United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > February 19

Event Notification Report for February 19, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           02/14/2003 - 02/19/2003



                              ** EVENT NUMBERS **



39585  39586  39587  39588  39589  39590  39591  39592  39593  39595  



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

|General Information or Other                     |Event Number:   39585       |

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

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

| REP ORG:  IOWA DEPARTMENT OF PUBLIC HEALTH     |NOTIFICATION DATE: 02/14/2003|

|LICENSEE:  UNIVERSITY OF IOWA                   |NOTIFICATION TIME: 11:22[EST]|

|    CITY:  IOWA CITY                REGION:  3  |EVENT DATE:        02/06/2003|

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

|LICENSE#:  0037-1-52-AAB         AGREEMENT:  Y  |LAST UPDATE DATE:  02/14/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |SONIA BURGESS        R3      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  GEORGE JOHNS                 |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| AGREEMENT STATE REPORT - MEDICAL EVENT                                       |

|                                                                              |

| The Iowa Department of Public Health provided the following via fax:         |

|                                                                              |

| "Here is a summary of the event that occurred a week ago:                    |

|                                                                              |

| "The University of Iowa (Iowa Radioactive Materials License No. 0037-1       |

| -52-AAB) provided a 700 Rad (7 Gy [Gray]) dose to an unintended site using a |

| Varian-TEM Ltd. Model VariSource HDR Remote Afterloader.  The planned area   |

| of treatment was a tumor in the bronchial area.                              |

|                                                                              |

| "The licensee measured and tested a catheter using the dummy source.  After  |

| the test, the catheter was placed in a box and sent for sterilization.  On   |

| February 6, 2003. the licensee used what they thought was the correct        |

| catheter during one fraction.                                                |

|                                                                              |

| "When the patient returned on February 13, 2002, for the second fraction, a  |

| medical physicist discovered that the catheter was 30 centimeters too        |

| short.                                                                       |

|                                                                              |

| "The dose was delivered to the skin in the nasal passages rather than the    |

| bronchial area.  The attending physician was present at the time the error   |

| was discovered and has been informed.  The patient has been advised of the   |

| error and given the option of discontinuing treatment.  The patient has      |

| elected to undergo treatment for the correct site.                           |

|                                                                              |

| "The cause of the error is currently under investigation and the licensee's  |

| report, which is due to IDPH by February 28, 2003, will address corrective   |

| actions."                                                                    |

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



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

|Hospital                                         |Event Number:   39586       |

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

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

| REP ORG:  DEPARTMENT OF VETERANS AFFAIRS       |NOTIFICATION DATE: 02/14/2003|

|LICENSEE:  PHILADELPHIA VA MEDICAL CENTER       |NOTIFICATION TIME: 14:32[EST]|

|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        02/03/2003|

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

|LICENSE#:  37-00062-07           AGREEMENT:  N  |LAST UPDATE DATE:  02/14/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |GLENN MEYER          R1      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  PAUL YURKO                   |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LOTH 35.3045(a)(3)       DOSE TO OTHER SITE > SP|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| POSSIBLE MEDICAL EVENT AT PHILADELPHIA VETERANS ADMINISTRATION MEDICAL       |

