Event Notification Report for November 09, 2006

HIGH PRESSURE CORE SPRAY SYSTEM VALVE INADVERTENTLY DE-ENERGIZED

"At 0644 hours (CST), the Main Control Room (MCR) received an alarm that the Division 3 Shutdown Service Water (SX) system was not available. The MCR also received an indication that a Division 3 SX motor operated valve for the plant service water to the SX header isolation valve, 1SX014C, was not available and discovered that there was no light indication for this valve. This valve is required to reposition following a High Pressure Core Spray (HPCS) system initiation. With the loss of power to the valve, this resulted in the Division 3 SX and the HPCS systems being inoperable. Since the HPCS system is a single train safety system, this event is reportable under 10CFR50.72(b)(3)(v)(D). An investigation is underway to determine the cause of the loss of power to the 1SX014C valve, however, preliminary indications are that an individual may have inadvertently bumped the breaker to the 'off' position.

"At 0742 hours, the investigation of the 1SX014C breaker indicated that the breaker was in the 'off' position (i.e., not tripped). The cubicle door for the 1SX014C breaker was opened. There were no abnormal or unusual indications in the cubicle. The 1SX014C valve was verified open; then the 1SX014C breaker was closed. The breaker was taken directly to the close position and not reset first. The 1SX014C breaker closed, indication returned to the MCR, and the alarm cleared. The breaker remained closed and HPCS system was returned to an available status.

"At 1047 hours, the Division 3 SX pump was started to confirm that operability of Division 3 SX and HPCS were restored by the actions taken to reclose the breaker at 0742 hours. The 1SX014C valve operated normally and Division 3 SX and HPCS were declared operable.

"The NRC Resident has been notified."

FAILURE OF WARNING HORNS

"At 0500 on 11/09/06, during a routine monthly test of the Criticality Warning System (CWS), a segment of the system covering the Dry Conversion Process (DCP) was found to have no functioning evacuation horns. Appropriate personnel were notified, the DCP processes were shut down, DCP personnel evacuated, and the area cordoned off. The activation of the evacuation horns in the balance of the plant were fully functional.

"A follow-up test was immediately scheduled for 0900. The building was evacuated and the emergency organization assembled in accordance with normal procedures. During this test, the DCP horns again failed to function.

"The Emergency Director determined that the processes stay shut down and all personnel remain out of the area while investigations and testing were conducted.

"The problem was located in the interface between the Data Acquisition Modules (DAM's) and the Auto-Call system that initiates the alarm signals. After a repair was completed, a re-test was completed which confirmed functionality of the DCP process area horns.

"Current plans are to resume normal operations beginning with the 1500 (evening) shift.

"This event is being reported within 24-hours pursuant to 10CFR70.50(b)(2) as a safety equipment failure."

The licensee will notify NRC Region II.

HYDROGEN ACCUMULATION DUE TO LOSS OF WATER SEAL

"On 11/9/06 at 0210 hours the Dry Conversion facility line 1 began starting up. At 0230 hours the fire alarm actuated in the Dry Conversion facility. Upon investigation, AREVA operations personnel discovered at approximately 0240 hours that the Hydrogen detector in the HF [hydrogen fluoride] Recovery room had tripped. Operations personnel immediately shutdown the process system. Operations personnel discovered that there was no water plug in the drain P-trap from the exhaust. Therefore, H2 from the reactor and calciner offgas leaked through the drain into the room with H2 enough to the point of setting off the H2 detector which has a set point of 20% of the LEL [Low Explosive Limit]. Hand held readings were taken and determined to be approximately 7% of the LEL at the lower elevation in the room to 25% of the LEL near the ceiling of the room.

"AREVA operations personnel contacted Environmental Health and Safety to determine the safety significance of the event. After reviewing the ISA for this system, EHS&L personnel deemed at approximately 1530 hours that the analysis of this system configuration meets the 24 Hour Reporting Criteria, 'Any event or condition that results in the facility being in a state that was riot analyzed, was improperly analyzed, or is different from that analyzed in the ISA and which results in failure to meet the performance requirements of 10CFR 70.61.'

