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Event Notification Report for July 14, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           07/11/2003 - 07/14/2003



                              ** EVENT NUMBERS **



39949  39983  39990  39991  39992  39993  39994  



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|General Information or Other                     |Event Number:   39949       |

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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 06/19/2003|

|LICENSEE:  AGI GEOTECHNICAL                     |NOTIFICATION TIME: 14:30[EDT]|

|    CITY:  VAN NUYS                 REGION:  4  |EVENT DATE:        06/19/2003|

|  COUNTY:                            STATE:  CA |EVENT TIME:        07:30[PDT]|

|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/11/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DALE POWERS          R4      |

|                                                |DOUG BROADDUS        NMSS    |

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

| NRC NOTIFIED BY:  KATHLEEN KAUFMAN             |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| CALIFORNIA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE            |

|                                                                              |

| [DELETED] , Director LA County Radiological Health Management of the CA      |

| Radiological Health Branch and  [DELETED]  Senior Health Physicist           |

| [DELETED] ) called to report that a Moisture Density Gauge (50 milli-Curies  |

| Am-241 and 10 milli-Curies Cs-137) (Manufacture Campbell Pacific, Model MC1, |

| serial # 11114098)  was stolen from a truck at 7:30 AM PDT.  The truck was   |

| at  7-11 in Torrance, California and the driver was inside the 7-11.  The    |

| driver noticed the missing material after he drove away from the 7-11.  The  |

| licensee is AGI Geotechnical  [DELETED] ).  The Torrance Police Department   |

| was notified.                                                                |

|                                                                              |

| * * * UPDATE ON 7/10/03 AT 0707 PM VIA EMAIL FROM R. GREGER * * *            |

|                                                                              |

| "On 6/19/03 AGI Geotechnical, a CA licensee, reported the theft that morning |

| of one of its portable nuclear gauges from a convenience store in Torrance,  |

| CA.  The gauge was taken from the bed of the operator's parked pick-up truck |

| by someone who apparently cut the lock on the chain that locked the gauge to |

| the pickup truck.  The licensee reported the theft to the local police       |

| department and placed an ad in the local press offering a reward for the     |

| return of the gauge.  On 7/7/03 the licensee reported having received a call |

| from an individual in response to the reward ad.  The individual indicated   |

| that he knew who had stolen the gauge and where it was. The licensee         |

| retrieved the gauge that day and returned it to its offices in Van Nuys, CA. |

| A state inspector visited the licensee to physically inspect the gauge and   |

| confirm its identity.  The gauge appeared to be in a normal condition,       |

| undamaged, with no evidence of a radiological hazard.  However, the          |

| transport case for the gauge was cracked in several places and was missing   |

| DOT labels, so it would need to be replaced.  The licensee will have the     |

| gauge checked and leak tested by the manufacturer's service representative   |

| to ensure that the radioactive source was not damaged."                      |

|                                                                              |

| Notified TAS (Whitney) and R4DO (Kennedy).                                   |

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|General Information or Other                     |Event Number:   39983       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 07/08/2003|

|LICENSEE:  GUIDANT CORPORATION                  |NOTIFICATION TIME: 15:28[EDT]|

|    CITY:  PEARLAND                 REGION:  4  |EVENT DATE:        06/19/2003|

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

|LICENSE#:  L05178-000            AGREEMENT:  Y  |LAST UPDATE DATE:  07/08/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |KRISS KENNEDY        R4      |

|                                                |JOHN HICKEY          NMSS    |

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

| NRC NOTIFIED BY:  HELEN WATKINS                |                             |

|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT                                                       |

|                                                                              |

| Spill of radioactive material.  On 6/19/2003, an employee inadvertently      |

| dropped a vial of P-32 on the floor.  The container spilled approximately    |

| 2900 millicuries of P-32 on the floor while contaminating one employee and   |

| several pieces of the licensee's equipment.  The employee was decontaminated |

| on site.  An initial clean-up wash was performed on the facility.  However,  |

| the radiation levels remained high.  The RSO (Radiation Safety Officer)      |

| directed that the floors be covered with 2 sheets of 4 ft by 8 ft plexiglas. |

| In addition, the licensee covered contaminated equipment with lead sheeting  |

| to prevent  the spread of contamination and elevated radiation levels in the |

| vicinity of the equipment.  The licensee is waiting 10 half-lives to release |

| the facility for full use.  All personnel entering the area are notified of  |

| the contamination and are warned of the radiation levels and potential       |

| contamination.                                                               |

|                                                                              |

| The incident was not reported within 24 hours per regulations.  Levels       |

| exceed release criteria.  The incident is being investigated.                |

|                                                                              |

| This incident is being reported under 10 CFR 30.50(b)(1), and Texas          |

| requirement 289.202(xx)(7)(A).                                               |

|                                                                              |

| Texas incident number I-8034.                                                |

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|Power Reactor                                    |Event Number:   39990       |

