Event Notification Report for August 28, 2000

STOLEN MOISTURE/DENSITY GAUGE

A CPM brand moisture/density gauge, model MC1DR, serial #MD9119207, was stolen from the back of a pickup truck in Columbus, Ohio. The gauge contains one 10 mCi Cs-137 source and one 50 mCi Am-241/Be source. The gauge and overpack were chained to the bed of the truck, but the chain was cut. The licensee has filed a report with the Columbus Police Department.

MEDICAL MISADMINISTRATION INVOLVING AN INITIAL UNDERDOSE OF IODINE-131 BECAUSE ONE OF TWO CAPSULES GOT STUCK IN A VIAL AT VA MEDICAL CENTER IN ALBANY, NEW YORK

On 08/09/00, a patient was scheduled to receive a prescribed iodine-131 dose of 5 mCi in order to facilitate a whole body scan. A nuclear medical technologist measured the applicable vial at 5 mCi and emptied the contents of the vial for administration to the patient. Apparently, only one of two capsules came out of the vial, and the patient was given only one capsule which represented 1.1 mCi of the prescribed 5-mCi dose. The nuclear medical technologist identified the error approximately 1 hour after the initial administration. The patient was immediately contacted but was unable to return to the Medical Center that day. The patient received the second capsule (3.68 mCi) on the following morning (08/10/00) approximately 21 hours after administration of the first capsule. It was reported that there were no negative impacts on the outcome of the scan, no adverse health affects to the patient, and no health and safety concerns.

The licensee did not believe that this event represented a medical misadministration but discussed the event with the NRC Region 1 office (Jim Dwyer). At approximately 1100 on 08/28/00, the NRC Region 1 office notified the licensee that this issue was considered to be a medical misadministration. Therefore, at 1316 on 08/28/00, the VA's National Health Physics Program reported this event to the NRC Operations Center for the VA Medical Center in Albany, New York.

(Call the NRC operations officer for the VA's National Health Physics Program contact telephone number.)

UNEXPECTED CLOSURE OF A RESIDUAL HEAT REMOVAL SYSTEM OUTBOARD SUCTION ISOLATION VALVE

The following text is a portion of a facsimile received from the licensee:

"During preparation to place the 'A' side residual heat removal system (RHR) into the shutdown cooling mode, it was discovered that the outboard suction isolation valve (10MOV-17) had gone closed. Previous to this evolution, both the 'A' [and] 'B' recirculation pumps were shut down. It is suspected that securing the [recirculation] pumps causes a pressure surge in the suction piping to the RHR system which causes a pressure switch to actuate. This pressure switch causes [valve] 10MOV-17 to go closed. No reactor pressure instruments indicated a pressure surge. Initial assessment determined that this event was not reportable. Upon subsequent review, it was determined that a [4]-hour notification should have been made."

The licensee stated that no alarms were received. A panel operator noticed that the valve had gone closed while verifying the system lineup before starting a pump. The 'A' side RHR system was subsequently placed in shutdown cooling, and everything operated properly.

It was also reported that the event occurred at 0851 on 08/28/00 and that the event was determined to be reportable at approximately 1630 on the same day. In addition, the licensee stated that similar events had previously occurred.

The licensee notified the NRC resident inspector.

(Refer to event #31648 dated 01/24/97, #25534 dated 05/19/93, #25231 dated 03/11/93, #25134 dated 02/25/93, #24447 dated 10/17/92, #18770 dated 06/26/90, #18330 dated 04/25/90, #18325 dated 04/24/90, #18183 dated 04/09/90, #18026 dated 03/20/90, and #17598 dated 01/20/90 for events involving closure of shutdown cooling suction/isolation valves for various [possibly similar] reasons.)

