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Event Notification Report for January 17, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           01/16/2003 - 01/17/2003



                              ** EVENT NUMBERS **



39508  39510  39515  39516  



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|General Information or Other                     |Event Number:   39508       |

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| REP ORG:  OK DEQ RAD MANAGEMENT                |NOTIFICATION DATE: 01/14/2003|

|LICENSEE:  ST FRANCIS HOSPITAL                  |NOTIFICATION TIME: 15:02[EST]|

|    CITY:  TULSA                    REGION:  4  |EVENT DATE:        01/13/2003|

|  COUNTY:                            STATE:  OK |EVENT TIME:        19:30[CST]|

|LICENSE#:  OK-07163-01           AGREEMENT:  Y  |LAST UPDATE DATE:  01/15/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |GARY SANBORN         R4      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  MIKE BRODRIECK               |                             |

|  HQ OPS OFFICER:  JASON FLEMMING               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT INVOLVING LOST SOURCES                                |

|                                                                              |

| The Licensee report the loss of five .355 microcurie, I-125 brachytherapy    |

| seeds.  The seeds were model # IAI-125A and they were inventoried upon       |

| receipt from the manufacture, Iso-Aid.  The seeds were being washed prior to |

| sterilization (this is a deviation from procedure) and the Licensee believes |

| they were washed down the drain to the public sewer system.  The Licensee    |

| reports that surveys do not indicate that they are in the sink or trap.      |

|                                                                              |

| ***UPDATE 01/15/03 1202 EST MIKE BRODRIECK TO MIKE NORRIS***                 |

|                                                                              |

| The seeds are actually .355 millicurie sources.  Notified NMSS (Brown) and   |

| R4DO (Sanborn).                                                              |

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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:  01/16/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |RICHARD BARKLEY      R1      |

|                                                |                             |

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

| NRC NOTIFIED BY:  DR. LEONARD SHABASON         |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LEXC 35.3045(a)(2)       DOSE > SPECIFIED EFF LI|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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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.                          |

|                                                                              |

| * * * UPDATE ON 1/16/03 AT 1123 BY SHABASONS TO GOULD * * *                  |

|                                                                              |

| The licensee originally reported this event under 10 CFR 35.3045(a)(1) and   |

| called to change it to 10 CFR 35.3045(a)(2).  The licensee estimates that    |

| the thyroid dose is <5 Rem.                                                  |

|                                                                              |

| The NRC Headquarters Operations Officer notified the R1DO (Richard Barkley)  |

| of this update.                                                              |

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|Power Reactor                                    |Event Number:   39515       |

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| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 01/16/2003|

|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 17:13[EST]|

|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        01/16/2003|

+------------------------------------------------+EVENT TIME:        16:40[EST]|

| NRC NOTIFIED BY:  RALPH YOUNG                  |LAST UPDATE DATE:  01/16/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD BARKLEY      R1      |

|10 CFR SECTION:                                 |                             |

|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|                                                   |                          |

|3     N          Y       100      Power Operation  |100      Power Operation  |

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                                   EVENT TEXT                                   

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| UNANALYZED CONDITION AT MILLSTONE 3                                          |

