Event Notification Report for January 27, 2009

MEDICAL EVENT - ACTUAL DOSE LESS THAN PRESCRIBED DOSE

"Two medical events were discovered on January 27, 2009, for patients treated during 2005 at VA Greater Los Angeles Healthcare System, Los Angeles, California.

"These two medical events involved patients who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distributions in the patients were associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose.

"These patient circumstances are interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1)(i).

"A 15-day written report for the medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager (Cassandra Frazier, NRC Region III) of the medical events."

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

MANUAL REACTOR TRIP DUE TO LOSS OF 4160V BUS

"Calibrations of the 'A' Unit 4160V Switchgear metering were in progress when the 'A' Unit 4160V Bus tripped. This resulted in the loss of the 'A' Feedwater Booster Pump (FWBP) and 'A' Condensate Pump (CDP). The Operating crew identified the loss of the 'A' FWBP with increasing RCS pressure and manually tripped the reactor. There were no other safety system actuations and the plant is stable at normal post-trip temperature and pressure."

All rods inserted during the trip. Decay heat is being removed via steam dumps to the condenser. The electrical grid is stable with plant loads being supplied by offsite power via the startup transformer. Both vital busses are being powered from offsite. During the transient, main steam relief valves did lift but have been reseated.

The NRC Resident Inspector has been notified.

PART 21 REPORT - WATER QUALITY DEFICIENCY

The following information was obtained from Fisher Controls International via facsimile:

Fisher Controls International issued a Fisher Information Notice: FIN 2009-02, that notified customers of an issue discovered during an internal audit of manufacturing procedures followed by Fisher Controls International LLC. Specifically, on orders processed by Fisher Controls that invoked demineralized water cleaning requirements, Fisher Controls erroneously certified that all orders met demineralized water requirements when all requirements could not be proven to be met.

To meet the certification requirements, demineralized water must meet the quality requirements of NQA-1. Fisher Controls uses FMP [Fisher Manufacturing Procedure] 12B3 to verify that demineralized water used to clean parts meets NQA-1. Fisher determined that water quality testing using FMP 12B3 performed from January 1, 2001 to May 1, 2008 did not meet the test protocols.

"Twenty two orders have been identified, from 500+ orders reviewed, which require either the use of demineralized water and/or NQA-1 high quality water for which Fisher cannot prove full compliance. It is important to note that this review was limited to nuclear assembly orders only. Safety-related parts orders were not included because final cleaning was done either with alcohol or acetone."

The affected plants are:

Indian Point 2
Seabrook
Millstone (two valves)
D.C. Cook
North Anna (two valves)
Catawba (seven valves)
Oconee (five valves)
McGuire (three valves)

PART 21 REPORT - PART NOT EVALUATED FOR ALL CRITICAL CHARACTERISTICS

The following information was obtained from Fisher Controls International via facsimile:

The equipment supplied included a 20 inch Fisher valve coupled to a Bettis actuator.

"The purpose of this Fisher Information Notice (FIN 2009-03) is to alert Alabama Power that as of January 16, 2009, Fisher Controls International LLC became aware of the possibility of a situation which may affect the performance of the applicable equipment.

"This notice applies only to the subject equipment supplied by Fisher Controls International LLC, identified above, that was provided to Alabama Power - Farley.

"Fisher Controls has determined that the subject items were provided with parts that were not properly processed per active valve requirements specified by the Alabama Power Order.

"Specifically, Fisher provided a coupler between the actuator drive lever and valve shaft that was not evaluated for all the critical characteristics deemed necessary for a commercial grade dedicated item per EPRI 5652 and Fisher Manufacturing Procedure FMP 2K27, 'Control of Commercial Grade Items to be Dedicated for Use in Nuclear Safety-Related Systems,' (Fisher Processing Level C).

"We [Fisher Controls] are reviewing the situation and will pursue a corrective action investigation to prevent problems like this in the future.

"Arrangements have been made with Alabama Power to retrofit a correctly processed part on the subject serial number.

"This is a formal notification; Alabama Power was notified of this situation on January 16, 2008."

The coupling provided to Alabama Power did not meet the hardness requirements specified in the order. The coupler provided was annealed versus quench-hardened.

UNIT 2 HPCI SYSTEM INOPERABLE FOR TWO HOURS DUE TO CONDENSATE IN EXHAUST LINE

"On January 27, 2009 at approximately 2007, the Unit 2 High Pressure Coolant Injection (HPCI) System was declared inoperable due to a sustained high level in the HPCI Exhaust Line Drain Pot. This sustained high level was caused by a failure of the HPCI Barometric Condenser Condensate Pump, which prevented the removal of the accumulated condensate. An alternate drain path was established and the exhaust line drain pot high level condition was cleared at 2202. However, due to this condition existing for approximately two hours, it cannot be assured that HPCI would have been able to perform its designed function under all conditions. The potential of HPCI system component damage or isolation from an exhaust line failure due to water hammer during a system initiation could not be positively eliminated.

"Initial safety significance: Minimal. The Reactor Core Isolation Cooling (RCIC) System, Automatic Depressurization (ADS) System, and Low Pressure Emergency Core Cooling Systems (ECCS) - two Loops of Core Spray and two Loops of Low Pressure Coolant Injection (LPCI) - remain operable.

"Manual actions have been taken to drain the HPCI Exhaust Line Drain pot and have been successful. Determination of the cause of the failure of the HPCI Barometric Condenser Condensate Pump and restoration to service are in progress."

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the State of North Carolina via facsimile:

"On January 27, 2009, a Therasphere (Y-90 microsphere) procedure was scheduled for a patient in Room 4, Special Procedures. The treatment was planned to deliver 110 Gy to the left lobe of the liver. The delivery apparatus was assembled according to manufacturer instructions, without incident. The treatment was initiated. During the first infusion, the Authorized User noticed fluid leakage at the outlet flow line and needle insertion at the source vial. The RSO was contacted. An attempt was made to continue the infusion. The liquid continued to leak at the outlet flow line and needle junction. No additional radioactivity was delivered to the patient. The procedure was terminated.

"Post procedure survey readings of the source vial indicated that approximately 65% of the intended radioactivity was delivered to the patient. This resulted in a dose of 70 Gy delivered to the left lobe of the liver.

"The Authorized User indicated that no adverse clinical symptoms are expected. This was the second treatment for this patient.

"The manufacturer (MDS Nordion) was notified of the device problem on 01/28/09.

"All liquid and contamination was contained by Radiation Safety personnel."

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

* * * UPDATE AT 1425 ON 2/06/09 FROM ALBRIGHT TO KLCO* * *

Notified that the event is documented by the North Carolina Radioactive Materials Branch as incident NC-09-11.

Notified the R1DO (Gray) and FSME (McIntosh).