"Evaluations determined that it is possible that enough H2 gas could have filled the room to cause an explosion in the HF Recovery room potentially causing a rupture of the HF holding tanks and piping. If an operator were present (this room is occupied approximately 5 to 10 times a week for 10 to 15 minutes each time) at the time of the explosion, it would be possible for the operator to receive sufficient injuries from HFA exposure to potentially make this an intermediate or high consequence event.

"Although this system has an H2 detector which, actuates a fire alarm, it is not designated as an IROFS.

"The process equipment associated with this scenario is still shut down and will remain shut down pending establishment of sufficient IROFS to meet the performance criteria of 10CFR 70.61. All other systems with the potential for H2 gas leaks are being re-evaluated to ensure that the performance criteria of 10CFR 70.61 is met.

"The material in the identified system that is in the tanks that could spill onto an operator is HF solution with trace amounts of Uranium.

"Safety significance is low. The HF Recovery, room is not normally occupied during operation, and then for only short periods of time (this room is occupied approximately 5 to 10 times a week for 10 to 15 minutes each time). There is no potential of an accidental nuclear criticality in the as found condition.

"The process equipment associated with this scenario is shut down and will remain shut down pending establishment of sufficient IROFS to meet the performance criteria of 10CFR 70.61. Related process systems that might have a similar potential are under evaluation to ensure that the same potential does not exist in these areas."

The licensee will notify NRC Region II.

EMERGENCY DIESEL GENERATOR ACTUATION DURING TESTING

"At 1444 on 11/09/06, after initial installation of the Alternate AC power source, post modification testing was being performed in accordance with STP-125.021, requiring an abnormal lineup of the 'B' diesel generator (DG). Prior to starting the test, potential unforeseen conditions were discussed, but not documented in STP-125.021. During the test, 'B' DG was secured and returned to the standby mode. As individual loads were manually loaded on the 1 DB bus, bus voltage momentarily decreased. When the 'B' emergency feedwater pump was loaded, an undervoltage condition on 1 DB existed momentarily, starting the 'B' DG. The 'B' Engineered Safety Features Actuation System load sequencer had been de-energized prior to the test as required by STP-125.021. The 'B' DG did not tie onto the 1 DB bus since the load sequencer was de-energized. Voltage on the 1 DB bus was restored by the Alternate AC source, which was supplying the bus for testing. All loads were successfully loaded on the 1 DB bus and the test was satisfactorily completed.

"After further review and evaluation, SCE&G considers the actuation of 'B' DG, while undergoing post modification testing of the Alternate AC power source, reportable under 10CFR50.72(b)(3)(iv)(A)."

The licensee notified the NRC Resident Inspector and will also notify State and local authorities.

DISCOVERED THAT A PATIENT RECEIVED AN UNDERDOSAGE

"During a routine NRC inspection on 12/18/06 Sandra Gabriel Ph.D, Senior Health Physicist from Region I, discovered a medical event that occurred on 11/9/06 involving a HDR (35.600) treatment.

"On 11/9/06 an HDR treatment patient received a dose of 1.37 Gy to Point A when the prescribed intended dose was 6.0 Gy.

"The following scenario lead to the medical event.

"A 6.0 cm tandem was inserted into the patient, however, the Authorized User asked the Authorized Medical Physicist to treat only a length of 4.0 cm to spare excess dose to normal structures. After the patient was treated, the Authorized Medical Physicist told the Authorized User he miscalculated the appropriate treatment length and what he thought was 2.0 cm from the end of the tandem was actually 20 cm from the tip of the tandem. The Authorized User and Authorized Medical Physicist calculated where 20 cm was, and this point was in fact outside of the patient's body, thus the patient only received dose from the ring portion of the applicator, resulting in a dose of 1.37 Gy to point A of the prescription plan.

"Since this dose was subtherapeutic, the Authorized User added an extra HDR treatment (during the course of treatments) and the patient received a total dose to point A of 31.37 Gy which was within 20% of the original intended total dose. The patient was made aware of the extra treatment that was necessary because of the under dosage on 11/9/06.

"A full written report will follow within 15 days as required by 10 CFR 35.3045."

* * UPDATE FROM FLANNERY (FSME) TO KOZAL AT 1213 ON 12/20/06 * * *

This event has been reviewed by the NRC medical review committee and determined to be a reportable medical event.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.