Event Notification Report for May 17, 2001

NOTIFICATION OF THE OCONEE COUNTY SHERIFF'S OFFICE

The switchboard was notified by an individual of a possible bomb threat concerning the Oconee site that was left on her home answering machine. The licensee notified the Oconee County Sheriffs Department to investigate. No other law enforcement agencies have been notified. They do not consider it a credible threat.

The NRC Resident Inspector will be notified.

* * * UPDATE ON 5/18/01 @ 1936 BY CONSTANCE TO GOULD * * *

The FBI and the County Sheriff have determined that the bomb threat was not a credible threat.

The NRC Resident Inspector will be informed.

The Reg 2 RDO(Wert) was notified.

SAFETY EQUIPMENT FAILURE

At 1440 on 05/17/01, the Plant Shift Superintendent (PSS) was notified by engineering that load cell calibration data for the C-333 U/5 C/9 and C-337 U/2 C/2 freezer sublimers is suspected to be non-conforming. The load cells are part of the High High Weight Trip System for the freezer sublimers which is required by TSR to be operable. It is suspected that a batch of 24 load cells do not meet the specifications credited in the existing setpoint calculations and the calibration procedures. The load cell calibration data from 2 other load cells in this batch indicated less weight than what is actually applied. It has been determined that this deficiency may affect the freezer sublimers ability to actuate the High High Weight Trip System at the required Limited Control Setting (LCS). This deficiency would not affect the ability of the freezer sublimers to actuate the High High Weight Trip System below the Safety Limit (SL). These 2 suspected freezer sublimers were declared inoperable by the PSS.

The safety system deficiency is reportable to the NRC as required by 10CFR76.120(c)(2). The equipment is required by TSR to be available and operable and should have been operating. No redundant equipment is available and operable to perform the required safety function.

The NRC resident inspector was notified..


* * * UPDATE ON 5/30/01@ 2337 BY WALKER TO GOULD * * * RETRACTION

Following the Identification of this problem, the suspected load cells were removed from service and tested. The test results were evaluated by the responsible System Engineer against the F/S set-point calculations and, although outside the optimum error band, the load cells were within the allowable error band and could have performed their intended safely function to trip the F/S at or below the High-High Weight Safety System setting. Thus, 10 CFR 76.120 (c)(2) reporting criteria is not met and the subject notification is being retracted. R3DO (M. Ring) notified.

The NRC Resident Inspector was notified.

The DOE Representitive will be notified.

AGREEMENT STATE REPORT

"ABSTRACT: A 0.326-millicurie I-125 seed was damaged and leakage occurred. Five Medi-Physics OncoSeed model 6711 brachytherapy seeds were loaded in a hollow needle for insertion into a prostate implant patient. During the insertion attempt, the needle tip struck bone. The radiation oncologist withdrew the needle and determined there was a slight bend in the needle. In attempting to straighten the needle, the radiation oncologist broke the needle into two pieces. The most distal seed was crimped and broken into two pieces as well. All items potentially in contact with the broken seed were immediately isolated. Contamination on the exterior of the broken seed was 0.012 microcuries. The patient was not contaminated. The broken seed will be held for decay. Implant personnel were instructed not to bend loaded needles to prevent this from recurring.

"What is the notification or reporting criteria involved? WAC 246-221-265 Leaking source

"Activity and Isotope(s) involved: 0.326 millicuries of I-125"

HOO NOTE: Event entered late - updated for dispatch in 5/25/01 events package.

24-HOUR NRC BULLETIN 91-01 RESPONSE

At 1640 CDT on 05/17/01, the Plant Shift Superintendent (PSS) was notified that the independent verification required by procedure CP2-CU-CH2137 was not performed. The maintenance segment was not independently verified to be isolated. The same person signed for performance as well as the verification of the segment isolation. NCSA 400.009 requires that fissile operations that credit AQ-NCS function that is disabled due to maintenance must be identified independently and disabled using a tagout prior to disabling the feature and commencing maintenance. This is done to prevent operation of a system while an AQ-NCS component function is disabled. Since the independent verification was not performed, the process condition was not maintained. Therefore, double contingency was not maintained.

SAFETY SIGNIFICANCE OF EVENTS:

While the NCS control was violated, the fissile operation containing the component(s) undergoing maintenance was tagged out using LOTO both as a standard maintenance practice in C-400 and due to other NCS requirements. In addition, the equipment items removed had no AQ-NCS function which was affected by the maintenance actions.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR):

In order for criticality to be possible, the components undergoing maintenance must have an AQ-NCS function that is disabled, and the affected operations must be subsequently performed with fissile solution. Additionally, the maintenance activity must be one of the relatively few maintenance activities that do not require tagout for another NCS reason, such as to prevent fissile solution from leaking from the system.

CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):

Double contingency for this scenario is established by implementing independently verifying the prevention of the affected fissile operation.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):

Maximum assay of 2.75 wt. % U-235.

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:

The first leg of double contingency is based on preventing operation of the Cylinder Wash Facility during maintenance affecting the AQ-NCS component. The components were properly identified as non-AQ-NCS; therefore, this control was not violated.

The second leg of double contingency is based on independently preventing operation of the Cylinder Wash Facility during maintenance affecting the AQ-NCS component. The requirement to independently verify the AQ-NCS function of all components affected by maintenance was not performed. The control was violated, and the process condition was not maintained.

Since the independent verification was not performed, the process condition was not maintained. Therefore, double contingency was not maintained.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

This condition was identified while reviewing completed maintenance work packages. There is no action that can be performed to resolve this condition and bring the process back into compliance since the maintenance activity has been completed.

The NRC Resident Inspector was notified, and the DOE Representative will be informed.

* * * UPDATE ON 5/22/01 @ 1235 BY HUDSON TO GOULD * * *

As a result of this NCS violation, a review of work packages was initiated to determine if other instances exist where the required second signature was not obtained. On 05/21/01 at 1520 CDT, the PSS was notified that another incident involving the violation of this requirement was discovered pertaining to maintenance on the RF (radio frequency) furnace.

The NRC Senior Resident has been notified of this event by Paducah personnel. The Reg 3 RDO (Burgess) and the NMSS EO (Cool) were informed by the NRC Operations Officer.

* * * UPDATE 1440 ON 5/25/2001 FROM WALKER TAKEN BY STRANSKY * * *

"This report updated on 5-25-01 to document the results of NCS reevaluation of the subject incidents. It has been determined that double contingency was maintained and these incidents are not reportable.

"The first leg of double contingency is based on preventing fissile operation of the equipment during maintenance affecting the AQ-NCS component. The components were properly identified as non-AQ-NCS, therefore, this control was not violated.

"The second leg of double contingency is based on independently preventing fissile operation of the equipment/system during maintenance affecting the AQ-NCS component. The requirement to independently verify the AQ-NCS function of all components affected by maintenance was not performed so this control was violated. Since the component does not have an AQ-NCS function, there was no process parameter being relied on for double contingency. Therefore, the process condition was maintained.

"Although the independent verification was not performed, there was no reliance on NOS parameters since the component had no AQ-NCS function. Therefore there was no parameter to lose and the process condition was maintained. Therefore, double contingency was maintained."

The NRC resident inspector has been informed of this update. Notified R3DO (Burgess).

UNUSUAL EVENT DECLARED - UNAUTHORIZED ACCESS INTO THE PROTECTED AREA.

Immediate compensatory actions taken upon discovery. The licensee contacted the St. Charles Parish Sheriff's Office. The NRC resident inspector was notified. The unusual event was declared at 0547 and terminated at 0556.