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Event Notification Report for June 18, 2003


                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/17/2003 - 06/18/2003



                              ** EVENT NUMBERS **



39631  39882  39929  39933  39934  39935  39936  39946  39947  



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

|Power Reactor                                    |Event Number:   39631       |

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

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

| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 03/02/2003|

|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 16:00[EST]|

|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        03/02/2003|

+------------------------------------------------+EVENT TIME:        14:30[EST]|

| NRC NOTIFIED BY:  CHARLES PIKE                 |LAST UPDATE DATE:  06/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |WALTER RODGERS       R2      |

|10 CFR SECTION:                                 |DAVID AYRES          R2      |

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

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

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

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

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| OFFSITE NOTIFICATION TO STATE AGENCY OF EXPIRED GREEN SEA TURTLE FOUND AT    |

| BARRIER NET                                                                  |

|                                                                              |

| "NRC notification [is] being made due to state notification to [the] Florida |

| Wildlife Commission regarding a Green Sea Turtle found dead at barrier net   |

| pursuant to 10 CFR 50.72(b)(2)(xi)."                                         |

|                                                                              |

| The turtle was found on the surface at the barrier net with no injuries or   |

| abnormalities except for fresh cuts common for turtles coming through pipes. |

| The cause of death is unknown at this time. A necropsy is planned.           |

|                                                                              |

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

|                                                                              |

| * * * UPDATE ON 3/15/03 @ 1033 EST FROM TEREZAKIS TO CROUCH * * *            |

|                                                                              |

| "On 3-15-03, a green sea turtle was retrieved from the plant's intake canal. |

| The turtle was determined to be in need of rehabilitation.  The injuries to  |

| the turtle are not causal to plant operation. Per the plant's turtle permit, |

| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified at |

| 0920 EST.  This non-emergency notification is being made pursuant to 10 CFR  |

| 50.72(b)(2)(xi) due to the notification of FWCC."                            |

|                                                                              |

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

|                                                                              |

| * * * UPDATE ON 3/19/03 AT 1222 EST FROM E. SUMNER TO RIPLEY  * * *          |

|                                                                              |

| "On 03/19/03 @ 1105 hrs., one loggerhead turtle was retrieved from the       |

| plant's intake canal.  The turtle was determined to be in need of            |

| rehabilitation.  The injury to the turtle is not causal to plant operation.  |

| Per the plant's turtle permit, the Florida Fish and Wildlife Conservation    |

| Commission (FWCC) was notified at 1115 EST."                                 |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

|                                                                              |

| * * * UPDATED ON 3/31/03 AT 1159 EST FROM W.L. PARK TO A. COSTA * * *        |

|                                                                              |

| "On 3-31-03 [1105 EST], a loggerhead sea turtle was retrieved from the       |

| plant's intake canal. The turtle was determined to be in need of             |

| rehabilitation. The injuries to the turtle are not causal to plant           |

| operation. Per the plant's turtle permit, the Florida Fish and Wildlife      |

| Conservation Commission (FWCC) was notified at 1105 EST. This non-emergency  |

| notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to the     |

| notification of FWCC."                                                       |

|                                                                              |

| The NRC Resident Inspector will be notified.                                 |

|                                                                              |

| * * * UPDATE 1235EST ON 4/9/03 FROM ANDY TEREZAKIS TO S.SANDIN * * *         |

|                                                                              |

| "On 4-9-03, a loggerhead sea turtle was retrieved from the plant's Intake    |

| canal. The turtle was determined to be in need of rehabilitation. The        |

| injuries to the turtle are not causal to plant operation. Per the plant's    |

| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC)  |

| was notified at 1100 EST. This non-emergency notification is being made      |

| pursuant to 10CFR50.72(b)(2)(xi) due to the notification of FWCC."           |

|                                                                              |

| The licensee informed the NRC resident inspector.  Notified R2DO(Landis).    |

|                                                                              |

| *** UPDATE ON 5/2/03 AT 1826 FROM S. OEHRLE TO A. COSTA ***                  |

|                                                                              |

| "On 5/2/03, a green sea turtle was retrieved from the intake canal.  The     |

| turtle  required rehabilitation.  The injuries were not causal to plant      |

| operation.  Per the plant's turtle permit, the Florida Fish and Wildlife     |

| Conservation Commission was notified at 1445 EDT.  This non-emergency        |

| notification is being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to        |

