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Event Notification Report for June 17, 2003




                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/16/2003 - 06/17/2003



                              ** EVENT NUMBERS **



39929  39940  39941  39942  39943  39944  39945  



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|General Information or Other                     |Event Number:   39929       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 06/12/2003|

|LICENSEE:  ST JOSEPH'S HOSPITAL                 |NOTIFICATION TIME: 15:59[EDT]|

|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        06/11/2003|

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

|LICENSE#:  L02279-000            AGREEMENT:  Y  |LAST UPDATE DATE:  06/12/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |FRED BROWN           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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| INCORRECT TREATMENT AREA DISCOVERED DURING A BREAST CANCER TREATMENT         |

|                                                                              |

| At the beginning of the 6th treatment the physicist discovered a geographic  |

| location error on the placement of a 3 curie +/- Iridium-192 source in the   |

| patient for treatment of breast cancer.  Discovered an input error on the    |

| five previous treatments.  Measurements should have been input to the Gamma  |

| Med Plus (HDR device) in millimeters were mistakenly entered in centimeters. |

| Steps for the 20 millimeter source should have been in 1 millimeter          |

| increments.  Therefore, the source was actually never in the patient's body. |

| The physicist has estimated 70 Gray superficial dose to the skin at a depth  |

| of up to 1 centimeter.  Deep dose (beyond 1 centimeter) is estimated at 30   |

| Gray.  The patient has developed a small red spot which is being monitored   |

| by the hospital for potential blistering.  The patient and the hospital have |

| agreed to re-start this patient's treatments.  Corrective actions to prevent |

| a re-occurrence of this event will follow with the Licensee's 15 day written |

| report of the incident.  Dose to original treatment site is in excess of 20% |

| of the intended dose.                                                        |

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|Power Reactor                                    |Event Number:   39940       |

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| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 06/16/2003|

|    UNIT:  [] [2] []                 STATE:  MI |NOTIFICATION TIME: 08:38[EDT]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        06/16/2003|

+------------------------------------------------+EVENT TIME:        05:15[EDT]|

| NRC NOTIFIED BY:  TODD CASPER                  |LAST UPDATE DATE:  06/16/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |DAVID HILLS          R3      |

|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   |

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

|                                                   |                          |

|2     N          N       0        Hot Shutdown     |0        Hot Shutdown     |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| VALID FEEDWATER ISOLATION SYSTEM SIGNAL GENERATED                            |

|                                                                              |

| A valid feedwater isolation signal (FWIS) was generated while controlling    |

| steam generator water level near 82% wide range during heat-up activities to |

| take the plant from Mode 4 to Mode 3.  The set point for FWIS is 67% narrow  |

| range, which is relatively close to the 82% wide range the plant was being   |

| controlled.  Level was allowed to get slightly higher which activated the    |

| FWIS.  No isolation occurred as the valves were already closed and level was |

| being maintained with auxiliary feedwater.  Level has been restored to less  |

| than the set point.                                                          |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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|Hospital                                         |Event Number:   39941       |

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| REP ORG:  GUTHRIE HEALTH CARE                  |NOTIFICATION DATE: 06/16/2003|

|LICENSEE:  GUTHRIE HEALTH CARE                  |NOTIFICATION TIME: 09:20[EDT]|

|    CITY:  SAYRE                    REGION:  1  |EVENT DATE:        06/12/2003|

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

|LICENSE#:  37-01893-01           AGREEMENT:  N  |LAST UPDATE DATE:  06/16/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |RAYMOND LORSON       R1      |

|                                                |DOUG BROADDUS        NMSS    |

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

| NRC NOTIFIED BY:  JOON PARK                    |                             |

|  HQ OPS OFFICER:  FANGIE JONES                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |

|LOTH 35.3045(a)(3)       DOSE TO OTHER SITE > SP|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE       |

