Event Notification Report for April 28, 2003

TEXAS AGREEMENT STATE REPORT ON DISABLED GAUGE FOR OIL CRACKING PLANT

"Licensee immediately suspended operations in the affected "reactor" (oil cracking plant) due to loss of measurement caused by loss of level/density measurements from an Ohmart Corporation (OC) Model SH-F2, source holder, containing 1 curie of Cs-137, Serial # 68526, located on the exterior surface of the SAS Sodium reactor, vessel # R-7202. Operators noted a loss of measurement at approximately 7:00 a.m. When investigating the outside of the reactor vessel, on-site personnel noted that the fixed gauge had broken free of its mounting bracket and fallen, face-down, approximately 10 feet to the ground. Plant personnel immediately notified Techstar, a subsidiary of Ohmart/Vega Corporation, for field service. A service technician arrived on scene, surveyed the gauge for radiation leakage, checked for contamination, and checked the functional operation of the gauge. The shutter was closed and locked by service personnel, until damage could be assessed. No damage was sustained by the gauge. The mechanism was fully functional and has been reinstalled on the reactor vessel. A set screw (a 3/4 to 1 inch bolt) had failed on the mounting bracket, due to suspected structural fatigue and vibration over 11 years since the gauge was installed (December 1992). The gauge was reinstalled in a bracket modified to fit on the welded beam (2-inch pipe), that will not allow the gauge to fall if the set screw fails in the future. All other gauges on site were checked by service personnel for security and possible deterioration on mounting hardware. This gauge was unique in this plant due to it's mounting which has now been upgraded to allow for fail-safe operation without loss of function should the bracket fail. Problem has been corrected by the service company. Modification to the mounting bracket and replacement of the set screw has rectified the cause of this incident and returned the reactor to operation."

PROVISIONAL REPORT OF MEDICAL MISADMINISTRATION

On 4/22/03, Nuclear Medical Technicians at St. Raphael Hospital received 2 vials ( 75 millicurie each) of I-131 that was to be administered to a patient later that afternoon. The vials were placed in their normal storage location. When the patient arrived, a nuclear technician administered only one vial of the I-131 which only gave the patient half of the prescribed dose. On 4/23/03, while preparing nuclear medicine for a different patient, a technician discovered the second vial of I-131 that was to be administered to the patient from the previous day. Upon discovery, the patient and the prescribing physician was notified of the error. The physician determined that the 27 hour span between doses would have no deleterious effects on the patient so the second dose was administered in the afternoon of 4/23/03. The intended dosage was 150 millicuries and the received dose was 142.4 millicuries. The RSO was notified at 0800 hrs. EDT on 4/24/03 and contacted NRC Inspector Richard McKinley who advised the licensee to make this notification.

STOLEN TROXLER GAUGE

Licensee reported that a Troxler Gauge Model 3430 serial number #029673 containing approximately 90 millicuries of Cs-137 and 44 millicuries of Am-241 was stolen from a construction site trailer in Guaynabo, Puerto Rico. Sometime between the evening of 4/25/03 and 10:00 on 4/28/03. The licensee has notified the local law enforcement.

Note From HOO: Troxler model 3430 normally has 8 millicuries of Cs-137.

* * * UPDATE ON 04/29/03 @ 1515 BY SOUSA TO GOULD * * *

The Troxler gauge was returned on 04/29/03 @ 1400 to the licensee. There appeared to be no damage to the gauge, but they will be performing a leak test on it.

FAILURE TO TAKE FITNESS FOR DUTY TEST

A contract supervisor refused to take a required fitness for duty test this morning. This action resulted in him being permanently denied access. His work history was reviewed and no discrepancy was found. The individual has turned in his resignation.

The NRC Resident inspector will be informed.

