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Event Notification Report for March 19, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           03/18/2003 - 03/19/2003



                              ** EVENT NUMBERS **



39666  39671  39676  39677  39678  





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|General Information or Other                     |Event Number:   39666       |

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| REP ORG:  NEW MEXICO RAD CONTROL PROGRAM       |NOTIFICATION DATE: 03/13/2003|

|LICENSEE:  CARDINAL HEALTH                      |NOTIFICATION TIME: 15:00[EST]|

|    CITY:  ALBUQUERQUE              REGION:  4  |EVENT DATE:        03/03/2003|

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

|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  03/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |MARK SHAFFER         R4      |

|                                                |THOMAS ESSIG         NMSS    |

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

| NRC NOTIFIED BY:  BILL FLOYD                   |                             |

|  HQ OPS OFFICER:  RICH LAURA                   |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| NEW MEXICO AGREEMENT STATE REPORT ON LOST SOURCE                             |

|                                                                              |

| "On March 3, 2003, Cardinal Health in Albuquerque shipped out an ammo-can,   |

| via Federal Express Overnight, containing 1.251 Giga-Becquerel of I-131 in   |

| an inorganic salt, solid state to the Cardinal Health facility in Amarillo,  |

| TX. for delivery on 03/04/03. The Amarillo facility called on Tuesday,       |

| 03/04/03, to state they never received it. [DELETED ] placed a call with     |

| Federal Express immediately to trace the package. She continued to place     |

| calls with Federal Express on 03/05/03 and 03/06/03 to check on the status   |

| of the package. On each occasion, Federal Express stated they had yet to     |

| locate the package. On Friday 03/07/03 I called [DELETED ] at our Quality    |

| and Regulatory Dept. to notify them of the missing package. He, in turn,     |

| placed a call with the New Mexico Environment Dept. On Monday, 03/10/03, I   |

| called Federal Express and spoke with [DELETED ] of the Amarillo office. She |

| stated that they had done a thorough search of the Amarillo office and could |

| not find the package. She also stated that there was to be a search of the   |

| Memphis location and that they would hopefully know something by Tuesday     |

| 03/11/03. I notified [DELETED ] of my conversation with Federal Express. We  |

| did not hear anything from FedEx on Tuesday. On Wednesday 03/12/03, I called |

| FedEx again and spoke with a representative by the name of [DELETED]. She    |

| confirmed that the package had still not been located. I then contacted      |

| [DELETED ] again to report the information. I also left a message with the   |

| New Mexico Environment Dept. regarding the current state of the matter. We   |

| will continue to monitor the situation. The tracking number for the package  |

| is [DELETED]."                                                               |

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|General Information or Other                     |Event Number:   39671       |

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| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 03/14/2003|

|LICENSEE:  COOK COUNTY HOSPITAL                 |NOTIFICATION TIME: 17:13[EST]|

|    CITY:  CHICAGO                  REGION:  3  |EVENT DATE:        03/14/2003|

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

|LICENSE#:  IL-01768-01           AGREEMENT:  Y  |LAST UPDATE DATE:  03/14/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |KENNETH O'BRIEN      R3      |

|                                                |THOMAS ESSIG         NMSS    |

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

| NRC NOTIFIED BY:  JILL CLINGER                 |                             |

|  HQ OPS OFFICER:  RICH LAURA                   |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| ILLINOIS AGREEMENT STATE REPORT ON LOST SOURCE                               |

