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Event Notification Report for July 10, 2003




                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           07/09/2003 - 07/10/2003



                              ** EVENT NUMBERS **



39978  39979  39985  39986  39987  





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

|General Information or Other                     |Event Number:   39978       |

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

| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/07/2003|

|LICENSEE:                                       |NOTIFICATION TIME: 11:04[EDT]|

|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        07/06/2003|

|  COUNTY:  ARAPAHOE                  STATE:  CO |EVENT TIME:        16:00[MDT]|

|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/07/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |KRISS KENNEDY        R4      |

|                                                |MARISSA BAILEY       NMSS    |

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

| NRC NOTIFIED BY:  GREG STASINOS                |                             |

|  HQ OPS OFFICER:  GERRY WAIG                   |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| AGREEMENT STATE REPORT - STOLEN ASPHALT CONTENT OVEN                         |

|                                                                              |

| The following is taken from a facsimile sent from the Colorado Department of |

| Health and Environment:                                                      |

|                                                                              |

| On 7/6/03 at 2230 MDT Robin Koons, Colorado State Department of Health and   |

| Environment, was notified by the Arapahoe County Hazmat Response Team of the |

| theft of an asphalt content oven at a construction site located on Highway   |

| 36, mile marker 119 - 20 miles east of Byers, CO. Arapahoe County Hazmat     |

| responded to initiate an investigation into the incident. Initial            |

| information and indications pointed to a moisture density gauge being        |

| stolen. The moisture density gauge has been found and accounted for. The     |

| asphalt content oven contains a 100 milliCurie (plus or minus 10%) Americium |

| 241:Be source. The oven is used to test for oily content in asphalt during   |

| road construction process. The area is considered a crime scene and has been |

| secured.                                                                     |

|                                                                              |

| Colorado Case Number: 2003-372                                               |

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

|General Information or Other                     |Event Number:   39979       |

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

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

| REP ORG:  TENNESSEE DIV OF RAD HEALTH          |NOTIFICATION DATE: 07/07/2003|

|LICENSEE:  Radiological Assistance, Consulting, |NOTIFICATION TIME: 13:09[EDT]|

|    CITY:  Memphis                  REGION:  2  |EVENT DATE:        06/26/2003|

|  COUNTY:                            STATE:  TN |EVENT TIME:        18:00[EDT]|

|LICENSE#:  R-79266               AGREEMENT:  Y  |LAST UPDATE DATE:  07/07/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |JOEL MUNDAY          R2      |

|                                                |THOMAS ESSIG         NMSS    |

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

| NRC NOTIFIED BY:  Debra Shults                 |                             |

|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| AGREEMENT STATE REPORT                                                       |

|                                                                              |

| "The [Tennessee Division of Radiological Health] was notified on Monday,     |

| June 30, 2003 by three employees of RACE [Radiological Assistance,           |

| Consulting, & Engineering] of a contamination event that occurred on June    |

| 26, 2003. The employees were sorting and segregating materials contaminated  |

| with low-level radioactive waste. The waste had been delivered to RACE by a  |

| waste broker. The employees ended the shift and frisked for personnel        |

| contamination prior to exiting the building. Several employees alarmed the   |

| PCM and were decontaminated prior to release. One employee had high levels   |

| of skin contamination and underwent several hours of decontamination.        |

| Preliminary results from urinalyses are negative according to the licensee.  |

| The employees are undergoing whole body counts today. The shop area was      |

| closed for routine business and decontaminated.  It was opened on Sunday,    |

| June 29, 2003. DRH staff from Memphis and Nashville visited the site to      |

| begin the investigation. Staff continue to investigate and will continue to  |

| keep the NRC informed of the status of our investigation. This incident is   |

| reportable under 1200-2-5.141 (2)(c)1(i) of 'State Regulations for           |

| Protection Against Radiation.'"                                              |

|                                                                              |

| Tennessee Report ID:  TN-03-100                                              |

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



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

|Power Reactor                                    |Event Number:   39985       |

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

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

| FACILITY: COMANCHE PEAK            REGION:  4  |NOTIFICATION DATE: 07/09/2003|

|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 03:05[EDT]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/09/2003|