| offsite notification."                                                       |

|                                                                              |

| The Licensee will notify the NRC Resident Inspector.  Notified R2DO          |

| (Munday).                                                                    |

|                                                                              |

| **** update on 05/24/03 at 1417 EDT FROM JOE HESSLING TO JOHN MACKINNON      |

| ****                                                                         |

|                                                                              |

| "On 5-24-03, a loggerhead sea turtle was retrieved from the plant's intake   |

| canal.  The turtle was determined to be in need of rehabilitation.  The      |

| turtle was very underweight and lethargic, no injuries or anomalies noted.   |

| Turtle's condition is not causal to plant operation.  Per the plant's turtle |

| permit the Florida Fish and Wildlife Conservation Commission (FWCC) was      |

| notified at 1345 EDT.  This non-emergency notification is being made         |

| pursuant to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC. NRC R2DO |

| (TOM DECKER) notified.                                                       |

|                                                                              |

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

|                                                                              |

| ****UPDATE ON 5/27/03 AT 10:49 FROM HESSLING TO LAURA****                    |

|                                                                              |

| "On 5-27-03, a loggerhead sea turtle was retrieved from the plant's intake   |

| canal. The turtle was determined to be in need of rehabilitation. The turtle |

| was underweight, and missing lower posterior marginals on left side.         |

| Turtle's injuries are not causal to plant operation. Per the plant's turtle  |

| permit, the Florida Fish and Wildlife Conservation Commission (FWCC) was     |

| notified at 0850 EDT. This non-emergency notification is being made pursuant |

| to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC."                  |

|                                                                              |

| Notified R2DO (T. Decker)                                                    |

|                                                                              |

| * * * UPDATE ON 06/17/03 AT 12:45 EDT FROM CALVIN WARD TO ARLON COSTA * * *  |

|                                                                              |

| "At approximately 12:45 p.m. on 6/17/03 a loggerhead turtle was rescued from |

| the St. Lucie Plant intake canal. The turtle was injured and will be         |

| transported to the State authorized sea turtle rehabilitation facility. The  |

| Florida Dept. of Environmental Protection (FDEP) was notified at 1:09 p.m.   |

| as required by the St. Lucie Plant Sea Turtle Permit - see the attached sea  |

| turtle stranding report (1 page).                                            |

|                                                                              |

| "Notification to the state government agency requires a four (4) Hr.         |

| Non-Emergency Notification to the NRC per 10 CFR 50.72(b)(2)(xi). There were |

| no unusual plant evolutions in progress which may have contributed to this   |

| event."                                                                      |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

|                                                                              |

| Notified R2DO (L. Wert).                                                     |

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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!

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

|Power Reactor                                    |Event Number:   39882       |

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

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

| FACILITY: COOPER                   REGION:  4  |NOTIFICATION DATE: 05/27/2003|

|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 05:32[EDT]|

|   RXTYPE: [1] GE-4                             |EVENT DATE:        05/26/2003|

+------------------------------------------------+EVENT TIME:        22:15[CDT]|

| NRC NOTIFIED BY:  WILLIAM GREEN                |LAST UPDATE DATE:  06/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |TROY PRUETT          R4      |

|10 CFR SECTION:                                 |                             |

|ADEG 50.72(b)(3)(ii)(A)  DEGRADED CONDITION     |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     N          N       0        Hot Shutdown     |0        Hot Shutdown     |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| REACTOR COOLANT SYSTEM PRESSURE/TEMPERATURE TS LIMITS WERE EXCEEDED          |

