Event Notification Report for November 17, 2003

PATIENT RECEIVED AN OVERDOSE DURING A BRACHYTHERAPY PROCEDURE

The licensee's RSO reported on 18 November 2003, that a patient, at Swedish Medical Center, Providence Campus, was scheduled to receive an intravascular Brachytherapy procedure that involved the use of a NOVOSTE Beta-Cath device. The device, Serial Number ZB638, employed a total activity of 2907 Megabecquerels (78.56 millicuries) of Strontium 90/Yttrium 90, in a sealed source-train, Serial Number 91837. The cardiologist was unable to insert the source-train for the treatment because, as reported by the RSO, it was into a small artery and the routing did not follow a direct path. This resulted in a 143 second, 13.78 Gray (1378 Rad), exposure to healthy patient tissue.

The source-train was partially inserted into the patient when the cardiologist experienced difficulty. A 143 second exposure time elapsed before the cardiologist withdrew the source-train even though medical center procedure requires the sources to immediately be withdrawn once a problem is understood. The delay apparently occurred as the cardiologist first worked to fully insert the source-train and then discussed correcting the problem with the oncologist.

The cause of the exposure was failure to follow established procedures. The cardiologist has been suspended from further licensed activities until the details of the event are fully understood. It is anticipated that no health affects to the patient will be realized as a result of the exposure. A DOH staff health physicist will pursue additional details of the event. There is no media attention at this time.

Patient and referring physician were notified.

FITNESS FOR DUTY

A vendor supervisor was determined to be under the influence of illegal drugs during a random fitness for duty screening. The vendor supervisor's access to the plant has been terminated. Contact the HOO for additional details.

The NRC Resident Inspector was notified of this event.

EVENT OR CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to mitigate the consequences of an Accident. During performance of scheduled surveillance test LIS-HP-310, Reactor Vessel High Water Level 8 [High Pressure Core Spray] HPCS Injection Valve Closure Instrument Channels A and B Functional Test, Instrument Maintenance personnel discovered one end of fuse 1B21A-F8 not fully seated. The other end of the fuse was fully seated, and was maintaining the un-clipped end in sufficient contact with the fuse holder to complete the circuit. Had the circuit been deenergized, a Control Room annunciator (1H13-P601 A404) would have alarmed, and High Pressure Core Spray (HPCS) automatic low level initiation circuits would have been disabled. The fuse was fully seated without incident.

"Upon discovery of the unseated fuse, the initial operability determination concluded that adequate contact was maintained to keep the circuit OPERABLE. After followup evaluation by Engineering, it was determined that continued OPERABILITY could not be assured during a seismic event. Failure of this fuse would prevent automatic actuation of HPCS on reactor vessel level low 2; and would prevent automatic closure of the HPCS discharge valve 1E22-F004 on reactor vessel level high 8. This would prevent the HPCS system, a single train safety system, from performing its design function during a Loss of Coolant Accident subsequent to a seismic event. This is reportable as an 8 hour ENS notification."

The licensee informed the NRC Resident Inspector.

DIVISION 1 AND 2 DIESEL GENERATORS AND ALL ECCS SYSTEMS WERE DECLARED INOPERABLE

While aligning the Emergency Service Water (ESW) to the swale, the sluice gates were opened without the ESW being aligned to the swale. This condition made both Div 1&2 Diesel Generators and all ECCS systems inoperable. The probable cause of this event is that the wrong procedure was used in this evolution. Procedure SOI-P45/49 sec 7.3.1 "ESW Pumphouse Forebay Emergency Supply Initiation" was used instead of the correct procedure SOI-P45/49 section 7.3.3. "Alignment of ESW to Pumphouse Forebay Emergency Supply". The condition was discovered at 1215 and corrected at 1220 after section 7.3.1 was exited and section 7.3.3 was used to complete the lineup to the swale.

The NRC Resident Inspector was notified.

* * * RETRACTED AT 1457 ON 12/02/03 BY LAUSBERG TO ROTTON * * *

"Further engineering analysis documented [that] the safety function of the Emergency Service Water (ESW) system was not lost while the system was inappropriately aligned. Also, plant design accounts for operator action to restore proper alignment and ensure continued functionality. Since the safety function of ESW was, and would continue to be maintained, the ECCS systems did not and would not lose the ability to perform their safety functions. Therefore, this condition is not reportable under 10CFR50.72(b)(3)(v)(B) and (D) as an event or condition that could have prevented fulfillment of a safety function and ENF 40326 is retracted."

The licensee notified the NRC Resident Inspector.

Notified R3DO Bruce Burgess.

REACTOR COOLANT SYSTEM LEAKAGE DUE TO A CRACKED SOCKET WELD

During routine operations activities a leak was identified in the area of EPV0109 (combined SI/RHR to Accumulator "D" outlet line vent). At 0900 it was determined that the leak was due to a cracked weld on the socket upstream of EPV0109. The leak rate is 25-30 drops per minute.

This condition is being reported as a degraded condition in the primary coolant system under 10CFR50.72(b)(3)(ii)(A).

The plant is currently in Mode 5 with RCS pressure at approximately 345 psig and temperature at approximately 125F. Shutdown cooling is being supplied by the "A" train Residual Heat Removal System.

The Resident Inspector has been notified.

SIGNIFICANT LEAK IN FIRE PROTECTION HEADER

"This is notification of a Special Report in accordance with Technical Requirement 7.1.1 of the North Anna Technical Requirements Manual.

"On November 17, 2003, at 1150 hours, the Main Control Room observed the start of all fire pumps and receipt of associated alarms. An investigation determined that a significant leak in the fire protection header occurred outside the protected area. The cause for the fire protection header leak has not been determined. In an effort to isolate the leak, two of the three fire pumps had to be shut down and the third pump was isolated. The leaking portion of the fire protection header was isolated by 1313 hours. The running fire pump was then used to refill and pressurize the fire protection header. By 1420 hours, the fire protection system had been returned to normal."

The licensee notified the NRC Resident Inspector.