+------------------------------------------------+EVENT TIME:        01:09[CDT]|

| NRC NOTIFIED BY:  LES MILLER                   |LAST UPDATE DATE:  07/09/2003|

|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |KRISS KENNEDY        R4      |

|10 CFR SECTION:                                 |                             |

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

|AESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|2     A/R        Y       99       Power Operation  |0        Hot Standby      |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP BREAKER OPENING WITH      |

| INITIATION OF AUXILIARY FEEDWATER SYSTEM AFTER THE TRIP                      |

|                                                                              |

| "At 0109 hrs. CDT, Unit 2 reactor tripped due to opening of RCP [Reactor     |

| Coolant Pump] 2-04 breaker resulting in "Rx >48% 1/4 loop flow low trip".    |

| Cause of the breaker opening is unknown and under investigation.  All        |

| systems responded as required.  Auxiliary Feed Water auto-start occurred due |

| to steam generator shrink, both motor driver AFW pumps and Turbine Driven    |

| AFW pump started (ESF)."                                                     |

|                                                                              |

| All rods inserted into the core during the trip.  The electrical grid is     |

| stable.  There were no power-operated or manual relief valve lifts during    |

| the transient.  The other unit was not affected by the transient.  Decay     |

| heat is being removed via steam generator blowdown and AFW.  The plant is    |

| maintaining at NOP/NOT in mode 3 until the cause of the breaker trip is      |

| known and repaired.  Pressurizer pressure control is in automatic.  There is |

| no identified primary-to-secondary leakage.                                  |

|                                                                              |

| The licensee has informed the NRC Resident Inspector.                        |

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



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

|Hospital                                         |Event Number:   39986       |

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

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

| REP ORG:  UNIVERSITY OF WISCONSIN - MADISON    |NOTIFICATION DATE: 07/09/2003|

|LICENSEE:  UNIVERSITY OF WISCONSIN              |NOTIFICATION TIME: 18:07[EDT]|

|    CITY:  Madison                  REGION:  3  |EVENT DATE:        07/09/2003|

|  COUNTY:  Dane                      STATE:  WI |EVENT TIME:        13:00[CDT]|

|LICENSE#:  48-09843-18           AGREEMENT:  N  |LAST UPDATE DATE:  07/09/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |CHRIS MILLER         R3      |

|                                                |SUSAN FRANT          NMSS    |

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

| NRC NOTIFIED BY:  RONALD BRESELL               |                             |

|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

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

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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



                                   EVENT TEXT                                   

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

| MEDICAL EVENT                                                                |

|                                                                              |

| At 1300 CDT on 7/9/03, an underadministration of Yttrium-90 (Y-90) occurred  |

| at the University of Wisconsin Hospital in Madison, WI.  A patient being     |

| treated for secondary liver cancer was to receive a dose of approximately 50 |

| millicuries of Y-90.  The dose was delivered using a SIRTECH (Selective      |

| Radiation Implantation) to pulse microspheres of Y-90 from a vial into the   |

| liver via a needle and catheter.                                             |

|                                                                              |

| During the procedure, the SIRTECH did not develop enough pressure to deliver |

| the entire dose to the patient, and only about 8 percent of the Y-90 was     |

| delivered to the patient (between 3-4 millicuries).  The remainder of the    |

| Y-90 microspheres were contained within the vial.                            |

|                                                                              |

| There was no adverse affect on the patient due to this underadministration,  |

| and the licensee is still investigating how to prevent a re-currence.  The   |

| patient was notified of the underadministration.                             |

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



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

|Power Reactor                                    |Event Number:   39987       |

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

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

| FACILITY: DRESDEN                  REGION:  3  |NOTIFICATION DATE: 07/10/2003|

|    UNIT:  [] [2] [3]                STATE:  IL |NOTIFICATION TIME: 04:03[EDT]|

|   RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3           |EVENT DATE:        07/09/2003|

+------------------------------------------------+EVENT TIME:        22:00[CDT]|

| NRC NOTIFIED BY:  RON WIGGINS                  |LAST UPDATE DATE:  07/10/2003|

|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CHRIS MILLER         R3      |

|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   |

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

|                                                   |                          |

|2     N          Y       99       Power Operation  |99       Power Operation  |

|3     N          Y       99       Power Operation  |99       Power Operation  |

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

                                   EVENT TEXT                                   

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

| CONTROL ROOM HVAC REFRIGERATION AND CONDENSING UNIT TRIPPED DURING           |

| SURVEILLANCE TEST                                                            |

|                                                                              |

| "At 2200 hours on July 9, 2003, the B Control Room HVAC Refrigeration and    |

| Condensing Unit (RCU) tripped and would not stay running during surveillance |

| testing.  The RCU is a single train system and therefore is reportable per   |

| SAF 1.8 and LS-AA-1400, Event Reporting Guidelines Section 3.2.7.  The RCU   |

| is required to operate during a design basis accident to remove heat from    |

| the Main Control Room.  The Air Filtration Unit (AFU) of CREVS [Control Room |

| Emergency Ventilation System] remains operable.  This places both units in a |

| 30 day LCORA [Limiting Condition for Operation Required Action] per Tech     |

| Spec 3.7.5 Required Action A.1."                                             |

|                                                                              |

| The licensee has notified the NRC Resident Inspector.                        |

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



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