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| FACILITY: SURRY                    REGION:  2  |NOTIFICATION DATE: 07/11/2003|

|    UNIT:  [1] [] []                 STATE:  VA |NOTIFICATION TIME: 13:24[EDT]|

|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        05/16/2003|

+------------------------------------------------+EVENT TIME:        07:14[EDT]|

| NRC NOTIFIED BY:  BARRY GARBER                 |LAST UPDATE DATE:  07/11/2003|

|  HQ OPS OFFICER:  MIKE RIPLEY                  +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |THOMAS DECKER        R2      |

|10 CFR SECTION:                                 |                             |

|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     N          N       0        Refueling Shutdow|0        Refueling Shutdow|

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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| INVALID EMERGENCY DIESEL START SIGNAL                                        |

|                                                                              |

| "The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not         |

| considered a Licensee Event Report.                                          |

|                                                                              |

| "With the unit in refueling shutdown and defueled, a loss of the 1B DC       |

| Electrical Bus occurred during maintenance activities associated with the 1B |

| Battery performance test.  The current leads from a load bank to the         |

| positive (+) terminal of the 1B Battery were being disconnected.             |

|                                                                              |

| "The Unit 1J Emergency AC Bus degraded and undervoltage protection relays,   |

| powered from the 1B DC Bus, deenergized and provided a start signal for the  |

| #3 Emergency Diesel Generator (EDG).  The #3 EDG started, however, the       |

| diesel did not load on the Unit 1J AC Bus due to the loss of control power   |

| to Unit 1J AC Bus circuit breakers.  The signal to start the #3 EDG on the   |

| emergency AC electrical power system was considered invalid because the Unit |

| 1 Emergency AC Bus did not experience an actual degraded/undervoltage        |

| condition.                                                                   |

|                                                                              |

| "Maintenance, Operations, and Engineering conducted a walkthrough of the     |

| restoration actions and step sequence and at 1252 hours, re-energized the 1B |

| DC Bus.  At 1550 hours, all loads were restored on 1B DC Bus.                |

|                                                                              |

| "The direct cause of the loss of the 1B DC Bus was the disconnection of the  |

| wrong battery discharge cables.  A root cause evaluation is being            |

| performed."                                                                  |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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

|Power Reactor                                    |Event Number:   39991       |

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| FACILITY: SURRY                    REGION:  2  |NOTIFICATION DATE: 07/11/2003|

|    UNIT:  [1] [] []                 STATE:  VA |NOTIFICATION TIME: 13:30[EDT]|

|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        05/23/2003|

+------------------------------------------------+EVENT TIME:        17:55[EDT]|

| NRC NOTIFIED BY:  BARRY GARBER                 |LAST UPDATE DATE:  07/11/2003|

|  HQ OPS OFFICER:  MIKE RIPLEY                  +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |THOMAS DECKER        R2      |

|10 CFR SECTION:                                 |                             |

|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|1     N          N       0        Refueling Shutdow|0        Refueling Shutdow|

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| INVALID EMERGENCY DIESEL START SIGNAL                                        |

|                                                                              |

| "The report is being made under 10 CFR 50.73(a)(2)(iv)(A) and is not         |

| considered a licensee Event Report.                                          |

|                                                                              |

| "With the unit in refueling shutdown and defueled, a loss of the 1B DC       |

| Electrical Bus occurred during maintenance activities associated with the 1B |

| Main Station Battery performance test.  The DC Bus voltage went to zero as a |

| result of the 1B-1 battery charger not assuming the load after the current   |

| sharing parallel charger 1B-2 was placed in stand-by.                        |

|                                                                              |

| "The Unit 1J Emergency AC Bus degraded and undervoltage protection relays,   |

| powered from the 1B DC Bus, deenergized and provided a start signal for the  |

| #3 Emergency Diesel Generator (EDG).  The #3 EDG started, however, it did    |

| not load on the Unit 1J AC Bus due to the loss of control power to Unit 1J   |

| AC Bus circuit breakers.  The signal to start the #3 EDG on the emergency AC |

| electrical power system was considered invalid because the Unit 1 Emergency  |

| AC Bus did not experience an actual degraded/undervoltage condition.         |

|                                                                              |

| "Operations personnel stripped the 1B DC Bus in accordance with abnormal     |

| procedures and restored the vital busses via manual transfer switches.       |

| Aligning the 1B-2 battery charger to the stripped bus reenergized the 1B DC  |

| Bus.                                                                         |

|                                                                              |

| "The direct cause of the loss of the 1B DC Bus was the failure of the 1B-1   |

| battery charger to pick up the load on the 1B DC Bus.  A root cause          |

| evaluation is being performed."                                              |

|                                                                              |

| The licensee notified the NRC Resident Inspector.                            |

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|Hospital                                         |Event Number:   39992       |