|                                                                              |

| At 2215 on 5/26/03 it was noted that Reactor Coolant System (RCS)            |

| Pressure/Temperature Limits for Non-Nuclear Heatup or Cooldown Following     |

| Nuclear Shutdown, Figure 3.4.9-1 of Technical Specifications, had been       |

| exceeded. This condition occurred due to Bottom Head Temperature being low   |

| due to a loss of forced circulation when Reactor Recirculation Pumps tripped |

| during the manual scram reported in notification 39881.  Reactor pressure    |

| was lowered and compliance with the curves has been reestablished.  An       |

| analysis of this condition is required to be conducted in accordance with    |

| Technical Specification Required Action 3.4.9 A.2 to determine RCS           |

| acceptability for continued operation.  The Reactor is required, as per LCO  |

| action statement, to be placed in Mode 4 by 1045 on 5/28/03.                 |

|                                                                              |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

|                                                                              |

| * * * UPDATE 1614EDT ON 6/17/03 FROM ED McCUTCHEN TO S. SANDIN * * *         |

|                                                                              |

| The licensee is retracting this event based on the following:                |

|                                                                              |

| "Retraction of Event Notification 39882:                                     |

|                                                                              |

| "On May 27, 2003, Cooper Nuclear Station reported that Reactor Coolant       |

| System (RCS) Pressure/Temperature (P/T) Limits for Non-Nuclear Heatup or     |

| Cooldown Following Nuclear Shutdown, Figure 3.4.9-1 of Technical             |

| Specifications, had been exceeded (Reference Event 39882). This condition    |

| occurred when Reactor Recirculation Pumps tripped during the manual scram    |

| reported in Event 39881. With the loss of forced circulation, stratification |

| of the reactor coolant occurred and the resultant bottom head (Lower Plenum) |

| temperatures were below the Technical Specification limit.                   |

|                                                                              |

| "The condition was reported in accordance with 10 CFR 50.72(b)(3)(ii)(A) as  |

| an event or condition that results in the condition of the nuclear power     |

| plant, including its principal safety barriers, being seriously degraded.    |

|                                                                              |

| "CNS was in Mode 3 (Hot Shutdown) when the P/T Limits were exceeded. Reactor |

| pressure was lowered and compliance with the curve was reestablished. Per    |

| Limiting Condition for Operation (LCO) 3.4.9, Condition B, required Action   |

| B.2, the reactor was required to be in Mode 4 (Cold Shutdown) by 1045 on May |

| 28, 2003. The reactor was placed in Mode 4 at 0844 on May 27, 2003.          |

|                                                                              |

| "The Technical Specification required evaluation to determine that the RCS   |

| is acceptable for operation prior to entering Mode 2 (Startup) or Mode 3 has |

| been completed. The evaluation determined that pressure and temperature data |

| recorded during the condition demonstrate that the P/T Limits were           |

| maintained for the Upper Vessel/Steam Dome and Beltline Regions for the      |

| duration of the event.                                                       |

|                                                                              |

| "The recorded data for the Lower Plenum exceeded TS Figure 3.4.9-1 which is  |

| a composite curve established by superimposing limits derived from stress    |

| analyses of those portions of the reactor vessel and head that are the most  |

| restrictive. The analysis developed a bottom head (Lower Plenum) specific    |

| P/T curve using bottom head specific stresses and material properties.       |

| Considering this bottom head P/T curve, the evaluation results demonstrate   |

| that region specific P/T Limits for the Lower Plenum region of the vessel    |

| were maintained for the duration of the event.                               |

|                                                                              |

| "This event is bounded by the existing fatigue analysis for a loss of        |

| Feedwater Pumps. The transient has been captured in the fatigue monitoring   |

| program. The vessel usage factor of 1.0 has not been exceeded. Consequently, |

| the reactor vessel maintains adequate structural integrity for continued     |

| operation.                                                                   |

|                                                                              |

| "CNS is retracting this event based on the evaluation which demonstrates     |

| that the plant safety barrier (RCS) was not degraded."                       |

|                                                                              |

| The licensee informed the NRC resident inspector.  Notified R4DO(Powers).    |

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



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

|General Information or Other                     |Event Number:   39929       |

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

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

| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| 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.                                                        |

