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Event Notification Report for September 24, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/23/2003 - 09/24/2003

** EVENT NUMBERS **


40005 40169 40180 40191 40192 40194 40195 40196

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General Information or Other Event Number: 40005
Rep Org: GENERAL ELECTRIC COMPANY
Licensee: GENERAL ELECTRIC COMPANY
Region: 4
City: SAN JOSE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JASON POST
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/18/2003
Notification Time: 12:13 [ET]
Event Date: 07/18/2003
Event Time: [PDT]
Last Update Date: 09/24/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JACK FOSTER (NRR)
ANIELLO DELLA GRECA (R1)
JOHN MADERA (R3)
LINDA SMITH (R4)

Event Text

PART 21 REPORT INVOLVING IMPACT OF FUEL CHANNEL BOW ON CONTROL ROD BLADES

The following is a portion of text received as a fax:

"July 18, 2003
"MFN 03-045

"Subject: 60 Day Interim Notification: Impact of Fuel Channel Bow on Control Rod Blade Deviations

"Reference: Letter from Jason Post (GENE) to USNRC, 'Interim Surveillance Program for Fuel Channel Bow Monitoring', MFN 03-030 Revision 1, April 30, 2003

"This communication is to inform you that GE Nuclear Energy (GENE) has been evaluating a potentially reportable condition (PRC) on the impact of fuel channel bow on control rod blades. The original channel bow evaluation for increased fuel channel - control rod blade interference did not consider previously evaluated deviations in the control rod blade. Channel bow can cause increased deflection and stresses in control rod blades, which must be considered in control rod blade deviation evaluations. The PRC evaluation is limited to control rod blades delivered to those plants identified in the referenced letter, where an interim surveillance plan for channel bow monitoring is recommended, because those are the only plants where there is a concern about increased fuel channel - control rod blade interference.

"As described in the referenced letter, it was determined that BWR/6 and BWR/4 & 5 C-lattice plants with Global Nuclear Fuel (GNF) thick/thin channels potentially have increased channel bow that can cause fuel channel control rod blade interference. An interim surveillance program was provided to augment the surveillance requirements in the plant Technical Specifications until other actions, which mitigate or limit the potential for control rod - fuel channel interference due to channel bow can be identified and implemented. This surveillance program provides early indication of potentially degraded operational performance and assurance that action is taken before reaching excessive levels of control rod interference. This surveillance plan is limited to BWR/6 and BWR/4&5 C-lattice plants with GNF thick/thin channels and GENE control rods. There have been no indications of excessive interference on BWR/2, 3 and 4 D-lattice plants, and as a result, they are excluded from the interim surveillance program.

"The PRC evaluation was initiated by GENE on May 19, 2003. GENE will not have completed the evaluation by July 18, 2003, when the 60 day evaluation period expires. Therefore, GENE is submitting this 60 Day Interim Notification under 10CFR21.21(a)(2) to inform the NRC that we are working on the issue, and to commit to report the results
of the evaluation no later than September 23, 2003."

GE Nuclear Energy has identified the following as affected plants: Clinton, Nine Mile Point 2, Fermi 2, Grand Gulf, River Bend, Limerick 1 & 2 and Perry 1.

*****UPDATE ON 9/24/03 AT 0055 FROM POST TO LAURA*****

GE submitted its 60 day update letter which indicated no change from previously submitted information.

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General Information or Other Event Number: 40169
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHICAGO PROSTATE CANCER CENTER
Region: 3
City: WESTMONT State: IL
County:
License #: IL-02015-01
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 09/18/2003
Notification Time: 12:33 [ET]
Event Date: 09/16/2003
Event Time: [CDT]
Last Update Date: 09/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
C.W. (BILL) REAMER (NMSS)

Event Text

AGREEMENT STATE REPORT -- MISSING IODINE-125 SEEDS

The following was received via email from the State of Illinois:

"On 9/16/2003, the agency was contacted by [DELETED] RSO at the Chicago Prostate Cancer Center in Westmont, IL (IL-02015-01). He indicated that on 9/11/2003, a package of unused radioactive seeds was being prepared to be returned to Amersham Health/Medi Physics in Arlington Heights, IL. At that time they noted that the package contained only 6 'strands' of sources whereas the paperwork for receipt on 9/4/2003 indicated 7 'strands' of sources to be present.

