Event Notification Report for August 31, 1999

TECHNETIUM-99m CONTAMINATION AT SPECTRUM PHARMACY

DURING PREPARATION OF CARDIOLITE, A VIAL CONTAINING 1.3 ml OF TECHNETIUM-99m (APPROXIMATELY 450 to 600 MILLICURIES) EXPLODED DURING PROCESSING. THE INDIVIDUAL WORKING IN THE AREA RECEIVED CONTAMINATION ON HIS FACE AND CLOTHING. THE INDIVIDUAL'S FACE WAS DECONTAMINATED AND HIS CLOTHING REMOVED. THE LICENSEE DECONTAMINATED THEIR EQUIPMENT AND TRANSPORT CASES; HOWEVER, THE CASES WERE EITHER INSUFFICIENTLY DECONTAMINATED OR THEY WERE RECONTAMINATED PRIOR TO DELIVERY. THE LICENSEE RECEIVED CALLS FROM 6 OR 7 HOSPITALS AND CLINICS WHO RECEIVED PACKAGES WITH EXTERNAL CONTAMINATION RANGING FROM 2,000 TO 20,000 DPM. DELIVERIES COULD HAVE BEEN MADE TO AS MANY AS 10 TO 12 HOSPITALS AND CLINICS.

HOO NOTE: SEE RELATED EVENTS 36094, 36095 AND 36102.

* * * COMMISSIONERS' ASSISTANTS' BRIEFING HELD AT 1430 EDT 8/31/1999 * * *

Briefer: Pederson (R3). Participants: Ploski, Dyer (R3); Congel (IRO); Cool (NMSS); Larkins (OSP); Gerke (OCA); Hart (SECY); Jones (Chrmn. Dicus); Moore (Comm. McGaffigan); Lubinski (Comm. Diaz); Doane (Comm. Merrifield).

LICENSEE RECEIVED TWO PACKAGES WHOSE NON-FIXED SURFACE CONTAMINATION LEVELS EXCEEDED THE ALLOWABLE LIMITS

THE HEART CENTER FOR EXCELLENCE LOCATED IN KALMAZOO, MI., RECEIVED TWO PACKAGES OF CARDIOLITE (TECHNETIUM-99m) THIS MORNING WHICH TESTED POSITIVE FOR NON-FIXED SURFACE CONTAMINATION. ONE PACKAGE CONTAINING 335 mCi MEASURED 2286 DPM AND THE OTHER CONTAINING 462 mCi MEASURED 5886 DPM (PRIMARILY ON THE FRONT FACE) GAMMA READING USING A CAPRAC INSTRUMENT. THE LOWER ACTIVITY PACKAGE WAS DECONTAMINATED WHILE THE HIGHER READING ONE WAS ISOLATED IN THE HOT LABORATORY. THE LICENSEE HAS INFORMED THE SHIPPER, SPECTRUM PHARMACY LOCATED IN MISHAWAKA, IN.

CONTACT THE NRC OPERATIONS CENTER FOR TELEPHONE NUMBERS.

HOO NOTE: SEE EVENTS #36093, #36095 AND #36102.

LICENSEE RECEIVED 3 PACKAGES FROM SPECTRUM PHARMACY INC WHICH WERE CONTAMINATED WITH TECHNETIUM 99M.

THE LICENSEE RECEIVED 3 CONTAMINATED PACKAGES WITH SURFACE READINGS RANGING BETWEEN 0.2 TO 0.3 MR/HR ON CONTACT AND 0.02 MR/HR AT 1 METER . THE WIPE TEST READINGS WERE 2,300 DPM/100 SQCM, 8,000 DPM/100 SQCM, AND 33,000 DPM/100 SQCM. THE PACKAGES WERE ISOLATED AND DECONTAMINATED TO <2,000 DPM/100 SQCM. WHEN ONE PACKAGE WAS OPENED THE LEAD PIG INSIDE WAS SWIPED AT 6,200 DPM/100 SQCM. THE LEAD PIGS IN THE OTHER TWO PACKAGES WERE <2,000 DPM/100 SQCM.