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

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| REP ORG:  WASHINGTON UNIVERSITY                |NOTIFICATION DATE: 07/11/2003|

|LICENSEE:  WASHINGTON UNIVERSITY                |NOTIFICATION TIME: 16:58[EDT]|

|    CITY:  ST. LOUIS                REGION:  3  |EVENT DATE:        07/09/2003|

|  COUNTY:                            STATE:  MO |EVENT TIME:        15:30[CDT]|

|LICENSE#:  24-00167-11           AGREEMENT:  N  |LAST UPDATE DATE:  07/11/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |MARK RING            R3      |

|                                                |SUSAN FRANT          NMSS    |

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

| NRC NOTIFIED BY:  SUSAN LANGHORST              |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

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

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| MEDICAL EVENT                                                                |

|                                                                              |

| The Radiation Safety Officer at Washington University reported that an under |

| dose of a radiopharmaceutical (Sm-153 Quadramet) was administered to a       |

| patient on 07/09/03.  The under dose was discovered at 1600 CDT on 7/10/03   |

| when it was determined that a significant amount of the radiopharmaceutical  |

| had leaked from the syringe.  The licensee determined that 54 millicuries    |

| out of the planned 55.8 millicuries had leaked from the syringe such that    |

| less than 4% of the planned dose was administered.  The licensee will be     |

| notifying the referring physician when he returns to his office on Monday,   |

| 07/14/03.  The licensee assumes the physician will then notify the patient.  |

|                                                                              |

| The licensee will provide a written report to Region 3.                      |

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|Power Reactor                                    |Event Number:   39993       |

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

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| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 07/11/2003|

|    UNIT:  [] [2] []                 STATE:  WI |NOTIFICATION TIME: 23:57[EDT]|

|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        07/11/2003|

+------------------------------------------------+EVENT TIME:        20:09[CDT]|

| NRC NOTIFIED BY:  RICK ROBBINS                 |LAST UPDATE DATE:  07/11/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK RING            R3      |

|10 CFR SECTION:                                 |TAD MARSH            NRR     |

|ACCS 50.72(b)(2)(iv)(A)  ECCS INJECTION         |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|2     N          N       0        Hot Standby      |0        Hot Standby      |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| MANUAL SAFETY INJECTION DUE TO PRESSURIZER LOW LEVEL                         |

|                                                                              |

| Unit 2 was in mode 3 with the main feedwater regulating valve controllers in |

| automatic.  Upon closure of the reactor trip breakers in preparation for     |

| critical approach, the main feed regulating valves opened causing a cooldown |

| of the reactor coolant system (RCS) and pressurizer low level.  The operator |

| response sequence included a manual reactor trip and manual safety           |

| injection.  There was no actual safety injection and the charging pumps made |

| up for the RCS shrinkage due to the cooldown.  Steam generator levels        |

| remained within their normal band range. A shutdown margin calculations was  |

| performed and verified satisfactorily.  All plant systems functioned as      |

| required and the unit is currently stable in mode 3.  The NRC Resident       |

| Inspector was in the Control Room during this incident.                      |

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



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

|Power Reactor                                    |Event Number:   39994       |

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

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

| FACILITY: FERMI                    REGION:  3  |NOTIFICATION DATE: 07/14/2003|

|    UNIT:  [2] [] []                 STATE:  MI |NOTIFICATION TIME: 01:57[EDT]|

|   RXTYPE: [2] GE-4                             |EVENT DATE:        07/13/2003|

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

| NRC NOTIFIED BY:  HARRY GILES                  |LAST UPDATE DATE:  07/14/2003|

|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |MARK RING            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       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| HPCI SYSTEM INOPERABLE AT FERMI 2                                            |

|                                                                              |

| "On 7/13/2003 at 2200 hours, while performing the HPCI Pump Time Response    |

| and Operability Test, the HPCI main steam supply outboard containment        |

| isolation valve, E4150F003, failed to close. The E4150F003 was declared      |

| inoperable and the HPCI main steam supply inboard containment isolation      |

| valve, E4150F002, was closed and de-activated per Technical Specifications.  |

| Isolating the HPCI main steam supply rendered HPCI inoperable. The E4150F003 |

| the was documented per the site corrective action process. All other ECCS    |

| equipment and RCIC are operable. This is being reported under                |

| 10CFR50.72(b)(3)(v)(D)."                                                     |

|                                                                              |

| The licensee notified the NRC Resident Inspector.  The licensee entered the  |

| applicable 14 day LCO for the HPCI system inoperability and initiated        |

| maintenance troubleshooting.                                                 |

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