Event Notification Report for January 19, 2004

CERTAIN PLANT DOORS MAY NOT BE ABLE TO WITHSTAND PRESSURE CREATED BY MAIN STEAM LINE BREAK

"On January 19, 2004, during on-going analysis of the effects of a Main Steam Line Break using new computer models, an issue was raised involving the capability of plant doors. Specifically, the preliminary analysis for a Main Steam Line Break in the Turbine Building determined that certain doors may not be able to withstand the initial pressure wave caused by a guillotine break of the main steam line.

"The preliminary analysis indicates that a pressure wave of approximately 2.7 psi is generated from such a main steam line break, which is more than the capability of several doors isolating safety-related equipment from the Turbine Building. The forces generated from this pressure wave could cause failure of the doors leading to both trains of low voltage switchgear, and the resultant steam environment could potentially render all low voltage AC equipment as well the station batteries inoperable. One train of the high voltage switchgear equipment could also be affected due to failure of the door leading to this room.

"Due to the potential loss of both trains of low voltage electrical distribution as a result of a steam line break, this issue is being reported as a non-emergency, 8-hour report in accordance with 10CFR50.72(b)(3)(ii)(B), a condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety. Current steam line pressures are low enough such that all doors are capable of withstanding any forces resulting from a steam line break. Engineering evaluation of the issue is continuing."

The NRC Resident Inspector has been notified of this issue by the licensee. The licensee also plans to make a media/press release regarding this issue.


*** UPDATE ON 02/20/04 AT 1022 EST FROM LARRY MYERS TO JEFF ROTTON ***

"Further review and evaluation of this issue has determined that the pressure wave from a main steam line break in the Turbine Building results in pressures of less than 1.0 psi. Therefore, the affected doors would be able to withstand this pressure wave with one exception. The one exception is the door to a High Voltage Switchgear Room, which is different from the other doors in that it opens into the Switchgear Room and therefore has a very low capability to withstand a positive pressure in the Turbine Building. However, additional analysis determined that in the event of a main steam line break and possible failure of the door, the resultant environment in the room (i.e., temperature, pressure, and humidity) would be within the capability of the enclosed equipment, and equipment operability would not have been challenged.

"Accordingly, this issue is no longer considered an unanalyzed condition that would have significantly degraded plant safety, and therefore the notification made per 10CFR50.72(b)(3)(ii)(B) is retracted."

Notified R3O (Gardner) and NRR EO (Reis)

DAMAGED MOISTURE DENSITY GAUGE

At approximately 10:30 CSTon 1/19/04, the Doe Run Company, located in Bunker, MO, reported that the source head of a moisture density gauge broke and fell to the floor. The gauge was being used in a slurry density line for mining and milling operations. The gauge is a Texas Nuclear, model SG-5191, gauge containing 500 millicuries of CS-137. The source serial number is B-1319. The licensee indicated that the area was isolated and the gauge manufacturer was contacted for corrective action. The source remained within the gauge head.

FITNESS FOR DUTY 24 HOUR REPORT FROM COMMANCHE PEAK

A non-licensed contract supervisor refused to take a fitness-for-duty test resulting in the termination of his site access. Contact the HOO for additional details.

The licensee indicated they will notify the NRC Resident Inspector.

KENTUCKY AGREEMENT STATE REPORT ON A MEDICAL EVENT

A medical event occurred on 1/19/04 at the Bowling Green Medical Center located in Bowling Green, Kentucky. Specifically, an inner vascular Brachytherapy treatment was planned. The catheter ran outside the body through an external valve which was inadvertently partially shut resulting in no dose to the target area. As a result, the doctor administering the treatment received .736 gray at his fingertips. Also, the patient received .736 gray to the thigh area. The source involved was 43.14 curies of strontium-90. There was no significant adverse health effects from this event. A review was initiated by the licensee to determine the cause and to initiate corrective actions.

NIH, DHHS REPORTED THE LOSS OF SIX VIALS OF TRITIATED ACETIC ACID FROM ITS NATIONAL INSTITUTE ON DRUG ABUSE

A vial box containing 10mCi tritiated acetic acid in each of six 1.5ml vials, held at -75°C for 22 months, was mistaken for a container of nonradioactive sample vials when its "Caution: Radioactive Materials" (CRAM) tape lost adhesion, separated from the vial box, and became obscured by accumulated frost. Although each of the 6 vials was labeled with a CRAM sticker noting the identity, activity, and inventory number assigned to its contents, these small stickers were not visible through the unopened box after prolonged storage. The container in question was mistakenly disposed of as biohazard waste, in a batch of approximately 50 boxes of identical size and appearance, all the rest of which contained nonradioactive samples.

The container at issue was initially recognized as missing when the lab for which it was being stored requested that 2 of the 6 remaining vials be delivered from a repository maintained in a locked freezer under exclusive control of the licensee's Radiation Safety Officer (RSO). An extensive search of agency freezers was undertaken to rule out the possibility that the container in question had been inadvertently merged, after losing its label, with other sample collections. Once this possibility was eliminated, the RSO concluded that the item had entered the biohazard waste stream and had been incinerated at a medical waste incinerator. Upon notification, the incinerator operator indicated that its incinerator was equipped with a high efficiency acid emissions scrubber, which would be expected to retain tritiated acetic acid. Retained byproduct material was buried mixed with 5 tons of scrubber absorbent and 40 tons of incinerator ash, the daily amounts shipped by that facility.

Among other steps taken to prevent recurrence, a large lockable multicompartment acrylic box was fabricated, with
an internally mounted vinyl CRAM sign, for long-term ultracold storage of radioactive materials being held for future distribution.