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



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

|General Information or Other                     |Event Number:   39933       |

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

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

| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  QUALITY TESTING                      |NOTIFICATION TIME: 13:00[EDT]|

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

|  COUNTY:                            STATE:  AZ |EVENT TIME:        08:00[MST]|

|LICENSE#:  AZ07-491              AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  GODWIN                       |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| ARIZONA LICENSEE, QUALITY TESTING, REPORTED A MISSING TROXLER MOISTURE       |

| DENSITY GAUGE                                                                |

|                                                                              |

| "At approximately 8:00 AM MST June 10, 2003,  Arizona was informed by the    |

| Licensee Radiation Safety Officer that they believe a Troxler Model 3411 B   |

| SN 4647 moisture-density gauge was missing and had been since 5:00 AM.  At   |

| approximately 8;30 MST the Agency was informed that gauge fell off of the    |

| truck and had been recovered by JSW Concrete Contractor.  The gauge was      |

| recovered from Price Road under the Fry Road Overpass.  The Department of    |

| Public Safety and the Chandler Police were notified prior to recovery.  The  |

| Licensee took possession of the gauge at approximately 9:00AM. There were no |

| indications the gauge had been opened.  Inspection by the State Agency       |

| revealed several possible violations."                                       |

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



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

|General Information or Other                     |Event Number:   39934       |

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

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

| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  CHRISTUS SANTA ROSA                  |NOTIFICATION TIME: 14:47[EDT]|

|    CITY:  SAN ANTONIO              REGION:  4  |EVENT DATE:        06/13/2003|

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

|LICENSE#:  L02237-001            AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  WATKINS                      |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| WRONG DOSAGE ADMINISTERED TO A PATIENT DUE TO HUMAN ERROR                    |

|                                                                              |

| Discovery of right patient/ right radiopharmaceutical but wrong dosage.      |

| Patient returned after 48 hours for a scan. Doctor asked the tech for the    |

| prescription that was issued.  The tech had ordered the wrong dose for the   |

| prescribed procedure.  A thyroid scan was conducted with 2.3 millicuries of  |

| Iodine -131 vs. the required 300 microcuries of I-131.  As corrective action |

| any I-131 dose will require concurrence of the physician prior to ordering   |

| the dose.  The cause was due to human error since the radiopharmacy sent the |

| dose as ordered by the Tech.                                                 |

|                                                                              |

| Both the referring physician and the patient have been informed of the       |

| error. The physician has stated that the dose error has caused no injury to  |

| the patient.                                                                 |

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



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

|General Information or Other                     |Event Number:   39935       |

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

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

| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  COLLEGE STATION HOSPITAL             |NOTIFICATION TIME: 15:14[EDT]|

|    CITY:  COLLEGE STATION          REGION:  4  |EVENT DATE:        06/11/2003|

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

|LICENSE#:  L02559                AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  WATKINS                      |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| SIX VIOLATIONS FOUND DURING RECENT INSPECTION AT A TEXAS LICENSED FACILITY   |

