Event Notification Report for February 28, 2002

MEDICAL MISADMINISTRATION DURING STENT RESTENOSIS IRRADIATION

"On 02/28/02, patient was scheduled for irradiation of an in stent restenosis using the Novoste Beta-Cath system, specifically 30 mm serial number 88746.

"The cardiologist stated the reference vessel diameter was 2.7 mm

"The standard dose for a reference diameter of 2.7 mm is 18.4 Gy delivered in 3'22".

"The patient was identified, and pre-procedure patient survey was performed. The novoste unit was prepped, placed in sterile bag and catheter attached, by the authorized user, system was pressurized to verify water flow through the system. The sources were sent to the treatment position in the catheter and verified visually by authorized user and medical physicist that the sources were in the proper location within the catheter. The sources were returned to the source holding area with a green light indicating they were in the safe position.

"The authorized user took the Novoste system to the patient and the cardiologist inserted the treatment catheter through the arrow sheath protector and forwarded the treatment catheter to the desired treatment location, verified via fluoroscopy.

"When the treatment catheter was in place, the cardiologist indicated the location to be correct, the authorized user indicated he was ready to send the sources, and upon acknowledgement the sources were sent to treatment location under fluoroscopy. The distal marker was visualized but the proximal marker wasn't seen. The cardiologist rotated the C-arm to change the perspective of the image. The proximal marker still wasn't visualized.

"The authorized user then attempted to return the sources to the safe position in the Novoste device. There was no indication of the sources returning to safe position. The catheter was immediately removed from the patient and taken to the safety box. The medical physicist then attempted to return the sources to the safe position and verify their location. This attempt was unsuccessful.

"The patient was surveyed and found to be at background.

"Utilizing multiple wet gauze pads, the catheter was wiped clean in an attempt to locate the sources visually. The sources were not seen. The catheter was then passed over the survey meter, with the unit in the box to determine if the sources were in the catheter. There were no sources in the catheter,

"At this time, the cardiologist was asked if he wanted to change systems and continue the treatment. The authorized user and cardiologist decided to abort the procedure. The patient was notified of the decision by the cardiologist at this time.

"The Novoste system was removed from the Cath lab in the safety box. Under visual inspection there appeared to be 6 source pellets and proximal marker in the source holding area of the Novoste unit. The remaining 6 source pellets and distal marker appeared to be in the base of the catheter that fits into the Novoste unit.

"All sources were visually accounted for, Novoste was called, and problem reported.

"Novoste representative arrived within 2 hours of notification, and was able to return all sources to the safe location, with the unit indicating the safe condition,

"Upon inspection, there was some type of material (black) in the source holding chamber. This material apparently restricted movement of the source pellets out of the source holding chamber,

"The Novoste unit was immediately removed from service and it and the catheter was placed in the lead shield container to be returned to Novoste for evaluation.

"The time estimate for the time the distal marker was seen and the system removed from patient was approximately 30 seconds.

"The treatment was never actually started as the proximal marker was never visualized and that is the indication to start the timer, thus starting the treatment.

"The only definite location of the sources is that the distal marker was at the proper location in the catheter.

"If one assumes the six pellets were behind the distal marker for 20 seconds, then the dose would be approximately 1.8 Gy to a length of 0.5 - 0.75 mm.

"This would be a maximum dose estimate, as part of the time they were being remove from the patient, and in vessels that were much large than 2.7 mm diameter."

The licensee stated that NRC Region 3 was notified of this event on 2/28/02.

CONTROL ROOM VENTILATION SYSTEM DECLARED INOPERABLE

"On February 26, 2002 at 1030 hours it was discovered that Unit 1 Electrical Auxiliary Building Fire Damper 3V111VFF314 was in its failed closed position. On February 27, 2002 at 1035 hours, it was determined that with the 'A' and 'C' Trains of the Control Room Ventilation system in Emergency Makeup and Cleanup Filtration mode the Control Room environment was not at a 0.125 inches water gauge positive pressure with respect to adjacent areas as required by Surveillance Requirement 4.7.7.e.3. The 'A' and 'C' trains of Control Room Ventilation system were declared inoperable. The 'B' Train of Control Room Ventilation was already inoperable at this time as part of a planned Train 'B' maintenance window. This condition (all three trains of Unit 1 Control Room ventilation inoperable) placed the unit in Technical Specification 3.7.7 LCO Action Statement 'c', requiring restoration of at least one train within 12 hours, or be in Hot Standby within the next 6 hours. The fire damper was repaired, and flow balancing of the affected ventilation system was performed. Following satisfactory completion of operability surveillance testing to verify that the required differential pressure was restored, Trains 'A' and 'C' of Control Room Ventilation were declared operable at 2045 hours on February 27, 2002. Although the 'A' and 'C' Trains were fully capable of providing the emergency CRE [Control Room Envelope] makeup and cleanup filtration function during the degraded condition, a 0.125 inches water gauge positive differential pressure between the control room and adjacent spaces required by Technical Specifications was not maintained. Therefore, the safety function of the Control Room Ventilation system to mitigate the consequences of radiological dose to operators during accident conditions nay not have been fulfilled, and this notification is being made pursuant to 10 CFR 50.72(b)(3)(v)."