HOO NOTE: SEE EVENTS #36093, #36094 AND #36102.

SIX (6) GENERAL LICENSE STRONTIUM-90 SOURCES DETERMINED MISSING

BETWEEN 1994-1995, SIX (6) STRONTIUM-90 SOURCES WERE REMOVED FROM EQUIPMENT FOR STORAGE AT THE COVINGTON, GA., FACILITY. SUBSEQUENT TO THAT TIME, GENERAL MILLS HAS LOST TRACK OF THE LOCATION OF THESE SOURCES. AN INDEPENDENT CONSULTING FIRM, SAFETY & ECOLOGY LOCATED IN KNOXVILLE, TN, WAS UNSUCCESSFUL IN LOCATING THE SOURCES AT THE SITE USING A SODIUM IODIDE DETECTOR. THE MISSING SOURCES AT ADAPTIVE TECHNOLOGY, INC., THICKNESS GAUGES MODEL #ATI-100 (SERIAL #0030034 THROUGH 0030039) EACH CONTAINING 500 MICROCURIES SR-90. THE LOCATION WHERE THE SOURCES WERE UTILIZED WAS THE GENERAL MILLS FACILITY LOCATED IN COVINGTON, GA. THE LICENSEE HAS CONDUCTED A THOROUGH INVESTIGATION AND BELIEVES THAT IF THE SOURCES WERE DISPOSED OF MORE THAN LIKELY THEY WERE SENT TO A LANDFILL. THIS IS BASED ON COMPANY POLICY OF NOT SELLING SURPLUS EQUIPMENT DUE TO THE POTENTIAL DISCLOSURE OF TRADE SECRETS. THE LICENSEE HAS REQUESTED THAT THE NRC REGIONAL OFFICE CONTACT THEIR CORPORATE HEADQUARTERS TO DISCUSS WHETHER A FOLLOWUP WRITTEN REPORT IS NECESSARY.

CALL THE HEADQUARTERS OPERATIONS CENTER FOR CONTACT TELEPHONE NUMBERS.

UNIT OUTSIDE DESIGN BASIS DUE TO APPENDIX R ISSUE

"Three electrical cable tray fire barriers installed in 1986 to provide separation for the Unit 1 charging pumps were found to be installed in the wrong location. The existing condition could allow a fire to propagate through the cable trays such that all three charging pumps could become unavailable to assist in performing a safe shutdown under Appendix R condition. Hourly fire rounds have been implemented as a compensatory measure and the charging pumps are tentatively classified as operable but degraded. Formal operability determination in progress."

The licensee has inspected Unit 2, and verified that the barriers are correctly installed on the unit. The NRC resident inspector has been informed by the licensee.

OFFSITE NOTIFICATION DUE TO ANTIFREEZE SPILL ONSITE

At approximately 0900, a vendor vehicle used to excavate the soil for installation of a water treatment facility modification released about 10 gallons of ethylene glycol to the site grounds when its radiator failed. Since this amount is greater than the reportable quantity, the New York State Department of Environmental Conservation was notified. Licensee and vendor personnel have cleaned up the spill. No hazardous material reached the discharge canal to the Hudson River.

The NRC resident inspector has been informed of this event by the licensee.

OUTSIDE DESIGN BASIS REPORT INVOLVING FAILURE TO MEET UPDATED FINAL SAFETY ANALYSIS REPORT (UFSAR) COMMITMENT FOR FLOOD PROTECTION

NRC Notification of Condition Outside the Design Basis for TMI-1

"GPU Nuclear determined at 1235 hours on August 31, 1999 that a condition outside the design basis of the plant as documented in Section 2.6.5 of the TMI-1 UFSAR exists and that this is immediately reportable to the NRC in accordance with 10 CFR 50.72 (b)(i)(ii)(B). Two (2) floor drains located in the Reactor Building Personnel access hatch area of the TMI-1 Intermediate Building (a building not protected from a flood) were determined to provide an unprotected flow path into the Spent Fuel Building sump in the event of the maximum predicted flood at TMI-1. This is not in conformance with a commitment made to the NRC as documented in Section 2.6.5.i of the TMI-1 UFSAR.

