Event Notification Report for October 27, 1999

Safety System Actuation

At 1705 CDT on 10/27/99, the Plant Shift Superintendent's (PSS) office was notified that a primary condensate alarm was received on the C-360 position 2 autoclave Water Inventory Control (WIC) System. The WIC system is required to be operable while heating in mode 5 according to TSR 2.1.4.3. The autoclave was checked according to the alarm response procedure, removed from service and declared inoperable by the PSS. Troubleshooting was initiated and is continuing in order to determine the reason for the alarm.

The safety system actuation is reportable to the NRC as required by Safety Analysis Report, section 6.9, table 1 criteria J.2, Safety System actuation due to a valid signal as a 24-hour event notification.

The NRC resident inspector has been notified.

* * * UPDATE 2220EST ON 11/5/99 FROM E.G. WALKER TO S. SANDIN * * *

"On 11/2/99, the same type of actuation occurred on the C-360 autoclave No. 1 while out of service and open. While investigating this invalid actuation, it was discovered that the gain adjustment on one of the WICS channels had drifted out of tolerance. Discussions with the component manufacturer concluded that the WICS alarm cards are susceptible to drift due to age and fluctuations in temperature. These cards are exposed to ambient temperatures, but the cards are rated for the range of temperatures at the autoclaves. Given this and other indications that the WICS actuation signals were invalid, i.e., not the result of water backing up in the drain, it has been concluded that the subject actuation on 10/27/99 was caused by [an] invalid signal (instrument drift) and thus does not meet the criteria for reporting and should be retracted."

The NRC resident inspector has been notified of this retraction. Notified R3DO(Creed).

- PLANT FIRE PROTECTION PROGRAM PROCEDURES DID NOT INCLUDE CERTAIN FIRE ZONES -

During the performance of a licensee Fire Protection Audit, it was discovered that an error existed in plant procedures designed to shut the plant down in the event of a fire in plant areas where hot shorts could challenge safe plant operation. In 1994, a new style air-operated HPCI/RCIC test return valve was installed in the plant. At the time, it was recognized that due to cable run locations, hot shorts could be created in the event of a fire in certain areas that would cause the valve to open inadvertently. This would cause bypass of standby feedwater flow to the condensate storage tank instead of the reactor pressure vessel (RPV) and challenge the ability to maintain RPV level. Plant procedures for dedicated shutdown were revised to isolate air to that valve to prevent this response for fires in specified zones. However, during a recent licensee audit, it was discovered that hot shorts for the test valve could exist for fires in some plant zones not previously identified. This was discovered at 1700 on 10/27/99. The procedure has since been corrected to add these zones.

This event constitutes a non-compliance with the approved Fire Protection Program which could have adversely affected the plant's ability to achieve and maintain safe shutdown in the event of a fire. This is reportable as a condition not in compliance with Fermi 2 Operating License NPF-43, License Condition 2.C.9. This notification is required to be submitted within 24 hours in accordance with NRC License NPF-43, Section 2.F.

The licensee plans to notify the NRC Resident Inspector.

UNEXPECTED EXPOSURE

AT 1300 ON 10/27/99, A PATIENT RAISED HER BED IN ORDER TO HAVE LUNCH. WHEN THE PATIENT RAISED THE BED, THE BRACHYTHERAPY APPLICATOR CAME OUT OF ITS POSITION AND ENDED UP BETWEEN THE LEGS OF THE PATIENT. AT 1315, THE PATIENT'S RADIATION ONCOLOGIST PHYSICIAN CAME TO REMOVE THE BRACHYTHERAPY APPLICATOR AND DISCOVERED IT LAYING BETWEEN THE LEGS OF THE PATIENT. THE BRACHYTHERAPY APPLICATOR WAS REMOVED BY THE PHYSICIAN. THE LOCAL AREA SKIN DOSE TO THE PATIENT LEG WAS CALCULATED TO BE 22 RAD. THE PATIENT WAS TO HAVE RECEIVED 2000 RAD, BUT INSTEAD RECEIVED 1978 RAD. THE PATIENT'S PRIVATE PHYSICIAN WILL BE NOTIFIED. THE PATIENT DID NOT RECEIVE ANY ADVERSE HEALTH AFFECTS FROM THIS INCIDENT.

