Event Notification Report for March 21, 2005

LOSS OF SAFETY PARAMETER DISPLAY SYSTEM (SPDS) FUNCTION FOR GREATER THAN 8 HOURS.

The following information was provided by the licensee

"On 3-21-05 the Plant Computer system was removed from service at 0753 for scheduled maintenance. The system was not verified restored until 1558. This is in excess of the eight hours allowed by 10CFR50.72(b)(3)(xiii). The Plant Computer system supplies the Safety Parameter Display System (SPDS) function, which is required for Emergency Assessment Capability. The Plant Computer is currently operable."

"This event did not effect the plant operations. The unit is stable in Mode 1 at 100% power."

"The NRC Resident inspector has been informed."

HPCI DECLARED INOPERABLE - ENTERING 14 DAY LCO ACTION STATEMENT

The following information was provided by the licensee by fax.

"At approximately 17:00 on March 21, 2005, while performing required surveillance testing on the Unit 3 HPCI system, the HPCI Condensate Storage Tank (CST) suction valve (MO-3-23-17) failed to close after the HPCI Torus suction valves (MO-3-23-57 & MO-3-23-58) were full open. Failure of the CST suction valve MO-3-23-17 to close when a Torus suction path was established, required entry into Technical Specification 3.3.5.1 for loss of initiation function for CST level low and Torus level high (Functions 3d, 3e). The loss of initiation function under Technical Specification 3.3.5.1 required that the HPCI system be declared inoperable in one (1) hour after discovery. HPCI was initially declared inoperable at 16:41 for surveillance testing. HPCI inoperability has been maintained as of that time. Pursuant to 10CFR 50.72(b)(3), this notification is being made due to Unit 3 HPCI inoperability, which prevents fulfillment of a Safety Function."

Initial troubleshooting hints that the cause of the failure may be due to a limit switch malfunction.

The NRC Resident Inspector was notified.

MEDICAL EVENT - TOTAL DOSAGE DELIVERED IS LESS THAN THE PRESCRIBED DOSAGE

During a quarterly review of written directives by hospital personnel, it was noted that a patient was administered a dosage of 12.51 millicuries of the isotope NaI-131 for hyperthyroidism instead of the prescribed dosage of 21 millicuries. Radiopharmaceutical unit dose dispensing records as well as internal scheduling paperwork confirm that the 12 millicuries dosage was in fact ordered and subsequently administered to the correct patient. The root cause of this event has been determined by the licensee to be lack of strict attention to detail and they have evaluated their policy and procedures to prevent reoccurrence. The attending physician has reviewed the patient's records and felt that there would be no adverse affect due to this misadministration. He will notify the patient regarding this incident.

AGREEMENT STATE REPORT - LOST 12 UNUSED I-125 THERAPY SEEDS TOTALING 4.8 MILLICURIES

The State provided the following information via facsimile:

"On March 21, 2005, the licensee, Western Medical Center, shipped 12 unused I-125 therapy seeds of 0.4 mCi/seed (4.8 mCi total) to GE Healthcare via Fed-Ex. On April 19, 2005, Fed-Ex notified the licensee by letter that the shipment had apparently been lost in transit. The shipment has not yet been located. [The State] will update NMED as more information becomes available."

The Fed Ex shipment information will be forthcoming from the State as they receive it.

The State report number is 051905.

* * * UPDATE ON 05/19/05 AT 14:58 EDT FROM HAMRICK TO KNOKE * * *

"The number of seeds should be 14 at 0.391 mCi/seed for a total of 5.474 mCi (as of 2/26/05; activity is now about 2.12 mCi).

"The shipment left the licensee's facility on 3/21/05 via FedEx to GE Healthcare in Arlington, IL.

"On 3/24/05, the licensee was first notified by GE Healthcare that they had received the package, but that it did not contain the seeds, but some type of brackets. The licensee notified FedEx, who initiated a tracking operation. On 4/19/05, the licensee received written notice from FedEx that the package still had not been found. The records internal to FedEx indicated the package had apparently been damaged during the shipment, and FedEx speculates the shipping papers were switched with the other shipment. [The State] will provide additional information at the close of the investigation into this matter."

Notifications were given to R4DO (Nease) and NMSS (Moore & Correia)

* * * UPDATE ON 05/20/05 AT 15:30 EDT FROM THE STATE ( HAMRICK) VIA E-MAIL * * *

"This is a follow up to the reported lost shipment of I-125 seeds, which are now found. The seeds were delivered to the shippee, GE Healthcare, on March 24, 2005. The contact from GE Healthcare to the licensee in California indicated they had received an unexpected package from them (containing some type of brackets), but was not intended to indicate they had not received the package containing the seeds. The California licensee interpreted the information from GE Healthcare to mean that the seeds they had shipped had not arrived, however this apparently was not the case. Receipts of non-radioactive and radioactive shipments are handled separately at GE Healthcare, so the call to the California licensee was only to report the receipt of the unexpected non-radioactive shipment.

Thus, GE Healthcare received the seeds on March 24, 2005, and knew they had received them on that date. There was simply a misunderstanding in the communication with the California licensee."

Notifications were given to R4DO (Nease) and NMSS (Correia)

OFFSITE NOTIFICATION TO DERM ABOUT FUEL OIL SPILL

On 3/21/05 at 1045, the Control Room was notified of a fuel oil spill. The event was believed to have occurred on Saturday, 3/19/05 between 1900 and 0300. The amount of fuel oil ( Grade 2 Diesel) that was spilled was approximately 219 gallons and dispersed over a distance of about 1 mile. The cause of the spill was possibly due to a valve left open on the tanker after making a fuel delivery. The long trail of oil was made as the tanker left the site. The spill is contained and being cleaned up at this time. The area will be excavated and transported to Redland Construction.

The location of the fuel oil spill occurred outside of the Nuclear Plant protected area at the new fossil plant. Construction site.

DERM (Department of Environmental Resources Management) will be notified by Turkey Point Land Utilization representative.

The NRC Resident Inspector will be notified.