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Event Notification Report for May 30, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           05/29/2003 - 05/30/2003



                              ** EVENT NUMBERS **



39883  39884  39888  39889  39890  39891  



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|General Information or Other                     |Event Number:   39883       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 05/27/2003|

|LICENSEE:  GUIDANT CORPORATION                  |NOTIFICATION TIME: 10:17[EDT]|

|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        05/23/2003|

|  COUNTY:                            STATE:  TX |EVENT TIME:        15:50[CDT]|

|LICENSE#:  L05178-000            AGREEMENT:  Y  |LAST UPDATE DATE:  05/27/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |WILLIAM JONES        R4      |

|                                                |LAWRENCE DOERFLEIN   R1      |

+------------------------------------------------+TOM ESSIG            NMSS    |

| NRC NOTIFIED BY:  OGDEN                        |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| MALFUNCTION OF A HIGH DOSE RATE AFTERLOADER                                  |

|                                                                              |

| During a heart procedure at the Union Memorial Hospital in Maryland with a   |

| Galileo III (HDR - High dose rate afterloader) device using a Phosphorus -   |

| 32 source wire, of up to 600 millicuries, a malfunction occurred with the    |

| active wire in place in the patient's heart.  When the source was to be      |

| retracted the source would not retract.  The physician utilized the machine  |

| interrupt to try to get the source to move to the shielded position and it   |

| failed.  The physician then pushed the system STOP button to get the source  |

| to retract and it also failed to perform the retraction.  The physician then |

| moved to the hand-wheel to retract the source, but this function also        |

| malfunctioned.  At this point the physician pulled the entire catheter and   |

| dropped it to the Operating Room floor.   The power cord was then removed    |

| from the wall receptacle depriving the machine of power and then the source  |

| retracted to the fully shielded position.  The licensee was informed that    |

| this would constitute a Therapy Event within the State of Texas and the      |

| state would need a complete report and an emergency read of all badged       |

| personnel in the OR during the procedure.   The Licensee responded that the  |

| machine was not within the State of Texas.   A report to the state of Texas  |

| is still required by License Condition # 16 due to failure of the drive      |

| mechanism of the GALILEO III to retract the source to safe storage until the |

| fourth emergency procedure was performed.                                    |

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|General Information or Other                     |Event Number:   39884       |

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| REP ORG:  NEW MEXICO RAD CONTROL PROGRAM       |NOTIFICATION DATE: 05/27/2003|

|LICENSEE:  SPECTRATEK SERVICES                  |NOTIFICATION TIME: 12:49[EDT]|

|    CITY:  ALBUQUERQUE              REGION:  4  |EVENT DATE:        05/23/2003|

|  COUNTY:                            STATE:  NM |EVENT TIME:        16:30[MDT]|

|LICENSE#:  TA-172-21             AGREEMENT:  Y  |LAST UPDATE DATE:  05/27/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |WILLIAM JONES        R4      |

|                                                |DOUG BROADDUS        NMSS    |

+------------------------------------------------+CAUDLE JULIAN        R2      |

| NRC NOTIFIED BY:  WILLIAM FLOYD                |                             |

|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT                                                       |

|                                                                              |

| On 5/22/2003, the licensee sent a shipment of radioactive material to Elite  |

| Airfreight in Houston, TX.  On 5/23/2003 at approximately 1630 MDT, Elite    |

| Airfreight contacted the licensee to inform them that only 2 of the 3 boxes  |

| of radioactive material in the shipment had arrived in Houston.  The         |

| licensee contacted Federal Express, who tracked the missing package to the   |

| Fedex facility in Memphis, TN.  Fedex planned to send the missing package to |

| Houston on 5/24/2003.  As of 5/27/2003, the package still had not arrived in |

| Houston.  The licensee contacted Fedex again, and was told the package was   |

| still in Memphis, and would be shipped to Houston today (5/27/2003).         |

|                                                                              |

| The missing package is a 12X12X12 inch fiberboard box containing 40          |

| millicuries of Antimony-124, and has a Transportation Index of 4.  This      |

| event is state of New Mexico event number NM03-02.                           |

|                                                                              |

| Notified the R4 Duty Officer (W. Jones), R2 Duty Officer (C. Julian), and    |

| NMSS (D. Broaddus)                                                           |

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|Power Reactor                                    |Event Number:   39888       |

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| FACILITY: BROWNS FERRY             REGION:  2  |NOTIFICATION DATE: 05/29/2003|

|    UNIT:  [] [] [3]                 STATE:  AL |NOTIFICATION TIME: 05:43[EDT]|

|   RXTYPE: [1] GE-4,[2] GE-4,[3] GE-4           |EVENT DATE:        05/29/2003|

+------------------------------------------------+EVENT TIME:        02:39[CDT]|

| NRC NOTIFIED BY:  RAY SWAFFORD                 |LAST UPDATE DATE:  05/29/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |CAUDLE JULIAN        R2      |

|10 CFR SECTION:                                 |                             |

|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|                                                   |                          |

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

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                                   EVENT TEXT                                   

