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Event Notification Report for April 2, 2003



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/01/2003 - 04/02/2003

                              ** EVENT NUMBERS **

39581  39706  39707  39708  39710  39718  39719  39720  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39581       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 02/12/2003|
|    UNIT:  [] [2] []                 STATE:  AZ |NOTIFICATION TIME: 16:13[EST]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        02/07/2003|
+------------------------------------------------+EVENT TIME:        17:20[MST]|
| NRC NOTIFIED BY:  MARKS                        |LAST UPDATE DATE:  04/01/2003|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|AINC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       98       Power Operation  |98       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LEAKAGE DISCOVERED FROM HIGH PRESSURE SAFETY INJECTION SYSTEM OUTSIDE        |
| CONTAINMENT                                                                  |
|                                                                              |
| "On February 7, 2003, at approximately 17:20 Mountain Standard Time (MST),   |
| Palo Verde Unit 2 discovered leakage from the high pressure safety injection |
| system outside containment that could contain highly radioactive fluids      |
| during a serious transient or accident exceeded the safety analysis leakrate |
| limit. The drain valve that was the source of the leakage was promptly       |
| tightened to return to within the analysis limit and subsequently repaired   |
| to further reduce leakage to a level as low as practicable. There was no     |
| release of radioactivity to the environment as a result of this event.       |
| There were no adverse safety consequences resulting from the event.          |
|                                                                              |
| The "loss of safety function" reporting requirement would be triggered by    |
| the described condition because the post-LOCA dose calculations assume no    |
| more than 1500 ml/hour leakage outside of containment in the 10 CFR 100      |
| siting analysis.  At the time of discovery, the leakage was 1715 ml/min      |
| (102900 ml/hr). Therefore the safety function to control the release of      |
| radioactive material such that the dose to a member of the public would not  |
| exceed 10 CFR 100 limits during a potential LOCA was not fulfilled.          |
|                                                                              |
| At the time of the discovery the condition was promptly corrected so no ENS  |
| report was thought to be required, however on further review it was noted    |
| that the reporting requirement states "Any event or condition that at the    |
| time of discovery could have prevented.." and therefore remains immediately  |
| reportable even if the condition no longer exists."                          |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| *** RETRACTED ON 4/1/03 AT 1605 EST FROM D. STRAKA TO A. COSTA ***           |
|                                                                              |
| "This notification is a RETRACTION of the February 7, 2003, ENS #39581 which |
| reported a Palo Verde Nuclear Generating Station Unit 2 loss of safety       |
| function to control the release of radioactive materials due to leakage from |
| the high pressure safety injection system outside containment that could     |
| contain highly radioactive fluids during a serious transient or accident     |
| arid exceed the safety analysis Ieakrate limit.                              |
|                                                                              |
| "At the time of discovery, the leakage was assumed to exceed the 10 CFR 100  |
| limits for dose to a member of the public during a potential LOCA [Loss of   |
| Coolant Accident]. Therefore the safety function to control the release of   |
| radioactive material would not be fulfilled.                                 |
|                                                                              |
| "PVNGS [Palo Verde Nuclear Generating Station] System Engineering            |
| re-evaluated the condition and has concluded that the identified leakage was |
| well within the limiting large break loss of coolant accident analysis and   |
| that the 10 CFR 100 limits would not have been exceeded. Therefore, the loss |
| of a safety function DID NOT exist and the condition is not reportable.      |
|                                                                              |
| "The NRC Resident Inspector has been notified."                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39706       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 03/27/2003|
|LICENSEE:  SOURCE TECH MEDICAL                  |NOTIFICATION TIME: 16:22[EST]|
|    CITY:  SCHAUMBERG               REGION:  3  |EVENT DATE:        03/26/2003|
|  COUNTY:                            STATE:  IL |EVENT TIME:        15:00[CST]|
|LICENSE#:  IL-02062-01           AGREEMENT:  Y  |LAST UPDATE DATE:  03/27/2003|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MICHAEL PARKER       R3      |
|                                                |RUDOLPH BERNHARD     R2      |
+------------------------------------------------+E. WILLIAM BRACH     NMSS    |
| NRC NOTIFIED BY:  JOE KLINGER (E-MAIL)         |                             |
|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - LOST OR STOLEN IODINE SOURCES                       |
|                                                                              |
| The following information was received via e-mail from the Illinois          |
