Event Notification Report for November 01, 2002

AGREEMENT STATE REPORT INVOLVING UNACCOUNTED FOR Po-210 SOURCE

Licensee reported that a 1.5 millicurie Po-210 source is unaccounted for. The source is believed to be at the facility and a search is being performed.

AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION

"On 11/1 /2002, the Radiation Oncologist was administering a EndoVascular brachytherapy procedure to the patient using a Novoste Beta Cath source. It was noticed on the image monitor by the Radiation Oncologist and the Cardiologist that the distal marker began to move, raising the possibility of source movement despite adequate pressure (as noted by the amber lights). A decision was made by the Radiation Oncologist and the Cardiologist to remove the entire system immediately. The catheter system with its transfer device attached was removed and returned to the 'bailout box'. The patient was surveyed right away and found to have no radioactivity. The transfer device and catheter were surveyed. The sources were found within the system. The sources were successfully returned to the transfer device without any problem. The transfer device was visually checked and surveyed again. The activity remained the same as in the pre-procedure survey. Since the source could not be safely extended again, the treatment was discontinued. 71% of the prescribed dose was delivered. The patient received 29% less dose than prescribed: No increase in complications expected. While one cannot be fully sure of the reduction in control rates, the dose delivered appears to be within the range (800 cGy to 3000 cGy in the Scripps and Gamma 1 trials and 13% less than the WRIST trial) to benefit in preventing restenosis. The patient and the referring physician were informed was informed of this event.


"Novoste Model: TDA 0040 transfer device; Ser # 83178
Source strength: Source train Ser # 474/01; Source Strength 1.92 GBq
Source length: 40 mm
Diagnosis: Coronary artery restenosis
Prescribed treatment: 1840 cGy at 2 mm
Treatment site and length: RCA; 40 mm
Present during procedure: Cardiologist, Radiation Oncologist, Physicist, and Radiation Therapy Physicist ."

INVALID SPECIFIED SYSTEM ACTUATION DUE TO POST MAINTENANCE TESTING

"Per 10CFR50.73(a)(1), we make the following report under 10CFR50.73(a)(2)(iv)(A)

"At 1727 on 11/01/02, while performing Solid State Protection System Post-Modification Testing (PMT), a fault in Logic Train R resulted in an invalid Train A Safety Injection (SI) actuation signal, Containment Ventilation Isolation (CVI), and Containment Phase A isolation.

"We provide the following information:
(a) The specific train and systems that were actuated: Train 'A' Safety Injection signal resulted in actuation of ESF Diesel Generator 21, Containment Isolation Phase 'A', Containment Ventilation Isolation and other designated equipment designed to start on a safety injection signal.
(b) Whether each train actuation was complete or partial: This actuation signal only affected Train 'A' and was complete.
(c) Whether or not the system started and functioned successfully: All affected systems functioned properly."

The Licensee has notified the NRC Resident Inspector.

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE

"A Troxler Electronic Laboratories, Inc. Model 3411B, portable gauging device [serial number 7940, containing approximately 8.0 millicuries of Cs-137 (source serial number CC-571), and approximately 40 millicuries of Am-241/Be (source serial number CAA-4262)] was stolen from the bed of a pickup truck while the licensee's employee went into [ ] Food & Drug to purchase some batteries. The gauging device's source rod was locked in the safe shielded position, the gauging device's transport case was locked, and the transportation case was chained to the licensee's pickup truck. Bolt cutters were used to remove the gauging device from the pickup truck."

The Licensee notified the West Valley City Police.

The state of Utah has issued a press release.

DEGRADED PLANT CONDITION DUE TO LOSS OF SAFETY RELATED OFFSITE POWER

"This report is being filed per 10CFR50.72.b.3. This is an eight hour notification of a degraded plant condition based on a loss of safety related offsite power.

"At 1508 hours, Central New York Power Control notified Nine Mile Point Unit 1 control room staff that a Low Contingency Voltage alarm had been received. Per plant procedures NMP1 entered a 24-hour shutdown Limiting Condition of Operation per Technical Specification 3.6.3. Power Control's Load Flow Computer program that monitors the 115 kV grid for NMP1, determined that there is insufficient voltage (based on the grid loading) to supply NMP1 ECCS loads during a LOCA.

"NMP1 has started its DIV 1 emergency diesel generator (EDG). DIV 1 ECCS bus is currently being supplied by the DIV 1 EDG. Plant operators are currently starting the DIV 2 EDG; it will supply DIV 2 ECCS bus.

"Power is still available for other non-safety related buses from offsite, however for safety related buses it is considered degraded."

The Licensee has notified the NRC Resident Inspector.

UNANALYZED CONDITION FOR PRESSURIZER LEVEL TRANSMITTER CABLE SEPARATION

"During an internal (Self Assessment) Fire Protection Program Review, documentation discrepancies were found related to Pressurizer Level Transmitters LT-101Y and LT-101X (Normal Operating Level Indications) and LT-106 (Cold Calibrated Shutdown Indication). The information did not provide adequate documentation to ensure Appendix R cable separation was met in Containment. A field verification was performed and confirmed that Appendix R cable separation for the above mentioned Pressurizer Level transmitters may not exist. The Plant engineering Department is continuing to evaluate the situation and a Plant Review Committee (PRC) meeting is planned for later this evening to review Engineering's conclusions."

"Currently the affected transmitters are operable and this issue relates to Appendix R Licensing Documentation only."

The Licensee notified the NRC Resident Inspector.

HPCI INOPERABLE DUE TO INDICATED HIGH DIFFERENTIAL PRESSURE ALARM

"On November 1, 2002 at 16:41 hours, a High Pressure Coolant Injection (HPCI) Steam Line Break high differential pressure alarm was received, which caused a HPCI Steam Isolation System 'A' signal, closure of the 2-E41-F003, HPCI Steam Supply Outboard Isolation Valve, and a closure signal to the normally closed 2-E41-F041, Torus Suction Valve. Temperature indications, inspection of associated trip instrumentation, and local inspection confirmed that all temperatures for the HPCI system were normal and no steam or line break was present. The high differential pressure alarm cleared at 16:49 hours.

"Investigation is currently in progress and drifting of a differential pressure transmitter is suspected.

"This event is reportable in accordance with 10CFR50.72(b)(3)(v)(D) since the HPCI system is needed to mitigate the consequences of an accident.

"INITIAL SAFETY SIGNIFICANCE EVALUATION
"The Reactor Core Isolation Cooling (RCIC) system is operable and Unit 2 has entered the Technical Specification action statement to restore the HPCI system in 14 days. Therefore, this event poses minimal safety significance.

"CORRECTIVE ACTIONS
"Initial actions were taken to verify no evidence of a steam leak using available indications and an inspection of HPCI steam lines, Further investigation is in progress on the associated differential pressure transmitter."

The Licensee has notified the NRC Resident Inspector.