| CENTER                                                                       |

|                                                                              |

| Informed by a representative of the Department of Veteran's Affairs National |

| Health Physics Program (NHPP) that a possible medical event may have         |

| occurred at the Philadelphia Veterans Administration Medical Center.  The    |

| event took place on February 3, 2003 but was not determined until it was     |

| discussed on February 13, 2003.                                              |

|                                                                              |

| The procedure being performed at the time of the event was a permanent       |

| prostate seed implant brachytherapy.  The nuclide involved is I-125.  A      |

| fraction of the seeds intended to be implanted into the prostate were        |

| recovered from the bladder.  The medical authorized user (the physician      |

| prescribing and performing the procedure) rewrote the written directive in   |

| the operating room to reflect the number of seeds that were successfully     |

| implanted into the prostate.  Calculations are presently being made to       |

| determine the exposure to the bladder.  Preliminary calculations indicate    |

| that there are no deterministic effects to the patient as a result of the    |

| event.  All the seeds are presently accounted for.  There was no patient     |

| intervention. The NHPP is currently investigating the event.                 |

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



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

|General Information or Other                     |Event Number:   39587       |

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

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

| REP ORG:  STATE OF CALIFORNIA                  |NOTIFICATION DATE: 02/14/2003|

|LICENSEE:  UNIVERSITY OF CALIFORNIA AT SAN DIEGO|NOTIFICATION TIME: 16:55[EST]|

|    CITY:  SAN DIEGO                REGION:  4  |EVENT DATE:        02/13/2003|

|  COUNTY:  SAN DIEGO                 STATE:  CA |EVENT TIME:        07:30[PST]|

|LICENSE#:  1339-37               AGREEMENT:  Y  |LAST UPDATE DATE:  02/14/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |CHARLES MARSCHALL    R4      |

|                                                |PATRICIA HOLAHAN     NMSS    |

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

| NRC NOTIFIED BY:  BARBARA HAMRICK              |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| AGREEMENT STATE REPORT- UNIVERSITY OF CALIFORNIA AT SAN DIEGO SAFETY         |

| EQUIPMENT FAILS TO FUNCTION                                                  |

|                                                                              |

| The following information was obtained via e-mail from California Department |

| of Health Services, Radiological Health Branch:                              |

|                                                                              |

| "At approximately 7:30 am [PST], February 13, 2003, the University of        |

| California at San Diego (California Radioactive Materials No. 1339-37) was   |

| performing one of the monthly Quality Assurance (QA) tests on their High     |

| Dose Rate Afterloader (HDRA).  They had a treatment scheduled for later that |

| morning, and the guide tubes and extenders were already attached in          |

| preparation for the treatment.  During the typical monthly check, the        |

| licensee disconnects two of the guide tubes, and attaches the QA catheter,   |

| placing one end in the well chamber to measure the source strength, and that |

| is what occurred this time.  However, when the channel was set to run the QA |

| test, the operator inadvertently set the wrong channel, and the source was   |

| extended into one of the guide tubes, rather than through the QA catheter    |

| and into the well chamber.  When the operator tried to retract the source,   |

| it would not retract.                                                        |

|                                                                              |

| "The operator used a survey meter at the door of the treatment room to       |

| verify the source was still out, and re-confirmed that with the indication   |

| on the room monitor.  After several attempts to retract the source from the  |

| console, the operator entered the room, and placed all the guide tubes into  |

| the emergency source pig, and closed the lid.  The operator states the       |

| dose-rate in the room, with the source in the pig was reduced to             |

| approximately 3 milliR/hr at one foot from the pig.  He estimates he was     |

| within one meter of the unshielded source for no more than 5 seconds, and    |

| that his hand was within one foot of the source for approximately 3 seconds. |

| Currently, the licensee estimates the dose to the operator as under 100      |

| millirem whole body.  They have sent his dosimeter for emergency processing. |

| It is unknown at this time if he was wearing an extremity dosimeter.         |

|                                                                              |

| "After placing the guide tubes with the source in the pig, the operator left |

| the room, locked it, and contacted Nucletron Corporation to service the      |

| device.  The licensee contacted the State of California with this            |

| information at approximately 10:30 am PST on February 14, 2003.  The State   |

| of California is investigating this event, and will provide updated          |

| information as needed.  This event would be reportable to the NRC pursuant   |

| to 10 CFR 30.50(b)(2), and to the State of California under the comparable   |

| California regulation (17 CCR 30295)."                                       |

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



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

|Fuel Cycle Facility                              |Event Number:   39588       |

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

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

| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 02/15/2003|

|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 16:15[EST]|

| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        02/14/2003|

|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        19:00[CST]|

|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  02/15/2003|

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

|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |

|LICENSE#:  GDP-1                 AGREEMENT:  Y  |SONIA BURGESS        R3      |

|  DOCKET:  0707001                              |PATRICIA HOLAHAN     NMSS    |

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

| NRC NOTIFIED BY:  STEVEN SKAGGS                |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NBNL                     RESPONSE-BULLETIN      |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| CRITICALITY CONTROL 24-HOUR (BULLETIN 91-01) REPORT                          |