| Department of Nuclear Safety:                                                |
|                                                                              |
| "[DELETED], RSO of SourceTech Medical [(DELETED)] in Carol Stream, IL called |
| at 1500 hours on March 26, 2003, to report that he had received a shipment   |
| of returned I-125 seeds.  The dose rate on the surface of the package was 9  |
| [millirem/hr] instead of the expected dose rate of less than 0.5             |
| [millirem/hr].   Upon opening the box, 2 loose sources were found on top of  |
| the packing material.  7 sources were noted in the shipping papers.   An     |
| additional source was found in a partially loaded Mick applicator but there  |
| were no sources in the second Mick applicator.  A total of only 3 sources    |
| were found after looking through the other two lead containers in the        |
| package.                                                                     |
|                                                                              |
| "Based on assay of the three seeds, the 4 missing seeds are 425 [microcurie] |
| I-125 each for a total of 1.7 [millicurie].  The contents of the package     |
| (Fed Ex tracking no., [DELETED]) were obviously not prepared in accordance   |
| with instructions provided by Source Tech in that the lids to the containers |
| were not secured nor were the vials used in the lead containers as the       |
| instructions call for.  The carrier, Federal Express had been contacted by   |
| [DELETED] and the delivery truck surveyed.  No sources were located during   |
| the survey.   According to tracking information, the package had gone from   |
| St. Augustine through Jacksonville FL, Atlanta GA, Memphis TN, Chicago, IL   |
| and the Schaumburg IL sorting facility prior to delivery in Carol Stream.    |
| An inspector was dispatched to the Schaumburg facility at 15:45 to attempt a |
| search of the Schaumburg facility.                                           |
|                                                                              |
| "The sources were shipped from Slagley Hospital (Florida [DELETED]) in St.   |
| Augustine Florida on Monday 3/24/2003. [DELETED] tried contacting the site   |
| RSO, [DELETED], this afternoon but was unsuccessful.  The department         |
| contacted Mr. [DELETED] of the Florida program in their Orlando office and   |
| relayed the information available at the time (see above).  He indicated     |
| that he would attempt a call as well but suspected the hospital staff would  |
| be gone given the time of day (16:30) in Fla.  On 3/27/03, [DELETED]         |
| notified the department that he contacted the Florida licensee and the St.   |
| Augustine hospital claimed that they counted twice the seven seeds not used  |
| in a patient, placed them in a 'screwed sealed cartridge' then put them in a |
| shipping box for FedEx.  The department also informed [DELETED], Ph.D.,      |
| health physics consultant for FedEx, that there are apparently 4 iodine-125  |
| seeds in FedEx facilities or vehicles somewhere as indicated by the routing  |
| in the message below.  Jim Lynch of the NRC was also advised  of the         |
| situation. On 03/26/03, a departmental inspector  arrived at the Federal     |
| Express Depot located at 1270 Wilkening Road in Schaumburg; [DELETED] and    |
| explained the purpose of the visit.  The inspector was provided access to    |
| the package/truck staging area.  Based on the FedEx tracking number, the     |
| author was told that the bay used by the vehicle was the same one used in a  |
| previous, recent incident involving I-125 seeds.  Surveys were performed by  |
| the inspector using an Eberline Model PRM-6 ratemeter, serial number 1470,   |
| last calibrated on May 16, 2002, with an Eberline Model LEG-1 probe.         |
| Background readings were [approximately] 250 - 350 CPM.  Areas surveyed      |
| included the conveyor belt system, particularly junctions between belts,     |
| walkways, and the concrete pad where vehicles park for loading/unloading.    |
| Particular attention was paid to the area where the truck was unloaded and   |
| the seeds had been found in the previous incident.  No seeds were located by |
| the inspector.   The department is reviewing the packaging used by           |
| SourceTech and the instructions to see if there they can be improved to      |
| prevent recurrences.  The event was reported to the NRC Operations Center at |
| 1622 hours EST on 3/27/03 and assigned Event No. 39706.  A copy of this      |
| report was electronically forwarded to the Ops Center as well as the states  |
| of FL, GA, TN and NRC   Region III."                                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39707       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  NEW YORK STATE DEPT. OF HEALTH       |NOTIFICATION DATE: 03/27/2003|
|LICENSEE:  NOT AVAILABLE                        |NOTIFICATION TIME: 17:40[EST]|
|    CITY:                           REGION:  1  |EVENT DATE:        03/27/2003|
|  COUNTY:                            STATE:  NY |EVENT TIME:             [EST]|
|LICENSE#:  NOT AVAILABLE         AGREEMENT:  Y  |LAST UPDATE DATE:  03/27/2003|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PAMELA HENDERSON     R1      |
|                                                |E. WILLIAM BRACH     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT DANSEREAU (FAX)       |                             |
|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION                           |
|                                                                              |
| The following information was received from the New York State Department of |
