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Event Notification Report for August 5, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           08/04/2003 - 08/05/2003



                              ** EVENT NUMBERS **



39399  39972  40035  40042  40046  



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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!

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|Power Reactor                                    |Event Number:   39399       |

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| FACILITY: LASALLE                  REGION:  3  |NOTIFICATION DATE: 11/22/2002|

|    UNIT:  [] [2] []                 STATE:  IL |NOTIFICATION TIME: 21:17[EST]|

|   RXTYPE: [1] GE-5,[2] GE-5                    |EVENT DATE:        11/22/2002|

+------------------------------------------------+EVENT TIME:        16:50[CST]|

| NRC NOTIFIED BY:  JOHN J. REIMER               |LAST UPDATE DATE:  08/04/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        R3      |

|10 CFR SECTION:                                 |                             |

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

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

|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

|2     N          Y       97       Power Operation  |97       Power Operation  |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE                                 |

|                                                                              |

| "This report is being made pursuant to 10CFR50.72(b)(3)(v)(D), Event or      |

| Condition that could have prevented fulfillment of a Safety Function needed  |

| to Mitigate the Consequences of an Accident.  During inspection of the High  |

| Pressure Core Spray (HPCS) 2VY02A area cooler, missing sheet metal screws    |

| were discovered.  This could have prevented the High Pressure Core Spray     |

| System (HPCS), a single train safety system, from performing its design      |

| function during a seismic event. This also made the Division 3 Diesel        |

| Generator inoperable.  This is reportable as an 8 hour ENS notification.     |

|                                                                              |

| "The required actions of Technical Specification (TS) 3.5.1 were entered on  |

| 11/22/02 at 1650 when the system was made inoperable.  TS 3.8.1 does not     |

| require Division 3 Diesel Generator operability if HPCS is declared          |

| inoperable.  Preparations to replace the missing sheet metal screws are in   |

| progress.  All other Emergency Core Cooling Systems are operable at this     |

| time.  An extent of condition review will be performed on all divisions for  |

| both units."                                                                 |

|                                                                              |

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

|                                                                              |

|                                                                              |

| * * * UPDATE ON 11/23/02 @ 1333 BY CLARK TO GOULD * * *                      |

|                                                                              |

| "Subsequent to ENS notification EN #39399, repairs were affected to the HPCS |

| area cooler (2VY02A) and the system was returned to operable.   An extent of |

| condition inspection was performed on the remaining Unit 1 and Unit 2        |

| divisional area coolers.   During these inspections it was discovered that   |

| the Unit 1, Division 2 area cooler (1VY03A) was also missing several sheet   |

| metal screws.   The system was removed from service, repaired and returned   |

| to operable.   No problems were discovered on either of the two remaining    |

| Unit 1 divisional area coolers.                                              |

|                                                                              |

| During inspection on Unit 2, the Division 2 area cooler (2VY03A) was missing |

| all of its sheet metal screws.   At the time of discovery of the Division 2  |

| inoperability, the HPCS (Division 3) area cooler had already been repaired   |

| and declared operable.   It was determined however, that at some point both  |

| the HPCS (Division 3) and Division 2 Emergency Core Cooling System (ECCS)    |

| injection subsystems were under these conditions simultaneously.  Per        |

| Technical Specification (TS) 3.5.1 Bases when this combination of ECCS       |

| subsystems are inoperable, the plant is in a condition outside of the design |

| basis.                                                                       |

|                                                                              |

| Investigation of equipment and maintenance history will be performed to      |

| determine if any additional periods existed with multiple divisions under    |

| these conditions simultaneously.  At this time all divisional area coolers   |

| on both Units have been inspected.  Those with deficiencies have been        |

| repaired and declared operable."                                             |

|                                                                              |

| The NRC Resident Inspector was notified.                                     |