|                                                                              |

| The following information was obtained from the regulatee via facsimile:     |

|                                                                              |

| "At 1900 on 2-14-03, the Plant Shift Superintendent (PSS) was notified that  |

| the C-333 "E" Surge Drum, 0-25 psia pressure recorder was not working and    |

| the 0-2 pressure recorder was off-scale.  The 0-25 psia pressure recorder    |

| had failed violating the requirements of a Safety Related Item (SRI)         |

| credited in NCSE [Nuclear Criticality Safety Evaluation] 016.  As a result,  |

| the shiftly pressure checks could not be performed.  Instead of installing a |

| sample buggy to measure pressure, the drum pressure was reduced in order to  |

| read the pressure on the 0-2 [psia] pressure chart recorder.  The purpose of |

| the pressure check is to identify if wet air in-leakage has begun on the     |

| surge drum bank.                                                             |

|                                                                              |

| "Double contingency has been restored since the ability to read pressure in  |

| the surge drum bank using a properly operating AQ-NCS [Augmented Quality -   |

| Nuclear Criticality Safety] pressure instrument has been restored.           |

|                                                                              |

| "The NRC Resident Inspector has been notified of this event.                 |

|                                                                              |

| "SAFETY SIGNIFICANCE OF EVENTS:                                              |

|                                                                              |

| "Although pressure readings could not be taken due to a failed AQ-NCS        |

| pressure instrument, there are several important mitigating factors.  First, |

| the integrity of the drum bank has been maintained.  Second, the uranium has |

| been maintained in the gas phase.                                            |

|                                                                              |

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

| CRITICALITY COULD OCCUR)                                                     |

|                                                                              |

| "These drums are used to store gasses. Therefore, in order for a criticality |

| to be possible, wet air would have to react with any UF6 in the drum. The    |

| leak would have to occur over a long period, in order to create a large mass |

| of U02F2 and then sufficiently moderate the material.                        |

|                                                                              |

| "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);                                       |

|                                                                              |

| "The material in the Surge Drum is in a gaseous state. System NCS limit is   |

| 1.7 wt.% U235.                                                               |

|                                                                              |

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

| OF THE FAILURES OR DEFICIENCIES                                              |

|                                                                              |

| "The first leg of double contingency is based on maintaining the integrity   |

| of the surge drum system against wet air in leakage. This integrity is       |

| assured by a SRI for the unlikely breach of the surge drum system.           |

| Structural integrity of the drum is intact, therefore this SRI is            |

| maintained.                                                                  |

|                                                                              |

| "The second leg of double contingency is based on the performance of shiftly |

| pressure checks using an AQ-NCS instrument as an indication of wet air       |

| in-leakage. The required checks could not be performed due to a failed       |

| instrument, resulting in a loss of this control. Instead of installing a     |

| sample buggy to measure pressure, the drum pressure was reduced in order to  |

| read the pressure on the 0-2 pressure chart recorder. Since there are two    |

| controls on one parameter, double contingency was not maintained.            |

|                                                                              |

| "Even though moderation control was maintained, double contingency is based  |

| on two controls on moderation. Therefore, double contingency was not         |

| maintained.                                                                  |

|                                                                              |

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

| IMPLEMENTED:                                                                 |

|                                                                              |

| None."                                                                       |

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



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

|Power Reactor                                    |Event Number:   39589       |

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

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

| FACILITY: PALISADES                REGION:  3  |NOTIFICATION DATE: 02/16/2003|

|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 03:10[EST]|

|   RXTYPE: [1] CE                               |EVENT DATE:        02/16/2003|

+------------------------------------------------+EVENT TIME:        02:53[EST]|

| NRC NOTIFIED BY:  STAN ROGERS                  |LAST UPDATE DATE:  02/16/2003|

|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+

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

|EMERGENCY CLASS:          UNUSUAL EVENT         |Patrick Hiland       IRO     |

|10 CFR SECTION:                                 |SONIA BURGESS        R3      |

|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |JOHN ZWOLINSKI       NRR     |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

