Event Notification Report for February 24, 2005

REMOVABLE RADIOACTIVE SURFACE CONTAMINATION ON A PACKAGE

The Department of Veterans Affairs, National Health Physics Program reported that a package received at one of its facilities had removable radioactive surface contamination that exceeded limits. The package was received on 2/24/05 at the VA Southern Nevada Health Care System in Las Vegas, NV. The package had a contamination level of 85,000 DPM over a 300 square cm wipe. The contamination was identified as Technetium-99M via spectral analysis.

The package was received from Bio Tech, a commercial pharmacy in Las Vegas. Southern Nevada Health Care notified Bio Tech and the pharmacy has sent a representative to the facility to assist in the investigation. The package was delivered by a pharmacy delivery vehicle and the status of any contamination in the vehicle is unknown. There was no apparent damage to the package.

Appropriate steps have been taken to prevent the spread of contamination.

OFFSITE NOTIFICATION RELATED TO HEART ATTACK FATALITY

"At 1423 the control room received an emergency phone call of an employee who was experiencing intermittent unconsciousness and in cardiac arrest. The individual was transported to a local hospital where he was declared deceased at 1530. 29CFR1904.39(b)(5) requires to report a fatality to OSHA caused by a heart attack at work. This ENS report is being made in accordance with 50.72(b)(2)(xi) contact of off site agency."

There was no radioactive contamination involved in this event. The licensee does not plan any media or press release and has not notified any other government agencies besides OSHA. The NRC Resident Inspector will be notified.

ESF ACTUATION FOLLOWING TRIP OF REACTOR PROTECTION MOTOR-GENERATOR SET

A trip of the "A" RPS M-G set resulted in an "A" Group 2 isolation and startup of the standby gas treatment system. There was a preliminary report of a possible fire/smoke smell in the vicinity of the M-G set. However, when an operator reported to the location there was no observed fire. The fire brigade was also dispatched but found no fire or smoke in the M-G set area.

The licensee is preparing to place the RPS on its alternate power supply. This will allow the Group 2 isolations and standby gas treatment system actions to be reset. The cause of the M-G set trip is still under investigation.

The licensee will be notifying the NRC Resident Inspector as well as state and local authorities.

POTENTIAL BREACH OF SECONDARY CONTAINMENT DURING SEISMIC EVENT.

The licensee provided the following information:

"This event notification is being made to report an event that could have prevented fulfillment of the safety function to mitigate the consequences of an accident IAW 10CFR50.72(b)(3)(v)(D).

"The potential for creation of an actual hole through Secondary Containment (SC) via the Plant Service Water (TSW) system high point reactor building auto vents (TSW-AV-1A and TSW-AV-1 B) exists if a seismic event occurs and the Seismic Category 2 TSW loop-seal piping outside of Secondary Containment is breached (e.g., because of a pipe break) and has drained.

"Neither of the above conditions presently exists. However, a Secondary Containment breach could occur as a result of a single passive failure (i.e., pipe break in the TSW loop-seal piping described above). TSW-AV-1A and TSW-AV-1B are designed to open automatically when neither TSW system pump is operating to break the vacuum condition that would otherwise exist in the piping. When TSW-AV-1A and TSW-AV-1B are open in vacuum breaker mode, the resultant hole size into the TSW system piping would exceed the allowable Secondary Containment cumulative hole size [ of 32 square inches total], if the loop seal were also breached as described above. Due to this condition Secondary Containment was declared INOPERABLE at 1800 PST 2/24/05. As a compensatory measure to prevent exceeding the allowable Secondary Containment cumulative hole size, one of the two TSW reactor building auto vents (TSW-AV-1B) was isolated by closure of a manual valve (TSW-V-55B). This action was completed at 1828 PST 2/24/05 and the Secondary Containment was declared OPERABLE. One TSW auto vent is sufficient to perform the vacuum breaker function."

This condition was found by the licensee's System Engineer. The extent of condition and long term corrective action is under review by licensee.