|                                                                              |

| A patient was referred for treatment, due to reoccurring prostate cancer, to |

| the hospital where he had previously had treatment, seeds were implanted     |

| around May 2001.  A scan of the previous treatment of implanted seeds        |

| determined that many of the seeds were not located in the prostate, but in   |

| adjacent tissue where they would have been ineffective in treatment.  Also,  |

| a review of the records indicated a scan was performed in early 2002, but    |

| was not followed up on. The patient and referring physician have been        |

| informed.  The hospital is conducting an investigation into the event and    |

| also developing a plan to provide appropriate treatment for the patient.     |

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|Power Reactor                                    |Event Number:   39942       |

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| FACILITY: CLINTON                  REGION:  3  |NOTIFICATION DATE: 06/16/2003|

|    UNIT:  [1] [] []                 STATE:  IL |NOTIFICATION TIME: 09:34[EDT]|

|   RXTYPE: [1] GE-6                             |EVENT DATE:        06/16/2003|

+------------------------------------------------+EVENT TIME:        07:43[CDT]|

| NRC NOTIFIED BY:  TODD MORGAN                  |LAST UPDATE DATE:  06/16/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |DAVID HILLS          R3      |

|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       93       Power Operation  |93       Power Operation  |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| LOSS OF SAFETY PARAMETER DISPLAY SYSTEM FOR GREATER THAN 8 HOURS             |

|                                                                              |

| "At 0743 CDT on June 16, 2003, the Safety Parameter Display System (SPDS)    |

| was out of service for greater than eight hours due to the loss of the       |

| Nuclear Steam Supply (NSS) Computer, which provides the computer points for  |

| SPDS.                                                                        |

|                                                                              |

| "10CFR50.72(b)(3)(xiii), which states 'the licensee shall notify the NRC as  |

| soon as practical and in all cases                                           |

| within 8 hours of the occurrence of any event that results in the major loss |

| of emergency assessment capability.'                                         |

|                                                                              |

| "The loss of SPDS is considered a major or loss of safety assessment         |

| capability. The site defines a 'major loss'                                  |

| of SPDS, 'when the SPDS function is not available in the control room for    |

| greater than eight hours.' This is                                           |

| consistent with NUREG-1022, EVENT REPORTING GUIDELINES 10CFR 50.72 and 50.73 |

| section 3.2.13,                                                              |

| Loss of Emergency Preparedness Capabilities. The NSS Computer went down at   |

| 2343 on June 15, 2003 (CDT).                                                 |

| The eight-hour unavailability of SPDS expired at 0743 on June 16, 2003       |

| (CDT). Repair efforts have been                                              |

| underway continuously to restore the NSS Computer and return SPDS to         |

| service. The expected return to                                              |

| service for SPDS is on June 16, 2003. All other plant conditions are         |

| normal."                                                                     |

|                                                                              |

| The licensee has notified the NRC Resident Inspector.                        |

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

|Power Reactor                                    |Event Number:   39943       |

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

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| FACILITY: PILGRIM                  REGION:  1  |NOTIFICATION DATE: 06/16/2003|

|    UNIT:  [1] [] []                 STATE:  MA |NOTIFICATION TIME: 13:03[EDT]|

|   RXTYPE: [1] GE-3                             |EVENT DATE:        06/16/2003|

+------------------------------------------------+EVENT TIME:        08:01[EDT]|

| NRC NOTIFIED BY:  KEN GRACIA                   |LAST UPDATE DATE:  06/16/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |RAYMOND LORSON       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   |

