Event Notification Report for February 22, 2002

MEDICAL MISADMINISTRATION INVOLVING UNDERDOSE TO CANCER PATIENT

A female patient undergoing brachytherapy treatment for cancer at the Danbury Hospital in Norwalk, CT, was prescribed 4600 Rad using a Cs-137 source. One of the five seeds (21.23 mg Radium equivalent) was found in a trash can. This resulted in an estimated delivered dose of 3458 Rad which is 24.8% less than prescribed. All hospital staff entering the area where the trash can was located had personal dosimetry such that no unmonitored exposures occurred. The licensee is conducting a review to determine appropriate corrective actions. The prescribing physician has been informed by the hospital. The licensee notified RI Office(Bhalla). Call the Headquarters Operations Officer for contact information.

UNIT 2 COMMENCED A TS REQUIRED SHUTDOWN AFTER DECLARING A SI PUMP INOPERABLE

"On February 20, 2002, at approximately 0100 CST. OI-163, 'SI, RHR, and CS Pump Runs,' was being performed on Safety Injection (SI) pump 2P-15B. This procedure is used to bump the pump to ensure bearing lubrication as a preventive maintenance activity. When the pump was started, motor current increased as normal, but then decayed to less than 10 amps. Additionally, the pump appeared to develop no discharge pressure. In the field, the auxiliary operator noted a loud bang near the end of the coastdown and further noted excessive seal leakage. At approximately 0105 CST, SI pump 2P-15B was declared inoperable, LCO 3.5.2 was declared not met, and TS Action Condition A.1 was entered. Tech Spec LCO 3.5.2. ECCS-Operating, requires two ECCS trains to be operable in Modes 1, 2, and 3. LCO 3.5.2, Condition A, requires an inoperable ECCS train to be restored to an operable status within 72 hours.

"Subsequent inspection of the pump following disassembly of the casing revealed damage to the rotating element, the coupling and shaft keys between the pump and the motor, the pump internal wear rings, and other components. At this time, we believe the pump damage was due to gas binding in the pump as a result of back leakage through two check valves. This allowed nitrogen saturated water from the 'A' SI accumulator to migrate to the 2P-15B pump. Repair of the pump has proceeded with the expectation that the pump would be repaired, tested and returned to service prior to the expiration of the 72 hours allowed in the action statement. However, as of approximately 1400 CST, we determined that we were unlikely to complete the remaining repairs and the required pump testing before the expiration of the action statement. Accordingly, at that time activities were initiated to commence a shutdown of PBNP Unit 2 and at approximately 1448 CST the shutdown of the unit was initiated."

The licensee is decreasing power at 30%/hr and anticipates entry into Mode 3 at approximately 1930CST. The licensee informed the NRC Resident Inspector.

LOSS OF ASSESSMENT CAPABILITY DUE TO FAILURE OF THE ERDADS SYSTEM

"A failure of the ERDADS [Emergency Response Data Acquisition and Display System] computer due to errors in the primary and backup systems. This resulted in the loss of all ERDADS data. The failure also resulted in the loss of offsite communications capability (ERDADS link)."

The licensee informed the NRC Resident Inspector.

ACTIVATION OF THE WATER INVENTORY CONTROL SYSTEM

At 1630 CST, on 2/22/02 the Plant Shift Superintendent (PSS) was notified of an activation of the Water Inventory Control System (WICS) on #1 autoclave in the C-360 building. Approximately 50 minutes into the heat cycle, the Hi Primary Condensate alarm was received, and steam supply to the autoclave was automatically isolated. Operators investigated the alarm. The autoclave was removed from service, and the WICS was declared inoperable. Further investigation will be performed by the System Engineer and Instrument Maintenance to determine the exact cause of the alarm. The purpose of the WICS is to limit the amount of water in the autoclave and is a safety system required by TSR 2.1.4.3.

The PSS determined that this event is a 24 Hour Event Report due to a valid automatic activation of a Q safety system.

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

* * * RETRACTED AT 1519 EST 03/06/2002 BY TOM WHITE TO GERRY WAIG * * *

"Based on evidence found during post-event investigation, this actuation was initiated by a spurious signal (not a condition that this system is designed to protect against). This investigation revealed an equipment problem that generated a spurious electrical signal causing a false (invalid) actuation of the Water Inventory Control System (WICS). The secondary WICS cable was discovered to be resting in hydraulic oil and to have a small insulation injury exposing the wire. The conduit, which houses the cable, was inadvertently filled with hydraulic oil from a spill that occurred on Jan 22, 2002. This cable was repaired and system retested satisfactorily with no anomalies. The NRC Senior Resident Inspector has been notified of the retraction."

Notified R3DO (John Madera) and NMSS (John Hickey).

AGREEMENT STATE REPORT - LOCK MALFUNCTION ON CAMERA

"On Friday February 22, 2002, a radiographer from METCO discovered that the lock on the Amersham 660 radiography camera with 60 curies of Ir-192 would not release to allow an exposure. The Environmental Manager from LA Pigment believed the auto-lock on the exposure device failed. The RSO at METCO responded within 30 minutes. The RSO stated that he cleaned the lock with WD-40 and the lock functioned after that. The RSO believes the lock was just dirty."