Event Notification Report for July 10, 2001

PLANT SHUTDOWN REQUIRED DUE TO FAILED CONTAINMENT LEAK RATE TEST

The licensee was conducting normal technical specification surveillance of containment leak rate and determined that the personnel access airlock has failed the surveillance. The plant commenced a technical specification required reactor shutdown to Mode 3 at 1611 EDT on 7/10/01. The licensee will remain in Mode 3 until the airlock is repaired.

The licensee has notified the NRC Resident Inspector and the State of Connecticut.

MEDICAL MISADMINISTRATION INVOLVING TREATMENT TO WRONG SITE

There were 2 patients prepared for treatment with a gamma knife. The wrong treatment package was used for the first patient. There were 4 of 8 shots administered to the wrong site before it was discovered that the wrong package was being used. The patient received approximately 13 gray over a short period to a small area. The consequences of the exposure are not known at this time and are being investigated and the patient's progress will be followed for some time. The patient received the correct treatment subsequently. The attending physician has been notified and the patient will be informed tomorrow.

There is a review and evaluation of procedures on going to determine how to insure this event is not repeated.

24 HOUR REPORT - NRC BULLETIN 91-01

The following text is a portion of a facsimile received from PORTSMOUTH:

At 0910 on 07/10/2001 it was identified that control #5 of NCSA-0705_076.A03 was not being maintained for two filter press plates covered in plastic. NCSA-0705_076.A03 requires that no inadvertent containers that could contain greater than 2.5 liters of solution be permitted in any areas in which uranium bearing solution could be accumulated in the inadvertent container. The loose plastic wrapped on the filter press plates had the potential to deform into a container that would exceed the maximum criteria identified in the NCSA. This constitutes a loss of one control (geometry) of the double contingency control principle identified in NCSA-0705_076.A03. No fissile material leaked in the area while the plastic wrap was present.

NCSA-0705_076.A03 compliance was reported restored at 1010 hours.

SAFETY SIGNIFICANCE OF EVENTS:

The safety significance is low because at the time of the event there was no uranium bearing material present that could leak into the inadvertent container. The area in question is designated an 'Inadvertent Container Area' due to the presence of the Complexing Hand table. However. the Hand table is not currently in operation. The next nearest fissile material operation is Microfiltration which is currently in operation, but is more than 15 feet from the location of the plastic wrap in question. Nevertheless, the presence of an inadvertent container at that location is a violation of NCS controls and one leg of the double contingency principle described in NCSE-0705_076.E03.

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

For a criticality to occur, the following events would be required: The complexing Hand table would have to be in operation and be processing uranium bearing liquid with an unknown or high concentration of uranium. Then a leak in this system must occur such that an unsafe amount of liquid sprays (presumably under pressure) from the Hand table system onto the plastic wrap in question. The liquid would then have to collect and deform the plastic wrap such that more than 2.5 liters collects to a depth greater than 1.5 inches forming an unsafe geometry.

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

Inadvertent containers are controlled based upon volume (2.5 liters maximum) or geometry (1.5 inches in depth or 4 inches in diameter. Flexible material (e.g., plastic wrap) is specifically controlled such that solution cannot pool to a depth grater than 1.5 inches,

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

No uranium bearing material was involved in this event. There were no leaks of uranium bearing material in the area while the inadvertent container was present. The event involves the presence of an unsafe geometry container that could collect solution in the event of a spill.

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

Loose plastic wrap placed over filter press plates in an inadvertent Container Area was not configured or secured such that it cannot be deformed into an inadvertent container with an unsafe accumulation potential. This is a violation of control #5 of NCSA-0705_076.A03. Use of Inadvertent Containers

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

Requirements of an NCS Anomalous condition entered. At the direction of an NCS engineer, the condition was corrected.

Portsmouth personnel notified the NRC Resident Inspector.

16 OF 17 FLOOD PANELS FOUND TO BE NON-FUNCTIONAL

"A second quarter 2001 inspection per Procedure PM-3586-10 identified miscellaneous deficiencies (e.g., deteriorated gasket material, obstructions, deficient bolting) with flood panels such that 16 of 17 are considered non-functional. There is no current operability concern due to the river level and the analyzed need for both snow melt and heavy rains to require the use of these panels. We are currently working on a plan to correct deficiencies. Reference: USAR Section 2.4.3.5"

The licensee noted that this report was due yesterday. However, the licensee determined this afternoon (7/11/2001) that a report should have been made.

The licensee intends to notify the NRC Resident Inspector.