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Event Notification Report for February 20, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           02/19/2003 - 02/20/2003



                              ** EVENT NUMBERS **



39585  39587  39589  39596   



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|General Information or Other                     |Event Number:   39585       |

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| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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."                                                                    |

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|General Information or Other                     |Event Number:   39587       |

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| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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)."                                       |

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|Power Reactor                                    |Event Number:   39589       |

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| 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:  02/19/2003|

|  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  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| 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.                                                                    |

|                                                                              |

| * * * UPDATE AT 1301 EST ON 2/19/03 BY HOWIE CROUCH * * *                    |

|                                                                              |

| The licensee has terminated the NOUE declared on 2/16/03.  The licensee has  |

| restored full capability to provide make-up water to the plant's service     |

| water intake (ultimate heat sink).  The NRC Resident Inspector has been      |

| notified by the licensee. Headquarters Operations Officer notified R3DO      |

| (Miller), NRR EO (Zwolinski), FEMA and DIRO (Hiland).                        |

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|Power Reactor                                    |Event Number:   39596       |

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| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 02/19/2003|

|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 15:43[EST]|

|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        02/13/2003|

+------------------------------------------------+EVENT TIME:        09:54[CST]|

| NRC NOTIFIED BY:  JAMES CUNNINGHAM             |LAST UPDATE DATE:  02/19/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |KRISS KENNEDY        R4      |

|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 DUE TO SERIOUS PHYSICAL INJURY AT AMEREN UE CALLAWAY    |

| PLANT                                                                        |

|                                                                              |

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

|                                                                              |

| "At 0954 [CST] on February 13, 2003, the Control Room was notified of a      |

| personnel injury in the Turbine building. After examination by the site      |

| doctor, the individual was transported off site for treatment. Subsequently, |

| on February 18, 2003, the individual was admitted to the hospital for        |

| further treatment.                                                           |

|                                                                              |

| Preliminary investigation indicates that the individual was struck in the    |

| face with a flying object. The individual was using a filter change out tool |

| and attempting to disconnect a 2" Camflex plug. The line was apparently      |

| pressurized resulting in ejection of the plug toward the individual's face   |

| when it was disconnected.                                                    |

|                                                                              |

| The Missouri Public Service Commission was notified at 2:02 pm CST on        |

| February 19,2003 of the serious injury.                                      |

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