"The TMI-1 UFSAR section 2.6.5 states:

'Various components which are protected for achieving and maintaining a safe shutdown condition, in compliance with the commitment made to the Atomic Energy Commission. include, but are not limited to, the following locations and type of flood protection:
(applicable sections e and i listed below, non-applicable sections not included)

e. Intermediate Building
1) Stop logs
2) Drain system designed for flood condition


i. General

All openings that are potential leaks (ducts. pipes, conduits, cable trays, and so forth) arc sealed.'

"Engineering inspection and design review conducted, on August 31,1999 identified the potential non-conforming condition that the two (2) floor drains drain to the Fuel Handling Building sump through a normally open valve. The TMI Flood Protection procedure does not specify that the valve is to be closed in the event of a pending flood.

"This condition was reported to Mr. Steve Sandin of the NRC Operations Center at 1315 hours on August 31, 1999 (Event Notification No. 36099) by J. Schork, TMI Plant Review Group Chairman. A follow-up fax was sent to Mr. Sandin at 301-816-5151.

"The non-conforming condition has been documented in the GPU Nuclear corrective action program. Immediate corrective action is in progress to modify the site flood protection procedure to require the installation of plugs in the flowpaths identified in the event of a pending flood. In addition, a review of the extent of the identified condition will be performed and reported in the followup licensee event report."

The licensee will inform the NRC resident inspector.

RCIC SYSTEM ISOLATION WHILE BEING RETURNED TO SERVICE

While returning the reactor core isolation cooling (RCIC) system to service following maintenance, a momentary high steam flow signal caused an inboard RCIC steam supply isolation. As a result, the RCIC turbine warmup valve closed. The isolation signal was reset, and system warmup resumed.

The licensee reported that momentary high steam flow signals have been observed on previous occasions while warming the RCIC turbine. The NRC resident inspector has been informed of this event by the licensee.

- HOSPITAL RECEIVED TWO CONTAMINATED PACKAGES FROM SPECTRUM PHARMACY, INC -

ON 08/31/99, GOSHEN GENERAL HOSPITAL, GOSHEN, IN, RECEIVED TWO CONTAMINATED PACKAGES CONTAINING NUCLEAR MEDICAL DRUGS FROM SPECTRUM PHARMACY, INC, MISHAWAKA, IN. THE WIPE TEST READINGS FOR THE FIRST PACKAGE RECEIVED AT 0830 CDT WERE AS HIGH AS 3100 DPM/100 SQ CM AND FOR THE SECOND PACKAGE RECEIVED AT 1200 CDT WERE AS HIGH AS 2345 DPM/100 SQ CM. THE ADMINISTRATIVE LIMIT FOR GOSHEN GENERAL HOSPITAL IS 2000 DPM/100 SQ CM. THE PACKAGES HAVE BEEN PLACED IN THE HOSPITAL HOT LAB BEHIND LEAD SHIELDING. A HOSPITAL REPRESENTATIVE NOTIFIED A SPECTRUM PHARMACY REPRESENTATIVE.

HOO NOTE: REFER TO RELATED EVENTS #36093, #36094, AND #36095.

AUTOMATIC REACTOR TRIP WITH COMPLICATIONS

An automatic reactor trip/turbine trip occurred due to an overtemperature differential temperature (OTdT) trip signal. The licensee was replacing Channel 3 pressurizer low pressure trip bistables when a spurious OTdT trip signal occurred on Channel 4, completing the 2/4 logic. Following the trip, control rod K-2 of Control Bank D had an indicated position of 14.4 steps out from fully inserted. All other control rods are fully inserted.

