Event Notification Report for February 17, 2005

MISSING CALIBRATION SOURCE

"On January 22, 2005 a radiation protection technician discovered that a radiation detector calibration source was missing from its locked storage cabinet. An investigation was initiated and efforts to locate the source continue but the source has not been located. The source is approximately 2 inches in diameter in the form of a metal disc containing 0.0154 micro-curies of Thorium-230 that is used to calibrate SAC-4 alpha counters. The source is labeled and poses no radiological hazard to individuals that could unknowingly be in close proximity to it. The source was last used to calibrate a SAC-4 alpha counter on 1/20/2005.

"10CFR20.2201(a)(1)(ii) requires a telephone report to the Operations Center in accordance with 10CFR50.72 within 30 days of the loss of licensed material in a quantity greater than 10 times the quantity specified in Appendix C to Part 20. The quantity specified in Appendix C for Thorium-230 is 0.001 micro-curies; therefore, this report is required."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - TOTAL DOSE DELIVERED DIFFERS FROM PRESCRIBED DOSE

Licensee called to report that on 02/16/05, the hospital performed a prostate seed implant. It was discovered after the implants were performed that the activity content for the first set of seeds (63 seeds) was incorrect. The hospital had ordered 0.27 millicuries per seed of I-125 and received 0.37 millicuries per seed. The order had been placed and confirmed with the seed manufacturing company, but the incorrect activity per seed was sent for the first of three implants for this patient. The documentation that was supplied with the order did identify the first set of seeds containing 0.37 millicuries per seed. Both the patient and the referring physician have been notified of the error. A post implant CT was performed to attempt to accurately calculate the dose overage, but the licensee determined that process would be difficult to verify. Licensee is evaluating methods to prevent reoccurrence (such as - perform own source calibration, verify documentation prior to implantation). Licensee did state that there was no unintended permanent functional damage to an organ or physiological system.

EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE DUE TO UNANALYZED CONDITION

The following information was provided by the licensee via facsimile:

"During testing of the Division 2 Diesel Generator Testable Rupture Disc (TRD), it was discovered that excessive force was needed to open its damper. The function of the TRD is to open to relieve exhaust pressure should the diesel generator's non-safety exhaust silencer become blocked. Upon inspection of the TRD, some deformation was noted on the TRD damper. Since the possibility that the condition might exist on the other two divisional diesel generators could not be ruled out, they were also declared inoperable and LCO 3.0.3 entered. An unanalyzed condition potentially exists because a change in engineering design potentially affected multiple trains. Since all three diesel generators are inoperable, a loss of off-site power would challenge safe shutdown capability, the ability to remove decay heat and accident mitigation.

"A plant shutdown required by Technical Specifications (LCO 3.0.3) was required due to declaring all 3 divisional diesel generators inoperable. LCO 3.0.3 was entered at 1730 hrs on 2/17/05. No power reduction was required as the Division 2 Diesel Generator was declared operable at 2011 after unlatching its Testable Rupture Disc (TRD) [and LCO 3.0.3 was exited].

"The resident NRC inspector was informed of the LCO 3.0.3 entry and exit [and this event notification]. No other notifications of governmental agencies or the press are planned."

At the time of the notification to NRC Headquarters, the Division 1 EDG TRD had been unlatched and declared operable. The Division 3 EDG TRD was expected to be unlatched within the next hour.

24 HOUR 91-01 RESPONSE BULLETIN AND PART 70 APP A UNANALYZED CONDITION

The following information was provided by licensee via email:

"The sponge jet blast system is a non-favorable geometry (NFG) decontamination unit that scours contaminated items with pressurized hydrogenous sponge media imbedded with aluminum oxide to decontaminate the items. The safety basis of the system is based upon extremely conservative calculations modeling 1-3g/cc Uranium dioxide in a specified, controlled sponge jet media. Based upon these calculations, criticality is not credible in the sponge jet system when using the specified media, which is the only media allowed in the unit. This critical item, for which an IROF (discussed below) was put in place, was that the physical characteristics of the sponge jet media could never be changed without criticality analysis.

"During a routine procedure review, a criticality safety engineer noticed that specific manufacturer and product information he had previously required was not present in the procedure for the sponge jet blaster.

"An IROF had been specified for the equipment with an action expected stating, 'Operator/Area Engineer utilize only approved aluminum oxide sponge media.' The configuration control process was bypassed and the approved sponge jet blast media was replaced with a media with double the specific gravity of the approved media and four times the content of hydrogenous material.

"In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a 24-hour notification, specifically, 'Any nuclear criticality safety incident, in an analyzed system, for which less than previously documented double contingency protection remains (multi-parameter control or single parameter control) and less than a safe mass is involved.'

"Also, in accordance with Appendix A to Part 70--Reportable Safety Events (b) Twenty-four hour reports. Events to be reported to the NRC Operations Center within 24 hours of discovery:(1) Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of § 70.61.

" Sponge jet blaster contained the unauthorized material with contamination levels (2700 ppm U preliminary results) of Uranium. This is two orders of magnitude less than a critical concentration for an optimally moderated mixture. A very conservative mass estimate was made assuming the entire unit was filled with the 2700 ppm material, when less than 1/4 of the unit would contain material at any given time. This mass calculation estimates the mass total at 3.149 kg U which is an order of magnitude less than a critical mass. A more realistic estimate is 0.25 kg U [based on the amount of sponge media actually in the jet blaster (5 bags)].

"Summary of Activity: The Sponge jet blaster has been shut down.

"Conclusions: There was much less than a critical mass of SNM involved. There was much less than a critical concentration. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed.