Event Notification Report for March 12, 2007

INCORRECT RADIONUCLIDE ADMINISTERED TO PATIENT

The licensee was performing a gall bladder study that required a dose of 5 millicuries of Tc-99 to be administered. A participant in the study was given the wrong radionuclide Gallium Citrate (Ga-67), accelerator produced, in error. Both syringes containing the doses were located in the same case, which was delivered to Sibley Hospital by Mallinckrodt. The licensee informed the patient of the error and that there is minimal risk of adverse effects to the patients health.

The actual dose versus the prescribed dose is still under investigation. Additional corrective actions will be determined at a later date.

* * * UPDATE 0900 EDT ON 3/13/07 FROM JORDIE KECK TO S. SANDIN * * *

The licensee is retracting this report after conducting a review that concluded no reporting criteria was met. Notified R1DO (Hott) and FSME (Morell).

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.

AGREEMENT STATE REPORT - LOST/STOLEN EXIT SIGNS

The State provided the following information via email:

"On 3/14/07 the Strongsville Ohio Police Department was notified that ten (10) tritium exit signs were missing and presumed stolen from a storage area at a local shopping center construction site. The apparent theft occurred between 3 PM on 3/12/07 and 1 PM on 3/13/07. The contractor reporting the incident stated that the signs could have been taken by anyone that had access to the construction site, because many different contractors were using the same storage area. The ten signs were all packaged in one box. The signs are manufactured by SRB Technologies as the Betalux-E Life Safety Sign, Model 171. They are distributed by Cooper Lighting under the name Sure Lites, TRX1 series. The signs are rated for a 20-year life cycle."

Ohio event # - OH70003

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

AGREEMENT STATE REPORT - IRRADIATOR WATER CONDUCTIVITY GREATER THAN LIMIT

"On March 13, 2007, the Agency was notified by the licensee that their source pool conductivity had exceeded 100 microsiemens per centimeter (uS/cm). The facility had completed a source replacement the week of February 21, 2007 and had regenerated their ion exchange resin on March 9, 2007. On March 11, 2007, the water conductivity was found to be 269.1 uS/cm. The licensee conducted an investigation and found that the system used to control the regeneration of their ion exchange resins, had failed to operate properly due to a power outage. The purification resins were replaced and the conductivity was reported to be 69.34 uS/cm on March 30, 2007 and 1 uS/cm on April 4, 2007. The licensee has upgraded the control system and is measuring conductivity twice a day to prevent a reoccurrence."

Texas report number - I - 8402

INVALID TUBINE DRIVEN AUXILIARY FEEDWATER PUMP STARTS

"This report describes three invalid actuations of the Unit 2 Turbine Driven Auxiliary Feedwater (TDAFW) pump that occurred on March 12,2007. This report is being made in accordance with 10CFR50.73(a)(1), which states, in part, 'In the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than actuation of the reactor protection system (RPS) when the reactor is critical, the licensee may, at its option, provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.'

"On March 12, 2007 at 2027, while performing operator rounds, Operations personnel heard a venting noise coming from the vicinity of the Main Steam Line 2-04 to Auxiliary Feedwater Pump Turbine Steam Supply Valve. One of the Operators put his hand close to the exhaust pilot valve, restricting the venting air flow, which increased the sensing pressure on one of the valve's ports. The valve swapped, exhausting the diaphragm. This caused the TDAFW steam supply valve to fail open and the TDAFW pump started and reached full flow. Operations responded to the event by manually running back the Main Turbine load to 1100 Mew to ensure Reactor Power remained less than 100%. The TDAFW pump was secured and the steam supply valve hand switch was placed in AUTO.

"At 2056, an I&C technician was leak checking the valve actuator and tubing joints. The I&C technician got within close proximity of the Main Steam Line 2-04 to Auxiliary Feedwater Pump Turbine Steam Supply Valve and restricted the venting air flow, which increased the sensing pressure on one of the exhaust pilot valve's ports. The pilot valve swapped, exhausting the diaphragm. The TDAFW Steam Supply Valve failed open again and the TDAFW pump started a second time and reached full flow.

"At 2100, Shift Operations placed the steam supply valve in pullout and declared the TDAFW inoperable. To prevent further inadvertent starts, Operations decided to close the upstream isolation valve. While in the process of closing the isolation valve, the Operator heard air venting from the vicinity of the Main Steam Line 2-04 to Auxiliary Feedwater Pump Turbine Steam Supply Valve. The Operator put his hand under the exhaust pilot valve such that the air flow was restricted, which increased the sensing pressure on one of the valve's ports. The pilot valve swapped, exhausting the diaphragm. The TDAFW steam supply valve failed open again and the TDAFW pump started a third time. Since the upstream isolation valve was partially closed, the TDAFW pump only reached a partial flow of 235 gpm. Shift Operations initiated a clearance to prevent further inadvertent TDAFW pump starts and a work order was initiated to determine the failure mechanism. On March 13, 2007 at 2223, Shift Operations declared the TDAFW pump operable.

"The specific train and system that actuated was the third AFW train on Unit 2. During each of the three TDAFW pump starts, the system started and functioned correctly. During the first two pump starts, the train actuation was complete. As described above, on the third start the train actuation was partial due to less than full flow being developed.

"The second and third TDAFW pump starts took place during trouble shooting and clearance isolation activities, respectively, which occurred prior to the cause being identified. The three AFW invalid actuations occurred due to incorrect setup of the exhaust pilot valve for the Main Steam Line 2-04 to Auxiliary Feedwater Pump Turbine Steam Supply Valve.

"The NRC Resident Inspector will be notified of this report."