Event Notification Report for June 12, 2006

UNUSUAL EVENT DUE TO A POSTING OF HURRICANE WARNING AT THE SITE

"Crystal River 3 is in a Hurricane Warning area. The site is evaluating the need for a plant shutdown at this time."

The declaration of NOUE is per the licensee's Emergency Action Guidelines due to posting of the hurricane warning. There are currently no significant equipment problems or LCOs that might be impacted by the impending weather conditions. The licensee will provide updates as appropriate if weather conditions change or a decision to shutdown is made.

The licensee notified the NRC Resident Inspector, State, and Local authorities.

* * * UPDATE FROM M. WOLF TO M. ABRAMOVITZ AT 1530 ON 06/13/06 * * *

The hurricane warning necessitating the entrance by the site into the Unusual Event was exited by the state this morning at 11 am. The site waited until high tide passed and exited the Unusual Event at 1511.

The licensee notified the NRC Resident Inspector. Notified R2DO (Ayers), NRR EO (Jung), IRD (Blount), DHS (S. York) , and FEMA (E. Casto).

HPCI INITITATION SIGNAL DUE TO TURBINE TRIP SIGNAL DURING STARTUP

"Feedwater was being place into long path recirculation mode in accordance with N1-OP-16 to support a chemistry sample. During this evolution, reactor water level rose high enough such that the High Level Annunciator (92.2") was received, the turbine tripped [off of the turning gear] and a HPCI [High Pressure Coolant Injection] initiation signal was received as per design. HPCI system did not initiate flow and no pumps started because the Feedwater Booster Pumps were not in service (pull-to-lock). HPCI was reset and Reactor Water level [was] restored to the operating band 65" - 83".

"A copy of this Notification Worksheet will be provided to the Resident Inspector.

"This event has been captured on Condition Report 2006-2703. A prompt investigation has been performed."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - HIGHER DOSE THAN PLANNED ADMINISTERED DURING BRACHYTHERAPY TREATMENT

A brachytherapy dose for prostate cancer treatment included a planned 145 Gy dose to be accomplished using permanently implanted I-125 seeds. A computer is used as part of the hospital's procedures for determining the quantity of seeds to implant to arrive at the total prescribed dose using the dose per seed. Hospital staff incorrectly entered the dose per seed as 0.27 millicuries instead of 0.34 millicuries into the computer. This resulted in the computer calculating a quantity of 100 seeds to be used and resulted in a 26% higher dose than intended. The error in the calculation was not discovered until after the actual implant was accomplished.

The medical consequences of the overdose include possible rectal complications in the future. Remedial actions could include removal of the prostate. The doctors are investigating other treatment options. The patient was being informed of the overdose and treatment options at the time of this report.

LOSS OF SPDS DURING PLANNED COMPUTER MAINTENANCE

"On 6/12/06 at 07:54 am CDT, the Wolf Creek Generating Station removed the Nuclear Plant Information System (NPIS) computer from service for planned maintenance. Following this maintenance, one of the NPIS multiplexers (MTJX 'D') failed to re-establish communications with the computer, and efforts to restore the computer to service have been unsuccessful. The failure to restore the NPIS computer has resulted in a loss of functionality of the Safety Parameters Display System (SPDS). Efforts continue to restore the NPIS computer to service, which will restore SPDS functionality. Due to SPDS being lost for longer than a short period of time, Wolf Creek Nuclear Operating Corporation is making this ENS notification pursuant to the criteria of 10 CFR 50.72(b)(3)(xiii). There is no other loss of emergency assessment capability concurrent with the ongoing loss of SPDS. Plant personnel have entered the appropriate Off-Normal procedure and are obtaining local readings for the equipment that is normally monitored by SPDS and NPIS. It is unknown at this time when NPIS/SPDS will be restored."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM T. DAMASHEK TO P. SNYDER AT 1735 ON 6/13/06 * * *

SPDS has been restored as of 1605 CDT.

The licensee will notify the NRC Resident Inspector. Notified R4DO (Bywater).

MANUAL ACTIONS DETERMINED UNTIMELY FOR FIRE SAFE SHUTDOWN

"As part of an analysis to determine feasibility of manual actions, it was identified that three actions for Fire Area RAB 7 could not be performed within the times prescribed in the Post Shutdown Analysis. The subject fire area is subdivided by part height fire walls. Waterford 3 has an approved Appendix R deviation for the part height fire wall configuration.

"Assuming a fire in Fire Area RAB 7 Operator entry into that same fire area is required. Results of the analysis indicate that the conditions in Fire Zone RAB 7B rapidly exceed the habitability threshold and do not moderate before ten minutes, the time at which one of the three manual actions is required, given a fire in Fire Zone RAB 7A. Because the space becomes uninhabitable, the manual action in Fire Zone RAB 7A is not feasible.

"A continuous fire watch has been established within Fire Area RAB 7 as a compensatory measure. This condition is reportable within 8 hours pursuant to 10CFR 50.72(b)(3)(v)(A) as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to shut down the reactor and maintain it in a safe shutdown condition."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE - RADIOGRAPHY SOURCE DISCONNECTED FROM CAMERA

The State provided the following information via facsimile:

"Global X-Ray had a source disconnect at the McDermott Fabrication Facility in Amelia, LA on June 12, 2006. The radiographers were performing routine radiography on some welded pipe sections. After several exposures, the radiographers began having trouble with the crankout. The radiographers realized that the source had not come back to the shielded position at the end of the exposure. The radiographers followed Global X-Ray & Testing Operating and Emergency Procedures. The radiographers reset their boundaries to a 2 mR/hr level and maintained surveillance and called the office. The source was found in the source guide tube. The source was retrieved and returned to the exposure device with minimal exposure during retrieval. Both the exposure device and controls were sent to SPEC for evaluation. It appears that there was enough wear on the control adapter and the drive cable connector to allow a disconnect. Global ruled out a source misconnect being the problem due to the fact that the film that was exposed prior to the crank out trouble was developed and came out just as it should. There were no excessive exposures to the radiographers. The radiographers dosimeters read 10-12 mR and 35-40 mR. The retrieval process produced an exposure of 85 mR. The device that was involved with the disconnect is a SPEC 150 camera with serial number 139. The source in the camera was an 82 Ci [Curie] source of Ir-192 manufactured by SPEC with model number G-60 and serial number ND-1002."

LA Event Report Number: LA060012

OVERDOSE TO PATIENTS THYROID

The patient reported to the hospital for treatment Monday, June 12 at 11 am and was given 2 millicuries of I-131 as a thyroid treatment dose. The patient then returned on June 14, 2006, for a survey. The prescribing physician reviewed and checked the orders as sufficient for a medistatic survey. The survey results revealed that there was a 96 percent uptake to the thyroid. Using the survey results, a discrepancy was discovered. During an initial interview of the patient it was not determined that the patient had no prior history of cancer or any prior history of operations on the thyroid. Since the patient had no prior history it was determined that a dose of 200 microcuries of I-131 should have been used.

The results of this overdose could include loss of thyroid function. The consequences and possible remedies have been discussed with the patient.

The hospital plans on changing their interview sheet to a checklist type format to help avoid this problem in the future. The hospital also plans on performing a root cause analysis on this issue.