Event Notification Report for March 27, 2002

AGREEMENT STATE REPORT FOR A LOST GAUGE

"A general licensee reported the loss of an NDC Infrared Engineering Model 103, serial no. 773, containing 100 mCi of Am-241. The gauging device was initially installed in 1982. The general licensee is a manufacturer of packaging products. The device was apparently installed at one time in a plastic extruder line. In November 2000 it was reported to the Department as being on the laminator in the plant. While performing the inventory for the most recent Departmental self-inspection, the licensee was unable to account for this device. Licensee states that it conducted an extensive investigation of the circumstances surrounding the disappearance of the device. Their investigation continues and they will file the required report as soon as possible. The department's investigation is ongoing."

*****UPDATE State of Illinois to R. Laura on April 15, 2002 at 16:30****

The lost gage was found during renovations in the building.

AGREEMENT STATE REPORT FOR LOSS OF STATIC ELIMINATOR

"General licensee reported the loss of a Po-210 static eliminator device. The Licensee presumes that the device was recently lost during routine manufacturing operations. The device is manufactured by NRD and is Model P-2021, Serial no. A2BA986 containing approximately 2 mCi of Po-210. The Licensee will continue to search and file the required written report."

MEDICAL MISADMINISTRATION

"On March 21, 2002, the physician ordered a Resting Myoview scan on a patient. This patient was assigned a different room and the Nuclear Medicine department was not notified. When the technologist went to inject the patient he verbally identified the patient and injected the wrong patient with 20.6 mCi of Tc-99m Myoview. The technologist was suppose to identify the patient by the ID bracelet but did not. The technologist has been retrained in the procedure. This misadministration was discovered when the correct patient was called in for the scan and the patient had not been injected. The patient that received the misadministration was notified. There was no apparent harm or injury to the patient. The patient that received the misadministration was not suppose to be injected with radiopharmaceuticals at all. The physician received enough information from the stress test on the correct patient so that patient did not need to be injected again."

A PACKAGE RECEIVED ONSITE EXCEEDED EXTERNAL RADIATION LIMITS

The licensee reported the discovery of a container on a shipping vehicle which exceeded the external radiation limits of greater than 200 millirem/hour. The bottom of the container read as high as 1000 millirem/hour. The container had not been opened yet. The container contains a refueling tool called a stellite ball punch. The licensee notified the carrier, shipper and the NRC Resident Inspector.

MEDICAL MISADMINISTRATION

A female patient received an underdose during a gynecological treatment when an applicator containing the brachytherapy source being used was displaced from her body. The prescribed dose was 2240 cGy (rads); however, a dose of only 1212 cGy was actually administered. The sources were secured in a safe location and the patient has been discharged from the facility.

The licensee has already contacted NRC Region III regarding this event.

POSSIBLY MISSING IRIDIUM SEEDS

The licensee was notified that a package containing Ir-192 brachytherapy seeds was being returned to the facility from Alpha-Omega Services because of a discrepancy between the shipping papers and the actual package contents. The shipping papers indicated that 71 seeds were included in the shipment; however, only 63 seeds were actually present in the package. The package did not appear to have been opened or damaged during transit.

The licensee determined that the 8 missing seeds (1.39 mCi total activity) were, in fact, still in a secure location at their facility. They had been separated from the other sources and inadvertently excluded from the shipment.

SPURIOUS OPERATION OF THE REACTOR HEAD VENT VALVES IN THE SAFE SHUTDOWN REPORT(SSR) IS NOT CONSISTENT WITH THE NRC SAFETY EVALUATION REPORT.

Specifically the Section 3.4.3 of the SER states that spurious operation of the Reactor Head Vent (RHV) valves {SO-2(3)-0220-46 ann SO-2(3)-0220-47} which would result in Reactor Coolant inventory loss, will be prevented by a pre-fire action to ensure closure by removing power from these valves. However, the current SSR dispositions this postulated concern based upon the assumption that spurious operation of greater than one normally closed valve in a series combination is not considered a credible failure mode except for high/low pressure systems. As a result, there is no pre-fire action to ensure closure by removing power to RHV valves. The documentation (FPR revision and 50.59) that supports the change in the licensing position of these valves from that described in the SER to the current SSR has not been located.

A review was performed on the Fire Protection Report (FPR) which includes the Fire Hazard Analysis & Safe Shutdown Analysis, to evaluate the options for additional sources of water to address the loss of reactor inventory from the spurious actions of the reactor head vent valves. This review indicated that no specific circuit analysis was performed to determine what other available sources of water could be used for makeup of reactor inventory via the reactor head vent valves spurious operation. Therefore, in the event of a fire in the various assumed Appendix R fire zones, a qualified makeup source would not be available to mitigate the inventory loss introduced by the spurious operation of both RHV valves.