"The I-125 seeds are contained in a special rigid plastic carrier. This carrier has a marketing name of 'rapid strand'. Each 'strand' contains ten I-125 seeds in a rigid plastic holder which is then placed in a stainless steel holder with an opening at one end. When the seeds are in the holder, radiation readings are at or very near background levels of radiation. This holder has been sterilized at Medi Physics and as a result it is placed in a sealed pouch until it is ready to be used in the operating room. A full description with some diagrams can be found at http://www.hsrd.ornl.gov/sources/pdf/01360338.pdf.

"The package containing the six strands of seeds was picked up by Federal Express and returned to Medi Physics on 9/17/2003. [DELETED], RSO of Medi Physics participated in the inspection of the package to be sure that the problem was not just an administrative error. His inspection did not turn up the missing 7th strand. An inspection of previously used shipping containers from this site that had been returned to Medi Physics did not result in the recovery of the missing strand either. [DELETED] also had production perform an accounting check as well to see if perhaps only 6 strands had been originally shipped as a mistake. The check showed no outstanding seeds or strands from that lot that could not be accounted for, or shipped to another client as a result of a substitution.

"An agency inspector also visited the Chicago Prostate Cancer Center in Westmont on 9/17/2003 and attempted to locate the strand through radiation monitoring. He was not successful in recovering the strand. As a result, one strand containing a total activity of 5.94 [milliCuries] mCi (10 seeds with 594 micro Curie each) is missing. The licensee will continue its attempts to locate the missing seeds and will keep the agency updated with its efforts. The licensee was also advised that a written report is due to the Agency in 30 days."

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General Information or Other Event Number: 40180
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY SERVICES
Region: 4
City: SCOTTSDALE State: AZ
County:
License #: AZ-07-161
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: ERIC THOMAS
Notification Date: 09/19/2003
Notification Time: 13:00 [ET]
Event Date: 09/17/2003
Event Time: 13:00 [MST]
Last Update Date: 09/19/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"At approximately 1:00 PM September 17, 2003 the Agency was informed of a medical event. The reporting individual indicated that in the course of treating a breast cancer, a saline filled balloon was used to aid in positioning the HDR source, Iridium 192, approximately 9.589 curies. Starting September 15, 2003, a series of 10 fractional treatments was prescribed. Between each, an ultra sound image was made to assure the continued proper placement of the source. The ultra sound technician indicated all was ok for all treatments. After the series was completed, the balloon was deflated for removal and the physician then noted that the balloon had ruptured. A review of the retained ultra sound images indicated [that] starting with treatment 7 the balloon was deflated. The doses were recalculated and the tissue dose was 40 [percent] higher than prescribed. The adjacent skin dose was calculated to be 266 cGy [centigray] rather than the 175 cGy [centigray] as originally calculated. The licensee has proposed corrective measures to prevent a recurrence of this event. The balloon manufacturer has been informed of this event.

"The patient has been informed of the event. The medical review indicates some additional fat necrosis and possible inflammation may occur. It will be reviewed as a part of the patient follow up."

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Power Reactor Event Number: 40191
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DALE DAWSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/23/2003
Notification Time: 02:44 [ET]
Event Date: 09/22/2003
Event Time: 22:43 [CDT]
Last Update Date: 09/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GREG PICK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 78 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM RECEIVED DURING MAIN TURBINE CONTROL VALVE TESTING

"At 2243 on 9/22/2003 a Reactor scram occurred while performing Main Turbine control valve testing. Preliminary investigations indicate that high Reactor pressure was the signal that caused the scram. As a result of the scram, a Reactor low level 3 (9.7 inch) signal was received as expected from a high power scram due to the rapid coolant shrinkage. All expected actions for the low reactor level 3 (9.7 inch) signal occurred as expected. The plant is stable in Mode 3 (hot shutdown) with level being controlled with the Feedwater System and Reactor pressure being controlled with the Main Turbine Bypass valves."

All control rods fully inserted, no ECCS actuations were received, and the electrical grid is stable. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40192
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: RICH LAURA
Notification Date: 09/23/2003
Notification Time: 11:15 [ET]
Event Date: 09/23/2003
Event Time: 04:00 [EDT]
Last Update Date: 09/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ANNE BOLAND (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNANALYZED CONDITION DUE TO POTENTIAL RCS LEAKAGE AT OCONEE 1

"During a scheduled bare metal visual inspection of the Unit 1 reactor vessel head prior to RV head retirement, evidence of possible through wall leakage was observed on two control rod drive mechanism (CRDM) and one thermocouple (T/C) penetrations (nozzles 6 and 16 and T/C nozzle 7). Of these locations, only the T/C had been previously repaired (plugged) in December 2000.

