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Event Notification Report for June 16, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/13/2003 - 06/16/2003



                              ** EVENT NUMBERS **



39913  39914  39931  39932  39937  39938  39939  







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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:   39931       |

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| 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  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| 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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|Power Reactor                                    |Event Number:   39932       |

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| FACILITY: SURRY                    REGION:  2  |NOTIFICATION DATE: 06/13/2003|

|    UNIT:  [1] [] []                 STATE:  VA |NOTIFICATION TIME: 08:51[EDT]|

|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        06/13/2003|

+------------------------------------------------+EVENT TIME:        05:36[EDT]|

| NRC NOTIFIED BY:  J. SHELL                     |LAST UPDATE DATE:  06/13/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK LESSER          R2      |

|10 CFR SECTION:                                 |                             |

|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     M/R        Y       1        Startup          |0        Hot Shutdown     |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| MANUALLY REACTOR TRIP DUE TO INDICATION OF MISALIGNED ROD                    |

|                                                                              |

| "While inserting Shutdown Bank "B" during the Rod Swap portion of physics    |

| testing, Rod J-7 indicated a rapid drop from approximately 100 steps to 47   |

| steps on the CERPI (Computer Enhanced Rod Position Indication) panel.  The   |

| reactor operator stopped insertion of "B" shutdown bank and the CERPI        |

| indication for rod J-7 remained at 47 steps.  The remaining CERPIs in "B"    |

| shutdown bank varied from 96 to 100 steps                                    |

|                                                                              |

| "I&C and Engineering investigated and found no problems with the CERPI       |

| indication.  Physics testing was terminated and the reactor was manually     |

| tripped and 1-E-0 initiated.  All systems functioned as required on the      |

| trip.  Rod Drop time data from the CERPI program shows all rods in Shutdown  |

| Bank "B" had a drop time 1.24 to 1.27 seconds with the exception of J-7,     |

| which had a drop time of 1.04 seconds.                                       |

|                                                                              |

| "An investigation is ongoing as to the cause of rod J-7 indication."         |

|                                                                              |

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

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|Power Reactor                                    |Event Number:   39937       |

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| FACILITY: PEACH BOTTOM             REGION:  1  |NOTIFICATION DATE: 06/14/2003|

|    UNIT:  [2] [3] []                STATE:  PA |NOTIFICATION TIME: 02:05[EDT]|

|   RXTYPE: [2] GE-4,[3] GE-4                    |EVENT DATE:        06/13/2003|

+------------------------------------------------+EVENT TIME:        20:21[EDT]|

| NRC NOTIFIED BY:  BREIDENBAUGH                 |LAST UPDATE DATE:  06/14/2003|

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

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

|EMERGENCY CLASS:                                |CHRISTOPHER CAHILL   R1      |

|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   |

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

|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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| LOSS OF BOTH OFFSITE POWER SOURCES TO TECHNICAL SUPPORT CENTER               |

|                                                                              |

| "During severe thunderstorms in the area power was lost to the onsite        |

| Technical Support Center (TSC) for approximately 90 minutes.  These storms   |

| caused both offsite power sources to the TSC to de-energize at 2021.  Grid   |

| operators began restoration activities immediately and power was restored to |

| the facility at approximately 2200. Investigation is in progress for the     |

| cause of the line tripping."                                                 |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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|Power Reactor                                    |Event Number:   39938       |

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

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| FACILITY: HARRIS                   REGION:  2  |NOTIFICATION DATE: 06/14/2003|

|    UNIT:  [1] [] []                 STATE:  NC |NOTIFICATION TIME: 14:32[EDT]|

|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        06/14/2003|

+------------------------------------------------+EVENT TIME:        10:53[EDT]|

| NRC NOTIFIED BY:  BAKER                        |LAST UPDATE DATE:  06/14/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK LESSER          R2      |

|10 CFR SECTION:                                 |                             |

|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |

|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     M/R        Y       100      Power Operation  |0        Hot Standby      |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| REACTOR MANUALLY TRIPPED DUE TO MAIN FEEDWATER PUMP TRIP                     |

|                                                                              |

| At 10053 ,on 6/14/03, the reactor was manually tripped from 100% in response |

| to a trip of the "B" main feedwater pump (MFP).  Both motor-driven auxiliary |

| feedwater pumps  and the turbine driven auxiliary feedwater pump auto        |

| started due to the lo-lo steam generator level.  Operations personnel        |

| responded to the event in accordance with applicable plant procedures and    |

| the plant was stabilized at normal operating no-load reactor coolant system  |

| (RCS) temperature and pressure following the reactor trip.  The cause of the |

| MFP trip is still under investigation.  All rods fully inserted no ECCS      |

| actuation occurred and the PORV lifted and fully reseated.                   |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

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|Power Reactor                                    |Event Number:   39939       |

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

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| FACILITY: HARRIS                   REGION:  2  |NOTIFICATION DATE: 06/15/2003|

|    UNIT:  [1] [] []                 STATE:  NC |NOTIFICATION TIME: 14:45[EDT]|

|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        06/15/2003|

+------------------------------------------------+EVENT TIME:        09:28[EDT]|

| NRC NOTIFIED BY:  BRIAN BAKER                  |LAST UPDATE DATE:  06/15/2003|

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

+------------------------------------------------+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          N       0        Hot Standby      |0        Hot Standby      |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| AUTOMATIC ACTUATION OF THE AUXILIARY FEEDWATER SYSTEM WHILE IN HOT STANDBY   |

|                                                                              |

| "At 0928, on 6/15/03, with the reactor shut down in Mode 3, a feedwater      |

| isolation signal and an automatic start of both Motor-Driven Auxiliary       |

| Feedwater Pumps (AFW) occurred due to the trip of the last running Main      |

| Feedwater Pump. The event occurred as the plant operators closed the reactor |

| trip breakers per plant procedure OP-104 in preparation for a reactor        |

| startup. The Main Feedwater Regulating Valves (MFRVs) were in automatic and  |

| the MFRV block valves were open. With reactor coolant system average         |

| temperature at less than 564F and the reactor trip breakers open, a MFRV    |

| close signal is established via the P-4 permissive. Closing the reactor trip |

| breakers removed the permissive P-4 block signal that was maintaining the    |

| MFRVs closed. This allowed the MFRVs to open to the full open demand         |

| position. With the MFRVs feeding the steam generators and no load conditions |

| on the secondary plant, steam generator level exceeded the HI-HI level       |

| setpoint of 78%. This generated a turbine trip signal, a Main Feedwater      |

| isolation signal, and a trip of the Main Feedwater Pumps. The trip of the    |

| last running Main Feedwater Pump generated the automatic AFW actuation. This |

| condition is being reported as actuation of Auxiliary Feedwater System in    |

| accordance with 1O CFR 50.72(b)(3)(iv)(A).                                   |

|                                                                              |

| "A reactor trip signal was not generated during this event and no control    |

| Rods had been withdrawn from the reactor core at the time of the event.      |

|                                                                              |

| "The NRC Resident Inspector was notified."                                   |

|                                                                              |

| The plant is stable in mode 3 and the  AFW system is running to maintain     |

| steam generator levels. All systems functioned as required.                  |

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