Event Notification Report for January 31, 2008

24 HOUR REPORT OF RELEASE DETECTION SYSTEM FAILURE

"At 1406 CST, on 01-31-08 the Plant Shift Superintendent (PSS) was notified that an alarm was received for the C-333 Unit 3 Cell 5 UF6 Release Detection (PGLD) System. Operators responded to the panel and verified the alarm was false but when they attempted to test the system it failed. Preliminary troubleshooting indicates that the cause of the alarm may have been a momentary loss of power. This PGLD System contains detectors that cover the C-333 Unit 3 Cell 5 cell housing roof and inter-cell housing. At the time of this alarm, C-333 Unit 3 Cell 5 was operating above atmospheric pressure. TSR 2.4.4.1 requires that at least the minimum number of detector heads in the cell housing roof and inter-cell housing are operable during steady state operations above atmospheric pressure. With the Unit 3 Cell 5 PGLD system inoperable, none of the required 3 heads in the cell housing roof and inter-cell housing were operable. This PGLD System was declared inoperable, TSR LCO 2.4.4.1.B.1 was entered and a continuous smoke watch was put in place within one hour. An investigation is ongoing to attempt to conclusively and accurately determine the cause of the alarm.

"This event is being reported as a 24 hour event in accordance with 10 CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Senior Resident Inspector has been notified of this event."

AGREEMENT STATE REPORT - EQUIPMENT SAFETY FAILURE

"On Thursday, January 31, 2008 during a treatment of a patient an event occurred with the licensee's Leksell Gamma Knife Stereotactic teletherapy treatment unit (Model 24001 Type C).

"The patient treatment plan called for three exposure fractions. The first fraction was initiated at 10:25 a.m., without incident. After the normal termination time of treatment, the couch retracted fully and the patient's head was withdrawn from the unit. However, the shielding doors on the unit did not close. An Authorized Medical Physicist (AMP) then entered the treatment room, walked behind the unit, and closed the shielding doors manually. The licensee estimates that the AMP received an exposure of no more than 0.0083 mrem while closing the shielding doors. The patient was removed from the treatment room and a radiation survey was conducted to verify that the shielding doors had closed completely.

"Elekta was contacted (12:30 p.m. 01/31/08) and a service representative arrived and completed an evaluation of the Gamma Knife and could find no faults in any aspect of the Gamma Knife system operation. A decision was made by the Authorized User to complete the last two exposure factions. The remaining shots were successfully completed.

"The patient did not receive a radiation dose deviating from the written directive from the shielding doors not closing. The licensee was in constant contact with DHFS throughout this incident. This event will be followed up by DHFS on the next scheduled inspection (02/19/08).

"Event Report ID No WI-08-01

"License No.: 79-1281-01

"Event Type: HFS 157.13(17)(b)2.a - 'Equipment is disabled or thus to function as designed'"

MANUAL REACTOR SCRAM IN RESPONSE TO TRIP OF BOTH REACTOR RECIRC PUMPS

"At 1544 EST 01/31/2008, the reactor mode switch was taken to shutdown in response to the trip of both reactor recirc pumps. All control rods fully inserted into the core. The lowest reactor vessel water level reached was 157 inches. Reactor water level is being controlled in the normal band using CRD.

"The cause of the reactor recirc pump trips are under investigation at this time. There was no maintenance or testing in progress that would explain the pump trips.

"At the time of the scram all ECCS systems and Emergency Diesel Generators were operable with the exception of Division 1 RHR. Division 1 RHR Surveillance testing was in progress. Surveillance testing is complete. Division 1 RHR is available with administrative activities remaining before it will be declared operable. Isolations and actuations occurred as expected. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Any event that results in actuation of the reactor protection system (RPS) when the reactor is critical."

Decay heat is being removed to the main condenser via the turbine bypass valves. The electric plant is a normal shutdown lineup. No SRVs lifted during the reactor scram.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - MEDICAL EVENT RADIATION TREATMENT NOT ADMINISTERED PER INTENTION

The following report was made by e-mail:

"In Radiation Oncology, a treatment was ordered for an HDR cylinder gynecological treatment of 2 fractions of 600 cGy to 5 mm past the surface of the cylinder. The treatment form was most likely filled out by a resident and was signed by both the resident and the attending radiation oncologist as stated by Environmental Health & Safety staff. When the radiation oncologist typed the official written directive into the IMPAC system, (Information for Management, Planning, Analysis and Coordination System), her intention was to treat 2 fractions of 600 cGy to the surface of the cylinder. The treatment was planned according to the written form to 5 mm past the surface of the cylinder. This plan was checked and signed off by the treating physician and was the treatment given to the patient. The radiation oncologist states that there should be no medical impact to the patient, as prescription to 5 mm past the surface of the cylinder is also an acceptable and standard treatment. The radiation oncologist has changed the prescription in IMPAC to reflect the dose that was given. The treating physician has notified both the referring physician and the patient."

A 'medical event' indicates potential problems in a medical facility's use of radioactive materials. It does not result in harm to the patient.