Event Notification Report for February 12, 2009

BRACHYTHERAPY SEEDS MISPLACED IN PATIENT

"A medical event was discovered on February 12, 2009, for a patient treated at the VA Greater Los Angeles Healthcare System, Los Angeles, California.

"The medical event involved a patient who had undergone permanent implant prostate seed brachytherapy on February 12, 2009, using iodine-125 seeds. Approximately five seeds were mistakenly placed more than one centimeter from the prostate toward the perineum. This treatment result is interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(3).

"The causes and clinical effects are under review. At this time, it is not believed that the misplaced seeds will cause any adverse deterministic effects to the patient.

"The permittee is aware of the requirements in 10 CFR 35.3045 regarding notification of the patient and referring physician. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, NRC Region III, of the medical event.

"The permit number for the facility involved in this medical event is VHA Permit No. 04-00181-04."

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.

CONTAMINATED WORKER SENT TO OFFSITE HOSPITAL FOR TREATMENT

"Operator was changing a filter in a glove box when he noticed liquid on his sleeve. Safety Department was notified and operator was found to be contaminated above limits. Decontamination attempts were unsuccessful due to nitric acid burn on forearm. Several small holes/cuts in rubber glovebox glove were identified. Operator was sent to medical facility for further evaluation. Operator was treated for second degree burns at medical facility and released.

"There were no exposures from licensed material. There were no actual consequences to the public or environment.

"Personal protective equipment was used by the worker. Emergency safety shower was available and utilized. Locker room shower was also available and utilized."

The NRC Resident Inspector was notified.

HIGH PRESSURE COOLANT INJECTION SUCTION SOURCE INSTRUMENT MALFUNCTION

"Unit 2 HPCI (High Pressure Coolant Injection) system is being considered inoperable due to the following information: (Condition Report 2009101257) The instrumentation associated with the automatic suction swap for Unit 2 HPCI was reviewed as a result of CR 2009100480 to confirm the set points that determine the condensate storage tank (CST) level at which the suction swap would occur. During the course of this review, the corporate design engineer contacted the level switch vendor to review the configuration of the level switches and to confirm the expected operation of the switches (2E41-N002 & 2E41-N003) given their configuration. Based on the configuration of the instrument lines and physical location of the level switches, the vendor reported that either liquid or gas would most likely be entrapped in the external cage of the Magnetrol level switches. This would prevent the instruments from performing their automatic swap function. Based on this information the 'as found' condition of the switches indicate that this condition has been present since the installation of the switches when implementing the DCP in 1991 which affects the operability of this instrumentation.

"Even though the suction swap instrumentation on low CST level is considered inoperable, there is no apparent actual adverse impact on nuclear safety. However, the instrumentation is included in the Technical Specifications and its inoperability would make HPCI inoperable if it is aligned to the CST rather than being aligned to the suppression pool. The normal system alignment is with its suction source to the CST, therefore HPCI is being considered as inoperable.

"Until the configuration of the level switches has been addressed, these Magnetrol level switches must be considered inoperable, the appropriate Technical Specification RAS [Required Action Statement] will be entered and the suction source for HPCI should be aligned to the suppression pool when HPCI is required to be operable. This condition only applies to Unit 2."

The licensee has notified the NRC Resident Inspector.

* * * UPDATED AT 1648 EDT ON 03/20/2009 FROM EDWEN URQUHART TO V. KLCO * * *

Event Report 44849 Retraction:

"On February 12, 2009, a condition was discovered where the physical location of level switches relied upon for automatically transferring the suction of the Unit 2 high pressure coolant injection (HPCI) system from the condensate storage tank (CST) to the suppression pool on low CST level did not meet the setpoints given in the Technical Specifications. Based on the information available at that time HPCI would have to be considered inoperable based on the fact that the affected instrumentation was inoperable and with HPCI aligned to the CST. Since the unit was shutdown HPCI was not required to be operable.

"After further review the determination has been made that at the time of discovery the 'as found' plant configuration associated with the suction swap setpoint for the Unit 2 high pressure coolant injection (HPCI) system could NOT have prevented the fulfillment of the safety function since the unit was in Cold Shutdown, and HPCI was not required to be operable. Based on this information this condition did not require an NRC notification in accordance with I0CFR50.72 and as such is being retracted through this update response. The condition will be reported in accordance with I0CFR50.73(a)(2)(v),"

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Sykes)

US COAST GUARD AND NEW JERSEY ENVIRONMENTAL HOTLINE NOTIFIED DUE TO CAPSIZED BOAT

"This notification is based on 10 CFR 50.72(b)(2)(xi) HCGS RAL 11.8.2.a Unusual Conditions Warranting a News Release or Notification of Government Agencies. The US Coast Guard and New Jersey State Environmental Hotline were contacted and provided the following communication.

"Between 14:00 and 15:00 hours today, an unmanned 25' boat owned by Atlantic Subsea (a PSEG Nuclear contractor) that was tied in the Hope Creek Generating Station barge slip, which is on the Delaware River, at Hope Creek Generating Station overturned and became partially submerged. There were no passengers onboard at the time. Atlantic Subsea reports that the boat contains approximately 40 gallons of gas in a sealed fuel system and 5 gallons of oil in a sealed oil system. Atlantic Subsea does not believe the sealed fuel or oil systems will leak, and there is NO indication of gas or oil leaking into the Delaware River. The gas tank does have a vent, but this vent is fitted with a mechanical vacuum breaker that is not expected to leak.

"Because of the wind and high seas, PSEG and Atlantic Subsea are unable to safely remove the boat or its contents from the water at this time. It is expected that the boat will be removed from the water tomorrow when the weather improves. PSEG is presently deploying absorbents into the entrance of the barge slip to contain any oil or gas that does leak. In addition, inspections of the water in and around the barge slip will be performed hourly. A notification will be made in the event that a discharge occurs.

"Atlantic Subsea has informed the Coast Guard.

"This is a courtesy notification only from PSEG Nuclear LLC's Hope Creek Generating Station. There is no evidence of a leak of petroleum products into the Delaware River."

The licensee notified the NRC Resident Inspector.