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

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| NOUE DECLARED DUE TO REDUCED PLANT SERVICE WATER FLOW                        |

|                                                                              |

| Licensee reported that service water pump intake bay level decreased         |

| requiring the shutdown of one dilution water pump to increase bay level to   |

| normal. Flow was reduced on the operating dilution water pump by throttling  |

| the discharge flow to maintain bay level at the normal operating level. The  |

| cause of the reduced service water bay level is being investigated. The      |

| licensee has notified the State of Michigan and VanBuren county. The         |

| licensee will contact the NRC Resident Inspector.                            |

|                                                                              |

| Notified FEMA of this event                                                  |

|                                                                              |

| * * * UPDATE AT 0418 EST ON 2/16/03 BY GERRY WAIG * * *                      |

|                                                                              |

| NRC entered monitoring phase of normal mode for this event at 0418 EST on    |

| 2/16/03 after decision maker brief (Jim Dyer, Geoffrey Grant, Tony Vegel,    |

| Pat Hiland, and John Zwolinski).                                             |

|                                                                              |

| * * * UPDATE AT 0825 EST ON  2/16/03 BY GERRY WAIG * * *                     |

|                                                                              |

| NRC exited monitoring phase of normal mode for this event at 0825 EST on     |

| 2/16/03 after briefing (J. Dyer/ R3 IRC members, S. Collins, J. Zwolinski,   |

| R. Zimmerman, D. Wessman, W. Kane, & P. Hiland).                             |

|                                                                              |

| * * * UPDATE AT 1600 EST ON 2/16/03 BY HOWIE CROUCH * * *                    |

|                                                                              |

| Divers are at Palisades and preparing to inspect (most likely tomorrow).     |

| The plant is stable and the bay level is stable.  The plant continues in the |

| Unusual Event.  Exit criteria will be root cause discovery.  It was noted    |

| that South Haven municipal water (near Palisades) was experiencing like      |

| symptoms.                                                                    |

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



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

|Power Reactor                                    |Event Number:   39590       |

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

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

| FACILITY: PRAIRIE ISLAND           REGION:  3  |NOTIFICATION DATE: 02/17/2003|

|    UNIT:  [1] [2] []                STATE:  MN |NOTIFICATION TIME: 13:34[EST]|

|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        02/17/2003|

+------------------------------------------------+EVENT TIME:        10:58[CST]|

| NRC NOTIFIED BY:  KEVIN JONES                  |LAST UPDATE DATE:  02/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |BRUCE BURGESS        R3      |

|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  |

|2     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| OFFSITE NOTIFICATION OF SEPTIC SYSTEM OVERFLOW                               |

|                                                                              |

| "On 2/17/03 at 1058, Xcel Energy Environmental Services completed            |

| notification to the Minnesota Pollution Control Agency (MPCA) concerning an  |

| approximately 300 gallon septic system overflow event.  The distribution     |

| system appears to be frozen due to cold weather and lack of snow cover,      |

| causing the pump discharge to flow out to grade.  Spill has been contained   |

| and cleanup completed."                                                      |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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



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

|Power Reactor                                    |Event Number:   39591       |

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

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

| FACILITY: DIABLO CANYON            REGION:  4  |NOTIFICATION DATE: 02/17/2003|

|    UNIT:  [] [2] []                 STATE:  CA |NOTIFICATION TIME: 13:57[EST]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        02/17/2003|

+------------------------------------------------+EVENT TIME:        08:30[PST]|

| NRC NOTIFIED BY:  JEFF KNISLEY                 |LAST UPDATE DATE:  02/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES MARSCHALL    R4      |

|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   |

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

|                                                   |                          |

|2     N          N       0        Refueling        |0        Refueling        |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| UNANALYZED CONDITION FOR ISOLATION CAPABILITY OF MANUAL VALVES IN  THE       |

