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Event Notification Report for January 29, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           01/28/2003 - 01/29/2003



                              ** EVENT NUMBERS **



39533  39534  39541  39542  39543  39544  



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|General Information or Other                     |Event Number:   39533       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 01/24/2003|

|LICENSEE:  GILES ENGINEERING ASSOCIATES         |NOTIFICATION TIME: 14:50[EST]|

|    CITY:  DALLAS                   REGION:  4  |EVENT DATE:        01/23/2003|

|  COUNTY:                            STATE:  TX |EVENT TIME:             [CST]|

|LICENSE#:  L04919                AGREEMENT:  Y  |LAST UPDATE DATE:  01/24/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |GREG PICK            R4      |

|                                                |JOHN DAVIDSON        IAT     |

+------------------------------------------------+SUSAN FRANT          NMSS    |

| NRC NOTIFIED BY:  HELEN WATKINS                |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE               |

|                                                                              |

| The following information was received from the Texas Department of Health,  |

| Bureau of Radiation Control (Texas incident I-7973):                         |

|                                                                              |

| "The nuclear gauge was stolen last night. (January 23-24, 2003).  It was     |

| stolen from an Econoline van parked overnight at an apartment complex. The   |

| gauge was locked inside its case and was inside a storage compartment in the |

| cargo area of the locked van. Access was gained by breaking out the windows  |

| of the van.                                                                  |

|                                                                              |

| "The gauge operator [DELETED] is uncertain of the exact time of the theft.   |

| He went out to dinner in his private vehicle and did not notice any problem  |

| with the van when he returned home at approximately 8 o'clock in the         |

| evening.  However, when he stepped outside at 4:30 am to warm up his wife's  |

| car, he noticed the Duncanville [Texas] police were on the scene. Three vans |

| parked within about 150 feet of each other, including his, had been          |

| burglarized in a similar fashion. One van belonged to an air conditioning    |

| company.                                                                     |

|                                                                              |

| "The thief took many other items from the van including concrete testing     |

| equipment, a coat, measuring tape and a couple of buckets of tools. The      |

| gauge and its case were taken. The case is clearly labeled with the          |

| company's name and phone number. Inside the case is a full set of paperwork  |

| identifying the gauge, a current leak test, and other documents containing   |

| the company's letterhead. The police report number is 03000589. The RSO      |

| notified Troxler in Arlington [Texas] of the theft."                         |

|                                                                              |

| The gauge is a Troxler Model # 3430, Serial # 031693, 40 millicuries         |

| Am-241/Be, 8 millicuries Cs-137.                                             |

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|General Information or Other                     |Event Number:   39534       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 01/24/2003|

|LICENSEE:  PROFESSIONAL SERVICES INDUSTRIES, INC|NOTIFICATION TIME: 17:53[EST]|

|    CITY:  CLUTE                    REGION:  4  |EVENT DATE:        11/25/2002|

|  COUNTY:                            STATE:  TX |EVENT TIME:             [CST]|

|LICENSE#:  L00203-001            AGREEMENT:  Y  |LAST UPDATE DATE:  01/24/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |GREG PICK            R4      |

|                                                |JOHN HICKEY          NMSS    |

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

| NRC NOTIFIED BY:  HELEN WATKINS                |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - DOSIMETRY LEFT IN RADIOGRAPHY AREA                  |

|                                                                              |

| The following information was received from the Texas Department of Health,  |

| Bureau of Radiation Control (Texas incident I-7972):                         |

|                                                                              |

| "During the monitoring period 11/25/2002 through 12/24/2002, radiographer    |

| [deleted] left his badge in an area where it was exposed by a radiography    |

| crew performing concrete rebar radiography with long exposure times.         |

| [deleted] phoned the licensee's corporate offices on January 23, 2003 to     |

| report a badge overexposure.   At the current time it is thought that the    |

| radiographer reported the incident to his supervisor [deleted] RSO in the    |

| Clute [TX] Office.  The date and time of that report is currently unknown.   |

| His badge exposure was measured at 8.266 Rem.  A final report has not been   |

| received from the badge processor by the Licensee's corporate office, only a |

| Fax transmittal.  The corporate office indicated the incident was not        |

| previously reported to the corporate office or they would have had the badge |

| submitted for emergency reading."                                            |

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|Power Reactor                                    |Event Number:   39541       |

