Event Notification Report for July 28, 2003

POTENTIALLY DAMAGED TROXLER MOISTURE DENSITY GAUGE

At approximately 1500 PDT on 7/28/03 a rubber tire compactor ran over a Troxler Model 3440, Serial No. 31827, gauge containing an 8 millicurie Cs-137 and a 40 millicurie Am-241:Be source. The sources were in the safe position at the time the incident occurred. The licensee performed rad surveys and did not observe any abnormal rad readings. The manufacturer was contacted and requested a photograph to evaluate any potential damage.

RPS ACTUATION, SPECIFIED SYSTEM ACTUATION

"On July 28, 2003, at approximately 18:54 Mountain Standard Time (MST) Palo Verde Unit 3 experienced an automatic reactor trip on low DNBR [Departure from Nucleate Boiling Ratio] from approximately 98% rated thermal power due to reduced reactor coolant system flow when the main turbine tripped during a grid perturbation. Unit 3 was at normal temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. This was an uncomplicated reactor trip. No emergency classification was required per the Emergency Plan. No automatic ESF actuations occurred and none were required. The operators initiated a manual Main Steam Isolation System (MSIS) actuation, in accordance with the emergency operations procedures in response to the loss of forced reactor coolant system flow. Safety related buses remained energized during and following the reactor trip. The Emergency Diesel Generators did not start and were not required. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event.

"Unit 3 is stabilizing at approximately 520 degrees F and 2150 psia pressure in Mode 3. The reactor coolant system remains in natural circulation with heat removal via the atmospheric dump valves and feedwater from the essential auxiliary feedwater system. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"Palo Verde Units 1 and 2 also observed the grid perturbation, but are continuing to operate in Mode 1 at approximately 98% rated thermal power. The cause of the perturbation is believed to be associated with switching in a nearby Hassayampa yard by Salt River Project. A fossil power plant in the vicinity also tripped off line during the grid perturbation event.

"The [NRC] Senior Resident Inspector was informed of the Unit 3 reactor trip and this notification. The Senior Resident Inspector has arrived on-site to observe response to the reactor trip."

* * * UPDATE 1437 EDT ON 7/29/03 FROM RAY BUZARD TO S. SANDIN * * *

The following information was provided as an update:

"This is a follow-up notification to the automatic reactor trip event reported on July 28, 2003 (ENS # 40029) for Palo Verde Unit 3. The plant remains stable in Mode 3 at approximately 585 degrees and 2250 psia. Reactor coolant system (RCS) forced circulation has been restored with two reactor coolant pumps (RCP) in operation. Heat removal remains via the atmospheric dump valves and the non-essential auxiliary feedwater pump is supplying steam generator feedwater. Off-site power has been restored and is supplying non-class loads.

"An RCS leak of approximately 1.7 gallons per minute has been identified through the seal on RCP 2A. Vacuum has been restored to the main condenser and activities are in progress to cool the plant down to Mode 5, Cold Shutdown, using the steam bypass control system, to facilitate RCP 2A seal replacement. The date of restart has not been established.

"The Resident Inspector was informed of this notification."

Notified R4DO(Shaffer).

SCRAP ZIRCONIUM RODS SHIPPED TO RECYCLER IN CANADA CONTAINING U-235 FUEL PELLETS

Between 3-4 weeks ago Westinghouse Hematite shipped approximately 18,000 scrap zirconium rods to Mississauga Metals and Alloys, Inc. in Brampton, Ontario, Canada for recycling. Scrap zirconium rods require a 100% visual inspection prior to shipment offsite to ensure that they do not contain any fuel pellets. Last Thursday on 7/24/03, the recycler discovered thirty-six (36) U-235 pellets (4.2 w/o) after processing about 25% of the scrap rods. The individual at Mississauga responsible for contacting Westinghouse did not return to work until Monday and, thus, Westinghouse was not informed until 0730 CDT on 7/28/03. The pellets contain a total of six (6) grams U-235. Westinghouse is dispatching staff to the recycling facility to assist in determining appropriate corrective actions.