Fuses have been pulled to remove power to and close a RHV valve on both Unit 2 and Unit 3 to comply with the SER. The action puts the plant in the configuration required if the RHV valves are considered a high-low pressure boundary. Completion of this action restores the plants compliance with the referenced SER.

Dresden Engineering will perform an evaluation that documents the RHV valves as a high-low pressure boundary and that the actions taken above are adequate to mitigate the multiple spurious failures which must be postulated when these valves are considered a high/low pressure boundary. A revision to the FPR will be made to document the results of this evaluation.

The NRC Resident Inspector will be notified.

***** RETRACTION AT 1815 EDT ON 05/24/02 FROM WARREN DEAGLE TO LEIGH TROCINE *****

The following text is a portion of a facsimile received from the licensee:

"On March 27, 2002 at 2230 CST, Dresden Station made an ENS Notification (EN 38809) regarding fuses that had not been removed from reactor head vent (RHV) valves. It was reported that the station's methodology for addressing fire induced spurious operation of the RHV valves in the safe shutdown report was not consistent with the NRC safety evaluation report. During preliminary reviews, it was postulated that a fire could result in spurious operation of these valves that in turn would result in reactor inventory loss. The postulated water source in the scenario was the opposite unit's Control Rod Drive system, which may not provide the makeup capability to maintain reactor water level above the top of active fuel (TAF)."

"The condition was reported in accordance with 10 CFR 50.72(b)(3)(ii)(B), as an Unanalyzed condition that significantly degraded plant safety."

"Upon further evaluation, it has been determined that a credible fire that would cause spurious operation of the RHV valves would not result in a loss in the High Pressure Coolant Injection (HPCI) system. Therefore, the HPCI system would have been available and capable to provide inventory makeup to the reactor vessel. Vessel water level would have been maintained above TAF. Based on the subsequent evaluation, the safety function (inventory control) would have been maintained at all times during post-fire safe shutdown of the unit."

"Therefore, based on the above conclusion, this notification is being retracted."

The licensee notified the NRC resident inspector. The NRC operations officer notified the R3DO (Christine Lipa).

LOST/STOLEN LNM>10X

"Background

"DEMCO placed vacuum cleaner 01-589 into service 10/11/01 for use in accordance with Radiological and Environmental procedures. The vacuum cleaner was labeled with PCB, Hazardous Waste and Radiological stickers based on anticipated use for paint abatement. The vacuum cleaner location was verified weekly during RCRA Satellite Area inspections and monthly during PCB inspections. In late January the vacuum cleaner was moved to the Waste Disposal Building for personnel decon of asbestos workers. Weekly and monthly inspections of the vacuum cleaner's location continued including a weekly inspection that was performed on Thursday 2/21/02.

"On Monday morning 2/25/02, DEMCO workers could not find the vacuum cleaner where they had left it.

"Immediate Actions

"2/25/02 DEMCO personnel searched areas that were likely to contain the vacuum cleaner (including all levels of the Waste Disposal Building, the hazardous waste storage area of the PAB, the RRF, the Hot Shop, and PCB storage areas).

"2/25/02 DEMCO enlisted Bechtel and HP personnel to help in the search and to validate the vacuum cleaner inventories.

"2/25/02 The night shift workers, who were cleaning up the area, were questioned about the vacuum cleaner, but could provide no insight into the vacuum cleaner's whereabouts. They were requested to look for the vacuum cleaner.

"2/26/02 A CR was written in the morning.

"Subsequent Searches

"Various informal and formal searches have been performed by DEMCO, Bechtel labor, HP Ops, Duratek, CY Ops and Bechtel Management.

"Seven suspect B-25 boxes and six suspect seavans were searched by removing their contents completely. These containers had been loaded in the relevant timeframe or contained asbestos.

"Areas searched (including grid by grid searches) include the Waste Disposal Building, PAB, Containment Building, Turbine Building, Pipe Chase and Pipe Trench, Service Building, Auxiliary Boiler Room, Diesel Generator Building, Screenwell House, Administration Building, Spent Fuel Building, Radwaste Reduction Facility, Spent Resin Facility, CY Maintenance Shop, Fire Brigade Shop, Chemical Warehouse, Resin Storage Building, Recycle Warehouse and Operating Engineers Maintenance Shop, Steam Generator Mock-up Building, Storage Seavans, and asbestos enclosures.

"The vacuum cleaner was not found during these searches."

The NRC Resident Inspector has been notified. The state of CT Department of Environmental Protection has been notified.