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| FACILITY: SEABROOK                 REGION:  1  |NOTIFICATION DATE: 01/28/2003|

|    UNIT:  [1] [] []                 STATE:  NH |NOTIFICATION TIME: 10:05[EST]|

|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        01/28/2003|

+------------------------------------------------+EVENT TIME:        09:20[EST]|

| NRC NOTIFIED BY:  RON STRICKLAND               |LAST UPDATE DATE:  01/28/2003|

|  HQ OPS OFFICER:  ARLON COSTA                  +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |DANIEL HOLODY        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  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| OFFSITE NOTIFICATION                                                         |

|                                                                              |

| "A fake news article was created on the internet.  This fake article appears |

| to be a CNN report that claimed Seabrook is under intense FBI investigation  |

| for dumping several radioactive uranium cores.                               |

|                                                                              |

| "The [NRC] resident inspector was notified at 09:20, and the shift manager   |

| was notified shortly after.  NRC would like to be notified if a press        |

| release will be [issued by Seabrook].                                        |

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|Power Reactor                                    |Event Number:   39542       |

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| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 01/28/2003|

|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 11:39[EST]|

|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        01/28/2003|

+------------------------------------------------+EVENT TIME:        09:30[EST]|

| NRC NOTIFIED BY:  DON ROLAND                   |LAST UPDATE DATE:  01/28/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |DAN HOLODY           R1      |

|10 CFR SECTION:                                 |                             |

|HFIT 26.73               FITNESS FOR DUTY       |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|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  |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| PRE-ACCESS CONTRACT SUPERVISOR ACCESS TERMINATED DUE TO A CONFIRMED POSITIVE |

| TEST                                                                         |

| FOR A CONTROLLED SUBSTANCE.                                                  |

|                                                                              |

| At 09:30 on 01/28/03, a contract supervisor for the turbine upgrade project  |

| had a confirmed positive for a controlled substance during a pre-access      |

| fitness for duty test.  The supervisor's access to the station has been      |

| suspended in accordance with the station's fitness for duty program.         |

|                                                                              |

| The NRC Resident Inspector was notified of this event by the licensee.       |

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|Hospital                                         |Event Number:   39543       |

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| REP ORG:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION DATE: 01/28/2003|

|LICENSEE:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION TIME: 17:27[EST]|

|    CITY:  ROYAL OAKS               REGION:  3  |EVENT DATE:        01/28/2003|

|  COUNTY:                            STATE:  MI |EVENT TIME:        10:30[EST]|

|LICENSE#:  21-01333-01           AGREEMENT:  N  |LAST UPDATE DATE:  01/28/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |MARK RING            R3      |

|                                                |M. WAYNE HODGES      NMSS    |

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

| NRC NOTIFIED BY:  CHERYL SCHULTZ               |                             |

|  HQ OPS OFFICER:  GERRY WAIG                   |                             |

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

|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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| MEDICAL MISADMINISTRATION - RADIATION DOSE EXCEEDED PLANNED DOSE             |

|                                                                              |

| The following is taken from a facsimile sent from the licensee:              |

|                                                                              |

| A patient with and injury in the right coronary artery was to be treated     |

| with Novoste Sr-90 40 mm [millimeter] 3.5 Fr [French] device for 4 minutes   |

| 31 seconds each for a pullback procedure. The radiation oncologist had       |

| difficulty with the device and had to perform an emergency bail-out. We      |

| later confirmed that the sources were stuck either inside or just slightly   |

| outside the device, so there was no dose to the patient. The decision was    |

| made to proceed with the treatment with the Novoste Sr-90 40 mm 5 Fr device. |

| The radiation oncologist scrubbed and primed the catheter with the dummy     |

| device. The change in the treatment device and new treatment time of 3       |

| minutes 41 seconds was noted on the QM form. The revised treatment time,     |

| however, was not entered into the stopwatch. Only the physicist verified the |

| time on the stopwatch and because of the similarities in the timing units (4 |

| m 31 s versus 3 m 41 s),did not catch the error in time on the stopwatch.    |

| At the end of the treatment the physicist noted that the timer had not been  |

| reset for the 5 Fr device. During the 50 extra seconds of treatment time the |

| patient received a dose of 28.2 Gy [Gray] rather than the prescribed dose of |

| 23 Gy (22.6% more than the prescribed dose). The patient was informed of the |

| error by the radiation oncologist and cardiologist later the same day. No    |

| adverse effect is expected for the patient                                   |

|                                                                              |

| "Some of the corrective actions under review include:                        |

| 1. Improve the double-checking process prior to the start of the treatment.  |

| Usually the radiation oncologist double checks the treatment time, but in    |

| this case he was scrubbed and could not fully confirm the change in the      |

| treatment time on the QM form. Also the clinical coordinator who double      |

| checks the time programmed into the stopwatch and handles the back-up timer, |

| was not available during this case,                                          |

| 2. The emergency bail out procedure disrupted the normal flow of the         |

| treatment. The team needs to be very aware of the greater vulnerability to   |

| error whenever emergency procedures are involved.                            |

| 3. Scheduling issues may need to be addressed.                               |

| 4. Additional training issues may need to be addressed."                     |

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|Fuel Cycle Facility                              |Event Number:   39544       |