Following the trip, 480 VAC bus 6A received an undervoltage trip signal, causing buses 2A, 3A, 5A, and 6A to transfer to their associated emergency diesel generators (EDGs) (22, 21, and 23, respectively). Buses 2A, 3A, and 5A are currently being supplied by the EDGs; however, the output breaker for EDG 23 tripped upon loading to bus 6A, which remains deenergized. Operators manually started the turbine driven auxiliary feedwater pump due to the loss of control power to one of the motor driven AFW pumps caused by the loss of bus 6A.

The unit is currently stable in hot standby. The licensee is currently troubleshooting bus 6A in anticipation of restoring power. The NRC resident inspector has been informed of this event by the licensee.

HOO Note: See Event #36107.

*** UPDATE 1415 EDT ON 9/4/99 FROM SANTINI TO POERTNER ***

Following the reactor trip on 8/31/99 and subsequent loss of power to 480v bus 6A, Technical Specification 3.0.1 had been entered since safeguards bus 6A was de-energized and the RCS temperature was greater than 350 degrees Fahrenheit (degf). During the trouble shooting phase of this event, 23 Service Water Pump (SWP) on the essential SW header was tagged out. 21 and 22 essential header SWPs were operable. This resulted in a period of time of approximately 15 hours (1430 on 8/31 to approximately 0530 on 9/1) where 23 SWP was inoperable. Technical Specification (TS) 3.3.F.1.b specifies that one essential service water pump may be inoperable for a period not to exceed 12 hours. Following the allowable period of 12 hours, 6 hours are allowed to place the plant in hot shutdown and following the 6 hours to hot shutdown, the plant shall be cooled below 350 degf using normal operating procedures. The 15 hours during which the 23 SWP was inoperable exceeded the 12 hour time limit. Since the plant was already in hot shutdown due to a reactor trip, the 6 hour time period to reach hot shutdown was not applicable. The plant cool down to less than 350 degf started at 0430 on 9/1/99. However, since TS 3.3.F.1.b specifies 12 hours and then a cool down to less than 350 degf for this circumstance, it is more restrictive and requires that the cool down should have started 2 hours earlier at 0230 on 9/1/99.

The NRC resident will be notified. Notified R1DO (ROGGE).

OFFSITE NOTIFICATION DUE TO OIL RELEASE TO DISCHARGE CANAL

"While draining water from the Dirty Oil Storage Tank, oil became entrained into the stream of water and was inadvertently released to the 5' turbine hall sump and subsequently to the discharge canal. Less than 1 gallon of oil was released before the flow was isolated. Actions were taken to absorb the oil in the canal but enough was evident to leave a sheen in the canal. No oil sheen was observed in the Hudson River. The NYS DEC was notified at 1550 on 8/31/99."

The licensee will inform the NRC resident inspector of this event.

TRUCKS CARRYING LOW SPECIFIC ACTIVITY MATERIAL (CONTAMINATED SOIL) LEAKING CARGO

Mr. Easton from the Pennsylvania Bureau of Radiation Protection (PA BRP) contacted the NRC Operations Center regarding a truck, carrying LSA-1 material from the Haddam Neck plant in Connecticut, which is leaking some of its cargo. The cargo of the truck is soil which is contaminated with small amounts of radioactive cesium-137 and cobalt-60. The truck is currently located at Exit 13 on Interstate 78. Lehigh County HAZMAT responders are onsite. The caller did not have specific information regarding the leakage rate or the amount of material that has been lost.

The driver was alerted to the possible leakage after the driver of another truck, located somewhere in New York State and also carrying LSA-1 cargo, discovered that his truck was leaking. The caller reported that the PA BRP was contacted regarding this event by the Connecticut Department of Environmental Protection.