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

|1     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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

| INABILITY TO ACTIVATE EMERGENCY SIRENS DUE TO EQUIPMENT FAILURE              |

|                                                                              |

| "It was discovered on 6/16/03 at 0755 that the plant sirens (Prompt Alert    |

| Notification System) were out of service since Sunday 6/15/03 at 0757 [the   |

| cause appears to be a continuous signal being transmitted by a siren].  The  |

| system was restored to service at 0830 on 6/16/03."                          |

|                                                                              |

| The licensee notified local authorities, the State and the NRC Resident      |

| Inspector.                                                                   |

|                                                                              |

| Similar incidents involving emergency sirens have been reported on 6/10/03   |

| (See EN #39912) and on 6/11/03 (See EN # 39918).                             |

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

|Fuel Cycle Facility                              |Event Number:   39944       |

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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 06/16/2003|

|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 19:45[EDT]|

| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        06/16/2003|

|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        14:00[CDT]|

|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  06/16/2003|

|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+

|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |

|LICENSE#:  GDP-1                 AGREEMENT:  Y  |KENNETH RIEMER       R3      |

|  DOCKET:  0707001                              |TIM MCGINTY          IRO     |

+------------------------------------------------+JANET SCHLUETER      NMSS    |

| NRC NOTIFIED BY:  W. F. CAGE                   |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NONR                     OTHER UNSPEC REQMNT    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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

| 4-HOUR REPORTABLE INCIDENT FOR WHICH A PRESS RELEASE WAS MADE                |

|                                                                              |

| "A fluorine gas release occurred in the C-410K facility while operators were |

| charging the gas system. The released gas caused a reaction which consumed a |

| small section of the gas system piping. No detectable quantities of the gas  |

| were measured outside the affected facility. The Emergency Action Level      |

| classification criteria for fluorine releases was not met. The release was   |

| isolated by facility operators. The media requested information from the     |

| plant concerning the release and the plant provided a verbal statement. This |

| statement constituted a 'media/press release' which required a 4 hour        |

| notification to the NRC as required by plant procedure UE2-RA-RE1030,        |

| 'Nuclear Regulatory Event Reporting'.                                        |

|                                                                              |

| "The NRC Senior Resident Inspector has been notified of this event."         |

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

|Power Reactor                                    |Event Number:   39945       |

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| FACILITY: COLUMBIA GENERATING STATIREGION:  4  |NOTIFICATION DATE: 06/16/2003|

|    UNIT:  [2] [] []                 STATE:  WA |NOTIFICATION TIME: 20:36[EDT]|

|   RXTYPE: [2] GE-5                             |EVENT DATE:        06/16/2003|

+------------------------------------------------+EVENT TIME:        13:30[PDT]|

| NRC NOTIFIED BY:  SCOTT BOYNTON                |LAST UPDATE DATE:  06/16/2003|

|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |DAVID GRAVES         R4      |

|10 CFR SECTION:                                 |                             |

|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| UNEXPECTED ISOLATION SIGNAL DURING TESTING WHICH RESULTED IN A MOMENTARY     |

| LOSS OF SHUTDOWN COOLING                                                     |

|                                                                              |

| "This event notification is being made to report an event that could have    |

| prevented the fulfillment of the safety function to remove residual heat. On |

| June 16, 2003, the plant was shutdown in Mode 4 with reactor vessel level    |

| being maintained between 60-120 inches. Operators were performing            |

| surveillance testing on the manual pushbutton isolation logic to the Nuclear |

| Steam Supply Shutoff System when an unexpected general outboard isolation    |

| signal was received. This resulted in the closure of RHR-V-8 (RHR shutdown   |

| cooling outboard containment isolation valve) and the interruption of        |

| shutdown cooling. Reactor Recirculation Pump B remained in service providing |

| forced flow through the reactor core. Operators restored from the            |

| surveillance, reset the isolation signal, and reopened RHR-V-8. Shutdown     |

| cooling was restored 12 minutes after RHR-V-8 went closed. Reactor vessel    |

| level and temperature remained stable during the period shutdown cooling was |

| not in service."                                                             |

|                                                                              |

| The licensee's incident and review board determined that the procedure was   |

| deficient in that it did not alert operators to the isolation signal which   |

| functioned as required. The licensee will inform the NRC resident inspector. |

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