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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 01/28/2003|

|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 22:57[EST]|

| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        01/28/2003|

|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:30[CST]|

|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  01/28/2003|

|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+

|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |

|LICENSE#:  GDP-1                 AGREEMENT:  Y  |MARK RING            R3      |

|  DOCKET:  0707001                              |FRED BROWN           NMSS    |

+------------------------------------------------+KEN RIEMER           R3      |

| NRC NOTIFIED BY:  TOM WHITE                    |                             |

|  HQ OPS OFFICER:  GERRY WAIG                   |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NBNL                     RESPONSE-BULLETIN      |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| NRC BULLETIN 91-01 24 HOUR NOTIFICATION - PADUCAH GDP                        |

|                                                                              |

|                                                                              |

| "At 1530 On 1-28-03, the Plant Shift Superintendent (PSS) was notified that  |

| the condenser pressure on Unit 4 Cell 9 in C-335 was not monitored at the    |

| require[d] frequency. When the condenser return valve will be closed and the |

| supply spool piece will remain in place, the condenser supply pressure must  |

| be maintained at 20 psig or less to ensure that less than 10Kg of water can  |

| enter the process gas system. In order to ensure the pressure Is maintained  |

| below the maximum allowable pressures a gauge is installed arid monitored at |

| a frequency of once every 8 hours for Unit 4 Cell 9 in C-335. The gauge was  |

| installed and first read at 2245 on 1-27-03. The next reading was taken at   |

| 0950 on 1-28-03. This period exceeded the 8 hours allowed. The NRC Resident  |

| Inspector has been notified of this event.                                   |

|                                                                              |

| "SAFETY SIGNIFICANCE OF EVENTS:                                              |

|                                                                              |

| "The pressure reading frequency was violate, however,  the RCW [Recirc       |

| Cooling Water] pressure limit was not exceeded. Although  a control relied   |

| upon for double contingency was violated.                                    |

|                                                                              |

| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW           |

| CRITICALITY COULD OCCUR                                                      |

|                                                                              |

| "In order for  criticality to be possible, there must be a large condenser   |

| leak at the same time as a high RCW pressure. In addition, the high RCW      |

| pressure condition would have to go unnoticed and uncorrected beyond the     |

| specified time limits.                                                       |

|                                                                              |

| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC       |

|                                                                              |

| "Double contingency is maintained by implementation of two controls on       |

| moderation.                                                                  |

|                                                                              |

| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS    |

| LIMIT AND WORST CASE CRITICAL MASS):                                         |

|                                                                              |

| "No known mass of licensed material exists in the condenser. System NCS      |

| limit is [deleted] wt.% U235.                                                |

|                                                                              |

| "NUCLEAR CRITICALITY SAFETY CONTROLS) OR CONTROL SYSTEMS(S) AND DESCRIPTION  |

| OF THE FAILURES OR DEFICITS                                                  |

|                                                                              |

| "The first leg of double contingency is based on the ability to identify a   |

| pressure exceedance of the RCW condenser pressure limit within 8 hours. RCW  |

| pressure readings are monitored at a frequency at 1/2 the time it would take |

| for an unsafe mass of moderator to leak into the process gas side. The RCW   |

| condenser pressure reading was obtained after the 8 hour time limit.         |

| Therefore, this leg of double contingency was lost.                          |

|                                                                              |

| "The second leg of double contingency is based on the ability to check the   |

| pressure reading within 16 hours and to take corrective actions within 23    |

| hours. The pressure was checked within 16 hours and was not In excess of the |

| limit. Since the pressure limit was not exceeded, this leg of double         |

| contingency was maintained.                                                  |

|                                                                              |

| "Since the first leg was lost, the double contingency principle was          |

| violated.                                                                    |

|                                                                              |

| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS              |

| IMPLEMENTED:                                                                 |

|                                                                              |

| "At the time of discovery, the appropriate frequency of monitoring was       |

| identified and initiated."                                                   |

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