The licensee intends to notify the NRC Resident Inspector.

AGREEMENT STATE REPORT - DAMAGED NUCLEAR GAUGE, SOURCE STILL SHIELDED

The following is taken from a faxed report:

Event Report ID No. NV-02-001

Desert Geotechnical, 3355 Spring Mountain Road, #4, Las Vegas, NV 89102 License No. 00-11-0370-01

Technician left gauge unattended while calibrating it. Gauge (Troxler 3440 No. 25287) was run over by a heavy truck. The source rod remains in the shielded position. Job site was Peaceway 9440 Peaceway, Las Vegas. Date of occurrence is Feb 28, 2002.

Nominal radionuclide, activity Cs-137 is 8 mCi and Am-241:Be is 40 mCi.

Licensee corrective actions are to be determined.

Enforcement Actions will be determined when on-site investigation is concluded.

The gauge has been placed in its shipping case and returned to the licensee's facility. Las Vegas personnel will conduct an on-site investigation to determine the condition of the gauge and perform radiation readings. The licensee will contact gauge manufacturer for shipping instructions.

SAFE SHUTDOWN CAPABILITY IMPACTED BY NON-CONSERVATIVE SG NR SETPOINT

"At 1625, Callaway Plant entered Technical Specification 3.0.3 because of Steam Generator (S/G) water level instrument channels being inoperable due to a non-conservative S/G Low-Low Level setpoint.

"Based upon a review of information provided by Westinghouse and Operating Experience 13294 from Diablo Canyon regarding unexpected response of S/G Narrow Range level trips not responding as expected, an assessment was performed of the S/G Narrow Range (NR) Low-Low Level trip setpoints at Callaway. This assessment determined that the present Low-Low Level trip at 14.8% did not account for the uncertainties associated with the differential pressure (dP) created by the steam flow past the mid-deck plate in the moisture separator section of the S/G. This dP phenomena will cause the S/G NR level channels to read higher than actual water level at high steam flows. Thus, the Low-Low Level trip setpoint is non-conservative.

"In the unlikely event of a Main Feed Line Break inside Containment, the potential exists that a required reactor trip on Low-Low S/G levels may be delayed or may not be received at all. In this scenario, other trip functions such as overtemperature delta-T would be expected to actuate in response to the initiating event. However, preliminary analyses indicates these would arrive in a different sequence, with preliminary calculations indicating that overtemperature delta-T trip actuation occurring early. The net effect on the UFSAR Chapter 15 accident analysis results is unknown. Thus, a condition exists in that a safety function could have been prevented.

"A plant power reduction was commenced at 1658, 2/28/02, to decrease reactor power to below 30% where engineering calculations indicate the S/G mid-deck plate dP condition will no longer result in a non-conservative setpoint. Actions needed to return to 100% reactor power are being evaluated under an Operability Determination in accordance with Generic Letter 91-18 and Admin Letter 98-10."

The licensee notified the NRC Resident Inspector.

See similar events, EN #'s 38697, 38702, 38713

NOTE: Exited TS 3.0.3 at 2205 CST on 2/28/02

AGREEMENT STATE REPORT - DISCOVERY OF AN ABANDONED GAUGE

"The NC Division of Radiation Protection was notified (on February 28, 2002) of the discovery of an abandoned Cesium 137 'fixed' gauge at a metal scrap yard located in Hertford, NC (NucorSteel). Most labels on the gauge are intact with the following information:

Texas Nuclear, LX-303, Series CN, Model 5207, S/N B34, Cs 137 - sealed source, 2.00 Ci (12-83)

The condition of the gauge is reported as 'shielded and the shutter closed'. The gauge has been secured and isolated from the public.

The NC Division of Radiation Protection has contacted Thermo Measure Tech and determined the reported gauge information to be accurate and further determined the gauge was sold/shipped to Essex Industrial Chemical(s) in January 1984 (there were a total of four gauges shipped S/Ns B31 - B34).

The NC Division of Radiation Protection has not been unable to contact Essex Industrial Chemical(s), but will continue attempts.

The Maryland State radiation protection program has been notified of the incident and is assisting."

INVALID ACTUATION OF TWO DIESEL GENERATORS DURING TESTING

"This is a verbal report in accordance with 10 CFR 50.73(a)(2)(iv)(A). It is not considered a Licensee Event Report. This event occurred with Unit 2 at full power while performing scheduled testing of the common accident signal logic. On February 28, 2002, at 1752 hours, an invalid signal caused the automatic actuation of the B and D Emergency Diesel Generators (EDGs). The EDGs functioned successfully. They were not required to tie to their respective 4kV shutdown boards because their boards were energized. The Reactor Protection System did not actuate. No other systems listed in 10CFR 50.73(a)(2)(iv)(B) were affected."

The licensee stated that the inadvertent actuation resulted from a surveillance test procedural compliance issue.

The licensee will contact the NRC Resident.