|                                                                              |

| On June 11, 2003 the Texas Department of Health, Bureau of Radiation Control |

| conducted a follow up inspection of licensed activities at the Humana        |

| Hospital Day Surgery Center DBA The Surgical Center (TSC), Bryan, Texas. The |

| inspection findings were discussed with Dr. Alikhan, Radiation Safety        |

| Officer and his staff In a preliminary exit briefing at close of             |

| inspection.                                                                  |

|                                                                              |

| Based on the results of his inspection., the Inspector has determined that   |

| at least 6 violations of the Agency requirements occurred. In addition, the  |

| violations were identified by this Agency rather than through the Licensee   |

| conducting Radiation Protection Program (RPP) audits.                        |

|                                                                              |

| The Inspector reviewed five (5) total patients affected, since the last      |

| inspection by this Agency conducted on January 18, 2001.  Utilization logs   |

| indicate that this number could increase given a review of the patients      |

| treated prior to January 18, 2001, with the use of the stroutium-90 eye      |

| applicator.  Therefore, as discussed with the RSO during the exit briefing,  |

| additional information may be required of TSC before the Agency can make a   |

| determination to conclude this issue. The Inspector informed the Licensee    |

| that the number and characterization of apparent violations could change as  |

| a review Is conducted.                                                       |

|                                                                              |

| Inspection Findings: Items of Noncompliance                                  |

|                                                                              |

| 1.  Violation of 25 TAC §289.256(ee)(1)(a)(i):                               |

| The Licensee failed to report and notify this Agency of a dose that differs  |

| from the prescribed dose by more than 5 rem (0.05 Sv) effective dose         |

| equivalent, 50 rem (0.5 Sv) to an organ or tissue, or 50 rem (0.5 Sv)        |

| shallow dose equivalent to the skin and either:                              |

|                                                                              |

| a. the total dose delivered differs from the prescribed dose by 20% or       |

| more.                                                                        |

|                                                                              |

| 2.  Violation of 25 TAC §289.202(e)(1):                                      |

|                                                                              |

| The Licensee failed to conduct a Radiation Protection Program (RPP),         |

| sufficient to ensure compliance with the provisions of §289.202. The RPP was |

| not developed, documented, and implemented.                                  |

|                                                                              |

| 3.  Violation of 25 TAC §289.201(g)(1)(b):                                   |

|                                                                              |

| The Licensee exceeded the six-month leak test interval for a sealed source   |

| of radioactive material for a 100mCi Sr-90 source, S/N 0214, during the time |

| period from January 18, 2001 until June 4, 2003.                             |

|                                                                              |

| 4.  Violation of 25 TAC §289.256(p)(1)&(2):                                  |

|                                                                              |

| At the time of the inspection, the Licensee had failed to generate written   |

| directives signed and dated by an authorized user prior to administration of |

| Sr-90 Brachytherapy.                                                         |

|                                                                              |

| (i)   prior to implantation: the treatment site, the radionuclide, number of |

| sealed sources and dose; and                                                 |

| (ii)  after implantation but prior to completion of the procedure: the       |

| radionuclide, treatment site, number of sealed sources, total sealed source  |

| strength and exposure time or, equivalently, the total dose.                 |

|                                                                              |

| 5.  Violation of 25 TAC§289.256(bb)(6)(A)(B)(C)&(D):                         |

|                                                                              |

| The Licensee failed to determine the calibration measurements of             |

| Brachytherapy sealed sources.                                                |

|                                                                              |

| 6. Violation of 25 T,AC §289.256(i)(2)(A)&(B):                               |

|                                                                              |

| The Licensee's Radiation Safety Committee has not been composed of the       |

| required personnel. By evidence of the January 30, 2003 Radiation Safety     |

| Committee minutes that identifies representatives to attendance, the         |

| Radiation Safety Officer and an authorized user of type of use permitted     |

| (surgery) by the license, were not present.                                  |

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



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

|General Information or Other                     |Event Number:   39936       |

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

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

| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  UNITED DAIRYMAN OF AZ                |NOTIFICATION TIME: 15:55[EDT]|

|    CITY:  TEMPE                    REGION:  4  |EVENT DATE:        06/12/2003|

|  COUNTY:                            STATE:  AZ |EVENT TIME:        16:20[MST]|

|LICENSE#:  AZ-GL                 AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  GODWIN                       |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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