AC FUSES USED IN DC SYSTEMS

A concern was raised during the Expanded System Readiness Reviews conducted earlier this year at Cook regarding the use of AC fuses in DC systems. Protection in the Cook 250 VDC system is through the use of Gould Type RF and Bussman Type FRN fuses. These fuses are not rated for use at the voltage levels that may be encountered in the Cook DC system.

Testing of the Gould fuses was recently completed and that showed that the fuses in the 0 to 60 amp range can fail in such a manner that adjacent components, equipment or personnel could be subjected to adverse conditions. Although they were not tested, Bussman has stated that their fuses will not operate safely at DC voltages over 125 VDC.

Although not evaluated in detail, Electrical Design Engineering has concluded that postulated failure of a fuse to safely clear a fault or overload in a safety related or non-safety related circuit could result in damage to adjacent safety related circuits. In addition, fuses are used as isolation points between non-safety related components and the safety related DC power supply system. A concern exists that an initiating event - HELB, seismic, LOCA - could simultaneously impact multiple non-safety related components. Consequently, if the isolation fuse fails to clear due to the voltage rating concern, or the slow response causes a coordination concern, the loss of multiple DC system panels or of the entire train(s) of the safety related DC system could be the result.

Electrical Design Engineering is evaluating replacement of the fuses.

Both units are currently shutdown and defueled. This issue will be resolved prior to startup.

The NRC Resident Inspector was notified of this event by the licensee.

MEDICAL MISADMINISTRATION

A patient received a fractional dose to the wrong area because of problems with the measuring device used to locate the dose. The reference point used was 950 mm, but it should have been 995 mm. The error resulted from the measuring device "snagging" on a kink in the cable, thus preventing complete insertion. The net result was an error of approximately 4.5 cm. The 380 cGy fraction was delivered to the end of the nose vice further in as prescribed. The fraction was one of four planned with a total intended dose of 1520 cGy. The source involved was 6.8 Ci of Ir-192.

The patient and doctor have been informed of the error. No adverse consequences are expected for the patient.

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DECLARED INOPERABLE

At 1750 EDT on 10/27/99, the HPCI System was declared inoperable and a 7 day limiting condition of operation was entered in accordance with Technical Specification 3.5.c. HPCI System surveillance testing conducted at 0130 EDT met applicable surveillance test acceptance criteria. A more detailed review of HPCI System startup transient data obtained during this testing identified potential problems with HPCI Turbine Speed Control. Evaluation of this transient data established a reasonable doubt concerning HPCI System operability under all design conditions. All other Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable. Reactor Core Isolation Cooling System is fully operable and the electrical grid is stable. The "B" Reactor Feedwater Pump is out of service for a turning gear problem.

The NRC Resident Inspector was notified of this event by the licensee.

MEDICAL MISADMINISTRATION

On 10/27/1999, a patient was to receive a dose of 120 Gy (12,000 rad) by way of implanted palladium seeds. The seeds that were ordered and delivered to the hospital had an activity of 1.05 millicuries each, instead of 1.4 millicuries, which would have been needed to obtain the prescribed dose. The physicians treating the patient made a decision to implant the seeds anyway, resulting in a dose of 90 Gy, and to supplement the dose by external beam. However, the written prescription kept in the hot lab was not annotated to include this change in treatment.

Therefore, this condition is being reported as a medical misadministration, in that the actual dose was 25% less than that prescribed. The licensee will contact the NRC Region III office regarding this issue.

* * * UPDATE AT 1601 ON 11/01/99 BY TOM BROWN TO JOLLIFFE * * *

The licensee desires to retract this event since palladium is regulated by the state of Missouri and not the NRC.

The NRC Operations Officer notified the R3DO Jim Creed and NMSS EO John Hickey.