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Event Notification Report for April 8, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/07/1999 - 04/08/1999

                              ** EVENT NUMBERS **

35552  35553  35554  35555  

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|Hospital                                         |Event Number:   35552       |
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| REP ORG:  BARNES-JUDISH HOSPITAL               |NOTIFICATION DATE: 04/07/1999|
|LICENSEE:  WASHINGTON UNIVERSITY, MO            |NOTIFICATION TIME: 09:10[EDT]|
|    CITY:  St. Louis                REGION:  3  |EVENT DATE:        03/09/1999|
|  COUNTY:                            STATE:  MO |EVENT TIME:        15:00[CDT]|
|LICENSE#:  24-00167-11           AGREEMENT:  N  |LAST UPDATE DATE:  04/07/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE BURGESS        R3      |
|                                                |FRED COMBS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOHN EICHLING                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| Description of the material                                                  |
|                                                                              |
| On March 9, 1999,  during preparation of preloaded needles for a permanent   |
| interstitial prostate implant,  a single  I-125 radioactive seed was lost.   |
| The seed was model 6711 manufactured by Medi-Physics, Inc., Amersham         |
| Healthcare, Arlington Heights, IL 60005. The seed originated from either lot |
| number E3254 or E3256. The seed is 4.5 mm in length and 0.8 mm in diameter.  |
| Radioactive material is absorbed on a silver core and encapsulated in a      |
| titanium shell. The apparent activity of the seed on March 9, 1999 was 0.37  |
| mCi. As of today the apparent activity is 0.26 mCi.                          |
|                                                                              |
| Description of the event                                                     |
|                                                                              |
| As stated above, the source was lost on March 9, 1999, at approximately 3    |
| p.m., during preparation of needles for a permanent prostate implant. The    |
| needle preparation procedure involves placement of seeds and spacers into    |
| needles under sterile conditions. At the time of the event, needle           |
| preparation was performed in a large operating room, which was also used to  |
| store surgical equipment. Needle tips are plugged with wax. During the       |
| course of the procedure there was a need to reload one of the needles. After |
| extracting seeds from the needle, two of the seeds were stuck in wax. The    |
| technologist attempted to separate the two seeds using tweezers. One of the  |
| seeds slipped from the tweezers and was ejected somewhere into the operating |
| room.                                                                        |
|                                                                              |
| Actions taken to recover material                                            |
|                                                                              |
| Immediately, the technologist attempted to locate the lost seed using a      |
| Geiger detector. She and another technologist spent 45 minutes looking for   |
| the seed. After an unsuccessful search, they contacted a physicist. The      |
| physicist performed a careful search also using a Geiger detector, which     |
| included a survey of the entire operating room and hallway, and the          |
| technologist's shoes, clothing, and hair. At this time, it was decided to    |
| lock the room and return in the morning. The following day, two physicists   |
| attempted to locate the lost seed using a NI and Geiger detectors. This      |
| search also proved unsuccessful. The following two days, members of the      |
| radiation safety team performed two additional searches, which were also     |
| unsuccessful.                                                                |
|                                                                              |
|                                                                              |
| Probable disposition of the material                                         |
|                                                                              |
| Approximately in the center of the operating room (6 feet away from the area |
| where the radioactive seeds were located) is a large drain. It is possible   |
| that the seed reached the drain and that it was lost in the drain.           |
|                                                                              |
| Possible exposure to individuals in unrestricted areas                       |
|                                                                              |
| The specific operating room is being used only for storage and it is         |
| estimated that no individual spends more than 0.5 hours/week in that room.   |
| The radiation levels in the room are at the background level. If the seed    |
| was lost in the drain, there would be no exposure to any member of the       |
| public due to the extremely low average energy of the source (28 kEv). The   |
| risk to individuals is further reduced due to relatively short half-life of  |
| I-125 (59.6 days).                                                           |
|                                                                              |
| Procedures or actions to prevent a recurrence                                |
|                                                                              |
| The licensee relocated the needle preparation procedure and equipment to a   |
| much smaller room (approximately 4x8 square feet). Should a seed be lost     |
| again it will be much easier to locate it in a small area.                   |
|                                                                              |
| Other pertinent information                                                  |
|                                                                              |
| The licensee has performed over 120 prostate implants that involved          |
| approximately 14,000 seeds. During this time, the licensee has lost only     |
| this one seed. This indicates that the system is well organized and that     |
| proper precautions are in place. However, to further improve the process we  |
| will prepare needles in the small room.                                      |
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|Power Reactor                                    |Event Number:   35553       |
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| FACILITY: LASALLE                  REGION:  3  |NOTIFICATION DATE: 04/07/1999|
|    UNIT:  [1] [] []                 STATE:  IL |NOTIFICATION TIME: 13:50[EDT]|
|   RXTYPE: [1] GE-5,[2] GE-5                    |EVENT DATE:        04/07/1999|
+------------------------------------------------+EVENT TIME:        12:13[CDT]|
