Event Notification Report for January 28, 2003

OFFSITE NOTIFICATION

"A fake news article was created on the internet. This fake article appears to be a CNN report that claimed Seabrook is under intense FBI investigation for dumping several radioactive uranium cores.

"The [NRC] resident inspector was notified at 09:20, and the shift manager was notified shortly after. NRC would like to be notified if a press release will be [issued by Seabrook].

PRE-ACCESS CONTRACT SUPERVISOR ACCESS TERMINATED DUE TO A CONFIRMED POSITIVE TEST
FOR A CONTROLLED SUBSTANCE.

At 09:30 on 01/28/03, a contract supervisor for the turbine upgrade project had a confirmed positive for a controlled substance during a pre-access fitness for duty test. The supervisor's access to the station has been suspended in accordance with the station's fitness for duty program.

The NRC Resident Inspector was notified of this event by the licensee.

* * * UDATE ON 01/29/03 AT 1414 EST FROM DON ROLAND TO GERRY WAIG * * *

"Please note the following correction:

"The contract supervisor had a confirmed positive test for a controlled substance during a random FFD test, not a pre-access test as previously reported. The error was a result of misinformation provided by the site testing facility to the Control Room. The individual remains suspended and his access to vital areas & work performance while employed at Susquehanna LLC is presently under review. The NRC residents have been notified."

Notified R1DO (Dan Holody)

MEDICAL MISADMINISTRATION - RADIATION DOSE EXCEEDED PLANNED DOSE

The following is taken from a facsimile sent from the licensee:

A patient with and injury in the right coronary artery was to be treated with Novoste Sr-90 40 mm [millimeter] 3.5 Fr [French] device for 4 minutes 31 seconds each for a pullback procedure. The radiation oncologist had difficulty with the device and had to perform an emergency bail-out. We later confirmed that the sources were stuck either inside or just slightly outside the device, so there was no dose to the patient. The decision was made to proceed with the treatment with the Novoste Sr-90 40 mm 5 Fr device. The radiation oncologist scrubbed and primed the catheter with the dummy device. The change in the treatment device and new treatment time of 3 minutes 41 seconds was noted on the QM form. The revised treatment time, however, was not entered into the stopwatch. Only the physicist verified the time on the stopwatch and because of the similarities in the timing units (4 m 31 s versus 3 m 41 s),did not catch the error in time on the stopwatch. At the end of the treatment the physicist noted that the timer had not been reset for the 5 Fr device. During the 50 extra seconds of treatment time the patient received a dose of 28.2 Gy [Gray] rather than the prescribed dose of 23 Gy (22.6% more than the prescribed dose). The patient was informed of the error by the radiation oncologist and cardiologist later the same day. No adverse effect is expected for the patient

"Some of the corrective actions under review include:
1. Improve the double-checking process prior to the start of the treatment. Usually the radiation oncologist double checks the treatment time, but in this case he was scrubbed and could not fully confirm the change in the treatment time on the QM form. Also the clinical coordinator who double checks the time programmed into the stopwatch and handles the back-up timer, was not available during this case,
2. The emergency bail out procedure disrupted the normal flow of the treatment. The team needs to be very aware of the greater vulnerability to error whenever emergency procedures are involved.
3. Scheduling issues may need to be addressed.
4. Additional training issues may need to be addressed."

NRC BULLETIN 91-01 24 HOUR NOTIFICATION - PADUCAH GDP


"At 1530 On 1-28-03, the Plant Shift Superintendent (PSS) was notified that the condenser pressure on Unit 4 Cell 9 in C-335 was not monitored at the require[d] frequency. When the condenser return valve will be closed and the supply spool piece will remain in place, the condenser supply pressure must be maintained at 20 psig or less to ensure that less than 10Kg of water can enter the process gas system. In order to ensure the pressure Is maintained below the maximum allowable pressures a gauge is installed arid monitored at a frequency of once every 8 hours for Unit 4 Cell 9 in C-335. The gauge was installed and first read at 2245 on 1-27-03. The next reading was taken at 0950 on 1-28-03. This period exceeded the 8 hours allowed. The NRC Resident Inspector has been notified of this event.

"SAFETY SIGNIFICANCE OF EVENTS:

"The pressure reading frequency was violated, however, the RCW [Recirc Cooling Water] pressure limit was not exceeded. Although a control relied upon for double contingency was violated.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR

"In order for criticality to be possible, there must be a large condenser leak at the same time as a high RCW pressure. In addition, the high RCW pressure condition would have to go unnoticed and uncorrected beyond the specified time limits.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC

"Double contingency is maintained by implementation of two controls on moderation.

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND WORST CASE CRITICAL MASS):

"No known mass of licensed material exists in the condenser. System NCS limit is [deleted] wt.% U235.

"NUCLEAR CRITICALITY SAFETY CONTROLS) OR CONTROL SYSTEMS(S) AND DESCRIPTION OF THE FAILURES OR DEFICITS

"The first leg of double contingency is based on the ability to identify a pressure exceedance of the RCW condenser pressure limit within 8 hours. RCW pressure readings are monitored at a frequency at 1/2 the time it would take for an unsafe mass of moderator to leak into the process gas side. The RCW condenser pressure reading was obtained after the 8 hour time limit. Therefore, this leg of double contingency was lost.

"The second leg of double contingency is based on the ability to check the pressure reading within 16 hours and to take corrective actions within 23 hours. The pressure was checked within 16 hours and was not In excess of the limit. Since the pressure limit was not exceeded, this leg of double contingency was maintained.

"Since the first leg was lost, the double contingency principle was violated.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

"At the time of discovery, the appropriate frequency of monitoring was identified and initiated."

1.3 MILLICURIES SULPHUR-35 SOURCE INADVERTENTLY DISCARDED AS REFUSE

On 1/20/03 a package was delivered from PerkinElmer Lifesciences located in Boston, MA to the Thomas Jefferson University Hospital. The package included two (2) medical isotopes used in research; 1.3 millicuries Sulphur-35 (Half-life 87.4 days) and 250 microcuries Tritiated Thymidine. The package was shipped as excepted quantity not subject to external labeling. A lab worker sometime between 1/23 and 1/24 discarded the package containing the two sources as trash which was collected on 1/27 at approximately 0500 hours and taken to the landfill.

The licensee conducted interviews emphasizing prompt handling, good communication and individual responsibility to prevent recurrence.