REACTOR TRIP FROM 100% POWER DUE TO A TURBINE TRIP

The licensee reported they had a turbine trip possibly due to the loss of output breakers which resulted in turbine overspeed causing the trip. The reactor trip from 100% was caused by the turbine trip. All rods fully inserted and there was no ECCS actuation, however one PORV lifted and reseated. All three emergency diesel generators auto started and loaded. The 4 reactor coolant pumps lost power, so the reactor was in natural circulation from 1645 to 1823 when they restored one coolant pump. The plant had lost power restored at 1904. They also had their aux. feedwater to auto start as expected due to a low steam generator level. The plant is currently stable and they are investigating the cause of the turbine trip.

The NRC Resident Inspector was notified along with the New York Public Service Commission

REDUCED REACTOR POWER FROM 100% TO HOT STANDBY DUE TO INOPERABLE ISOLATION VALVE

Unit 3 commenced a load reduction at 1835 to comply with T.S. 3.6.4, Containment Isolation Valve. The letdown isolation valve CV-3-200B was declared inoperable at 1600 due to indications there may be through valve leakage. Letdown is still currently in service. The intent is to isolate the letdown penetration once the unit is in mode 3, and affect troubleshooting and repairs.

The NRC Resident Inspector will be notified.

INTERIM SURVEILLANCE PROGRAM FOR FUEL CHANNEL BOW MONITORING (PART 21)

The control rod-fuel channel interference evaluation has been completed. It determined that BWR/6 and BWR/4 & 5 C-lattice plants with GNF thick/thin channels potentially have increased channel bow that can impact fuel bundle lift, loads on reactor internals, and control rod operability. An interim surveillance program has been developed to augment the surveillance requirements in the plant Technical Specifications until other actions, which mitigate or limit the potential for control rod-channel interference due to channel bow can be identified and implemented. The recommendations address the extent and frequency of surveillance actions, and the plants to which they should be applied. This surveillance program provides early indication of potentially degraded operational performance and assurance that action is taken before reaching excessive levels of control rod friction. This surveillance plan is limited to BWR/6 and BWR/4 &5 C-lattice plants with GNF thick/thin channels and GE control rods. There have been no indications of operational or scram problems on BWR/2, 3 and 4 D-lattice plants, and as a result, they are excluded from the interim surveillance program.

Plants Recommended for Surveillance Program

Clinton
Hope Creek
Nine Mile Point 2
Fermi 2
Grand Gulf
River Bend
LaSalle 1
LaSalle 2
Limerick 1
Limerick 2
Perry 1
Susquehanna 1
Susquehanna 2

*** UPDATE ON 4/30/03 AT 1841 FROM J.S. POST TO A. COSTA ***

GE Nuclear Energy has submitted correspondence to the USNRC to exclude the following plants from the surveillance program: Hope Creek, LaSalle1, LaSalle2, Susquehanna 1 and Susquehanna 2.

Notified R1DO(Jackson), R3DO(Gardner), R4DO(Pick) and NRR EO(Gillespie).

INVALID ACTUATION OF A CONTAINMENT VENT ISOLATION VALVE

The following information is provided as a 60 day telephone notification to NRC under 10 CFR 50.73 (a)(2)(iv)(A) in lieu of submitting a written LER to report a condition that resulted in an invalid actuation of the WBN Train B Containment Vent Isolation signal. NUREG1022, Revision 2 identifies the information that needs to be reported as discussed below.

(a) The specific train(s) and systems(s) that were actuated.

On April 28, 2003, at 2058 EST, a Train B Containment Vent Isolation (CVI) signal was received when the hand switch for the containment purge radiation monitor was placed in off, unblocking the monitor. The high radiation alarm was still locked in following maintenance on the monitor and was not cleared before unblocking. The containment radiation monitor was inoperable and was removed from service at the time the signal was received. The CVI was not responding to an actual plant condition.

(b) Whether each train actuation was complete or partial.

The actuation was considered complete. The CVI signal for Train B automatically isolated the containment vent system. The containment radiation monitor was considered inoperable due to the maintenance.

(c) Whether or not the system started and functioned successfully.

Train B Containment Vent Isolation signal automatically actuated and functioned successfully. The CVI signal was not in response to an actual plant condition. The containment radiation monitors were returned to service and the containment vent air cleanup unit was also returned to service.


The NRC Resident Inspector was notified.