Event Notification Report for March 19, 2007

OFFSITE NOTIFICATION MADE TO NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION

"Notified the New Jersey State, Department of Environmental Protection that Oyster Creek generating station was not in compliance with the NJPDES permit due to equipment malfunction.

"The malfunction was an electrical bus fault which resulted in a trip of both operating dilution pumps.

"Alternate power is now being supplied to the dilution pumps. The pumps have been restarted.

"There has been no observed impact on the environment.."


NRC Resident Inspector was notified of this event by the licensee.

STOLEN TROXLER MOISTURE DENSITY GAUGE

Licensee's truck was parked at worksite from 0930 until 1700 EDT on 03/19/07 with the gauge triple locked in the bed of the truck the entire day. When the licensee's employee was leaving the worksite at the end of the workday, it was noticed that the gauge was missing. The worksite is located Audenreid High School, 3301 Tasker Street, Philadelphia, PA. The Philadelphia Police Department was notified (Report # 07-17-011252). The gauge is a Troxler, Model 3430, Serial Number 030500 with a Cs-137 8 millicurie source, and an Am-241:Be 40 millicurie source.

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.

AGREEMENT STATE - CALIFORNIA - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days."

CA Report #032707

* * * UPDATED 1346 EDT ON 4/2/07 FROM CYNTHIA FLANNERY (FSME) * * *

"This event has been reviewed by FSME and found to be a 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.

INVALID SPECIFIED SYSTEM ACTUATIONS DURING TESTING

"This 60-day ENS report is being made per 10CFR 50.73(a)(2)(iv)(A) and 10CFR 50.73(a)(1) to report invalid automatic actuations of systems listed in paragraph (a)(2)(iv)(B), namely core spray (CS) and residual heat removal (RHR).

"Unit 2 commenced refueling outage activities on Saturday March 10, 2007. Relay replacements for the 4 kv safeguard bus LOCA auxiliary control time delay relays were planned for all four buses due to a relay failure on Unit 1 that was identified during the prior refueling outage testing.

"On Monday March 19, 2007, at 02:20 hours, during emergency diesel generator (EDG) surveillance testing a Unit 2 Division 3 LOCA signal was inadvertently initiated during the planned replacement of the D23 bus LOCA auxiliary control relay (162-117). The relay was being replaced at a pre-determined step in the test. The relay was in an energized state when removed. When the new relay was installed an unplanned actuation of LOCA load shedding and sequential loading occurred. The relay was subsequently replaced and tested successfully.

"D23 EDG had been secured just prior to the event. The following loads were tripped and automatically restored: 2C CS pump and D234 load center breaker. The C emergency service water (ESW) pump tripped and did not restart since the EDG was not running. The 2C RHR pump continued to run. The 2A CS loop received a partial actuation in that the Division 3 signal was initiated but the Division 1 signal was not initiated. The 2C CS pump was operating in full flow test mode; therefore, it tripped and re-started as designed and 2A CS pump did not start which was expected. The 2A CS loop automatic valve alignment is initiated by the Division 1 signal; therefore, no automatic 2A CS loop valve alignment occurred.

"On Wednesday March 21, 2007 at 14:08 hours during EDG surveillance testing a Unit 2 Division 2 LOCA signal was initiated during the test which started the D22 EDG and tripped the D224 load center breaker as expected. However, the load center breaker did not re-close which was not expected and other expected actions did not occur. At 14:41 hours, 33 minutes later, the remaining LOCA actions occurred when 2B RHR pump, 2B CS pump, and 2B reactor enclosure recirculation system (RERS) fan automatically started, and D224 load center breaker automatically closed due to a late actuation of the D22 bus LOCA auxiliary control relay (162-116). At 15:48 an additional unexpected relay actuation caused the 2B CS pump and D224 load center breaker to trip. The relay had been replaced earlier in the day and the ongoing testing was intended to satisfy the post maintenance test (PMT). However, the relay did not actuate at the point in the test designated as the PMT; the relay actuated unexpectedly 33 minutes later.

"The cause of the first event was a less than adequate technical review of a test revision that added a step to replace the bus LOCA auxiliary control relay. The affected tests have been revised to replace the relay at a point in the test when it is de-energized. The cause of the second event was an equipment failure due to an intermittent connection between the relay pin connector and the relay base. The affected relay and base have been replaced and tested successfully.

"All of the systems that received start signals functioned successfully. The only equipment malfunction was associated with the degraded relay. The RHR and CS starts were partial actuations. The D22 EDG train start was an expected actuation. The C ESW train was tripped but was not automatically started.

"This event is reportable per 10CFR50.73(a)(2)(iv)(A) since 2B RHR pump, 2B CS pump, and 2C CS pump automatically actuated on an invalid signal.

"Component data:
Equipment name: D22 Bus LOCA Aux Control Time Delay Relay
Equipment number: 162-116
Manufacturer: A348 Amerace Corp
Model number: ETR14D3A002
Serial number: 83330224"

The licensee notified the NRC Resident Inspector.