|                                                                              |

| Reg 3 RDO (Clayton) was informed.                                            |

|                                                                              |

| * * * RETRACTION ON 08/10/03 AT 1556 FROM LARRY R. BLUNK TO ARLON COSTA * *  |

| *                                                                            |

|                                                                              |

| "THIS REPORT CONCERNED THE DISCOVERY THAT THE COOLING COIL MOUNTING SCREWS   |

| FOR A NUMBER OF DIVISIONAL AREA COOLERS ON BOTH UNITS 1 AND 2 WERE NOT       |

| INSTALLED, WHICH COULD HAVE RENDERED THE ASSOCIATED ECCS SYSTEMS INOPERABLE  |

| DURING A SEISMIC EVENT.                                                      |

|                                                                              |

| "STRUCTURAL ANALYSES HAVE BEEN COMPLETED THAT DEMONSTRATE THAT THE SUBJECT   |

| DIVISIONAL COOLERS WERE OPERABLE WITH THE COOLING COIL MOUNTING SCREWS NOT   |

| INSTALLED.                                                                   |

|                                                                              |

| "THIS EVENT IS THEREFORE NOT REPORTABLE UNDER 10 CFR 50.72 (B)(3)(II)        |

| 'DEGRADED OR UNANALYZED CONDITION,' OR 10 CFR 50.72 (B)(3)(V)(D), 'EVENT OR  |

| CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION NEEDED  |

| TO MITIGATE THE CONSEQUENCES OF AN ACCIDENT.'                                |

|                                                                              |

| "THE SENIOR RESIDENT INSPECTOR HAS BEEN NOTIFIED."                           |

|                                                                              |

| Notified the R3DO (Christine Lipa).                                          |

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|Power Reactor                                    |Event Number:   39972       |

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

| FACILITY: SEQUOYAH                 REGION:  2  |NOTIFICATION DATE: 07/02/2003|

|    UNIT:  [1] [2] []                STATE:  TN |NOTIFICATION TIME: 00:17[EDT]|

|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/01/2003|

+------------------------------------------------+EVENT TIME:        18:45[EDT]|

| NRC NOTIFIED BY:  KEN STEVENS                  |LAST UPDATE DATE:  08/04/2003|

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

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

|EMERGENCY CLASS:          NON EMERGENCY         |JOEL MUNDAY          R2      |

|10 CFR SECTION:                                 |HAROLD CHRISTENSEN   R2      |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |ROBERTA WARREN       TAS     |

|NINF                     INFORMATION ONLY       |                             |

|                                                |                             |

|                                                |                             |

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

|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  |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| UNACCOUNTED FOR SECURITY WEAPON                                              |

|                                                                              |

| Unaccounted for security weapon. Immediate compensatory measures taken upon  |

| discovery.  TVA security and NRC Resident Inspector notified.  Refer to HOO  |

| Log for additional details.                                                  |

|                                                                              |

| * * * UPDATE ON 07/02/03 AT 0150 FROM HERBERT EAVES TO ARLON COSTA * * *     |

|                                                                              |

| TVA Police made offsite notification on 07/01/03 at 2300 EDT to the National |

| Crime Information Center pertaining to the unaccounted for security weapon.  |

| The NRC Resident Inspector will be notified of this event update.            |

|                                                                              |

| * * * UPDATE on 07/03/03 AT 1526 EDT FROM BONNIE SCHMETZLER TO MACKINNON * * |

| *                                                                            |

|                                                                              |

| Security weapon not found on site. Investigation being continued by TVA      |

| police. The NRC Resident Inspector will be notified of this update. R2DO     |

| (Joel Munday) & NSIR (Roberta Warren) notified.                              |

|                                                                              |

| * * * UPDATE ON 08/04/03 AT 1648 FROM MITCH TAGGERT TO ARLON COSTA * * *     |

|                                                                              |

| Unaccounted for security weapon was found. Plant security is investigating   |

| the incident. Refer to HOO Log for additional details.                       |

|                                                                              |

| The NRC Resident Inspector will be notified.  Notified R2DO (James Moorman)  |

| and TAS (Matt Kormann).                                                      |

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|General Information or Other                     |Event Number:   40035       |