| Health, Bureau of Environmental Radiation Protection:                        |
|                                                                              |
| "This notice is in regard to a medical misadministration involving a Novoste |
| Beta-Cath IVB 3.5F system, Model A1767 with AEAT Model SIC W.2 source train. |
| The event occurred on March 25, 2003.                                        |
|                                                                              |
| "Two attempts to advance the source train into the delivery catheter were    |
| unsuccessful. A third (and final) attempt resulted in the source train       |
| becoming stuck in the patient's femoral artery, somewhere in the lower groin |
| area. The sources could not be returned to the base unit. The treatment team |
| then removed the catheter, with the source extended, and placed these items  |
| into the emergency bailout box.                                              |
|                                                                              |
| "The licensee estimated that the patient received an exposure of 250 Rads to |
| an area of the femoral artery in the lower groin area. The oncologist and    |
| cardiologist decided not to proceed with IVB treatment of this patient.      |
| Hospital staff concluded that the misdirected radiation exposure would not   |
| have a significant health effect on the patient.                             |
|                                                                              |
| "This event meets the reporting requirements in 10 NYCRR 16. The facility    |
| will investigate the circumstances, procedures, training, history of use,    |
| etc., and will submit a written report within 7 days. The device, including  |
| catheter and hydraulic attachment (syringe) will be sent to the vendor for   |
| evaluation."                                                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39708       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 03/27/2003|
|LICENSEE:  THOMPSON ENGINEERING AND TESTING, INC|NOTIFICATION TIME: 15:18[EST]|
|    CITY:                           REGION:  2  |EVENT DATE:        03/27/2003|
|  COUNTY:                            STATE:  AL |EVENT TIME:             [CST]|
|LICENSE#:  694                   AGREEMENT:  Y  |LAST UPDATE DATE:  03/27/2003|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RUDOLPH BERNHARD     R2      |
|                                                |E. WILLIAM BRACH     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID WALTER (FAX)           |                             |
|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - LOST TROXLER MOISTURE/DENSITY GAUGE                 |
|                                                                              |
| The following information was received from Alabama Office of Radiation      |
| Control via facsimile:                                                       |
|                                                                              |
| "The Agency has been notified by Thompson Engineering and Testing, Inc. that |
| a Troxler Model 3440 Gauge (serial #32128) containing a maximum of 9         |
| millicuries of cesium 137 and 44 millicuries of americium 241/beryllium is   |
| missing. They have conducted a search of many of their Alabama offices, and  |
| have been unable to locate it.  Since their records do not show this device  |
| being used in some time, it had been in storage, and was not detected as     |
| lost until the six month leak test was due.  They are continuing to search   |
| for the gauge, and will notify this office of their findings."               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39710       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 03/28/2003|
|LICENSEE:  BAKER ATLAS                          |NOTIFICATION TIME: 12:15[EST]|
|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        03/26/2003|
|  COUNTY:                            STATE:  TX |EVENT TIME:        07:30[CST]|
|LICENSE#:  L05104                AGREEMENT:  Y  |LAST UPDATE DATE:  03/28/2003|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BLAIR SPITZBERG      R4      |
|                                                |TRISH HOLAHAN        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GLENN CORBIN                 |                             |
|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - INJURED AND CONTAMINATED EMPLOYEE TRANSFERRED       |
| OFFSITE                                                                      |
|                                                                              |
| The following information was obtained from Texas Department of Health,      |
| Bureau of Radiation Control via facsimile:                                   |
|                                                                              |
| "The Agency was notified that at 7:30 AM [CST] [on] 3/26/03, a neutron tube  |
| blew apart inside the pulse neutron facility located at 2001 Rankin Road,    |
| Houston, TX 77073-5114.  The employee that was involved received superficial |
| lacerations.  EMT's were notified at this time.  Immediately after the       |
| accident H-3 [tritium] contamination was found around the wound area.  The   |
| contamination was found in a swipe that was analyzed by the licensee using   |
| their laboratory located on the premises.  The swipe was found to have 19    |
| [nanocuries] of H-3 contamination.  The employee was transferred by          |
| ambulance to a local hospital.  We believe at this time it was Memorial      |
| Hospital.  The EMT's and the hospital were made aware of the radiological    |
| contamination and all precautions were taken.  The licensee requested that   |
