Event Notification Report for September 06, 2001

REACTOR CORE ISOLATION COOLING SYSTEM MADE INOPERABLE

"Columbia Generating Station Reactor Core Isolation Cooing (RCIC) system has been isolated and made inoperable per Technical Specification 3.5.3 and unavailable due to manual closure of the RCIC turbine trip valve. The manual closure of the RCIC turbine trip valve was required due to the loss of automatic trip capability of the turbine trip valve [due to a solenoid failure]. This loss of automatic trip capability under postulated conditions could cause a water hammer event significant enough to threaten primary containment.

"The RCIC system is a single train system and is listed in plant procedures as an Engineered Safety Feature (ESF).

"The RCIC system will function automatically or manually to inject water into the RPV if manually returned to service."

The licensee notified the NRC Resident Inspector.

* * * RETRACTED AT 1635 EST ON 11/5/01 BY ROBERT SHERMAN TO FANGIE JONES * * *

"Retraction for EN #38268, Regarding Closure of RCIC System Trip and Throttle Valve RCIC-V-1, November
5, 2001

"Automatic closure of the RCIC trip and throttle valve (RCIC-V-I) on low pressure in the RCIC pump discharge piping (i.e.., conditions in which voiding could be present in the RCIC pump discharge piping) prevents waterhammer by preventing automatic start or restart of RCIC. The closure of RCIC-V-1 under these conditions serves as a redundant and diverse backup to the closure of the RCIC pump discharge check valve RCIC-V-90. When it was discovered that RCIC-V-1 failed to close upon receipt of a system trip or valve close signal, system check valve RCIC-V-90 was determined to be operable thereby preventing conditions that could potentially result in waterhammer. Therefore, the condition of RCIC-V-1 failure to close upon receipt of a trip or close signal did not create a condition that could have resulted in potential waterhammer damaged to RCIC piping and containment."

The licensee notified the NRC Resident Inspector. The R4DO (Linda Smith) was notified.

4 HOUR REPORT - NRC BULLETIN 91-01

The following is taken from a facsimile report:

At 0600, on 9-06-01, the Plant Shift Superintendent (PSS) was notified that moisture sampling results on Unit 1 Cell 2 even R-114 system in building C-337 were above allowable limits of NCSA CAS-011. NCSA CAS-011 sets the limit for moisture content in R-114 at 1760 ppm. The sample results showed that the actual moisture content in C-337 Unit 1 Cell 2 even R-114 system was 2100 ppm.

Set point calculations for the R-114 moisture meters used by Cascade personnel to determine the moisture content of R-114 for Cascade coolant systems was found biased low with respect to moisture content. The meters are used to detect high moisture levels in the R-114. An R-114 system containing a high moisture content is required to be independently verified drained prior to removing the fluorinating process environment. Since the setpoint calculation was potentially in error, R-114 with a potentially high moisture content was not immediately drained according to NCSA CAS-002. This control prevents a moderating environment within the process gas system from exceeding 50% relative humidity at 70 degrees F.

The NRC Acting Senior Resident has been notified of this event.

SAFETY SIGNIFICANCE OF EVENTS:
The final determination of whether the moisture content limit has been exceeded cannot be made until the moisture meter "as-found" calibration data can be reviewed. This data a not currently available. However, the plant is pro-actively taking the compensatory actions as though the moisture meter were in error until such time as the calibration data can be reviewed as a final determination made.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR:
In order for a criticality to be possible a fissile deposit containing greater than a critical mass would have to absorb greater than 10 kg of water.

CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC:
Two controls on moderation.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
No known deposits of concern at this time.

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
Double contingency for this scenario is established by implementing two controls on moderation.

The first leg of double contingency is based on immediately draining the R-114 upon determination that it contains a high moisture content. The set point calculation derived for the R-114 moisture meter was biased low with respect to moisture content. Due to the set point calculation error the R-114 system was not immediately drained as required by the NCSA which may have allowed an unknown quantity of water to enter the process system. Since the quantity of water in-leakage to the process system cannot be quantified the process condition was exceeded and double contingency was not maintained.

The second leg of double contingency is based on independently verifying the immediate draining of the R-114 upon determining that it contains a high moisture content. The set point calculation derived for the independent R-114 moisture meter was biased low with respect to moisture content. Due to the set point calculation error the R-114 system was not independently verified as being immediately drained as required by the NCSA which may have allowed an unknown quantity of water to enter the process system. Since the quantity of water in-leakage to the process system cannot be quantified the process condition was exceeded and double contingency was not maintained.

Since double contingency is based on two controls on moderation, double contingency was not maintained.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
The R-114 system is in the process of being drained. The process system will then be sampled for R-114 per CP3-CO-C02029 and appropriate actions contained therein will be performed.

PATIENT GIVEN TECHNETIUM-99 MDP INSTEAD OF MYOVIEW.

Nuclear Medicine Technologist placed a vial that he thought contained technetium-99 myoview into a carrier and took it across the hallway. He administered 32.2 millicuries of technetium-99 MDP instead of 32.2 millicuries of technetium-99 myoview to a patient walking on a tread mill. The nuclear Medicine Technologist discovered that the patient received the incorrect technetium while imaging the patient. The Nuclear Medicine technologist notified the radiologist of the error but has not contacted the patient or the patients physician. The patient's physician left for the weekend after the technetium-99 myoview had been administered to the patient. No harm to the patient due to incorrect technetium given to the patient.

MISSING TROXLER DENSITY GAUGE.


Western Technologies, out of Albuquerque, accidentally left a 3430 Troxler moisture density gauge at mile marker 49 on US highway 550. The moisture density gauge was out of its transport case laying on the side of the highway when the it was left behind. The driver immediately, within an hour, returned to the location and discovered that the gauge was missing. State of New Mexico has recommended to the licensee that they offer a reward for the missing gauge.

* * * UPDATE 1851 9/12/2001 FROM MILLER TAKEN BY STRANSKY * * *

The state reported that the missing gauge has been recovered. Notified R4DO (Shaffer).

STUCK SOURCE

The licensee reported that a 15 mCi Am-241 source, used for soil moisture measurements, had become stuck within a 6 foot length of tubing. Attempts to retrieve it using the attached cable were unsuccessful. The source was retrieved by digging up the tubing, cutting off the bottom portion and pushing the source back up through the tube. The source was returned to its shipping container. The dosimetry of the individual who performed the retrieval has been sent to the vendor for analysis.

An inspector from NRC Region I is currently performing a site visit to the USDA office in Beltsville, MD, from where this report originated.