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Event Notification Report for June 13, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/12/2003 - 06/13/2003



                              ** EVENT NUMBERS **



39913  39914  39925  39926  39927  39928  39930  39931  



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|General Information or Other                     |Event Number:   39913       |

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| REP ORG:  WA DIVISION OF RADIATION PROTECTION  |NOTIFICATION DATE: 06/10/2003|

|LICENSEE:  SWEDISH HOSPITAL AND MEDICAL CENTER  |NOTIFICATION TIME: 15:40[EDT]|

|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        04/16/2002|

|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|

|LICENSE#:  WN-M008-1             AGREEMENT:  Y  |LAST UPDATE DATE:  06/10/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |DOUG BROADDUS        NMSS    |

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

| NRC NOTIFIED BY:  ARDEN C. SCROGGS             |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISADMINISTRATION       |

|                                                                              |

| The following agreement state report was received by the NRC Operations      |

| Center via email:                                                            |

|                                                                              |

| "This is notification of an event in Washington State as reported to the     |

| Washington Department of Health, Division of Radiation Protection.           |

|                                                                              |

| "STATUS: new and closed                                                      |

|                                                                              |

| "Licensee: Swedish Hospital and Medical Center                               |

| "City and State: Seattle, Washington                                         |

| "License Number: WN-M008-1                                                   |

| "Type of license: Broad B (medium broad)                                     |

|                                                                              |

| "Date of event: 16 April 2002 (the department was notified on 16 May 2003    |

| after the licensee performed a standard QA case review.  The licensee        |

| submitted a full report of the incident, dated 29 May 2003).                 |

|                                                                              |

| "Location of Event: 747 Summit Avenue, Seattle, Washington                   |

|                                                                              |

| "ABSTRACT: An error occurred due to incorrect determination of treatment     |

| time.  Treatments are planned by use of a graph.  This treatment called for  |

| a 3.0 mm vessel.  When the graph was used to determine treatment time, a     |

| time for using a larger vessel was incorrectly selected.  This resulted in   |

| an extended treatment causing a 25% overexposure to the patient.             |

|                                                                              |

| "When licensee staff discovered the error, the treatment protocol was        |

| changed to require two qualified people to independently verify that the     |

| treatment/dwell time has been correctly established.  This changed was made  |

| as a result of their case review procedure.                                  |

|                                                                              |

| "There was no media coverage.  A Departmental investigation was not          |

| performed due to the length of time between incident and notification, and   |

| that the licensee had performed a self-imposed corrective action.  The       |

| department will follow-up during routine visits to ensure that the licensee  |

| is operating per the new protocol.                                           |

|                                                                              |

| "What is the notification or reporting criteria involved? Misadministration  |

|                                                                              |

| "Activity and Isotope(s) involved: 53.5 mCi (maximum),                       |

| Strontium-90/Yttrium-90 as sealed sources.                                   |

|                                                                              |

| "Overexposures? The patient was the only person overexposed.  There was no   |

| overexposure to any member of the treatment team, staff, or general public.  |

|                                                                              |

|                                                                              |

| "Lost, Stolen or Damaged?  Not Applicable                                    |

|                                                                              |

| "Disposition/recovery: Treatment procedures were amended to require written  |

| review of the intended treatment by both Radiation Oncologist and            |

| Radiological Physicist.                                                      |

|                                                                              |

| "Leak test: 21 February 2002, by the manufacturer.                           |

|                                                                              |

| "Vehicle: Not Applicable                                                     |

|                                                                              |

| "Release of activity?  None                                                  |

|                                                                              |

| "Activity intended: Not Applicable                                           |

|                                                                              |

| "Misadministered activity received:  Not Applicable                          |

|                                                                              |

| "Device: Novoste Beta-Cath, source train # 484/00.                           |

|                                                                              |

| "Exposure: (intended/actual); 18.4 Gy/23 Gy                                  |

|                                                                              |

| "Consequences: Licensee now uses protocol that requires two people who       |

| independently verify the correct vessel size, dwell time, and intended dose. |

| The excess exposure is not expected to produce any undesirable effects.      |

|                                                                              |

| "Was patient or responsible relative notified? Yes                           |

|                                                                              |

| "Was written report provided? Yes                                            |

|                                                                              |

| "Was referring physician notified? Yes                                       |

|                                                                              |

| "Consultant used? No                                                         |

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|General Information or Other                     |Event Number:   39914       |