| all materials removed or used at the hospital, and in the ambulance be       |
| returned to the licensee.  [Urinalysis] was [performed] on the employee and  |
| found to be at baseline levels.  Contamination was contained in the building |
| where the accident happened and contamination on the floor was               |
| decontaminated to background levels.  The licensee is following up with the  |
| hospital concerning the contaminated clothing, and debris associated with    |
| the incident.  The licensee will submit a report within thirty days."        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39718       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COLUMBIA GENERATING STATIREGION:  4  |NOTIFICATION DATE: 04/01/2003|
|    UNIT:  [2] [] []                 STATE:  WA |NOTIFICATION TIME: 13:53[EST]|
|   RXTYPE: [2] GE-5                             |EVENT DATE:        04/01/2003|
+------------------------------------------------+EVENT TIME:        10:50[PST]|
| NRC NOTIFIED BY:  FRED SCHILL                  |LAST UPDATE DATE:  04/01/2003|
|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANTHONY GODY         R4      |
|10 CFR SECTION:                                 |JOHN DAVIDSON        IAT     |
|DDDD 73.71(b)(1)         SAFEGUARDS REPORTS     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       97       Power Operation  |97       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| VULNERABILITY DISCOVERED IN A SAFEGUARD SYSTEM AT COLUMBIA GENERATING        |
| STATION                                                                      |
|                                                                              |
| Immediate compensatory measures taken upon discovery.                        |
|                                                                              |
| Licensee will notify the NRC Resident Inspector.                             |
|                                                                              |
| Contact the Headquarters Operations Officer for additional details.          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   39719       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  YORK HOSPITAL                        |NOTIFICATION DATE: 04/01/2003|
|LICENSEE:  YORK HOSPITAL                        |NOTIFICATION TIME: 16:45[EST]|
|    CITY:  YORK                     REGION:  1  |EVENT DATE:        03/30/2001|
|  COUNTY:                            STATE:  PA |EVENT TIME:             [EST]|
|LICENSE#:  37-07161-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/01/2003|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RONALD BELLAMY       R1      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DEBRA SWAIM                  |                             |
|  HQ OPS OFFICER:  ARLON COSTA                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LICENSEE TRANSFERRED RADIOACTIVE MATERIAL TO NON-LICENSED ENTITY             |
|                                                                              |
| On March 30, 2001, the Licensee transferred a Varian 6/100 linear            |
| accelerator containing depleted uranium source for disposal to a recipient   |
| who was not authorized to possess depleted uranium.  The linear accelerator  |
| was eventually sold and transferred to a clinic in Reynosa, Mexico.  On      |
| October 14, 2002 the Licensee submitted a written report on this incident to |
| Region 1.  The NRC has issued Office of Investigation Report No. 1-2002-036, |
| Inspection Report No. 03003085/2002001 and the Licensee has responded to     |
| these two reports via correspondence with Region 1, dated March 27, 2003.    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39720       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 04/01/2003|
|    UNIT:  [] [2] []                 STATE:  FL |NOTIFICATION TIME: 19:46[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        04/01/2003|
+------------------------------------------------+EVENT TIME:        16:03[EST]|
| NRC NOTIFIED BY:  CALVIN WARD                  |LAST UPDATE DATE:  04/01/2003|
|  HQ OPS OFFICER:  ARLON COSTA                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MIKE ERNSTES         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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSER VACUUM                          |
|                                                                              |
| "At 1603 EST, PSL [Plant Saint Lucie] Unit 2 was manually tripped due to     |
| increasing condenser backpressure (loss of vacuum).  The manual trip is      |
| considered an RPS [Reactor Protection System] actuation.  The plant was      |
| stabilized in Mode 3.  Auxiliary Feedwater actuation occurred due to reduced |
| steam generator level, as expected.  The 2A and 2B AFW [Auxiliary Feedwater] |
| pumps started and supplied feedwater to the 2A and 2B S/Gs [steam            |
| generators].  The 2C (steam driven AFW pump tripped.  This was not expected. |
| The 2C AFW pump has been reset for operation, but was not tested."           |
|                                                                              |
| The reactor was shutdown with all control rods fully inserted, the unit is   |
| currently stable in mode 3 with the main feedwater pumps supplying cooling   |
| to the steam generators.  With the exception of the 2C steam driven AFW      |
| pump, all other electrical power sources and decay heat removal systems      |
| functioned as required.  This incident had no impact on Unit 1 which remains |
| at full power.                                                               |
|                                                                              |
| The Licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+