Event Notification Report for March 29, 2006

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO HPSI INOPERABILITY

"On 3/29/06 at 1215, the left train High Pressure Safety Injection [HPSI] Pump P-66B subcooling valve CV-3070 was declared inoperable due to valve failing to stroke. Technical Specification Limiting Condition for Operation 3.5.2 ECCS - Operating, Required Action B.1 requires HPSI train to be restored to operable status within 72 hours. This required action expires on 04/01/06 at 1215. It has been determined that it will not be possible to restore operability prior to the expiration of this action statement.

"A Technical Specification required shutdown to Primary Coolant system temperature < 325 degrees F will be initiated on March 31, 2006 at 2100. The site will then commence a planned refueling outage that was scheduled to begin on April 01, 2006."

The licensee notified the NRC Resident Inspector.

* * * * UPDATE from Dan Malone to MacKinnon on 04/03/06 at 1451 EDT * * * *

Event date changed from 03/28/06 to 03/29/06. NRC Resident Inspector notified by licensee.

R3DO (Anne Marie Stone) notified.

UNIT 3 SHUTDOWN DUE TO POTENTIAL SAFETY INJECTION TANK GASKET ISSUE

"On March 27, 2006, with Unit 2 in Mode 4 while starting up from a refueling outage, [Southern California Edison (SCE)] discovered that the gasket used to seal the manway cover for Safety Injection Tank (SIT) T-008 had become partially dislodged. The gasket is a 'flexitalic' type gasket which consists of a long section of crushable wire that is coiled and compressed between the manway cover and the safety injection tank flange. For SIT T-008, the flexitalic gasket had uncoiled and extended down into the SIT and prevented SIT outlet check valve MU040 from fully sealing in the closed position. On March 28, SCE inspected the remaining three SITs (SITs # 007, 009 and 010) and found the flexitalic gaskets degraded but intact and not interfering with other components.

"When this condition was discovered at Unit 2, San Onofre Unit 3 was operating at approximately 100 percent power. Similar flexitalic gaskets are also used for the manway covers on the four SITs at Unit 3. At 0001 PST on March 29, 2006, SCE conservatively declared both trains of the emergency core cooling system at Unit 3 inoperable. This placed Unit 3 in a TS 3.0.3 shutdown action statement. Plant Operators began the required Unit 3 shutdown at about 0050 on March 29, 2006. SCE is providing this phone notification to the NRC in accordance with 10 CFR 50.72(b)(2)(i) for the initiation of any nuclear plant shutdown required by the plant's Technical Specifications."

The electric grid in the area is stable and Emergency Diesel Generators are available on Unit 3. There is no maintenance being performed on systems required for shutdown on Unit 3.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION AT 12:14 ON 5/30/2006 FROM L. CONKLIN TO ABRAMOVITZ * * *

"On March 29, 2006, SCE reported the initiation of the shutdown to the NRC Operations Center (Event Log No. 42451).

"At the time, SCE was concerned that if the gaskets were uncoiled they might have interfered with operation of the ECCS.

"After completing the plant shutdown, SCE inspected and found the gaskets degraded but not extending into the SIT and its discharge piping. In addition, subsequent evaluations by the SONGS NSSS vendor Combustion Engineering (now Westinghouse) determined the degraded gaskets (even if uncoiled and interfering with SIT outlet check valve from fully closing) would not have prevented the ECCS from performing its required safety function.

"Consequently, SCE was not required to declare Unit 3 ECCS inoperable and SCE is retracting the phone report to the NRC (Event Log No. 42451). SCE will submit a voluntary LER to document this condition.

"At the time of this report, Unit 2 and Unit 3 are in Mode 1 at approximately 100% power. The San Onofre Resident Inspector has been notified of this event and will be provided with a copy of this report."

Notified the R4DO (Spitzberg).

AGREEMENT STATE REPORT OF A POSSIBLE RELEASE OF F-18 FDG (FLUORO-2-DEOXYGLUCOSE)

The following is a summary of the report received from the Wisconsin Department of Health and Family Services via e-mail:

"On March 27, 2006 a vial containing approximately 2.77 Ci of F-18 FDG was not received at the drawing station after the synthesis had been completed. Licensee stated that the monitoring equipment indicated the synthesis had been completed and the F-18 had been delivered to the drawing station. The radiopharmaceutical synthesizers are located in a shielded mini-cell. The mini-cell door was opened to investigate and the delivery line was observed to be disconnected. The mini-cell was then closed and operations were discontinued until the next day allowing for decay. The half-life of F-18 FDG is 1.82 hrs. Radiation and contamination surveys were performed outside the closed mini-cells and surrounding areas. No contamination was found.

"On March 28, 2006 the licensee contacted DHFS by telephone to report the incident. The licensee subsequently faxed in a preliminary report to DHFS.

"This will be followed up on Friday March 31, 2006 during a reactive inspection by a DHFS inspector."

Wisconsin Rpt No.: 36

DIFFERENT LENGTH BUCKET AND APPLICATOR USED DURING BRACHYTHERAPY DOSE

Following a vaginal/cervical/uterine brachytherapy dose it was noted during a side by side comparison that a different length bucket and applicator were used. Because the applicator was shorter than the bucket, the applicator did not reach the end of the bucket during administration of the dose. Review of the x-ray taken to confirm placement during the exam showed that the dose distribution given to the patient was different than originally intended. It is estimated that the dose varied by greater than 20 percent. The dose was lower than the intended dose.

The prescribing physician did not note any apparent ill effects to the patient during a follow-up physical examination. The event occurred because the licensee did not do a direct physical comparison of the bucket and applicator prior the exam. The licensee sorted all applicators and buckets following the event to create matched sets. The licensee is considering modifying procedures to include physical comparison of the applicator and bucket in the future. The oncology physician was to inform the patient of the differing dose.