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Event Notification Report for March 31, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/30/2004 - 03/31/2004

** EVENT NUMBERS **

General Information or Other	Event Number: 40611
Rep Org: TENNESSEE DIV OF RAD HEALTH Licensee: SAINT FRANCIS HOSPITAL Region: 1 City: MEMPHIS State: TN County: License #: R-79104 Agreement: Y Docket: NRC Notified By: DEBRA SHULTS HQ OPS Officer: STEVE SANDIN	Notification Date: 03/26/2004 Notification Time: 14:53 [ET] Event Date: 03/25/2004 Event Time: 08:45 [EST] Last Update Date: 03/26/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RONALD BELLAMY (R1) ROBERTO TORRES (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A MISADMINSTRATION DURING EYE TREATMENT

"Event description: A pterygium patient was scheduled to receive a 42.5 second treatment utilizing a 100 millicurie Srontium-90 sealed source manufactured by 3M Company, model number 6D1A. The dosimetrist programmed the manual timer for 4 minutes and 25 seconds. During the treatment, the physician questioned the treatment time and it was terminated after 2 minutes and 30 seconds. The prescribed dose was 20 Gy. The patient received 70.59 Gy. The patient and the physician were notified of the misadministration. The licensee notified the Division the same day of the event. The licensee will submit a written report within 15 days. This incident is reportable under 1200-2-5-.32 (79) (e) (4) of 'State Regulations for Protection Against Radiation.'"

TN Event Report ID No.: TN-04-035

General Information or Other	Event Number: 40613
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: GLOBAL GEO ENGINEERING Region: 4 City: WEST COVINA State: CA County: License #: 6899-30 Agreement: Y Docket: NRC Notified By: BARBARA HAMRICK HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 03/27/2004 Notification Time: 19:00 [ET] Event Date: 03/26/2004 Event Time: 22:00 [PST] Last Update Date: 03/27/2004
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVID GRAVES (R4) PATRICIA HOLAHAN (NMSS) AARON DANIS (TAS) VICTOR GONZALES (MEX)

Event Text

STATE LICENSEE, GLOBAL GEO ENGINEERING, REPORTED A TROXLER GAUGE WAS STOLEN FROM A TECHNICIAN'S TRUCK.

A Troxler moisture/density gauge, Model 3430, with nominal activity of 10 mCi Cs-137 and 30 mCi Am-241, was stolen from the back of a flat bed truck sometime after 10:00 pm on 3/26/04, and before 5:00 am 3/27/04. The truck was parked at the technician's residence in West Covina. The technician involved worked late last night, and took the gauge home and left it chained to the flat bed truck overnight. The licensee contacted the West Covina PD. The licensee will be offering a $500 reward for the return of the gauge.

Power Reactor	Event Number: 40624
Facility: NINE MILE POINT Region: 1 State: NY Unit: [ ] [2] [ ] RX Type: [1] GE-2,[2] GE-5 NRC Notified By: RICHARD LANGE HQ OPS Officer: ARLON COSTA	Notification Date: 03/29/2004 Notification Time: 20:52 [ET] Event Date: 03/29/2004 Event Time: 17:22 [EST] Last Update Date: 03/30/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): KENNETH JENISON (R1)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
2	N	N	0	Refueling	0	Refueling

Event Text

OFFSITE NOTIFICATION OF A FATALITY

"The purpose of this report is to notify the NRC of a fatality involving a [contract] worker from Nine-Mile Point Unit 2, for which a news release is planned. Specifically, at 1541[EST], the Nine Mile Point Unit 2 Control Room was notified of an individual (located in a non-radiological area) experiencing dizziness and tightness in his chest. The Fire Brigade responded and requested an ambulance at 1558. At 1633, the worker left the site in an ambulance. At 1722, Nine Mile Point Unit 2 was notified that the individual passed away at Oswego Hospital."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 3/30/04 AT1433 EST FROM STEPHEN FREGEAU TO A. COSTA * * *

"The purpose of the report is to update and clarify the description of the fatality involving a worker at Nine-Mile Point Unit 2. The initial notification occurred on March 29, 2004 at 2052. The utility wants to clarify that this fatality was the result of a medical emergency and was not occupationally related. The utility [did not issue a press release for the initial event notification] does not plan on issuing a press release concerning this incident [update]."

The licensee notified the NRC Resident Inspector of this update.

Notified R1DO (Jenison).