|                                                                              |

| "This report is being submitted to report an unanalyzed condition that could |

| significantly degrade plant safety in accordance with                        |

| 10CFR50.72(b)(3)(ii)(B). As the result of an engineering analysis, it was    |

| determined that the fire safe shutdown strategy may not be adequate to       |

| ensure that the plant can achieve and maintain safe shutdown for certain     |

| fire scenarios.                                                              |

|                                                                              |

| "On January 16, 2003, with Millstone Unit 3 in Mode 1 at 100% power, and as  |

| a result of transient analysis of certain fire shutdown scenarios, it was    |

| determined that postulated extended loss of all seal cooling events have the |

| potential for over-pressurization of the Reactor Coolant Pump (RCP) No.1     |

| seal leak-off line. The RCP No. 1 seal return line is designed to recover    |

| low pressure and temperature leak-off volume and return it to the volume     |

| control tank or charging pump suction. In response to a Cable Spreading      |

| Area, Control Room, or Instrument Rack Room fire, operation could be         |

| impacted because Emergency Operating Procedures (EOPs) may not adequately    |

| mitigate the scenario where a loss of all RCP seal cooling results in        |

| increased RCP seal leakage. This increased seal leakage assumption causes    |

| above normal pressure and temperature fluid conditions within the No. 1 seal |

| return line. The over-pressurization that may occur could challenge the seal |

| leak-off line structural integrity and a pressure boundary failure is        |

| considered possible. Per BTP 9.5-1, the credited injection pathway needs to  |

| be sufficient to preclude draining of the pressurizer below the indicating   |

| range. Because this condition would significantly complicate shutdown in the |

| event of fire in these areas, this condition is being reported as an         |

| unanalyzed condition that significantly degrades plant safety, pursuant to   |

| 10 CFR 50.72 (b)(3)(ii)(B).                                                  |

|                                                                              |

| "This condition assumes a fire of sufficient magnitude to cause a loss of    |

| all AC power which results in an extended loss of all seal cooling. This is  |

| considered to be a low probability event.                                    |

|                                                                              |

| "Compensatory measures are in place and include continuous fire watches in   |

| the Cable Spreading Area and the Instrument Rack Room. The continuous fire   |

| watch in the Control Room is satisfied by the presence of the Control Room   |

| staff. Additional fire extinguishers in impacted areas are in place.         |

| Administrative control requiring prior Shift Manager approval have been      |

| implemented to set limits on ignition source permits, use of transient       |

| combustibles, and use of flammable liquids within the impacted areas.        |

| Compensatory measures will remain until needed EOP revisions, plant          |

| modifications, or further analysis are made to address this condition. This  |

| condition remains under evaluation in accordance with the Millstone          |

| Corrective Action Program."                                                  |

|                                                                              |

| The Licensee has informed the NRC Resident of this event.                    |

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|General Information or Other                     |Event Number:   39516       |

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| REP ORG:  SCIENTECH                            |NOTIFICATION DATE: 01/16/2003|

|LICENSEE:                                       |NOTIFICATION TIME: 21:52[EST]|

|    CITY:  IDAHO FALLS              REGION:  4  |EVENT DATE:        01/15/2003|

|  COUNTY:                            STATE:  ID |EVENT TIME:             [MST]|

|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  01/16/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |RICHARD BARKLEY      R1      |

|                                                |JAY HENSON           R2      |

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

| NRC NOTIFIED BY:  MARTIN BOOSKA                |TAD MARSH            NRR     |

|  HQ OPS OFFICER:  GERRY WAIG                   |JACK FOSTER  via fax NRR     |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 10 CFR 21.21 POTENTIAL DEFECTIVE COMPONENTS                                  |

|                                                                              |

| The following is taken from a facsimile received from Scientech, Inc.:       |

|                                                                              |

| "SCIENTECH, Inc.'s subsidiary, NUS Instruments, Inc. (NUSI) has determined   |

| that Basic Components, supplied in two CMM 900 Modules to                    |

| Entergy-Fitzpatrick (P.O. #4500510231) and one CMM900 module to              |

| Constellation-Nine Mile Point (P.O. #00-31440) contain a defect that is      |

| reportable under 10CFR21. Additionally, NUSI has determined that other       |

| clients (see attached list) have been supplied assemblies containing         |

| components that may contain similar defects. NUSI is currently in the        |

| process of determining all affected model numbers and serial numbers.        |

|                                                                              |

| "NUSI determined that this potential defect was reportable on January 9,     |

| 2003 and the SCIENTECH, Inc. President was informed January 15, 2003. All    |

| potentially affected clients are being notified concurrently with this       |

| notification.                                                                |

|                                                                              |

| "The defective component, OPA2111KP, was manufactured by Burr-Brown (aka TI  |

| or Texas Instruments-Tucson) and installed by NUSI in assemblies shipped to  |

| one or more of the clients identified in the attached client list. At this   |

| time only assemblies containing the OPA2111KP component have failed, as      |

| reported by Entergy-Fitzpatrick and Constellation-Nine Mile Point. NUSI has  |

| opened a 10CFR21 file concerning these components and has numbered it as     |

| 21-03-01.                                                                    |

|                                                                              |

| "TI has identified three additional part numbers (OPA111, 0PA404, and 3656)  |

| that NUSI currently uses that were manufactured by Tl utilizing the same     |

| process that was used for the manufacture of the defective OPA2111KP         |

| component; these other part numbers will require further evaluation.         |

|                                                                              |

| "A formal written report will be provided within 30 days of this             |

| notification."                                                               |

|                                                                              |

| Potentially affected plants include:                                         |

|                                                                              |

| Region 1: Nine Mile Point, Millstone, Fitzpatrick, IP2 &3, Beaver Valley,    |

| Salem/Hope Creek (PSE&G), Ginna, Pilgrim.                                    |

| Region 2: Brunswick, Robinson, Harris, Crystal River 3.                      |

| Region 3: Kewaunee                                                           |

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