INOPERABILITY OF THE PASS AND BOTH DIVISION I/II H2O2 MONITORING SYSTEMS

The following text is a portion of a facsimile received from the licensee:

"On 8/28/2000, at 1630, [the Division] I and [II] Hydrogen/Oxygen (H2O2) Containment Monitoring Systems were declared inoperable. The Division I system was declared inoperable on 8/28/2000, at 0818, for planned maintenance. Subsequently, the Division II system was declared inoperable due to a failed channel check."

"In addition, the Post Accident Sampling System (PASS) was previously declared inoperable. With the PASS and both Division I/II H2O2 Monitoring Systems inoperable, this event is reportable in accordance with 10 CFR 50.72(b)(2)(iii)(D)."

"Also, on 8/28/2000, at 1905, the Division I H2O2 Monitor was restored to operable [status] following completion of planned maintenance."

The licensee stated that the unit remained in a 30-day limiting condition for operation (LCO) and that a 7-day shutdown LCO was exited when the Division I H2O2 Monitor was restored to operable status.

The licensee notified the NRC resident inspector.

***** UPDATE/RETRACTION AT 0024 ON 09/08/00 FROM ANTHONY PETRELLI TO LEIGH TROCINE *****

The licensee is retracting this event notification. The following text is a portion of a facsimile received from the licensee:

"On 08/28/00, 1630 EDT, Nine Mile Point Unit 2 reported that Divisions 1 and 2 of the Hydrogen/Oxygen (H2/02) Containment Monitoring Systems were declared inoperable under Event Number 37266."

"[The licensee is] retracting that notification based on the fact that the Division 1 H2/O2 monitoring system was removed from service as part of planned maintenance in accordance with approved procedures and plant Technical [Specifications]. During planned maintenance, a discrepancy was found in the Division 1 H2/O2 system. Subsequent evaluation indicated that the condition discovered would not have prevented the system from performing its safety function if called upon. Therefore, this event is not reportable."

The licensee notified the NRC resident inspector. The NRC operations officer notified the R1DO (Dimitriadis).

NRC BULLETIN 91-01 RESPONSE (24-HOUR REPORT) - LOSS OF ONE CRITICALITY CONTROL

The following text is a portion of a facsimile received from Portsmouth personnel:

"At 1310 on 08/28/00, during a self assessment in the X-710 room 229, it was discovered that the U-235 mass log was not verified as required by NCSA 710-022. NCSA 710-022 control #4 states in part, 'A log entry shall consist of the measured U-235 mass values plus analytical uncertainty and shall be verified by a second knowledgeable person or supervisor.' This is [considered] a loss of one control."

"The PSS (Plant Shift Superintendent) directed the facility owner to enter an anomalous condition and directed NCS to oversee the recovery of the loss of one control."

"The log in question was verified as required by NCSA 710-022. Control [was] regained[,] and [the] anomalous condition [was] exited within 4 hours."

"[The] safety significance is low. The inventory log for the room showed 138 [grams] U-235. The allowable limit is 350 grams U-235."

"SAFETY SIGNIFICANCE OF EVENTS: The safety significance is low. The inventory log for the room showed 138 grams U-235 with an enrichment of <5% present in the room. The total allowable mass for the room is 350 grams U-235."

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR): If the U-235 for the room was at the maximum allowable value, there would need to be an additional 456 grams U-235 present [in] the room before the critical mass for full reflection, optimum moderation, and spherical geometry was exceeded. For this amount of U-235 to be present, multiple errors in the log book would need to occur."

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): The control parameter for this operation is mass. NCSA-0710-022 places two controls on this parameter. The combined mass of all fissile material is limited to 350 grams U-235. The [NCSA] requires [that] a log of U-235 mass inventory be maintained to demonstrate that the mass limit is not exceeded. Each log entry consists of the [mass] value plus analytical uncertainty. A log entry is made by the person responsible [for] the movement of U-235 into the room and is verified by a second knowledgeable person."

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE OF CRITICAL MASS): Approximately 138 grams [was] in the room [with] less than 5% U-235 solution."

