United States Nuclear Regulatory Commission - Protecting People and the Environment

Morning Report for November 5, 1999

                       Headquarters Daily Report

                         NOVEMBER 05, 1999

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                    REPORT             NEGATIVE            NO INPUT
                    ATTACHED           INPUT RECEIVED      RECEIVED

HEADQUARTERS                           X
REGION I            X
REGION II                              X
REGION III                             X
REGION IV                              X
PRIORITY ATTENTION REQUIRED  MORNING REPORT - REGION I  NOV. 05, 1999

Licensee/Facility:                     Notification:

                                       MR Number: 1-99-0043
The Medical Center At Princeton        Date: 11/04/99
Princeton,New Jersey                   NRC Operations Center
Dockets: 03002489 License No: 29-06750-01

Subject: BRACHYTHERAPY INCIDENT

Discussion:

On November 4, 1999, the licensee notified the NRC Operations Center of
an incident during a brachytherapy procedure.  At 0915 hours on November
4, 1999, a patient undergoing a brachytherapy procedure notified the
hospital staff that the brachytherapy source applicator had become
dislodged.  The hospital staff contacted the authorized user that had
inserted the sources and were instructed to relocate the applicator to
the foot of the bed.  The hospital's physicist estimates that the source
was in the vicinity of the patient's thigh for approximately 15 minutes
and at the foot of the bed for another 18 minutes before being placed in
a lead container.  The patient was scheduled to be treated for 22.79
hours with 21.8 milligram radium equivalent (54.8 millicurie) cesium-137
sources.  The actual treatment time was 18.45 hours.  The licensee is in
the process of calculating the local area dose to the patient's thigh and
feet.  The patient's referring physician will be notified.  According to
the authorized user, the patient did not receive any adverse health
consequences from this incident.

Regional Action:

On November 9, 1999, an NRC inspection will be conducted to follow up on
this incident.

Contact:  Penny Lanzisera            (610)337-5169
          Mohamed Shanbaky           (610)337-5209
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REGION I  MORNING REPORT     PAGE  2          NOVEMBER  5, 1999

Licensee/Facility:                     Notification:

New York Power Authority               MR Number: 1-99-0044
Indian Point 3                         Date: 11/05/99
Buchanan,New York                      PE/PC
Dockets: 50-286
PWR/W-4-LP

Subject: SUBSTANDARD GASKET MATERIAL FOR THE MAIN TURBINE TRIP OIL SYSTEM

Discussion:

During November 3-4, IP3 had to take the main turbine offline to replace
a defective gasket in the turbine trip oil system.  The gasket was of the
wrong material and had been supplied by Westinghouse, who may have also
supplied the same material to other plants.

NYPA became aware of a problem with substandard gasket material after it
caused a turbine/reactor trip at St. Lucie on October 29, 1999.  The
St. Lucie trip occurred 14 days after on-line power operations and it was
traced to the installation of a substandard gasket in the main turbine
trip oil system by a Siemens-Westinghouse work group during a recent
outage.  Because of the short duration for failure, IP3 began a prompt
shutdown on November 3.  Once the turbine was off-line, the main turbine
trip oil system was opened, and the gasket for the low bearing oil trip
device was inspected.  NYPA maintenance workers noted that a leak had
already developed and there was a visible tear through the body of the
gasket.  The gasket was replaced and the plant returned to power.

NYPA had previously identified that there were three sensors in the
turbine trip oil system in which the substandard gasket material could
have been installed.  The potential locations included the main bearing
oil pressure sensor, the turbine vacuum sensor, or the thrust bearing
sensor. Based on a detailed review of the material in the warehouse and
the material records for the gaskets they received, NYPA concluded that
the faulty gasket had to have been installed in the main bearing oil
pressure sensor.  This was later confirmed through the off-line
inspection. NYPA also concluded that the gaskets installed in the other
locations were acceptable.

Preliminary indications are that the inferior gaskets have been supplied
to utilities using Westinghouse turbine generators starting in April
1999.  Five nuclear plants are believed to have received the gaskets and
they include St. Lucie, IP3, Salem, Robinson, and Arkansas Nuclear One.
St. Lucie and IP-3 both have had outages since April and have been
adversely affected by the bad gasket material Salem has identified and
removed the substandard material from their warehouse.  The affected
plants and Westinghouse are aware of the problem.  The material has been
identified as being of substandard construction under a valid
Westinghouse part number being supplied by an as yet to be identified
sub-supplier.

Regional Action:

Routine Resident Follow-up.  Forwarded for review of generic
implications.

REGION I  MORNING REPORT     PAGE  3          NOVEMBER  5, 1999
MR Number: 1-99-0044 (cont.)


Contact:  John Rogge                 (610)337-5146
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