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Event Notification Report for January 16, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           01/15/2003 - 01/16/2003



                              ** EVENT NUMBERS **



39509  39510 39512  39513  39514  



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|Hospital                                         |Event Number:   39509       |

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| REP ORG:  ALLEGHENY GENERAL HOSPITAL           |NOTIFICATION DATE: 01/15/2003|

|LICENSEE:  ALLEGHENY GENERAL HOSPITAL           |NOTIFICATION TIME: 13:08[EST]|

|    CITY:  PITTSBURGH               REGION:  1  |EVENT DATE:        01/14/2003|

|  COUNTY:                            STATE:  PA |EVENT TIME:        15:00[EST]|

|LICENSE#:  37-01317-01           AGREEMENT:  N  |LAST UPDATE DATE:  01/15/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |RICHARD BARKLEY      R1      |

|                                                |THOMAS ESSIG         NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  JOE OCH                      |                             |

|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BOV2 20.2202(b)(1)       PERS OVEREXPOSURE/TEDE |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| ESTIMATED OVEREXPOSURE TO SKIN OR EXTREMITIES > 50 REM                       |

|                                                                              |

| An employee at the hospital was found to have an estimated 6 microcuries of  |

| I-131 contamination on his right index finger.  It is suspected that he      |

| received the contamination while working in the hot lab.  Decontamination    |

| efforts are in progress at this time.  There is no spread of contamination   |

| in the hot lab and an investigation is in progress.  The estimated exposure  |

| to the finger is > 50 Rem.                                                   |

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|Hospital                                         |Event Number:   39510       |

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| REP ORG:  PENNSYLVANIA HOSPITAL                |NOTIFICATION DATE: 01/15/2003|

|LICENSEE:  PENNSYLVANIA HOSPITAL                |NOTIFICATION TIME: 13:49[EST]|

|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        01/13/2003|

|  COUNTY:                            STATE:  PA |EVENT TIME:        12:00[EST]|

|LICENSE#:  37-06864-06           AGREEMENT:  N  |LAST UPDATE DATE:  01/15/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |RICHARD BARKLEY      R1      |

|                                                |                             |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  DR. LEONARD SHABASON         |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| DAMAGED IODINE-125 SEED RESULTS IN DOSE THAT DIFFERS FROM PRESCRIBED DOSE BY |

| >20 %                                                                        |

|                                                                              |

| "On Monday January 13, 2003 a prostate implant was performed on [DELETED].   |

| The seeds that were used were Amersham's Echoseed.  Each seed had an         |

| activity of 0.472 [millicurie] apparent activity (NIST 1999) on the day of   |

| the implant.  The actual activity is 1.78 times the apparent activity which  |

| results in an actual activity of 0.84 [millicurie].                          |

|                                                                              |

| "During the implant there was difficulty in removing a cartridge.  Once the  |

| cartridge was removed, there was some activity that registered in the Mick   |

| gun.   A blood clot that registered radioactivity was expelled from the gun  |

| and was isolated and the implant proceeded.  This involved the last seed in  |

| a Mick disposable cartridge.                                                 |

|                                                                              |

| "Once the implant was completed, the blood clot was examined and was found   |

| to contain a fragment of a seed.  The entire operating room was checked      |

| carefully to see if the other portion of the seed was anywhere on the        |

| operating room.  There was no contamination found in any of the instruments  |

| or in any of the used cartridges with the GM probe.  No seeds or any         |

| activity was discovered during cystography or in any of the trash in the     |

| operating room. The feet of all the individuals involved in the procedure    |

| were checked in case a seed adhered to a shoe covering.  It was assumed that |

| the remainder of the seed was placed in the patient's prostate. The          |

| radiation oncologist ordered that the patient be given a blocking dose of    |

| iodine in the form of Lugol's solution.  The radiation oncologist informed   |

| the patient that he was being placed on this medication because of the       |

| possibility that a leaking seed was implanted."                              |

|                                                                              |

| The prescribing physician has informed the patient.                          |

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|General Information or Other                     |Event Number:   39512       |