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| REP ORG:  MA RADIATION CONTROL PROGRAM         |NOTIFICATION DATE: 07/30/2003|

|LICENSEE:  WHEELABRATOR                         |NOTIFICATION TIME: 12:56[EDT]|

|    CITY:  DORCHESTER               REGION:  1  |EVENT DATE:        07/30/2003|

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

|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/30/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |JAMES NOGGLE         R1      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  MARIO IANNACCONE             |                             |

|  HQ OPS OFFICER:  BILL GOTT                    |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT ON DAMAGED GENERALLY LICENSED LEVEL GAUGE             |

|                                                                              |

| "On 7/28/03 Wheelabrator became aware that a TN [Texas Nuclear] Level Gauge, |

| Cs-137 100 mCi [milli Curie] [Model Number: 5197] SN # B728 (SS&D No.        |

| TX634D119B) had gone missing.  Plant was in shutdown and work was being      |

| performed on the associated hopper.  The gauge was removed not following     |

| standard procedure.   A search of the premises was conducted with negative   |

| results.  A consultant was hired, and located the gauge in a scrap metal     |

| pile on the morning of 7/30/03.  The shielding was partially melted away, it |

| was surmised that the gauge may have passed through the boiler. The          |

| consultant performed radiation surveys and placed the gauge in a metal       |

| container in the storage area.  The manufacturer was contacted, arrangements |

| will be made to return the gauge.                                            |

|                                                                              |

| "Cause description: Gauge removed from frame to accommodate work taking      |

| place on hopper (steel replacement).                                         |

|                                                                              |

| "Precipitating factor: Not secured in storage area; typically used a secure  |

| holding area prior to shipping/installation."                                |

|                                                                              |

| State Event Number: MA 03-0023                                               |

|                                                                              |

| Wheelabrator is located at 100 Salem Turnpike, Saugus, MA.                   |

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|General Information or Other                     |Event Number:   40042       |

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| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 07/31/2003|

|LICENSEE:  RUSH COPLEY MEDICAL CENTER           |NOTIFICATION TIME: 17:50[EDT]|

|    CITY:  AURORA                   REGION:  3  |EVENT DATE:        07/28/2003|

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

|LICENSE#:  IL-01207-01           AGREEMENT:  Y  |LAST UPDATE DATE:  08/01/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |BRUCE BURGESS        R3      |

|                                                |DANIEL GILLEN        NMSS    |

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

| NRC NOTIFIED BY:  JOE KLINGER                  |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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

