Event Notification Report for November 10, 2003

SAFEGUARD VULNERABILITY - PHYSICAL SECURITY

Discovered vulnerability in a safeguard system that could allow access to a controlled access area for which compensatory measures were not employed.

The licensee notified the NRC Resident Inspector.

TAS notified Region IAT member who will followup for NRC.

Contact the Headquarters Operations Officer for additional details.

* * * UPDATE ON 11/13/03 @ 1340 BY T. MANZELLA/ R. MURILLO TO GOULD * * * RETRACTION

After further review it was determined that there was no vulnerability that would allow access to a controlled access area, therefore the licensee is retracting this event.

The NRC Resident Inspector was notified.

AGREEMENT STATE REPORT FOR LOST/STOLEN SOURCE

"On October 30, 2003, during a routine inventory of sources, it was discovered that a Nickel-63 electron capture source that had been in storage since January 23, 1996, was missing. An exhaustive search of source storage areas did not locate the source. However, upon questioning employees that had access to the source storage area, one employee recalled that the source in question had been picked up by a Health Physics Technician from the manufacturer, it was believed during the year 1998. The manufacturer denies having the source picked. A search of paperwork is ongoing to locate a transfer document, if one exists."

UNUSUAL EVENT DECLARATION DUE TO RELEASE OF FLAMMABLE GAS THAT MAY IMPACT NORMAL STATION OPERATIONS

A 1/8 inch sealant injection plug for the Main Generator was discovered out of it's location. This allowed the leakage of hydrogen gas into the Turbine Building. Fire Brigade leader responded and observed a flammable concentration of hydrogen. All available ventilation was initiated, and non-essential personnel were evacuated from the 75 foot level of the Turbine Building. Maintenance personnel responded and were able to reinstall the plug. Hydrogen levels were reduced to less than flammable. No radiological release occurred or is expected.

An Unusual Event was declared at 0908 on 11/10/2003 and terminated at 0908. Unusual Event was declared based on EAL 18a.3 - Release of toxic or flammable gas from anywhere near site or on site that may adversely impact normal station operations.

The licensee notified the NRC Resident Inspector and New Hampshire.

AUTOMATIC REACTOR TRIP DUE TO FALSE RCP BREAKER OPEN SIGNAL

"Reactor Protection System actuation in response to an indicated (not an actual) 2A RCP [Reactor Coolant Pump] breaker open position signal. All reactor protection and support systems operated as expected. The Aux Feedwater System started as required in response to the tripping of both Steam Generator Feed Pumps. All 3 RCPs are running; none have tripped.

"Not understood is the indication of the 2A RCP breaker open when the breaker has remained closed."

The licensee reported that all control rods fully inserted; decay heat is being rejected to the condenser via the steam dumps; a steam generator atmospheric relief may have momentarily lifted during the transient; and that the electrical grid is stable. The licensee will be notifying the NRC Resident Inspector.

TRANSPORTATION EVENT - SYRINGES LOST FROM COURIER VEHICLE

The licensee reported that at 0700 ET on 11/10/03, a courier was transporting syringes containing Technetium-99M and Flourine-18 when, while driving over the Key Bridge in Georgetown, District of Columbia, the trunk of the vehicle popped open and 2 boxes were released just past the bridge in Georgetown. Everything was recovered except for 1 syringe containing 15 millicuries of Flourine-18 calibrated at 1145 ET with a 2-hr half life and 1 pig containing a syringe with 2 millicuries Technetium-99M calibrated at 1300 ET with a 6-hr half life. Pieces of the syringe containing the Flourine-18 were recovered and it was believed that the syringe had been run over by a truck. A radiation survey was performed and only very low readings were found where the syringe had been broken. The pig containing the syringe with Technetium-99M was not recovered and it is believed to have rolled into a storm drain near the intersection of Reservoir Road and M Street in Georgetown. The licensee and the local Hazmat Team determined that there was no need to attempt a recovery of the material from the storm drain.

The licensee had initially notified the VA Dept. of Health, DC Department of Health, and US DOT (NRC) of the released Flourine-18 prior to realizing that the syringe containing Technetium-99M was also missing. The licensee will be updating these agencies.

BYPASSING THE PRESSURE SUPPRESSION FUNCTION OF THE TORUS

"On 11/10/2003 at 07:20 CST it was discovered, during a control room panel walk-down, that Dresden U2 had primary containment valves 2-1601-56 Torus Purge valve and 2-1601-21 DW (drywell) Purge valve open simultaneously. This valve alignment created a flow path from the Drywell to the Torus, effectively bypassing the pressure suppression function of the torus water volume during a LOCA (Loss of Coolant Accident) condition. This condition placed U2 containment in an unanalyzed condition, not capable of performing the intended design function, which is to mitigate the consequences of a LOCA. The proper valve alignment was restored at 07:26 CST which restored U2 primary containment to operable status per TS (Tech. Spec) 3.6.1.1.