| COMPONENT COOLING WATER SYSTEM                                               |

|                                                                              |

| "During the eleventh refueling outage on Unit 2 (2R11), component cooling    |

| water (CCW) system manual valve CCW-2-18 was found to have a damaged liner.  |

| The subject valve is used to separate the two vital normally cross-tied CCW  |

| trains in case of a CCW leak either as an independent event or as a passive  |

| failure following a loss of coolant accident. Valve CCW-2-18 would not have  |

| performed its licensing/design function of providing CCW train isolation.    |

|                                                                              |

| "The licensing/design bases for this CCW System, as discussed in table 9.2-7 |

| of the FSAR and in SSER 16, is for a maximum 200 gpm leak to occur. Leakage  |

| would be detected by falling level in the CCW surge tank. Because of the     |

| remaining 4000 gallons in the CCW surge tank after receipt of the low-level  |

| alarm, there would be at least 20 minutes for the operator to isolate the    |

| leak before the surge tank is empty. The period is extended if the           |

| automatically operated, Design Class II, normal makeup path functions as     |

| designed and adds makeup water to the system. PG&E's abnormal operating      |

| procedure, OP AP-11, has provision for aligning a 250 gpm Class I supply of  |

| water to the CCW surge tank.                                                 |

|                                                                              |

| "The design/licensing basis of a 200 gpm leak being isolated in 20 minutes   |

| assumes that manual valves used during the isolation operation hold and      |

| terminate the leak. There is no evidence that PG&E nor the NRC have          |

| considered that a leak would not be isolated upon completion of actions to   |

| separate the trains. The identified condition, though not believed to        |

| represent a safety concern, is different than that discussed in SSER 16.     |

| Therefore, the condition is considered to be outside the design basis for    |

| the plant."                                                                  |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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



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

|Power Reactor                                    |Event Number:   39592       |

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

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

| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 02/17/2003|

|    UNIT:  [1] [] []                 STATE:  FL |NOTIFICATION TIME: 15:29[EST]|

|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        02/17/2003|

+------------------------------------------------+EVENT TIME:        14:13[EST]|

| NRC NOTIFIED BY:  JOE HESSLING                 |LAST UPDATE DATE:  02/17/2003|

|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK LESSER          R2      |

|10 CFR SECTION:                                 |                             |

|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     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| 8-HOUR NON-EMERGENCY NOTIFICATION DUE AUTOMATIC START AND LOAD OF THE 1B     |

| EMERGENCY DIESEL GENERATOR                                                   |

|                                                                              |

| The following information was obtained from the licensee via facsimile:      |

|                                                                              |

| "While performing maintenance activities to replace a failed undervoltage    |

| relay on 1B3 4160 VAC bus, the undervoltage protection triggered a load shed |

| on the 1B3 4160 VAC bus causing a loss of power to the bus and automatic     |

| start and load of the 1B Emergency Diesel Generator.  Although the potential |

| for this event was previously briefed for the relay replacement, this event  |

| is being reported under 10CFR50.72(b)(3)(iv)(A)."                            |

|                                                                              |

| The  load shed caused a loss of the 1B motor-generator (MG) set but both MG  |

| sets are 100%  capacity sets. There were no adverse consequences due to the  |

| trip of the 1B MG set.                                                       |

|                                                                              |

| The licensee has informed the NRC Resident Inspector.                        |

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



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

|General Information or Other                     |Event Number:   39593       |

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

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

| REP ORG:  CARBOLINE COMPANY                    |NOTIFICATION DATE: 02/17/2003|

|LICENSEE:  CARBOLINE COMPANY                    |NOTIFICATION TIME: 16:44[EST]|

|    CITY:  BRENTWOOD                REGION:  3  |EVENT DATE:        02/17/2003|

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

|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  02/17/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |JOHN ZWOLINSKI       NRR     |

|                                                |CHARLES MARSCHALL    R4      |

+------------------------------------------------+SONIA BURGESS        R3      |

| NRC NOTIFIED BY:  MARIKAY SPECHERT             |MARK LESSER          R2      |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |GLENN MEYER          R1      |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| 10 CFR PART 21 NOTIFICATION - CARBOLINE COMPANY                              |