| ARIZONA LICENSEE, UNITED DAIRYMEN OF AZ, DISCOVERED A DAMAGED HYDROGEN 3     |

| EXIT SIGN                                                                    |

|                                                                              |

| At approximately 4:20 PM MST June 12, 2003, the Agency was informed by the   |

| General Licensee that they had discovered an EXIT sign containing Tritium    |

| was damaged. The sign contained 11.5 Curies of Tritium when installed.  The  |

| General Licensee had no idea when the sign was damaged, in fact, he was      |

| surprised to learn that it contained radioactive material.  The sign was a   |

| Safety Light Model XT.  When the Agency arrived on scene, it was determined  |

| that the light tubes were all missing for this sign.  One individual had     |

| used a ladder to attempt to replace the "light" bulbs since they were        |

| "burned" out.  Wet wipes taken of the remains of the sign did not detect     |

| hydrogen 3.   No one could tell the Agency of the condition of the glow      |

| tubes or where they are now located.  The sign was located in a 30,000       |

| square foot warehouse storing powdered milk. Evaporative coolers circulate   |

| cool air into the warehouse.                                                 |

|                                                                              |

| The Agency continues to investigate this incident.                           |

|                                                                              |

| The NRC and FBI will be notified of this event                               |

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



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

|Power Reactor                                    |Event Number:   39946       |

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

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

| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 06/17/2003|

|    UNIT:  [2] [3] []                STATE:  NY |NOTIFICATION TIME: 18:47[EDT]|

|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        06/17/2003|

+------------------------------------------------+EVENT TIME:        15:57[EDT]|

| NRC NOTIFIED BY:  SEAN EAGLETON                |LAST UPDATE DATE:  06/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |RAYMOND LORSON       R1      |

|10 CFR SECTION:                                 |HERB BERKOW          NRR     |

|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  |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| LOSS OF EMERGENCY SIREN CAPABILITY DUE TO EQUIPMENT FAILURE                  |

|                                                                              |

| "At 15:57 on 6/17/03, the network link used to activate all Emergency Sirens |

| was inoperable. As a result of the failed link, a total of 154 sirens in     |

| Westchester, Orange, Putnam and Rockland Counties in New York were           |

| inoperable. The network link was restored at 16:44 on 6/17/03; all Emergency |

| Sirens are currently operable.                                               |

|                                                                              |

| "Parties Notified: Westchester, Orange, Putnam and Rockland Counties, New    |

| York State and the IPEC NRC Resident Inspector were notified."               |

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



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

|Power Reactor                                    |Event Number:   39947       |

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

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

| FACILITY: RIVER BEND               REGION:  4  |NOTIFICATION DATE: 06/17/2003|

|    UNIT:  [1] [] []                 STATE:  LA |NOTIFICATION TIME: 23:35[EDT]|

|   RXTYPE: [1] GE-6                             |EVENT DATE:        06/17/2003|

+------------------------------------------------+EVENT TIME:        16:20[CDT]|

| NRC NOTIFIED BY:  SAM BELCHER                  |LAST UPDATE DATE:  06/17/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |DALE POWERS          R4      |

|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   |

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

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

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| HPCS SYSTEM RENDERED INOPERABLE DUE TO PERSONNEL ERROR                       |

|                                                                              |

| Text to follow from fax                                                      |

|                                                                              |

| "While performing scheduled maintenance activities on SWP-P2C, Standby       |

| Service Water Pump P2C, operators inadvertently removed an adjacent 4160     |

| volt switchgear breaker, E22-ACB002, which supplies the High Pressure Core   |

| Spray Pump, at 16:20 Central Daylight Time (CDT) on June 17, 2003 while      |

| operating at 100% power.  The HPSC pump breaker is adjacent to the SWP-P2C   |

| breaker on the same switchgear.  This action rendered the High Pressure Core |

| Spray system (HPCS) inoperable and unable to fulfill the HPCS safety         |

| function to mitigate the consequences of an accident.  This inadvertent      |

| action was immediately recognized by the control room operating team and     |

| immediate actions were taken to restore the system to operable.  The pump    |

| breaker was promptly restored and functional testing of the HPCS pump was    |

| completed at 16:36 CDT on June 17, 2003.  The High Pressure Core Spray       |

| system was restored to full operable status within 16 minutes.  All other    |

| divisional Emergency Core Cooling Systems (ECCS) were operable.  The Reactor |

| Core Isolation Cooling System (RCIC) was also operable during this time      |

| period.  Investigation into the removal of the HPCS pump breaker is in       |

| progress."                                                                   |

|                                                                              |

|                                                                              |

| The licensee informed the NRC resident inspector.                            |

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