"A review of plant data identified that this valve arrangement, which bypassed primary containment, had been in effect when U2 entered Mode 2 (Startup) from Mode 4 (Cold Shutdown) at 12:01 on Nov 9, 2003. In addition, this valve line-up existed for a duration greater than that allowed by TS 3.6.1.1 A.1 and B.1 (1 hour)."

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


**** Retraction on 12/31/03 at 1430 EST by J. Welch taken by MacKinnon ****

"Dresden has performed an engineering evaluation that bounds the plant conditions that existed while the two valves were simultaneously open. The evaluation concluded that the valves would have automatically closed in sufficient time to prevent exceeding the design limits of the primary containment during a postulated Design Basis Accident.

"Therefore, Dresden retract the ENS call associated with this event. This event will be the subject of an Licensee Event Report in accordance with the requirements of 10 CFR 50.73(a)(2)(i)(B), 'Any event or condition which was prohibited by the plant's Technical Specifications.'" R3DO (Ken Riemer) notified.

The NRC Resident Inspector was notified of the above retraction by the Licensee.

AGREEMENT STATE REPORT - STOLEN AND RECOVERED TROXLER MOISTURE DENSITY GAUGE

The State of California was informed at 1900, November 9, 2003 that Construction Testing & Engineering had reported the theft of one of their Troxler gauges (Model 3440, S/N 24168). The theft occurred on Friday November 7, 2003, and was reported to Sacramento County Sheriff. The sheriff detectives indicated that they would be questioning the operator who had possession of the gauge at the time it was stolen. An onsite inspection/investigation will be conducted.

The licensee RSO indicated that the theft had been on the local television news Monday morning along with photographs of the stolen device, and a reward for its recovery.

Subsequent to the initial report, the gauge was reported by an unknown party to be in a ditch in an area north of Sacramento. Sheriffs, Hazmat, and other agencies responded and the gauge was recovered without incident.

California Incident Report # 111003.

LESS THAN PRESCRIBED DOSE TO PATIENT

The licensee received from the pharmacy a dose of Samarium-153 isotope (93.5 millicuries) scheduled to be administered to a patient for bone pain treatment. The dose calibrator at the hospital indicated that the assayed activity of the Samarium-153 was 9.39 millicuries. The licensee called the pharmacy and questioned about the discrepancy that the assayed activity needed to be multiplied by a factor of 10 which made the calculated value equal to 93.9 millicuries. The dose was then administered to the patient.

About one hour later the pharmacy called and stated that the dose the patient received was in fact 9.39 millicuries of Samarium-153, realizing that the mistake was made due to the assumption that Samarium-153 is not just a pure beta emitter but actually gives off gamma radiation. The dose calibrator was accurate and the procedure was improperly followed by multiplying the assayed dose by a factor of 10.

The physician, the Radiation Safety Officer and the patient were notified of the mistake. The physician will administer the rest of the dose to the patient. The licensee will make policy and procedural changes to reflect the fact that Quadramet Samarium-153 emits gamma radiation and can be properly measured by the hospital's calibrator.

FITNESS FOR DUTY PROGRAM CONDITION

"On November 10, 2003, at 1740 hours it was determined that a Fitness-For-Duty program condition existed which required a 24-hour report to the NRC.

"Personnel with unescorted access are placed into different groups within the Fitness-For-Duty program. One of these groups, the Immune group, is for personnel not eligible for random test selection at our site, such as the NRC. The remaining groups become part of the random eligible population.

"During a review of the Fitness-For-Duty program it was discovered that the total number of personnel in the Immune population group was higher than normally expected (133 vs. 24). Some personnel required to be in the random eligible population were discovered to be in the Immune group, which rendered them ineligible for selection. (This primarily affected personnel transferring from an approved program within 30 days.). This resulted in non-compliance with 10 CFR 26.24.

"Security personnel are manually correcting the group listings, identifying the affected individuals, scheduling individuals still on site for testing, and notifying the plants where individuals potentially affected may have gone.

"A root cause investigation is presently being conducted to identify the extent, time frame, and cause of this event. If relevant information is uncovered as a part of the root cause investigation that affects the reportability determination, the NRC will be notified.

"This condition is being reported in accordance with 10CFR26.73."

The licensee has notified the NRC Resident Inspector

* * * RETRACTION AT 1553 ON 12/01/03 FROM SWEET TO GOTT * * *

Based on subsequent research, the licensee determined that the above event is not reportable as a significant event under 10 CFR 26.73.

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Bonser)