| NRC NOTIFIED BY:  TODD GRANLUND                |LAST UPDATE DATE:  04/07/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE BURGESS        R3      |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(1)(ii)     DEGRAD COND DURING OP  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       99       Power Operation  |99       Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| - A single failure could cause both trains of the switchgear heat removal    |
| system to be inoperable -                                                    |
|                                                                              |
| A new potential single failure scenario has been identified on the           |
| switchgear heat removal system, System VX.  Damper #1(2)VX22Y is the System  |
| VX exhaust air shaft isolation damper.  This damper is a normally open, fail |
| open damper.  This damper is closed if the System VX heat recovery fans are  |
| running.  If a single active failure were to occur, a short in the motor     |
| would drive the damper closed.  It is possible that the Division 2 and RPS   |
| MG set rooms could pressurize.  These rooms are adjacent to the control room |
| envelope.  If these rooms pressurize, it is possible that the 1/8 inch       |
| minimum positive differential pressure required between the VC/VE room and   |
| the adjacent VX rooms may not be maintained.  This would result in both      |
| VC/VE room switchgear heat removal system trains being inoperable.           |
|                                                                              |
| Long term corrective actions are being determined.                           |
|                                                                              |
| Damper  #1(2)VX22Y is common to both Unit 1 and Unit 2.  Unit 2 is currently |
| in Operational Condition 4 (Cold Shutdown) in a Refueling Outage.            |
|                                                                              |
| The licensee plans to notify the NRC Resident Inspector.                     |
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|Power Reactor                                    |Event Number:   35554       |
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| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 04/07/1999|
|    UNIT:  [1] [2] []                STATE:  MI |NOTIFICATION TIME: 16:01[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/07/1999|
+------------------------------------------------+EVENT TIME:        13:15[EDT]|
| NRC NOTIFIED BY:  MARY BETH DePUYDT            |LAST UPDATE DATE:  04/07/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRUCE BURGESS        R3      |
|10 CFR SECTION:                                 |STUART RICHARDS      NRR     |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| - Unit 1 and 2 EDG starting air system air compressors not safety related    |
| seismic category 1 -                                                         |
|                                                                              |
| This report is a four-hour notification in accordance 10CFR50.72(b)(2)(i),   |
| of a condition which was found while both reactors were shutdown, which, had |
| it been found while the reactor was in operation, could have resulted in the |
| nuclear plant being in an unanalyzed condition.                              |
|                                                                              |
| The Emergency Diesel Generator (EDG) system at Cook is comprised of four     |
| EDGs, two per unit. The EDGs are designed to start automatically upon        |
| receipt of a safety injection signal and/or a loss of offsite power signal   |
| and be ready to accept loads within 10 seconds of receiving the start        |
| signal.  The starting air system supplies compressed air for starting the    |
| EDGs, and each EDG has its own system consisting of two redundant starting   |
| air trains.  Each train has one receiver of sufficient volume for at least   |
| two EDG start attempts when pressurized to 220 psig.  The starting air       |
| system also provides compressed air for the starting air supply valve        |
| actuators, the diesel engine control system and the aftercooler cooling      |
| water regulating valves.  While the starting air receivers and piping are    |
| safety related seismic category 1, the compressors are not safety related    |
| nor are they seismically mounted.                                            |
|                                                                              |
| A potential deficiency in the design of the EDG starting air system has been |
| identified.  If the starting air compressors were lost during a seismic      |
| event, the ability of the starting air system could be impaired to the point |
| that the control air pressure necessary for the engine control system could  |
| not be maintained.  It is postulated that leakage from the system would      |
| result in a loss of air receiver pressure of approximately 25 psi in a 12    |
| hour period.  Based on preoperational test data, with a starting air         |
| receiver pressure of 132 to 188 psig, the control air pressure could drop    |
| below the critical value of 65 psig in less than two days.  Therefore, it is |
| possible that the EDG would not be able to sustain long term operability     |
| without the starting air compressors.                                        |
|                                                                              |
| Evaluation of this potential design deficiency is ongoing, as well as        |
| research into the licensing/design basis of the starting air system.  Both   |
| units are in Mode 5 (Cold Shutdown) with all four EDGs declared inoperable,  |
| but functional.  The EDGs were already inoperable due to HFA relay concerns, |
| and will remain inoperable until this problem is resolved.  With all four    |
| EDGs inoperable, the plant has additional offsite power lines to back up     |
| normal offsite power sources.  This condition was discovered during an       |
| extended plant system readiness review and has existed since initial plant   |
| criticality.  The Licensee informed the NRC Resident Inspector.              |
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|Power Reactor                                    |Event Number:   35555       |
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| FACILITY: SEABROOK                 REGION:  1  |NOTIFICATION DATE: 04/07/1999|
|    UNIT:  [1] [] []                 STATE:  NH |NOTIFICATION TIME: 16:47[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        04/07/1999|
+------------------------------------------------+EVENT TIME:        14:52[EDT]|
| NRC NOTIFIED BY:  GARY KILBY                   |LAST UPDATE DATE:  04/07/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |FRANK COSTELLO       R1      |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| The licensee notified the National Marine Fisheries and the NRC Resident     |
| Inspector that while cleaning the plant service water forebay, they          |
| discovered a dead seal.                                                      |
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