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| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 06/10/2003|

|LICENSEE:  EXXON MOBIL  CHALMETTE               |NOTIFICATION TIME: 15:17[EDT]|

|    CITY:  CHALMETTE                REGION:  4  |EVENT DATE:        06/10/2003|

|  COUNTY:                            STATE:  LA |EVENT TIME:        08:40[CDT]|

|LICENSE#:  LA-2247-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  06/10/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |DOUG BROADDUS        NMSS    |

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

| NRC NOTIFIED BY:  SCOTT BLACKWELL              |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - REFINERY  FIRE INVOLVING POTENTIAL DAMAGE TO        |

| NUCLEAR GAUGE                                                                |

|                                                                              |

| The following agreement state report was received at the Operations Center   |

| via fax:                                                                     |

|                                                                              |

| "Radiation source involved in fire [at 500 West St Bernard Hwy, Chalmette,   |

| LA]. The gauge was closed and had normal readings of 0.25 mR/hr.  Area       |

| barricaded and restricted.  A leak test was being performed.  The gauge was  |

| being overnighted to Ohmart for analysis.  The gauge contained 1600 mCi      |

| [millicuries] of Cs-137."                                                    |

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|Power Reactor                                    |Event Number:   39925       |

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| FACILITY: WATTS BAR                REGION:  2  |NOTIFICATION DATE: 06/12/2003|

|    UNIT:  [1] [] []                 STATE:  TN |NOTIFICATION TIME: 00:34[EDT]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        06/11/2003|

+------------------------------------------------+EVENT TIME:        23:45[EDT]|

| NRC NOTIFIED BY:  MIKE EARLES                  |LAST UPDATE DATE:  06/12/2003|

|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK LESSER          R2      |

|10 CFR SECTION:                                 |                             |

|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|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                                   

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| GREATER THAN 30% OF THE OFFSITE NOTIFICATION SIRENS OUT OF SERVICE DUE TO    |

| STORM                                                                        |

|                                                                              |

| Greater than 30% of the offsite prompt notification system sirens are out of |

| service due to storm related loss of power.  Repairs are presently in        |

| progress to restore power to the affected sirens (34 of 99).  State and      |

| Local agencies have been notified to implement compensatory measures if      |

| required.                                                                    |

|                                                                              |

| The NRC Resident Inspector will be notified by the licensee.                 |

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|Power Reactor                                    |Event Number:   39926       |

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

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| FACILITY: HADDAM NECK              REGION:  1  |NOTIFICATION DATE: 06/12/2003|

|    UNIT:  [1] [] []                 STATE:  CT |NOTIFICATION TIME: 12:09[EDT]|

|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        06/12/2003|

+------------------------------------------------+EVENT TIME:        11:20[EDT]|

| NRC NOTIFIED BY:  CAMPBELL                     |LAST UPDATE DATE:  06/12/2003|

|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CHRISTOPHER CAHILL   R1      |

|10 CFR SECTION:                                 |                             |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     N          N       0        Decommissioned   |0        Decommissioned   |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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| NOTIFICATION AUTOMATICALLY MADE TO THE OFFSITE FIRE DEPARTMENT               |

|                                                                              |

| The well water booster pump catastrophically failed setting off the smoke    |

| detector which sent a signal to the fire protection panel resulting in an    |

| automatic notification to the fire department.  The fire department          |

| responded, but there was no fire.  The smoke detector was probably set off   |

| from smoke when the pump motor failed.                                       |

|                                                                              |

| The NRC was notified.                                                        |

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

|Power Reactor                                    |Event Number:   39927       |

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

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

| FACILITY: WATTS BAR                REGION:  2  |NOTIFICATION DATE: 06/12/2003|

|    UNIT:  [1] [] []                 STATE:  TN |NOTIFICATION TIME: 14:43[EDT]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/28/2003|

+------------------------------------------------+EVENT TIME:        20:58[EDT]|

| NRC NOTIFIED BY:  MAYS                         |LAST UPDATE DATE:  06/12/2003|

|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK LESSER          R2      |

|10 CFR SECTION:                                 |                             |

|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|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                                   