SAFEGUARDS 1-HOUR REPORT

The licensee discovered a vulnerability in a safeguard system that could allow access to a controlled access area for which compensatory measures have not been employed. The licensee will notify the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

* * * RETRACTION ON 7/28/03 AT 1743 EDT FROM DAVID LANTZ TO GERRY WAIG * * *

"Consistent with guidance outlined in Generic Letter 91-03, Reporting of Safeguards Events, this call [event] is being retracted." The licensee has notified the NRC Resident Inspector.

Notified R4DO (Mark Shaffer), TAT (Roberta Warren).

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"Abstract:

"The agency [Illinois Department of Nuclear Safety] received a call July 29, 2003 from a nuclear medicine technician, at Rush Copley Medical Center in Aurora, IL [deleted]. She reported that a patient who was to receive a 4 milliCi unit dose of Tl-201 [Thallium-201] for a heart test instead received a 4 milliCi unit dose of I-131 [Iodine-131] on July 28, 2003.

"Circumstances surrounding the event, as reported by the technician, indicate that both the exterior lead container and syringe were labeled as being Tl-201. Although the injection occurred the previous day it was not determined that I-131 was involved until after the gamma cameras used for patient imaging were checked a second time on the morning of July 29th. Service engineers had been called to the site both days to inspect the cameras after both failed attempts to image the patient. The cause became evident when a gamma camera flood source that had been made from what was thought to be the remaining Tl-201 material in the syringe from 7/29/2003 showed peaks consistent with I-131. The assayed amount from Monday's records showed the dose to be within the expected range for a typical 4 milliCi Tl-201 diagnostic doses and as such, was considered to be normal. The technician indicated that the patient involved had been contacted by the referring physician, the onsite oncologists, the hospital Administrator and lawyer and was informed as to what had happened. The hospital has arranged to perform routine blood analysis throughout the year to monitor any changes in thyroid activity.

"The RSO [Radiation Safety Officer] and oncologist at the facility, [deleted], were then contacted by the Agency. He indicated that it is very unlikely that any changes will be noted in the patient. He reports that the dose administered, is only slightly larger than that typically ordered for whole body scans using I-131. Regardless, they have offered to provide routine blood testing of the patient throughout the year for T3, T4 and T7 thyroid hormones levels as part of a follow up evaluation.

"A call was then made to the Medi Physics/Amersham Health, [deleted] Wood Dale pharmacy facility where the doses had been prepared the previous Friday. [Deleted], Corporate RSO indicated that they were in the process of determining what had occurred but it appeared that when prescriptions and labels were taken from the computer system a 4 milliCi Tl-201 prescription was mistakenly put in with 4 other prescriptions for 4 milliCi unit doses of I-131 to be filled. Subsequently, the Tl-201 request was mistakenly filled as an I-131 prescription. The difference in nuclides was not noted by the pharmacist when the pre-generated Tl-201 labels were applied to the syringe and lead container which now held I-131.

"The Agency sent an investigator to the medical center on the morning or July 30 to observe the labeling on the container and syringe, receipt records, gamma camera QA tests and to verify by gamma spectrum analysis the presence of I-131 as well as to conduct preliminary interviews to obtain additional facts. The investigation then moved on to the pharmacy to continue their review of the event. Based on those visits, the information obtained largely confirmed the preliminary notification. The Agency is continuing its investigation of the matter and is expecting reports to be filed by both parties according to regulatory requirements.

"Preliminary estimates of EDE to the whole body of 355 Rem and 11,672 Rad to the thyroid based on ICRP 53 modeling assuming 55% uptake and standard man conditions has been calculated. Similar preliminary estimates based on the package insert assuming 25% uptake resulted in 1,628 Rads and 5,328 Rads respectively. The two estimates vary widely because of unknown factors associated with the patient's condition. NRC Operations Center was notified of the event at 17[50] on 31 July 2003 and assigned Event Number 40042."

*** UPDATED AT 1705 EDT ON 8/1/03 FROM KLINGER TO CROUCH ***

Last paragraph of above report was amended to read as follows:

"Preliminary estimates of dose to the thyroid range from 5,300 Rads to 11,700 Rads. The two estimates vary widely because of unknown factors associated with the patient's condition. NRC Operations Center was notified of the event at 1750 E.S.T on 31 July 2003 and assigned Event Number 40042."