Power Reactor	Event Number: 40625
Facility: QUAD CITIES Region: 3 State: IL Unit: [ ] [2] [ ] RX Type: [1] GE-3,[2] GE-3 NRC Notified By: JIM STORTZ HQ OPS Officer: BILL GOTT	Notification Date: 03/30/2004 Notification Time: 10:40 [ET] Event Date: 03/30/2004 Event Time: 07:40 [CST] Last Update Date: 03/30/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL	Person (Organization): MICHAEL PARKER (R3) TERRY REIS (NRR)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
2	A/R	Y	72	Power Operation	0	Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DURING TURBINE THRUST BEARING WEAR DETECTOR TESTING

"At 0740 hours [CST] during testing of the turbine thrust bearing wear detector, a main turbine trip occurred. This resulted in an automatic reactor scram due to turbine stop valve closure. Following the scram all Group II (Primary Containment) and Group III (Reactor Water Cleanup) isolations occurred as expected. All essential equipment functioned as required. Unit 2 remains in Mode 3 with reactor water level in the normal level band. An investigation into the Unit 2 turbine trip is in progress.

"Unit 1 was unaffected by the event and remains at 85% power."

All control rods fully inserted. Decay heat is being removed via steam to the main condenser using the bypass valves.

The Licensee notified the NRC Resident inspector.

Power Reactor	Event Number: 40626
Facility: POINT BEACH Region: 3 State: WI Unit: [ ] [2] [ ] RX Type: [1] W-2-LP,[2] W-2-LP NRC Notified By: CHARLES STALZER HQ OPS Officer: MIKE RIPLEY	Notification Date: 03/30/2004 Notification Time: 15:26 [ET] Event Date: 03/30/2004 Event Time: 12:15 [CST] Last Update Date: 03/30/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(i) - PLANT S/D REQD BY TS	Person (Organization): MICHAEL PARKER (R3) TERRY REIS (NRR)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
2	N	Y	100	Power Operation	82	Power Operation

Event Text

SAFETY INJECTION ACCUMULATOR LEVEL GREATER THAN ALLOWED BY TECHNICAL SPECIFICATION

"Unit 2 'A' Safety Injection Accumulator level was determined to be greater than level band allowed by technical specification 3.5.1 for Safety Injection Accumulators at 1127 [CST]. A power reduction in preparation for a normal reactor shutdown was commenced at 1215 in accordance with normal plant procedures.

"The Safety Injection Accumulator level instruments were in question due to one indicator being within the normal range and the other being off-scale high. During troubleshooting efforts, an ultra-sonic detector was used to verify 'A' Safety Accumulator tank level. The ultra-sonic detector indicated that level was above the high scale indication, and the accumulator was declared OOS due to being above the maximum accumulator volume allowed by SR 3.5.1.2 (<1136 cubic feet). The Unit 2 'B' Safety Injection Accumulator was unaffected by the event and remains operable.

"The Unit 2 'A' Safety Injection Accumulator level and pressure was returned to technical specification parameters at 1403. The Unit 2 shutdown was stopped with the unit at 82% power and actions are in progress to return to full power operation."

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 40628
Facility: SUMMER Region: 2 State: SC Unit: [1] [ ] [ ] RX Type: [1] W-3-LP NRC Notified By: ROBERT SWEET HQ OPS Officer: ARLON COSTA	Notification Date: 03/30/2004 Notification Time: 17:38 [ET] Event Date: 03/30/2004 Event Time: 11:29 [EST] Last Update Date: 03/30/2004
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): JOEL MUNDAY (R2)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	A/R	Y	10	Power Operation	0	Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LO-LO STEAM GENERATOR LEVEL

"On March 30, 2004, while at power, VCSNS [V.C. Summer Nuclear Station] personnel were performing a reactor building inspection to identify the source of reactor coolant system unidentified leakage that was within Technical Specification (TS) limits.

"At 1129 hours, a pressure boundary leak was identified at the seal injection line to reactor coolant pump 'C'.

"Pursuant to TS 3.4.6.2, Action a., VCSNS commenced a controlled reactor shutdown at 1410 on March 30, 2004.

"During the shutdown, the main turbine experienced higher than normal vibration. At 1516, the turbine was manually tripped at approximately 43% reactor power. Subsequent to the turbine trip, feedwater regulating valve IFV-498 failed in the closed position while in automatic with a full open demand signal. The cause of this failure is not known. The reactor automatically tripped at 1520 due to lo-lo level in the 'C' steam generator at 10% reactor power.

"All control rods fully inserted and all safety systems responded normally. Both motor driven emergency feedwater pumps started as required. The plant stabilized in mode 3."

The licensee notified the NRC Resident Inspector.