"Initial Safety Significance: Any RCS leakage from these penetrations would have been below the threshold of measurability by the reactor coolant system leakage measurement process. Total measured RCS leakage prior to unit shutdown was varying between 0.15 gallons per minute and .24 gallons per minute.

"Corrective Action: The reactor vessel head is scheduled for replacement during the present refueling outage. Therefore, there are no plans at this time to perform additional inspections or repairs on the current head."

The NRC Resident Inspector was notified.

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Power Reactor Event Number: 40194
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: RANDY CADE
HQ OPS Officer: ERIC THOMAS
Notification Date: 09/23/2003
Notification Time: 15:04 [ET]
Event Date: 09/23/2003
Event Time: 13:20 [CDT]
Last Update Date: 09/23/2003
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GREG PICK (R4)
TERRY REIS (NRR)
RICHARD WESSMAN (IRO)
GENE CANUPP (FEMA)
ODELL BARTLETT (DOE)
SAL MORONE (DHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNUSUAL EVENT

"While in Mode 5, refueling Shutdown with Core offload in progress a fuel assembly in the Spent Fuel Pool became ungrappled. The assembly is currently sitting on the top of the Spent Fuel pool racks resting against the Pool wall at approximately 15 degrees. There is no damage to the Fuel Assembly, evident by no change in area radiation dose rates. EAL 1.14, Plant Conditions Warrant Increased Awareness By Plant Staff or Government Authorities. An investigation has begun to determine the cause of the event and a team is being assembled to plan the fuel bundle recovery."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 9/23/03 AT 1857 EDT FROM RANDY CABE TO GERRY WAIG * * *

The licensee remains in a NOUE (Notice of Unusual Event) due to the ungrappled spent fuel assembly. The position of the spent fuel assembly remains the same as previously reported. No damage to the fuel assembly nor the spent fuel rack has been detected. No abnormal radiation readings have been observed. As a precaution, the licensee has suspended all fuel movement operations and evacuated the auxiliary and containment buildings. The licensee plans to stabilize the fuel assembly, attach a lifting tool, and place it into a permanent storage position in the spent fuel pool.

Notified R4DO (Greg Pick)

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Power Reactor Event Number: 40195
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: AL CLARK
HQ OPS Officer: GERRY WAIG
Notification Date: 09/23/2003
Notification Time: 15:15 [ET]
Event Date: 09/23/2003
Event Time: 12:27 [CDT]
Last Update Date: 09/23/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
GREG PICK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

SAFEGUARD SYSTEM VULNERABILITY DISCOVERED BY FT CALHOUN

The licensee discovered a vulnerability in a safeguard system that could have allowed access to a controlled area for which compensatory measures had not been employed. The licensee has notified the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 40196
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GORDON ROBINSON
HQ OPS Officer: RICH LAURA
Notification Date: 09/24/2003
Notification Time: 03:20 [ET]
Event Date: 09/24/2003
Event Time: 00:53 [EDT]
Last Update Date: 09/24/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
TODD JACKSON (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC SCRAM AT SUSQUEHANNA ON LOW WATER LEVEL

"At 0053 hours on September 24, 2003 with Susquehanna Unit 1 operating at 100% power an automatic reactor scram occurred due to low water level. At the time of the scram, reactor feed pump testing was in progress and the 'C' reactor feed pump tripped. The reactor recirc pumps runback initiated as expected when water level reached 30" with the feed pump tripped. Level continued to drop and reached the Level 3 auto scram setpoint. Level continued to drop and reached a low level of approximately -48" wide range. Reactor Core Isolation Cooling and High Pressure Coolant Injection auto started at their initiation setpoints and injected to the vessel to recover level. All level 2 and 3 containment isolations occurred as expected. The reactor recirc pumps tripped as expected when level 2 was reached. Reactor Pressure was controlled with bypass valves, there were no Safety Relief Valve lifts. There are no challenges to containment.

"Unit 1 is currently stable in Mode 3 with both reactor recirc pumps restarted. A human performance error was the cause of the reactor feed pump trip. Investigation is continuing into the plant response to the reactor feed pump trip."

The NRC Resident Inspector was notified of this event.

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