The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

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).                                                     |

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



!!!!!!!!! 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   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.                            |

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



                    

Page Last Reviewed/Updated Thursday, March 25, 2021