Licensee will inform the NRC Resident Inspector.

* * * RETRACTION FROM FRED SCHILL TO HOWIE CROUCH @ 1535 EDT ON 04/05/05 * * *

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"On 2/25/05, Columbia Generating Station reported (ref: EN 41442) a condition that was discovered while reviewing service water (TSW) system design documents. During the review, it was determined that Seismic Category II TSW piping in the turbine (TG) and radwaste (RW) buildings could rupture and drain during a seismic event. This event would result in an inoperable secondary containment (SC) because TSW system high point vent valves located within the SC would automatically open when the piping drained after rupturing. Such an event would allow direct communication between the SC atmosphere and the TG/RW atmospheres and exceed the leakage rate assumed in Columbia's accident analysis. There are two principal accidents in Columbia's safety analysis for which SC is credited as a mitigating system. These are the Loss Of Coolant Accident (LOCA) and the Fuel Handling Accident (FHA). The SC performs no active function in response to either of these limiting events, however, its leak tightness is required to ensure that the release of radioactive materials from the primary containment is restricted to those leakage paths and associated leakage rates assumed in the accident analysis, and that fission products entrapped within the SC structure will be treated prior to discharge to the environment.

"Assuming a seismic event of the magnitude (0.25g) of the Safe Shutdown Earthquake (SSE) occurred and ruptured the TSW piping causing SC to become inoperable, it is beyond Columbia's safety analysis to postulate a release of radioactive material beyond Part 100 limits for that event. This is because analysis shows that the SSE will not in itself cause a LOCA or an FHA and Columbia's design and licensing bases do not assume a LOCA or FHA coincident with a seismic event. In the event that the SSE made SC inoperable, the Technical Specifications (LCO 3.6.4.1.B) require that the plant be in mode 3 in 12 hours and in mode 4 in 36 hours. Since this is achievable, it is reasonable to conclude that, in the event previously reported, plant shutdown can be accomplished without radiological release and within the completion time of the action required by the Technical Specifications.

"The discussion in the guidance document (NUREG 1022) for reporting under Part 50.72(b)(3)(v) states the level of judgment for reporting under these criteria is a reasonable expectation of preventing fulfillment of a safety function. It also states that the intent of the criteria is to capture those events where there would have been a failure of a safety system to properly complete a safety function regardless of whether there was an actual demand. This discussion however, as the Part 50.72(b)(3)(v) and Part 50.73(a)(2)(v) criteria state, apply to safety functions of systems or structures that are needed to control the release of radioactive material, because safe shutdown of the plant without radiological release is assured post SSE (sans SC), as described in Columbia's design and licensing bases, SC would not be needed to control the release of radioactive material and therefore the reporting criteria is not met."

The licensee will be voluntarily submitting a Licensee Event Report as a method of information sharing with the rest of the industry.

The licensee has notified the NRC Resident Inspector. Headquarters Operations Officer notified R4DO (Howell).

MEDICAL EVENT

The following information was provide by the licensee via facsimile:

"[The Department of Veteran Affairs National Health Physics Program called] per 10 CFR 35.3045 to notify [the NRC] of a possible medical event at the VA Medical Center, Durham, North Carolina, a permittee under the VA license. This event was discovered on February 25, 2005.

On February 24, 2005, a permanent-implant prostate brachytherapy procedure was performed at the medical center. 84 Iodine-125 seeds were implanted in the patient. These seeds had around 400 microcuries per seed. A number of seeds were mistakenly placed in fatty tissue, outside of the intended area of treatment.

Based on a preliminary evaluation, a possible medical event occurred since the dose to the prostate was possibly more than 20 percent less than that prescribed and a dose to tissue other than the treatment site is possibly more than 50 rem and greater than 50% of the prescribed dose.

The authorized user notified the patient and will notify the referring physician within 24-hours of discovery.

The National Health Physics Program intends to conduct a reactive inspection next week.