Event Notification Report for March 26, 2003

AGREEMENT STATE REPORT - LOST OR STOLEN IODINE SOURCES

The following information was received via e-mail from the Illinois Department of Nuclear Safety:

"[DELETED], RSO of SourceTech Medical [(DELETED)] in Carol Stream, IL called at 1500 hours on March 26, 2003, to report that he had received a shipment of returned I-125 seeds. The dose rate on the surface of the package was 9 [millirem/hr] instead of the expected dose rate of less than 0.5 [millirem/hr]. Upon opening the box, 2 loose sources were found on top of the packing material. 7 sources were noted in the shipping papers. An additional source was found in a partially loaded Mick applicator but there were no sources in the second Mick applicator. A total of only 3 sources were found after looking through the other two lead containers in the package.

"Based on assay of the three seeds, the 4 missing seeds are 425 [microcurie] I-125 each for a total of 1.7 [millicurie]. The contents of the package (Fed Ex tracking no., [DELETED]) were obviously not prepared in accordance with instructions provided by Source Tech in that the lids to the containers were not secured nor were the vials used in the lead containers as the instructions call for. The carrier, Federal Express had been contacted by [DELETED] and the delivery truck surveyed. No sources were located during the survey. According to tracking information, the package had gone from St. Augustine through Jacksonville FL, Atlanta GA, Memphis TN, Chicago, IL and the Schaumburg IL sorting facility prior to delivery in Carol Stream. An inspector was dispatched to the Schaumburg facility at 15:45 to attempt a search of the Schaumburg facility.

"The sources were shipped from Slagley Hospital (Florida [DELETED]) in St. Augustine Florida on Monday 3/24/2003. [DELETED] tried contacting the site RSO, [DELETED], this afternoon but was unsuccessful. The department contacted Mr. [DELETED] of the Florida program in their Orlando office and relayed the information available at the time (see above). He indicated that he would attempt a call as well but suspected the hospital staff would be gone given the time of day (16:30) in Fla. On 3/27/03, [DELETED] notified the department that he contacted the Florida licensee and the St. Augustine hospital claimed that they counted twice the seven seeds not used in a patient, placed them in a 'screwed sealed cartridge' then put them in a shipping box for FedEx. The department also informed [DELETED], Ph.D., health physics consultant for FedEx, that there are apparently 4 iodine-125 seeds in FedEx facilities or vehicles somewhere as indicated by the routing in the message below. Jim Lynch of the NRC was also advised of the situation. On 03/26/03, a departmental inspector arrived at the Federal Express Depot located at 1270 Wilkening Road in Schaumburg; [DELETED] and explained the purpose of the visit. The inspector was provided access to the package/truck staging area. Based on the FedEx tracking number, the author was told that the bay used by the vehicle was the same one used in a previous, recent incident involving I-125 seeds. Surveys were performed by the inspector using an Eberline Model PRM-6 ratemeter, serial number 1470, last calibrated on May 16, 2002, with an Eberline Model LEG-1 probe. Background readings were [approximately] 250 - 350 CPM. Areas surveyed included the conveyor belt system, particularly junctions between belts, walkways, and the concrete pad where vehicles park for loading/unloading. Particular attention was paid to the area where the truck was unloaded and the seeds had been found in the previous incident. No seeds were located by the inspector. The department is reviewing the packaging used by SourceTech and the instructions to see if there they can be improved to prevent recurrences. The event was reported to the NRC Operations Center at 1622 hours EST on 3/27/03 and assigned Event No. 39706. A copy of this report was electronically forwarded to the Ops Center as well as the states of FL, GA, TN and NRC Region III."

AGREEMENT STATE REPORT - INJURED AND CONTAMINATED EMPLOYEE TRANSFERRED OFFSITE

The following information was obtained from Texas Department of Health, Bureau of Radiation Control via facsimile:

"The Agency was notified that at 7:30 AM [CST] [on] 3/26/03, a neutron tube blew apart inside the pulse neutron facility located at 2001 Rankin Road, Houston, TX 77073-5114. The employee that was involved received superficial lacerations. EMT's were notified at this time. Immediately after the accident H-3 [tritium] contamination was found around the wound area. The contamination was found in a swipe that was analyzed by the licensee using their laboratory located on the premises. The swipe was found to have 19 [nanocuries] of H-3 contamination. The employee was transferred by ambulance to a local hospital. We believe at this time it was Memorial Hospital. The EMT's and the hospital were made aware of the radiological contamination and all precautions were taken. The licensee requested that all materials removed or used at the hospital, and in the ambulance be returned to the licensee. [Urinalysis] was [performed] on the employee and found to be at baseline levels. Contamination was contained in the building where the accident happened and contamination on the floor was decontaminated to background levels. The licensee is following up with the hospital concerning the contaminated clothing, and debris associated with the incident. The licensee will submit a report within thirty days."

REACTOR VESSEL HEAD DEGRADED CONDITION

"During the unit 1 cycle 12 refueling and steam generator replacement outage, an inspection was performed of the vessel head in accordance with NRC Order EA-03-009. This bare metal inspection identified a potential leak indication at the head to penetration interface for CRDM (Control Rod Drive Mechanism) penetration #3. On March 26, 2003, at approximately 1012 hours EST, it was decided that the chemical samples have confirmed that the residue found at this interface contains boron, iron, and zinc, indicating that this was an RCS leak. This leak is most likely from a through wall crack in the RCS pressure boundary at the CRDM interface. Volumetric exams are planned to confirm the crack and to determine the scope of any repairs. In accordance with the Order, a 100% volumetric inspection is being prepared for this outage. Prior to this identification, this unit was rated as a 'low susceptibility category.' There had been no indication of RCS leakage during the previous cycle's operation. This notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A)."

The licensee has notified the NRC Resident Inspector.

*****UPDATE ON 4/4/03 AT 1355 FROM LEAHY TO LAURA*****

"The purpose of this notification is to update event #39704 concerning a potential pressure boundary leak at CRDM #3. TVA has completed both UT and PT examinations of CRDM #3. The results of these exams do not provide any indication of a crack in the RCS pressure boundary. Investigations are continuing as to the source of the residue found at the penetration. Based on the results of the vessel head examination, this investigation is focusing on determining whether the residue was a result of a prior leak from a non-RCS pressure boundary location."

Notified R2DO (A. Boland)

*****RETRACTED ON 4/4/03 AT 1702 EST FROM LEAHY TO LAURA*****

"The purpose of this notification is to retract the original 10 CFR 50.72 notification described in event notification #39704.
TVA's previous update to this notification stated that we had no indication of a pressure boundary crack and that we were continuing to investigate the source of the residue found near CRDM penetration #3. Isotopic analysis (Cesium isotopes) of the boron residue from the head now confirmed that the residue was over 10 years old and likely the result of a conoseal leak that occurred in that period. As such, TVA is retracting the original notification."

Notified R2DO (A. Boland)

SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS

"On 3/26/03 at 02:45 [CST], Unit 2 experienced a trip of the 2B Recirculation system variable frequency drive (VFD). The 2A VFD had tripped earlier in the shift. This resulted in entry into Technical Specification 3.4.1.B, which requires the plant to be placed in Mode 3 within 12 hours. The unit was manually scrammed at this time in accordance with plant procedures.

"This event is reportable within 4 hours per 10CFR 50.72 (b)(2)(i) as 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications'. It is also reportable per 10CFR 50.72(b)(3)(iv)(A) and 10CFR 50.73(a)(2)(i)(A) and (iv)(B)."

The cause of the Recirculation System VFD is being investigated. The licensee notified the NRC Resident Inspector.