Event Notification Report for June 11, 2003

AMERESIUM SOURCE LOST FOLLOWING F-16 CRASH

The Air Force reported that a F-16 fighter jet crashed in Arizona near Luke AFB yesterday with a 8 microcurie Americium - 241 source. The source could not be found.

INCORRECT TREATMENT AREA DISCOVERED DURING A BREAST CANCER TREATMENT

At the beginning of the 6th treatment the physicist discovered a geographic location error on the placement of a 3 curie +/- Iridium-192 source in the patient for treatment of breast cancer. Discovered an input error on the five previous treatments. Measurements should have been input to the Gamma Med Plus (HDR device) in millimeters were mistakenly entered in centimeters. Steps for the 20 millimeter source should have been in 1 millimeter increments. Therefore, the source was actually never in the patient's body. The physicist has estimated 70 Gray superficial dose to the skin at a depth of up to 1 centimeter. Deep dose (beyond 1 centimeter) is estimated at 30 Gray. The patient has developed a small red spot which is being monitored by the hospital for potential blistering. The patient and the hospital have agreed to re-start this patient's treatments. Corrective actions to prevent a re-occurrence of this event will follow with the Licensee's 15 day written report of the incident. Dose to original treatment site is in excess of 20% of the intended dose.

REACTOR PROTECTION SYSTEM ACTUATION DUE TO MAIN TRANSFORMER LOCKOUT RELAY TURBINE TRIP

"At 1453 EDT on 6/11/03, Unit 1 experience a reactor trip due to a main transformer lockout relay turbine trip. All equipment operated as designed. 10 CFR 50.72(b)(2)(iv)(B). Main transformer 'C' appears to have an internal fault, [and] may need to be replaced. All control rods inserted fully.

"A valid actuation of the Auxiliary Feedwater System resulted, due to the reactor trip. 10 CFR 50.72(b)(3)(iv)(A). The unit is stable, using main feedwater and condenser steam dump [as a means of heat removal].

All safety-related systems are available except for Unit 1 Emergency Diesel Generator which is out of service for maintenance.

The licensee notified the NRC Resident Inspector.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABLE CHILLERS

"At 1409 on 6/11/03, both Control Complex Chillers were declared inoperable. The inoperability resulted in an entry into ITS 3.0.3 due to the inability to comply with ITS 3.7.18. At 1505 CR-3 [Crystal River Unit 3] began a power decrease in compliance with the actions of ITS 3.0.3. This is a 4-hour reportable event as required by 10 CFR 50.72(b)(2)(i).

"At 1618 on 6/11/03 the operating Control Complex Chiller was declared Operable and the actions of ITS 3.0.3 were exited. The plant has been returned to full power operation.

"The safety significance of this event was small. The Control Complex cooling safety function was available through the use of existing procedures and available alternate cooling methods. At 1456, an available Control Complex Chiller was manually loaded and is currently providing all required cooling to the control complex in automatic mode."

The licensee notified the NRC Resident Inspector.

GREATER THAN 30% OF THE OFFSITE NOTIFICATION SIRENS OUT OF SERVICE DUE TO STORM

Greater than 30% of the offsite prompt notification system sirens are out of service due to storm related loss of power. Repairs are presently in progress to restore power to the affected sirens (34 of 99). State and Local agencies have been notified to implement compensatory measures if required.

The NRC Resident Inspector will be notified by the licensee.

SIX VIOLATIONS FOUND DURING RECENT INSPECTION AT A TEXAS LICENSED FACILITY

On June 11, 2003 the Texas Department of Health, Bureau of Radiation Control conducted a follow up inspection of licensed activities at the Humana Hospital Day Surgery Center DBA The Surgical Center (TSC), Bryan, Texas. The inspection findings were discussed with Dr. Alikhan, Radiation Safety Officer and his staff In a preliminary exit briefing at close of inspection.

Based on the results of his inspection., the Inspector has determined that at least 6 violations of the Agency requirements occurred. In addition, the violations were identified by this Agency rather than through the Licensee conducting Radiation Protection Program (RPP) audits.

The Inspector reviewed five (5) total patients affected, since the last inspection by this Agency conducted on January 18, 2001. Utilization logs indicate that this number could increase given a review of the patients treated prior to January 18, 2001, with the use of the stroutium-90 eye applicator. Therefore, as discussed with the RSO during the exit briefing, additional information may be required of TSC before the Agency can make a determination to conclude this issue. The Inspector informed the Licensee that the number and characterization of apparent violations could change as a review Is conducted.

Inspection Findings: Items of Noncompliance

1. Violation of 25 TAC §289.256(ee)(1)(a)(i):
The Licensee failed to report and notify this Agency of a dose that differs from the prescribed dose by more than 5 rem (0.05 Sv) effective dose equivalent, 50 rem (0.5 Sv) to an organ or tissue, or 50 rem (0.5 Sv) shallow dose equivalent to the skin and either:

a. the total dose delivered differs from the prescribed dose by 20% or more.

2. Violation of 25 TAC §289.202(e)(1):

The Licensee failed to conduct a Radiation Protection Program (RPP), sufficient to ensure compliance with the provisions of §289.202. The RPP was not developed, documented, and implemented.

3. Violation of 25 TAC §289.201(g)(1)(b):

The Licensee exceeded the six-month leak test interval for a sealed source of radioactive material for a 100mCi Sr-90 source, S/N 0214, during the time period from January 18, 2001 until June 4, 2003.

4. Violation of 25 TAC §289.256(p)(1)&(2):

At the time of the inspection, the Licensee had failed to generate written directives signed and dated by an authorized user prior to administration of Sr-90 Brachytherapy.