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| REP ORG:  ROCKBESTOS-SUPRENANT CABLE CORP.     |NOTIFICATION DATE: 01/15/2003|

|LICENSEE:  ROCKBESTOS-SUPRENANT CABLE CORP.     |NOTIFICATION TIME: 16:42[EST]|

|    CITY:  EAST GRANBY              REGION:  1  |EVENT DATE:        01/14/2003|

|  COUNTY:                            STATE:  CT |EVENT TIME:             [EST]|

|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  01/15/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |RICHARD BARKLEY      R1      |

|                                                |THOMAS DECKER        R2      |

+------------------------------------------------+DAVID HILLS          R3      |

| NRC NOTIFIED BY:  RICHARD C. BROWN             |GARY SANBORN         R4      |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |JACK FOSTER          NRR     |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| INITIAL NOTIFICATION OF 10 CFR PART 21 DEFECT/FAILURE TO COMPLY              |

|                                                                              |

| "The following information is supplied in accordance with the requirements   |

| of 10 CFR 21.                                                                |

| "I. Name and address of individual informing the Commission:                 |

|                                                                              |

| [Deleted]                                                                    |

|                                                                              |

| "II. Identification of the basic component supplied which fails to comply or |

| contains a defect:                                                           |

|                                                                              |

| "The KXL 760D insulation system (chemically crosslinked only) provided in    |

| some of the Firewall III cables manufactured from January 1992 thru June     |

| 1995 may include an alternate resin which was not part of the baseline       |

| qualification testing.                                                       |

|                                                                              |

| "III. Identification of the firm supplying the basic component which fails   |

| to comply or contains a defect:                                              |

|                                                                              |

| "The Rockbestos-Surprenant Cable Corp., East Granby, CT facility.            |

|                                                                              |

| "IV. Nature of the defect or failure to comply and the safety hazard which   |

| is created:                                                                  |

|                                                                              |

| "Nature of Defect: An alternate resin material may have been substituted in  |

| the insulation system for Firewall III cables (chemically crosslinked cables |

| only).                                                                       |

| Potential Hazard: The chemically cured insulation system utilizing KXL 760D  |

| for cables manufactured from January 1992 thru June 1995 may not be          |

| enveloped by qualification report QR5804.                                    |

|                                                                              |

| "V.  The date on which the information of such defect or failure to comply   |

| was obtained:                                                                |

|                                                                              |

| "On the basis of our evaluation it was determined on January 14, 2003 that a |

| defect or failure to comply as defined by 10 CFR 21 existed.                 |

|                                                                              |

| "VI. The number and location of all basic components which contain a defect  |

| or falls to comply:                                                          |

|                                                                              |

| "The number and location of all basic components which may contain a defect  |

| or fail to comply is yet to be determined.                                   |

|                                                                              |

| "VII. The corrective action which has been, is being, or will be taken; the  |

| name of the individual or organization responsible for the action; and the   |

| length of time that has been or will be taken to complete the action:        |

|                                                                              |

| "Based on testing and analysis, both resin suppliers indicated that both     |

| resins were quite similar and they were not able to distinguish or identify  |

| one resin from the other. Documented evidence of their conclusion has been   |

| requested. Rockbestos-Surprenant has instituted a similarity analysis        |

| program on both resins that is expected to be completed by March 14, 2003.   |

| Preliminary test results indicate that the two resins are indistinguishable. |

| A full report will be available upon completion of the similarity analysis   |

| program.                                                                     |

|                                                                              |

| " VIII.  Any advice related to the defect or failure to comply about the     |

| basic component that has been, is being, or will be given to purchasers:     |

|                                                                              |

| "Purchasers will be advised not to install any Firewall III cables that      |

| employ the chemically cured insulation material that were manufactured from  |

| January 1992 thru June 1995 until the results of the similarity program are  |

| known. Further advice will be provided at that time."                        |

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|Power Reactor                                    |Event Number:   39513       |

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| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 01/15/2003|

|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 21:01[EST]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        01/15/2003|