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| DEGRADED ACCIDENT MITIGATION FEATURE                                         |

|                                                                              |

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

|                                                                              |

| "On 05/29/2003 at 0239 [CDT], during performance of 3-SR-3.5.1.7, HPCI [High |

| Pressure Coolant Injection] Main and Booster Pump Developed Head and         |

| Flowrate Test at Rated Reactor Pressure, following release of the HPCI Trip  |

| Push button, the HPCI Turbine Stop Valve, 3-FCV-73-18, did not return to the |

| OPEN position as required by the surveillance. The SR [Surveillance          |

| Requirement] was stopped.                                                    |

|                                                                              |

| "This is reportable as an 8 hour report in accordance with                   |

| 10CFR50.72(b)(3)(v)[(D) as 'Any event or condition that at the time of       |

| discovery could have prevented the fulfillment of the safety function of     |

| structures or systems that are needed to:  (D) Mitigate the consequences of  |

| an accident.'                                                                |

|                                                                              |

| "This is also reportable as a 60 day written report in accordance with       |

| 10CFR50.73(a)(2)(vii) as 'Any event where a single cause or condition caused |

| at least one independent train or channel to become inoperable ...in a       |

| single system designed to:  (D) Mitigate the consequence of an accident.'"   |

|                                                                              |

| The licensee has notified the NRC Resident Inspector.                        |

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|Hospital                                         |Event Number:   39889       |

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| REP ORG:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION DATE: 05/29/2003|

|LICENSEE:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION TIME: 08:54[EDT]|

|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        05/29/2003|

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

|LICENSE#:  37-0018-07            AGREEMENT:  N  |LAST UPDATE DATE:  05/29/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |LAWRENCE DOERFLEIN   R1      |

|                                                |DOUGLAS BROADDUS     NMSS    |

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

| NRC NOTIFIED BY:  ROB FORREST                  |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|BLO2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| LOSS OF RADIOACTIVE SOURCE                                                   |

|                                                                              |

| "On Tuesday April 29, 2003, a laboratory supervisor at the Hospital of the   |

| University of Pennsylvania (HUP) notified Environmental Health and Radiation |

| Safety that a package of 250 [microcurie] of P-32 was not received by her    |

| lab as expected on April 25, 2003.  The package was shipped as an excepted   |

| package not subject to external labeling.                                    |

|                                                                              |

| "The package was delivered by materials management staff and left in the     |

| hallway near the laboratory with other supplies instead of being delivered   |

| directly to the lab as required.                                             |

|                                                                              |

| "The radiation safety investigation determined that housekeeping staff       |

| removed the package unopened from the hallway and disposed of it in the      |

| regular trash.  Based on the activity and exposure rate, this package did    |

| not present an exposure to any employee or member of the general public.     |

|                                                                              |

| "Corrective actions have been initiated with laboratory, materials           |

| management and housekeeping staff to prevent reoccurrence."                  |

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|Power Reactor                                    |Event Number:   39890       |

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| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 05/29/2003|

|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 12:40[EDT]|

|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        05/28/2003|

+------------------------------------------------+EVENT TIME:        07:30[CDT]|

| NRC NOTIFIED BY:  GARY HARRINGTON              |LAST UPDATE DATE:  05/29/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK RING            R3      |

|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  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| DISCOVERY OF A CONTROLLED SUBSTANCE WITHIN THE KEWAUNEE PLANT PROTECTED      |

| AREA                                                                         |

|                                                                              |

| "On 5/28/03 at approximately 0730 CDT on-site testing  of a substance proved |

| positive for a controlled substance. The substance was found by a member of  |

| plant staff on the plant grounds within the protected area. The plant staff  |

| member took possession of the substance and immediately contacted Security   |

| staff personnel for assistance. There were no personnel noted in the area of |

| the substance [at the time of discovery]. After confirming the substance, it |

| was turned over to Kewaunee County Sheriff's Department."                    |

|                                                                              |

| Contact the Headquarters Operations Officer for additional details.          |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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|Power Reactor                                    |Event Number:   39891       |

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

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| FACILITY: FT CALHOUN               REGION:  4  |NOTIFICATION DATE: 05/30/2003|

|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 00:43[EDT]|

|   RXTYPE: [1] CE                               |EVENT DATE:        05/29/2003|

+------------------------------------------------+EVENT TIME:        21:18[CDT]|

| NRC NOTIFIED BY:  DON KURTTI                   |LAST UPDATE DATE:  05/30/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |KRISS KENNEDY        R4      |

|10 CFR SECTION:                                 |                             |

|NONR                     OTHER UNSPEC REQMNT    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|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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| 161 KV WAS DECLARED INOPERABLE DUE TO THE PREDICTED POST TRIP VOLTAGE BELOW  |

| SETPOINT                                                                     |

|                                                                              |

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

|                                                                              |

| " [Abnormal Operating Procedure] AOP-31 '161KV GRID MALFUNCTIONS' was        |

| entered due to the predicted post trip 161 KV voltage dropping to 160.6 KV   |

| on the PCMMINT [Personal Computer Monitoring of Missouri, Iowa and Nebraska  |

| Transmission] computer monitoring program.  161 KV was declared inoperable   |

| due to the predicted post trip voltage being below the 160.7 KV setpoint.    |

| Tech Spec 2.7(2)C, 72 hour LCO was entered.  Both emergency diesel           |

| generators are operable.                                                     |

|                                                                              |

| "Main generator VARS [Volt-Amperes Reactive] were raised from 100 to 150     |

| MVARS lagging in an attempt to raise predicted post trip voltage.  Predicted |

| voltage rose above 161 KV for approx. 5 minutes and then lowered below 161   |

| KV again to 160.8 KV and is now fluctuating.  System Operations was notified |

| and stated that 161 KV actual voltage remained at approx. 164 KV and that    |

| the electrical grid was stable.                                              |

|                                                                              |

| "Design Engineering was notified and hypothesizes that MAPP [Mid-America     |

| Power Pool] values into PCMMINT program may not be valid and that they will  |

| attempt to validate the inputs."                                             |

|                                                                              |

| The licensee has notified the NRC Resident Inspector.                        |

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