(i) prior to implantation: the treatment site, the radionuclide, number of sealed sources and dose; and
(ii) after implantation but prior to completion of the procedure: the radionuclide, treatment site, number of sealed sources, total sealed source strength and exposure time or, equivalently, the total dose.

5. Violation of 25 TAC§289.256(bb)(6)(A)(B)(C)&(D):

The Licensee failed to determine the calibration measurements of Brachytherapy sealed sources.

6. Violation of 25 T,AC §289.256(i)(2)(A)&(B):

The Licensee's Radiation Safety Committee has not been composed of the required personnel. By evidence of the January 30, 2003 Radiation Safety Committee minutes that identifies representatives to attendance, the Radiation Safety Officer and an authorized user of type of use permitted (surgery) by the license, were not present.

AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO HIGH HIGH STEAM GENERATOR WATER LEVEL

"On 06/11/03, Unit 2 Reactor tripped via Turbine Trip due to high-high Steam Generator level. All Control Rods fully inserted. Unit stable in Mode 3 (Hot Standby). Auxiliary Feedwater system was manually started and currently maintaining steam generator levels. Investigation is in progress to determine initial cause for loss of feed to the 2A Steam Generator from its associated low power feedwater regulating valve."


Coming out of a refueling outage reactor power was at 30% when it was noticed that main feedwater regulating valves were oscillating. Reactor power was reduced to 20% and the low power feedwater regulating valves were placed in service so testing of the main feedwater regulating valves could be performed. During testing of the main feedwater regulating valves at approximately 22% reactor power low power feedwater flow to the 2A Steam Generator ceased. The dual indications for the low power feedwater regulating valve indicated that the valve was open but Steam Generator 2A water level was decreasing. Since main feedwater regulating valve was being tested the 100% bypass low power feedwater regulating valve was opened. Steam Generator water level began to increase rapidly so the valve was closed. 2A Steam Generator level began to decrease so the 100% bypass low power feedwater regulating valve was reopened. This time 2A Steam Generator water level increase above 88% narrow range which caused an automatic turbine trip. Since reactor power was greater than 15% the reactor automatically tripped due to the turbine trip. All rods fully inserted into the core. Since the reactor core had very little decay heat the main steam isolation valves were closed and both motor driven auxiliary feedwater pumps were manually started. Motor Driven Auxiliary Feedwater Pumps and Steam Generator PORVs operation is maintaining the plant in a Hot Standby condition. All emergency core cooling systems are fully operable and the emergency diesel generators are fully operable if needed. The electrical grid is stable. The licensee believes that the stem of the low power feedwater regulating valve separated from the valve which in turn caused the valve to close while still having dual indication that the low power feedwater valve was open.

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

INABILITY TO ACTIVATE EMERGENCY SIRENS DUE TO EQUIPMENT FAILURE

"On June 11, 2003 at 0810 hours, the control room was notified that all Prompt Alert and Notification System (PANS) sirens were inoperable. All necessary notifications to local towns and MEMA (Massachusetts Emergency Management Agency) have been made. A backup plan (route altering) is in place in the event of an emergency at Pilgrim station. It was determined that one of the sirens was transmitting a continuous radio signal to the remaining sirens, preventing actuation. The faulty siren was isolated from the system at 1125 hours."

The licensee informed both state and local agencies and the NRC resident inspector.

This condition involving a different siren in the system occurred on 6/10/03. See EN #39912.

CONTROLLED PLANT TS SHUTDOWN DUE TO LOSS OF HVAC SYSTEM

"On 6/11/03 at 12:17, the 'A' Control Structure Chiller tripped. The 'B' Control Structure Chiller was already inoperable for maintenance on the 'B' Chiller Fans. With the loss of Control Structure HVAC System the ability to maintain temperatures in various spaces including Relay rooms, Control Room Floor Cooling and Emergency Switchgear rooms was lost. Units 1 and 2 entered [Technical Specifications] TS 3.0.3 and a controlled shutdown of both units were commenced at 13:15. The 'A' Chiller was restarted at 12:47 and cooling was reestablished to the required areas, however the 'A' chiller is not considered operable at this time. The 'B' Chiller was placed in service and was declared operable at 13:20 [and the controlled shutdown of both units were terminated]."

"This constitutes a Tech Spec required shutdown and requires a 4-hr ENS notification in accordance with 10 CFR 50.72(b)(2)(i). The failure also requires an 8-hr ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(A-D) due to the loss of a safety function."

The licensee notified the NRC Resident Inspector.

SECURITY REPORT INVOLVING A PLANT SECURITY OFFICER

Discovery of criminal act involving individual granted access to the site. Immediate compensatory measures taken upon discovery. The licensee informed local law enforcement and the NRC resident inspector. Contact the Headquarters Operations Officer for additional details.

*** UPDATE ON 6/11/03 AT 2029 FROM D. POPP TO A. COSTA ***

The non-licensed employee was determined to be under the influence of alcohol during a "for cause" test. The individual's access to all NMC facilities has been revoked. Contact the Headquarters Operations Officer for additional details.

OFFSITE NOTIFICATION TO STATE OF TENNESSEE MADE DUE TO LOSS OF POWER TO EMERGENCY SIRENS

The following information was obtained from the licensee via facsimile:

"On June 11, 2003, 23 of the 108 emergency sirens were out of service because of a storm passing through the area, causing power outages. The TVA Operations Duty Specialist notified the State of Tennessee of the loss of the sirens. This report is being made to NRC in accordance with 10 CFR 50.72(b)(2)(xi) as a situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been made. As power was restored to the area, the sirens were returned to service.

"This report is being made at this time since Sequoyah Operations personnel have become aware that the State of Tennessee was notified by the TVA Operations Duty Specialist on June 11, 2003."

The TVA Operations Duty Specialist is based in a location different from the Sequoyah plant.

The licensee has notified the NRC Resident Inspector.