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

| INVALID ACTUATION OF A CONTAINMENT VENT ISOLATION VALVE                      |

|                                                                              |

| The following information is provided as a 60 day telephone notification to  |

| NRC under 10 CFR 50.73 (a)(2)(iv)(A) in lieu of submitting a written LER to  |

| report a condition that resulted in an invalid actuation of the WBN Train B  |

| Containment Vent Isolation signal. NUREG1022, Revision 2 identifies the      |

| information that needs to be reported as discussed below.                    |

|                                                                              |

| (a) The specific train(s) and systems(s) that were actuated.                 |

|                                                                              |

| On April 28, 2003, at 2058 EST, a Train B Containment Vent Isolation (CVI)   |

| signal was received when the hand switch for the containment purge radiation |

| monitor was placed in off, unblocking the monitor. The high radiation alarm  |

| was still locked in following maintenance on the monitor and was not cleared |

| before unblocking. The containment radiation monitor was inoperable and was  |

| removed from service at the time the signal was received. The CVI was not    |

| responding to an actual plant condition.                                     |

|                                                                              |

| (b) Whether each train actuation was complete or partial.                    |

|                                                                              |

| The actuation was considered complete.  The CVI signal for Train B           |

| automatically isolated the containment vent system. The containment          |

| radiation monitor was considered inoperable due to the maintenance.          |

|                                                                              |

| (c) Whether or not the system started and functioned successfully.           |

|                                                                              |

| Train B Containment Vent Isolation signal automatically actuated and         |

| functioned successfully.  The CVI signal was not in response to an actual    |

| plant condition.  The containment radiation monitors were returned to        |

| service and the containment vent air cleanup unit was also returned to       |

| service.                                                                     |

|                                                                              |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

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



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

|Other Nuclear Material                           |Event Number:   39928       |

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

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| REP ORG:  US AIR FORCE                         |NOTIFICATION DATE: 06/12/2003|

|LICENSEE:  US AIR FORCE                         |NOTIFICATION TIME: 15:53[EDT]|

|    CITY:  LUKE AFB                 REGION:  4  |EVENT DATE:        06/11/2003|

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

|LICENSE#:  42-23539-01AF         AGREEMENT:  Y  |LAST UPDATE DATE:  06/12/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  RAM BHAT                     |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

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

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| AMERESIUM SOURCE LOST FOLLOWING F-16 CRASH                                   |

|                                                                              |

| The Air Force reported that a F-16 fighter jet crashed in Arizona near Luke  |

| AFB yesterday with a 8 microcurie Americium - 241 source.  The source could  |

| not be found.                                                                |

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



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

|Other Nuclear Material                           |Event Number:   39930       |

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

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

| REP ORG:  US AIR FORCE                         |NOTIFICATION DATE: 06/12/2003|

|LICENSEE:  US AIR FORCE                         |NOTIFICATION TIME: 16:42[EDT]|

|    CITY:  CANNON AFB               REGION:  4  |EVENT DATE:        06/10/2003|

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

|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  06/12/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  REFOSCO                      |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

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

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| LOST EXIT SIGN                                                               |

|                                                                              |

| The US air Force reported that one tritium exit sign was determined missing  |

| after an inventory check on 06/10/03 at Cannon AFB, NM.  Prior to January -  |

| February contractor work the sign was accounted for.                         |

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



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

|Power Reactor                                    |Event Number:   39931       |

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

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

| FACILITY: GRAND GULF               REGION:  4  |NOTIFICATION DATE: 06/13/2003|

|    UNIT:  [1] [] []                 STATE:  MS |NOTIFICATION TIME: 02:44[EDT]|

|   RXTYPE: [1] GE-6                             |EVENT DATE:        06/13/2003|

+------------------------------------------------+EVENT TIME:        00:30[CDT]|

| NRC NOTIFIED BY:  FRANK WEAVER                 |LAST UPDATE DATE:  06/13/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |DAVID GRAVES         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  |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| EMERGENCY SIREN ACUTATED                                                     |

|                                                                              |

| "Grand Gulf Control Room was notified by the Louisiana Office of Emergency   |

| Preparedness that an Emergency Siren was initiated. There is no reason for   |

| this siren to have actuated.  The siren has been secured and deenergized.    |

| This event is being reported due to the local media broadcasting a no        |

| emergency message.  The total number of emergency sirens remains above       |

| 75%(precent)."                                                               |

|                                                                              |

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

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