The NRC Operations Center hosted a conference call between PA BRP, NRC Region 1, NMSS, and EPA Region 3 to discuss this event.

* * * UPDATE 2212 8/31/1999 FROM RANDY EASTON TAKEN BY STRANSKY * * *

Mr. Easton contacted the Lehigh County HAZMAT responders, who reported that the material leaking from the shipment is not soil, but a clear liquid (perhaps rainwater). A total volume of about a cup has been released at the scene. The State of Pennsylvania declined to request NRC assistance in responding to this event. Health Physics and HAZMAT personnel from Haddam Neck will be responding to the scene in the morning, and the trucks will be returned to Haddam Neck.

A second conference call was held between PA BRP, NRC Region 1, and EPA Region 3 to discuss additional information regarding the event.

UNUSUAL EVENT DUE TO LOSS OF MOST CONTROL ROOM ANNUNCIATORS

An Unusual Event was declared at 2155 EDT due to an unplanned loss of greater than 75% of the control room safety system annunciators for longer than 15 minutes. The licensee reported that the annunciators are currently inoperable, and that additional panel walkdowns are being performed. The unit is currently stable in Hot Standby following a reactor trip earlier today (see EN 36104). The NRC resident inspector has been informed, and is in the control room.

* * * UPDATE AT 0157 EDT ON 9/1/99 BY MARK STUBBLE TO FANGIE JONES * * *

The plant conditions are improving and the plant is stable in Hot Shutdown. The annunciators have been restored. The previous problem with 480 VAC busses on Event #36104 has been found to be related to the loss of the annunciators. Further evaluation is ongoing and the licensee expects to exit the Unusual Event soon.

The licensee notified the NRC Resident Inspector. The HOO notified the R1DO (John White), NRR EO (David Matthews), and IRO Manager (Charles Miller).

* * * UPDATE AT 0343 EDT ON 9/1/99 BY MARK STUBBLE TO FANGIE JONES * * *

The plant exited the Unusual Event at 0330 EDT, the plant is in normal Hot Shutdown. The licensee has notified the NRC Resident. The HOO notified the R1DO (John White), NRR EO (David Matthews), IRO Manager (Charles Miller), and FEMA (Gene Canupp).

MICROFILTRATION SYSTEM pH PROBES DISCOVERED TO BE OUT OF TOLERANCE

"On 8/31/99 at 1200 hrs, the Plant Shift Superintendent was notified that a previously discovered X-705 Microfiltration System (MFS) pH probe out of tolerance condition likely existed during a time period when the MFS was in operation. The out of tolerance condition was in a non-conservative direction and previously discovered during a routine weekly surveillance on 8/27/99. An evaluation to determine the condition existed while the MFS was in operation was initiated at that time. Engineering suspected that the probe calibration may have been affected when the probes were exposed to a high pH solution on 8/23/99. Subsequent discussion with the probe manufacturer confirmed that a high pH solution could affect probe calibration. As a result, it was concluded that the out of tolerance condition likely existed from approximately 8/23/99 to 8/27/99.

"The out of tolerance condition affected 2 of the 3 pH probes (2 out of 3 logic required to activate the safety system). The as found data for the 2 probes indicated they would actuate at 6.73 pH and 6.65 pH, which is below the 7 pH required setpoint. A review of the MFS operational history indicated that the MFS pH was maintained above a 7 pH during the time the probes are suspected to have been out of tolerance."

The NRC resident inspector has been informed of this notification.

*** RETRACTION AT 1145 EDT ON 9/10/99 FROM SPAETH TO POERTNER ***

Based on completion of Engineering Evaluation EVAL-PS-1999-0523, the plant has determined that the pH probes were out of tolerance in a conservative direction and therefore would have actuated earlier than required.

The NRC resident inspector has been notified.

Notified R3DO (Phillips), and NMSS (Piccone).