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: One of the controls on the mass parameter was not performed. A second knowledgeable person did not perform the log verification as required by [the] NCSA. The safety significance of the event is low due to the small amount of U-235 involved."

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: "A second knowledgeable person verified the current mass log. A [second] person verified today's log to ensure administrative correctness."

Portsmouth personnel notified the NRC resident inspector and the Department of Energy site representative.

24-HOUR NRC BULLETIN 91-01 REPORT

"On 8/28/00 at 1529, during implementation of NCSA 0705_076 (Inadvertent Containers) a concern was raised about the maximum distance of spray from a leak from a pressurized pipe. Calculations were reevaluated and the corrected spray distance for the system in question resulted in a distance of 106 feet. This new distance for the system in question is greater than the original implementation distance of 15 feet, which the NCSA had previously predicted for the entire X-705. This is considered a loss of one control. The control considered lost is control #2 which states in part, 'When unattended all potential inadvertent containers shall be:
-modified to prevent unsafe accumulation
-covered to prevent the in-leakage of spilled materials
-oriented to prevent an unsafe accumulation

"The PSS(Plant Shift Superintendent) directed the facility custodian to enter an anomalous condition. The system in question was previously shut down prior to recalculation of the spray distance. The same equipment remains shutdown until compliance with NCSA 0705_076 can be determined.

"SAFETY SIGNIFICANCE OF EVENTS:

"Safety significance is low. The resulting situation is conservatively being identified as a violation of one control contained in NCSA 0705_076 which requires that all potential inadvertent containers utilized in the X-705 be modified, covered, or oriented to prevent an unsafe accumulation. However, since the system in question maintained its physical integrity and thus no uranium bearing material was involved the safety significance of this event is low.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR):

"If a sufficient amount of uranium bearing material had leaked, spilled, splashed from the micro filtration system and the resuming material accumulated on/in an inadvertent container, an unsafe geometry could have resulted. If the leaking solution had contained a sufficient amount of uranium, the resulting configuration could have been sufficient for a criticality to occur. it should be noted that the allowed safe geometry and volume limits established in NCSA 0705-076 are based on optimally moderated solution which contains uranium enriched to 100 wt% U235.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC):

"The parameter which was violated during this upset was maintaining geometry/volume controls regarding potential accumulation points available on/in nearby inadvertent containers.

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE OF CRITICAL MASS):

"No uranium-bearing material was actually involved in the upset.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:

"NCSA 0705_076 takes credit for the physical integrity of systems which contain uranium bearing materials. NCSA 0705_076 also takes Credit that unsafe volume/geometry containers are either modified, covered or oriented while in areas where uranium bearing material can leak, spill or spray to prevent an unsafe configuration from resulting in the event of a leak. The administrative control #2 was not being followed for the new area identified where uranium bearing materials can leak, spill or spray. The resulting situation is conservatively being identified as a violation of the administrative control in NCSA 0705_076.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:

"The PSS (Plant Shift Superintendent) directed the facility custodian to enter an anomalous condition. The system in question was previously shut down prior to recalculation of the spray distance. The same equipment will remain shutdown until NCS (Nuclear Criticality Safety) can assist in determination of operability of that system and compliance with NCSA 0705_076."

The NRC resident inspector has been informed of this event.

* * * UPDATE 1021EDT ON 9/9/00 FROM JEFF CASTLE TO S. SANDIN * * *

"9/9/00 - Update #1 - An engineering evaluation (EVAL-PS-2000-0415) of the system and pumps associated with implementation of NCSA_0705_076 identified that the spray distances used to originally determine the reportability of this event were excessive. The original distance (15 feet) used to implement this NCSA has since been identified to adequately bound the credible scenarios for solutions spraying from various systems in the X-705. This issue would not have been reportable based on the newly acquired information as a result of the recent technical review."

The NRC resident inspector and DOE site representative have been informed. Notified R3DO(Shear).