and has notified the Nuclear Regulatory         |
| Commission.                                                                  |
|                                                                              |
| "Plant security forces acted promptly and effectively in handling the        |
| incident and received outstanding support from local law enforcement. The    |
| FBI is handling the investigation."                                          |
|                                                                              |
| The Licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39435       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FRAMATOME                            |NOTIFICATION DATE: 12/10/2002|
|LICENSEE:  FRAMATOME                            |NOTIFICATION TIME: 14:41[EST]|
|    CITY:                           REGION:     |EVENT DATE:        12/10/2002|
|  COUNTY:                            STATE:     |EVENT TIME:             [EST]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  12/10/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KRISS KENNEDY        R4      |
|                                                |CHRISTOPHER GRIMES   NRR     |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JERALD S. HOLM               |                             |
|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POWERPLEX INCORE MONITORING SYSTEM                                           |
|                                                                              |
| Location of fuel assemblies in BWR/6 reactors with the POWERPLEX incore      |
| monitoring system may affect their orifice pressure loss coefficients by as  |
| much as 40%.  The GE core monitoring system uses average orifice loss        |
| coefficient values for all assemblies in the core, and a recent evaluation   |
| by GE for current fuel designs indicates that the assumption may be          |
| non-conservative by up to .01 in predicted MCPR.                             |
|                                                                              |
| Analyses have been performed at Grand Gulf and River Bend, the two BWR/6     |
| reactors in the U.S. which use the POWERPLEX incore monitoring system, to    |
| assess the impact of using position dependent orifice loss coefficients.     |
| The analyses indicate that for Grand Gulf, MCPR is non-conservatively over   |
| predicted by not more that 2%, and that LHGR and MAPLHGR are                 |
| non-conservatively under predicted by not more than 2%.  For River Bend, the |
| analyses indicate that MCPR is non-conservatively over predicted by up to    |
| 1.2%, LHGR is non-conservatively under predicted by up to 0.7%, and MAPLHGR  |
| is non-conservatively under predicted by up to 0.6%.                         |
|                                                                              |
| The affected plants, Grand Gulf and River Bend, have been notified by        |
| Framatome.  Compensatory measures were recommended to apply an               |
| administrative penalty on the allowed values of MCPR, LHGR, and MAPLHGR.     |
| The POWERPLEX incore monitoring input decks have been modified to include    |
| the correct orifice loss coefficients.  The plants are currently operating   |
| with correct orifice loss coefficients in the POWERPLEX incore monitoring    |
| system.                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   39436       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  R. M. WESTER ASSOCIATES CONSULTING   |NOTIFICATION DATE: 12/10/2002|
|LICENSEE:  TSI ENGINEERING                      |NOTIFICATION TIME: 18:18[EST]|
|    CITY:  ST LOUIS                 REGION:  3  |EVENT DATE:        12/10/2002|
|  COUNTY:                            STATE:  MO |EVENT TIME:        14:30[CST]|
|LICENSE#:  24-32205-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/10/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PATRICK HILAND       R3      |
|                                                |NADER MAMISH         IRO     |
+------------------------------------------------+LARRY CAMPER         NMSS    |
| NRC NOTIFIED BY:  ROBERT WESTER                |                             |
|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| HUMBOLT MOISTURE DENSITY GAUGE DAMAGED                                       |
|                                                                              |
| At a construction site in Downtown St. Louis, a moisture density gauge was   |
| run over by a high lift.  The gauge was in the uncovered position, and is    |
| currently buried in the soil.  Local fire department was notified, and came  |
| to the site to measure radiation levels.  Levels were 112 mr/hr at a         |
| distance of 3 feet.  The area has been secured, awaiting arrival of a        |
| hazardous material removal team from R.M. Wester Associates (license         |
| #24-20091-01).  The hazmat team will remove the gauge and any contaminated   |
| soil that they find.  Humbolt is also dispatching an environmental response  |
| team to the site.  The moisture density gauge contains 10 mCi of Cs-137 and  |
| 40 mCi of Am-241.                                                            |
|                                                                              |
| The R3 PAO was notified.  The R3DO (P. Hiland) contacted the state of        |
| Missouri.                                                                    |
|                                                                              |
| **** UPDATE AT 2030 EST FROM R3DO AND DARREL WIEDEMAN TO MIKE RIPLEY ****    |
|                                                                              |
| Gauge has been recovered.  Actual readings were 1.25 mr/hr at 3 feet.  Gauge |
| was slightly damaged, but the source was intact.  No contamination was found |
| in the area.  Humbolt representative was on the scene.                       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39437       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 12/11/2002|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 02:41[EST]|
|   RXTYPE: [1] GE-2                             |EVENT DATE:        12/11/2002|
+------------------------------------------------+EVENT TIME:        02:30[EST]|
| NRC NOTIFIED BY:  STEVE FULLER                 |LAST UPDATE DATE:  12/11/2002|
|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MICHELE EVANS        R1      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO FAA                                                  |
|                                                                              |
| Licensee made an offsite notification to FAA due to loss of power to plant   |
| stack lighting.  FAA assigned notification number MIV-212/061-RG.  FAA was   |
| again notified at 0230 EST that the stack lights were returned to service,   |
|                                                                              |
| Licensee notified NRC resident.                                              |
+------------------------------------------------------------------------------+