+------------------------------------------------+EVENT TIME:        20:10[EST]|

| NRC NOTIFIED BY:  JOE GALLAGHER                |LAST UPDATE DATE:  01/15/2003|

|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          UNUSUAL EVENT         |DAVID HILLS          R3      |

|10 CFR SECTION:                                 |TAD MARSH            NRR     |

|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |NADER MAMISH         IRO     |

|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|BUTCH DUNDRIFF       FEMA    |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |

|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     A/R        Y       100      Power Operation  |0        Hot Standby      |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| UNUSUAL EVENT DECLARED DUE TO FIRE IN THE MAIN TRANSFORMER >15 MIN.          |

|                                                                              |

| Unusual event declared at 2025 EST due to fire in the Unit 1 main            |

| transformer caused main turbine trip, resulting in a reactor trip.  All      |

| control rods fully inserted, all reactor coolant pumps are running with      |

| offsite power available. Cause of fire is unknown at this time. Fire was out |

| at 2045 EST.  Off-site fire assistance was called but fire was out prior to  |

| their arrival.  One person transported off-site for minor injury due to      |

| fall.  Environmental issues due to transformer oil and fire suppression.     |

| Environmental personnel are on-site.  Clean-up is in progress.               |

|                                                                              |

| NRC Resident Inspector has been informed.                                    |

|                                                                              |

| ***Update 1/15/03 2238 Dan Malone to Howie Crouch***                         |

|                                                                              |

| Unusual Event terminated at 2220 EST.                                        |

|                                                                              |

| NRC Resident Inspector has been notified.  Notified R3DO (Hill), NRREO       |

| (Marsh) and FEMA.                                                            |

|                                                                              |

| ***Update 1/15/03 2339 EST Brian Bates to Howie Crouch***                    |

|                                                                              |

| "At 2010 on 1/5103, a fault occurred in the Unit 1 Main Transformer,         |

| resulting in a fire.  The fault caused an automatic main generator trip and  |

| an immediate turbine trip and reactor trip.  The fire was originally         |

| extinguished at 2035, with one minor reflash that was promptly controlled by |

| the fire brigade.  The Emergency Plan was activated at the Unusual Event     |

| level due to a fire within the protected area not being extinguished within  |

| fifteen minutes.  All applicable notifications were made for the Emergency   |

| Plan declaration, including a one-hour report to the NRC at 2100 (event      |

| notification # 39513).  There was one minor personnel injury involved which  |

| required off-site medical attention, due to an individual suffering a fall   |

| and smoke inhalation. Offsite notifications were made to the National        |

| Response Center, Michigan Emergency Alert System, and the Local Emergency    |

| Planning Commission regarding the spilled transformer oil, which is          |

| currently being cleaned up. The auxiliary feedwater system actuated due to   |

| low steam generator levels after the reactor trip, as expected. There were   |

| no significant complications in the plant response to the reactor trip, and  |

| the unit is stable in Mode 3. The Unusual Event was exited at 2220."         |

|                                                                              |

| The Licensee notified the NRC Resident Inspector of this update.             |

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|Power Reactor                                    |Event Number:   39514       |

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| FACILITY: PALISADES                REGION:  3  |NOTIFICATION DATE: 01/15/2003|

|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 22:12[EST]|

|   RXTYPE: [1] CE                               |EVENT DATE:        01/15/2003|

+------------------------------------------------+EVENT TIME:        21:15[EST]|

| NRC NOTIFIED BY:  DAVID VANDEWALLE             |LAST UPDATE DATE:  01/15/2003|

|  HQ OPS OFFICER:  JASON FLEMMING               +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |DAVID HILLS          R3      |

|10 CFR SECTION:                                 |                             |

|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|1     N          Y       100      Power Operation  |95       Power Operation  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| TECHNICAL SPECIFICATION SHUTDOWN DUE TO STEAM GENERATOR CHANNELS DECLARED    |

| INOPERABLE                                                                   |

|                                                                              |

| "On January 15, 2003 at 2115 hours a Technical Specification required        |

| shutdown was initiated in accordance with the Technical Specification 3.0.3. |

| Technical Specification 3.0.3 had been entered due to all four steam         |

| generator low-level channels in each steam generator being declared          |

| inoperable when the low-level trip setpoints were determined to be set below |

| the allowable value specified in Technical Specification 3.3.1, 'Reactor     |

| Protection System Instrumentation', and Technical Specification 3.3.3.  '    |

| Engineered Safety Features Instrumentation'."                                |

|                                                                              |

| NRC Resident Inspector has been informed.                                    |

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