Event Notification Report for July 09, 2003

AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP BREAKER OPENING WITH INITIATION OF AUXILIARY FEEDWATER SYSTEM AFTER THE TRIP

"At 0109 hrs. CDT, Unit 2 reactor tripped due to opening of RCP [Reactor Coolant Pump] 2-04 breaker resulting in "Rx >48% 1/4 loop flow low trip". Cause of the breaker opening is unknown and under investigation. All systems responded as required. Auxiliary Feed Water auto-start occurred due to steam generator shrink, both motor driver AFW pumps and Turbine Driven AFW pump started (ESF)."

All rods inserted into the core during the trip. The electrical grid is stable. There were no power-operated or manual relief valve lifts during the transient. The other unit was not affected by the transient. Decay heat is being removed via steam generator blowdown and AFW. The plant is maintaining at NOP/NOT in mode 3 until the cause of the breaker trip is known and repaired. Pressurizer pressure control is in automatic. There is no identified primary-to-secondary leakage.

The licensee has informed the NRC Resident Inspector.

MEDICAL EVENT

At 1300 CDT on 7/9/03, an underadministration of Yttrium-90 (Y-90) occurred at the University of Wisconsin Hospital in Madison, WI. A patient being treated for secondary liver cancer was to receive a dose of approximately 50 millicuries of Y-90. The dose was delivered using a SIRTECH (Selective Radiation Implantation) to pulse microspheres of Y-90 from a vial into the liver via a needle and catheter.

During the procedure, the SIRTECH did not develop enough pressure to deliver the entire dose to the patient, and only about 8 percent of the Y-90 was delivered to the patient (between 3-4 millicuries). The remainder of the Y-90 microspheres were contained within the vial.

There was no adverse affect on the patient due to this underadministration, and the licensee is still investigating how to prevent a re-currence. The patient was notified of the underadministration.

* * * RETRACTION AT 0615 EDT ON 07/17/03 FROM BRESELL TO GOTT * * *

The licensee determined that the technician had misinterpreted the measurement of the Y-90 administered to the patient and determined that the correct amount of Y-90 was administered. Because the correct amount of Y-90 was administered, the licensee is retracting the event. The licensee discussed this with Deborah Piskura, NRC Region III.

Notified R3DO (Riemer) and NMSS EO (Pierson)

CONTROL ROOM HVAC REFRIGERATION AND CONDENSING UNIT TRIPPED DURING SURVEILLANCE TEST

"At 2200 hours on July 9, 2003, the B Control Room HVAC Refrigeration and Condensing Unit (RCU) tripped and would not stay running during surveillance testing. The RCU is a single train system and therefore is reportable per SAF 1.8 and LS-AA-1400, Event Reporting Guidelines Section 3.2.7. The RCU is required to operate during a design basis accident to remove heat from the Main Control Room. The Air Filtration Unit (AFU) of CREVS [Control Room Emergency Ventilation System] remains operable. This places both units in a 30 day LCORA [Limiting Condition for Operation Required Action] per Tech Spec 3.7.5 Required Action A.1."

The licensee has notified the NRC Resident Inspector.

* * * Retraction on 07/15/03 at 1924 EDT by Dennis Francis taken by MacKinnon * * *

"On July 9, 2003, an ENS notification was made regarding the 'B' Control Room HVAC Refrigeration and Condensing Unit Inoperability. The (event) was reported as a condition that would have prevent the fulfillment of a safety function. However, after a review of the actual circumstances it was determined that the system did not trip as was believed at the time of the notification. The system was thought to have tripped because a trip indicator light for the refrigeration compressor in the main control room was illuminated. The breaker was inspected and no adverse condition observed. Further investigation revealed that the trip indicator was illuminated due to the local control switch being in the AUTO-AFTER-START position. Therefore when the compressor would not cycle off due to temperature, the trip indicator would illuminate. Even though the condition does not (affect) operability, it does indicate a false trip indication. Then normal position for this switch is AUTO-AFTER-STOP. In this position the amber trip light indicator will not illuminate when the compressor turns off to low temperature in the main control room.

"The switch position of AUTO-AFTER-START did not affect the ability of the system to perform its safety function. Therefore the ENS notification (Ref. EN # 39987) is being retracted." NRC R3DO (RIEMER) notified.

The NRC Resident Inspector will be notified of this retraction by the licensee.

MEDICAL EVENT

The Radiation Safety Officer at Washington University reported that an under dose of a radiopharmaceutical (Sm-153 Quadramet) was administered to a patient on 07/09/03. The under dose was discovered at 1600 CDT on 7/10/03 when it was determined that a significant amount of the radiopharmaceutical had leaked from the syringe. The licensee determined that 54 millicuries out of the planned 55.8 millicuries had leaked from the syringe such that less than 4% of the planned dose was administered. The licensee will be notifying the referring physician when he returns to his office on Monday, 07/14/03. The licensee assumes the physician will then notify the patient.

The licensee will provide a written report to Region 3.