|                                                                              |

| "On March 13, 2003 the RSO of Cook County Hospital called the Illinois       |

| Northern Regional office to report that an Sr-90 eye applicator source was   |

| missing from its storage location along with some exempt quantity            |

| calibration and reference sources and some associated records. A thorough    |

| survey of the facility had been conducted the previous two days with no      |

| success. This hospital is going through the process of relocating to new     |

| facilities immediately adjacent to the existing site. At first it was        |

| thought that these sources had been moved with other brachytherapy sources   |

| and had been merely overlooked in the transition. Further inspection showed  |

| that was not the case. Apparently the source has been mistakenly removed     |

| during efforts to clean and prepare the area for occupancy by another        |

| hospital department. This probably occurred at the end of January 2003 based |

| on interviews with several associated individuals. The room where the source |

| cabinet had been stored had been cleaned and its contents sent for disposal  |

| or relocation to the new oncology department on January 30 and 31. The       |

| Department sent an inspector to the facility the next morning, 14 March, to  |

| conduct interviews, perform monitoring, verify the extent of the search      |

| efforts undertaken to this point and make an independent evaluation of the   |

| reported fate of the device. Surveys of several areas with a variety of      |

| appropriate rate meters and probes including old and new storage locations,  |

| oncology departments, shipping and receiving docks, waste handling locations |

| and nuclear medicine departments were unsuccessful in recovery of the        |

| applicator. Interviews with the RSO, facility medical director, radiation    |

| oncologist, supervisory radiation technician and individuals who performed   |

| the clean out work do not provide any additional information as to the fate  |

| of the source as all state that they did not remove the source from its      |

| storage cabinet. The source was initially 35 milliCuries in 1955 and has     |

| since decayed to approximately 11 millicuries to date. The source does not   |

| appear in the NRC SSDR due to its age. The manufacturer is listed as         |

| TRAUSLAT with model number RA-1 and a serial number of 183. Given the        |

| situational circumstances, the existing presence of nearby brachytherapy     |

| sources of Cs-137 and a teletherapy source in the area, the limited access   |

| to the room, control of keys, and the disappearance of records along with    |

| check sources leads the RSO as well as the Department inspector to believe   |

| that the eye applicator and exempt quantity reference sources were           |

| inadvertently disposed as waste back in late January 2003. There is a slight |

| potential that the material may be discovered in the hospital as the various |

| departments continue their relocation to new facilities. The licensee will   |

| file the required report and the department will take appropriate action     |

| based on additional information received. Event reported to NRC Operations   |

| Center on at 1713 ET 14 March 2003 and assigned event number 39671."         |

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|Other Nuclear Material                           |Event Number:   39676       |

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| REP ORG:  DEFENSE DISTRIBUTION DEPOT           |NOTIFICATION DATE: 03/18/2003|

|LICENSEE:  DEFENSE DISTRIBUTION DEPOT           |NOTIFICATION TIME: 08:06[EST]|

|    CITY:  NEW CANTERBURY           REGION:  1  |EVENT DATE:        02/24/2003|

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

|LICENSE#:  37-30062-01           AGREEMENT:  N  |LAST UPDATE DATE:  03/18/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |PETE ESELGROTH       R1      |

|                                                |DAVID AYRES          R2      |

+------------------------------------------------+THOMAS ESSIG         NMSS    |

| NRC NOTIFIED BY:  DAVID MACK                   |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| LOST AMERICIUM-241 SEALED SOURCES                                            |

|                                                                              |

| On 3/18/2003,  NRC Headquarters was informed by the master materials         |

| licensee (located in New Cumberland, PA) that on 3/17/2003, it was           |

| discovered by the licensee that two Americium-241 sealed sources were        |

| unaccounted for.  The sources were tracked to a shipment facility at Warner  |

| Robbins Air Force Base on 2/24/03, but there is no record that the sources   |

| were shipped out of the facility or where they might be stored.   The        |

| sources are contained in a laser transmitter/receiver and contain 4          |

| microcuries of Americium-241.                                                |

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|Power Reactor                                    |Event Number:   39677       |

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| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 03/18/2003|

|    UNIT:  [1] [2] [3]               STATE:  AZ |NOTIFICATION TIME: 15:15[EST]|

|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        03/18/2003|

+------------------------------------------------+EVENT TIME:        10:00[MST]|

| NRC NOTIFIED BY:  DON STRAKA                   |LAST UPDATE DATE:  03/18/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |CLAUDE JOHNSON       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  |

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

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

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                                   EVENT TEXT                                   

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| OFFSITE NOTIFICATION                                                         |

|                                                                              |

| The Governor's Office of the State of Arizona issued a press release         |

| regarding National Guard deployment at the Palo Verde Nuclear Generating     |

| Station (PVNGS). The press release was issued at approximately 10:00 MST     |

| 03/18/03.                                                                    |

|                                                                              |

| The Palo Verde Nuclear Generating Station has no plans to issue a press      |

| release at this time.                                                        |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

|                                                                              |

| Notified R4DO (C. Johnson)                                                   |

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|Power Reactor                                    |Event Number:   39678       |

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| FACILITY: PALISADES                REGION:  3  |NOTIFICATION DATE: 03/18/2003|

|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 21:05[EST]|

|   RXTYPE: [1] CE                               |EVENT DATE:        03/18/2003|

+------------------------------------------------+EVENT TIME:        20:47[EST]|

| NRC NOTIFIED BY:  TROY POLHAMUS                |LAST UPDATE DATE:  03/18/2003|

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

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

|EMERGENCY CLASS:          ALERT                 |JAMES CREED          R3      |

|10 CFR SECTION:                                 |JIM DYER             R3      |

|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |STUART RICHARDS      NRR     |

|                                                |NADER MAMISH         IRO     |

|                                                |ROY ZIMMERMAN        NSIR    |

|                                                |M. DUNKER            FEMA    |

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

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

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

|1     N          N       0        Refueling        |0        Refueling        |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| ALERT DECLARED DUE TO FIRE IN CABLE SPREADING ROOM                           |

|                                                                              |

| The licensee declared an alert at 2047 EST due to a fire in the cable        |

| spreading room which started at 2037 EST.  The fire was declared out by 2130 |

| EST in response to deenergizing 480 volt AC load center # 12.                |

| Preliminarily, the fire appears to have occurred within the breaker          |

| compartment on load center #12 supplying Charging Pump 55A .  Plant          |

| conditions remains stable with shutdown cooling continuing in service.       |

| There were no releases or other offsite consequences.                        |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

|                                                                              |

| * * * * UPDATE RECEIVED FROM J. MIKSA BY M. RIPLEY AT 2326 EST 03/18/03 * *  |

| * *                                                                          |

|                                                                              |

| The licensee terminated the alert at 2326 EST on 03/18/03.                   |

|                                                                              |

| Notified R3DO (J. Creed), NRR EO (S. Richards), DIRO (N. Mamish), FEMA       |

| (Watch Officer), DHS (S. Tull)                                               |

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