|                                                                              |

| The following information was obtained from the vendor via facsimile:        |

|                                                                              |

| "This letter serves to notify the Commission of a potential safety related   |

| noncompliance deviation in a basic component as defined in 10CFR Part 21.    |

| The noncompliance involves hard settling of Carboguard 890 Part B; the       |

| affected batches are 2A9266L, 2A9275L, and 2H9352L                           |

|                                                                              |

| "The hard settling of Carboguard 890 Part B would result in a mixed product  |

| that would have lower pigment volume concentration (PVC) than standard       |

| material that has been uniformly dispersed. Potential deficiencies would be  |

| a lack of film build during application as a result of a lower initial       |

| viscosity and the fact that some particles from the hard settling may have   |

| been dispersed into the mixed product. These particles could result in the   |

| clogging of spray gun tips or having particles embedded into the applied     |

| coating, which are aesthetically unpleasing. Overall the lack of pigment in  |

| the coating film affects the application and aesthetic properties of the     |

| coating and not the performance properties. The primary criteria for the     |

| epoxy coating's performance are that the stoichiometry of epoxy resin to     |

| amine curing agent are not changed by more than 10%. Based upon a prior      |

| non-nuclear occurrence we know that the hard settling does not alter the     |

| stoichiometry of the coating and the cure of the product will be within the  |

| parameters designed by the formulating chemist. Based upon prior testing of  |

| numerous coatings for use in nuclear power plants we have not seen any       |

| detrimental performance when lower PVC coatings were evaluated. Resin rich   |

| coatings are typically gloss coatings and they aid in radiation              |

| decontamination and chemical resistance. As such, Carboline does not feel    |

| that the performance of the coating will be adversely affected.              |

|                                                                              |

| "A database has been created documenting all shipments of the affected       |

| batches made within the 2002 calendar year to present; approximately 30      |

| utilities/customers are affected. All customers who our records indicate     |

| have been shipped batches 2A9266L, 2A9275L, and 2H9352L shall be notified    |

| promptly. We are requesting that customers review their stock of Carboguard  |

| 890 Part B and return the affected batches for replacement.                  |

|                                                                              |

| "In summary, Carboline has taken appropriate corrective action, notified the |

| NRC, and shall notify all customers promptly."                               |

|                                                                              |

| The affected parties are as follows:                                         |

| Consumers Energy - Palisades Generating Plant                                |

| Energy Steel & Supply - 2715 Padan Street, Auburn Hills, MI                  |

| Florida Power & Light - 9760 SW 344th St., Florida City, FL                  |

| Hutchinson & Gunter - 715 Grpve Street, Greensburg, PA                       |

| Imaging & Sensing Technology - IST Conax Nuclear, Inc., Buffalo, NY          |

| Newbury Sandblasting - PO Box 378, Newbury, OH                               |

| Nullifire Ltd. - Torrington Avenue, Coventry, UK                             |

| Point Beach Nuclear - 6610 Nuclear Road, Two Rivers, WI                      |

| Prairie Island - Welch, MN                                                   |

| Ameren/UE-CIPS - Callaway Plant                                              |

| Duke Energy Corp - Nuclear Assessment Division, SC                           |

| Ellis & Watts - 4325 Slick Lane, Bativa, OH                                  |

| FirstEnergy, Davis-Besse Oak Harbor, OH                                      |

| Howden Buffalo - New Philadelphia, OH                                        |

| Omaha Public Power - Fort Calhoun Nuclear Station                            |

| Palmer Industrial Coatings - Williamsport, PA                                |

| Rotork Controls - Rochester, NY                                              |

| TXU Electric - Glen Rose, TX                                                 |

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



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

|Power Reactor                                    |Event Number:   39595       |

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

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

| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 02/18/2003|

|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 12:40[EST]|

|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        02/18/2003|

+------------------------------------------------+EVENT TIME:        12:00[EST]|

| NRC NOTIFIED BY:  CHARLES PIKE                 |LAST UPDATE DATE:  02/18/2003|

|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES R. OGLE      R2      |

|10 CFR SECTION:                                 |ROBERTA WARREN       IAT     |

|DDDD 73.71(b)(1)         SAFEGUARDS REPORTS     |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

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

|2     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| 1- HOUR SAFEGUARDS REPORT                                                    |

|                                                                              |

| Unescorted access granted to contract employee inappropriately.  Immediate   |

| compensatory measures taken upon discovery.  Contact Headquarters Operations |

| Officer for details.                                                         |

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