| AGREEMENT STATE REPORT - MEDICAL EVENT                                       |

|                                                                              |

| The following information was received via e-mail from the Illinois          |

| Department of Nuclear Safety:                                                |

|                                                                              |

| "Abstract:                                                                   |

|                                                                              |

| "The agency [Illinois Department of Nuclear Safety] received a call July 29, |

| 2003 from a nuclear medicine technician, at Rush Copley Medical Center in    |

| Aurora, IL [deleted].  She reported that a patient who was to receive a 4    |

| milliCi unit dose of Tl-201 [Thallium-201] for a heart test instead received |

| a 4 milliCi unit dose of I-131 [Iodine-131] on July 28, 2003.                |

|                                                                              |

| "Circumstances surrounding the event, as reported by the technician,         |

| indicate that both the exterior lead container and syringe were labeled as   |

| being Tl-201.  Although the injection occurred the previous day it was not   |

| determined that I-131 was involved until after the gamma cameras used for    |

| patient imaging were checked a second time on the morning of July 29th.      |

| Service engineers had been called to the site both days to inspect the       |

| cameras after both failed attempts to image the patient.  The cause became   |

| evident when a gamma camera flood source that had been made from what was    |

| thought to be the remaining Tl-201 material in the syringe from 7/29/2003    |

| showed peaks consistent with I-131.  The assayed amount from Monday's        |

| records showed the dose to be within the expected range for a typical 4      |

| milliCi Tl-201 diagnostic doses and as such, was considered to be normal.    |

| The technician indicated that the patient involved had been contacted by the |

| referring physician, the onsite oncologists, the hospital Administrator and  |

| lawyer and was informed as to what had happened.  The hospital has arranged  |

| to perform routine blood analysis throughout the year to monitor any changes |

| in thyroid activity.                                                         |

|                                                                              |

| "The RSO [Radiation Safety Officer] and oncologist at the facility,          |

| [deleted], were then contacted by the Agency.  He indicated that it is very  |

| unlikely that any changes will be noted in the patient.  He reports that the |

| dose administered, is only slightly larger than that typically ordered for   |

| whole body scans using I-131.  Regardless, they have offered to provide      |

| routine blood testing of the patient throughout the year for T3, T4 and T7   |

| thyroid hormones levels as part of a follow up evaluation.                   |

|                                                                              |

| "A call was then made to the Medi Physics/Amersham Health, [deleted] Wood    |

| Dale pharmacy facility where the doses had been prepared the previous        |

| Friday.  [Deleted], Corporate RSO indicated that they were in the process of |

| determining what had occurred but it appeared that when prescriptions and    |

| labels were taken from the computer system a 4 milliCi Tl-201 prescription   |

| was mistakenly put in with 4 other prescriptions for 4 milliCi unit doses of |

| I-131 to be filled. Subsequently, the Tl-201 request was mistakenly filled   |

| as an I-131 prescription. The difference in nuclides was not noted by the    |

| pharmacist when the pre-generated Tl-201 labels were applied to the syringe  |

| and lead container which now held I-131.                                     |

|                                                                              |

| "The Agency sent an investigator to the medical center on the morning or     |

| July 30 to observe the labeling on the container and syringe, receipt        |

| records, gamma camera QA tests and to verify by gamma spectrum analysis the  |

| presence of I-131 as well as to conduct preliminary interviews to obtain     |

| additional facts.  The investigation then moved on to the pharmacy to        |

| continue their review of the event.  Based on those visits, the information  |

| obtained largely confirmed the preliminary notification.  The Agency is      |

| continuing its investigation of the matter and is expecting reports to be    |

| filed by both parties according to regulatory requirements.                  |

|                                                                              |

| "Preliminary estimates of EDE to the whole body of 355 Rem and 11,672 Rad to |

| the thyroid based on ICRP 53 modeling assuming 55% uptake and standard man   |

| conditions has been calculated.  Similar preliminary estimates based on the  |

| package insert assuming 25% uptake resulted in 1,628 Rads and 5,328 Rads     |

| respectively.  The two estimates vary widely because of unknown factors      |

| associated with the patient's condition.  NRC Operations Center was notified |

| of the event at 17[50] on 31 July 2003 and assigned Event Number 40042."     |

|                                                                              |

| *** UPDATED AT 1705 EDT ON 8/1/03 FROM KLINGER TO CROUCH ***                 |

|                                                                              |

| Last paragraph of above report was amended to read as follows:               |

|                                                                              |

| "Preliminary estimates of dose to the thyroid range from 5,300 Rads to       |

| 11,700  Rads.  The two estimates vary widely because of unknown factors      |

| associated with the patient's condition.  NRC Operations Center was notified |

| of the event at 1750 E.S.T  on 31 July 2003 and assigned Event Number        |

| 40042."                                                                      |

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|Power Reactor                                    |Event Number:   40046       |

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

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| FACILITY: HADDAM NECK              REGION:  1  |NOTIFICATION DATE: 08/04/2003|

|    UNIT:  [1] [] []                 STATE:  CT |NOTIFICATION TIME: 10:44[EDT]|

|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        08/04/2003|

+------------------------------------------------+EVENT TIME:        10:15[EDT]|

| NRC NOTIFIED BY:  MICHAEL HEYL                 |LAST UPDATE DATE:  08/04/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |

|10 CFR SECTION:                                 |                             |

|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          N       0        Decommissioned   |0        Decommissioned   |

|                                                   |                          |

|                                                   |                          |

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

                                   EVENT TEXT                                   

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

| OFFSITE NOTIFICATION TO STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL     |

| PROTECTION                                                                   |

|                                                                              |

|                                                                              |

| APPROXIMATELY ONE TEASPOON OF DIESEL FUEL OIL CONTACTED THE SOIL WHEN THE    |

| RAIN WASHED IT OFF THE TOP OF A PORTABLE FUEL OIL TANK.  THE AREA WAS        |

| CLEANED UP.  THE PORTABLE FUEL OIL TANK WAS MOVED TO A PAVED SURFACE.  THE   |

| LICENSEE NOTIFIED THE STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL       |

| PROTECTION OF THE OIL SPILL.                                                 |

|                                                                              |

| NRC RESIDENT INSEPCTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE.           |

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