Event Notification Report for March 12, 2001

DEFECTIVE IODINE-125 SEEDS.

One hundred thirty-three (133) I-125 sources each with an activity of approximately 0.3 millicuries were received by the Saint Vincent Medical Center located in Bridgeport, CT. The I-125 seeds are used for prostate implants. Upon receiving the sources they were counted and the seeds' activity was checked. They were then placed in a sterilization tray which has 10 wells (the seeds were distributed among the 10 wells). The tray has a cover which allows for steam circulation. The same day or the following morning the trays were sent forth to be sterilized. After sterilization the seeds are taken out of the sterilizer and the sterilizer surveyed. Nothing detectable was noted. Later that day the seeds were removed from the wells and loaded into needles. At the conclusion of this process the licensee did a survey of the area. It was then when the licensee found a rather high level of radiation, not high enough to be a seed. After further investigation the licensee concluded that the sterilization tray was contaminated and highly contaminated in the area of at least 5 of the 10 wells. The licensee's assumption is that one or more the seeds opened up during sterilization. The seeds were fine prior to sterilization. Total estimated removable contamination found on the tray was 4 microcuries. A more through survey was performed on everything that had came in contact with the tray. It was found that the inner wrapping that goes around the tray before it is placed in the sterilizer was contaminated. Nothing else that had come in contact with the tray was found to be contaminated. Personnel do not seem to be contaminated. The two people who were involved in the loading process are scheduled to have thyroid uptake exams today. This incident was reported to the seed manufacturer, Best Industries, and the seeds will be shipped back to them.

OFFSITE NOTIFICATION DUE TO FUEL OIL SPILL

The licensee notified the Maine Department of Environmental Protection (DEP) about a fuel oil spill. The spill was from a fuel tank on a portable compressor, at about 1015 EST the fuel line broke dumping about 30 gallons on the ground. About 20 to 25 gallons went into the storm water system and ended up in the adjacent cove. The licensee is working on containing the spill on the water and has contained the balance of the spill on the ground. The licensee has also notified the State Nuclear Inspector, the National Response Center, and will notify NRC Region 1 Decommissioning Branch

A supervisor contractor was determined to be under the influence of alcohol during a for cause fitness for duty test. The individuals access to the protected area was terminated.

Call HOO for further details.

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

24-HOUR VIOLATION OF LICENSEE CONDITION DUE TO EXCEEDING THERMAL POWER LIMIT

"License restriction of 3445 MWth for the unit was exceeded. Highest reading N-16 power was 104.93%. Highest reading Nuclear Instrumentation Power was approximately 97%. This event was initiated by a failure of Main Turbine EHC fluid pressure switch, which closed [the] extraction steam valves to [the] feedwater heaters. Unit has been stabilized at 85% Reactor Power."

Control Room Operators received a feedwater heater high level alarm alerting them to the isolation of extraction steam to both the high and low pressure feedwater heaters on both feedwater trains. The isolation of extraction steam caused a decrease in feedwater temperature thus adding positive reactivity which increased reactor thermal power. Operators responded promptly by reducing turbine load. The licensee plans on replacing the failed pressure switch and resuming full power operations. The licensee informed the NRC resident inspector.

LOSS OF VARIOUS COMMUNICATIONS CAPABILITIES DUE TO SEVERE WEATHER

"Following a series of severe thunderstorms that passed through the Baton Rouge area during the night it was discovered and reported to the Main Control Room at 0831 that all offsite sirens, State and Local Hotlines, the ESP Computer Notification System and Emergency Preparedness Radio were not available. Commercial telephones and NRC ETS phone lines were available during this period and continue to be available. The Offsite sirens were transferred to the backup transmitter within 10 minutes of discovery and restored as of 0828. As of 1500 hours, all but 2 State and Local Hotlines were restored. Efforts to restore the remaining communications systems continue."

The licensee informed the NRC resident inspector.

UNANALYZED CONDITION DUE TO AN INADEQUATE HELB BARRIER DURING A POSTULATED FEEDWATER LINE BREAK

"An unanalyzed plant condition may exist regarding a HELB barrier within the turbine building. The HELB barrier in question separates two different trains of essential 480 volt motor control centers and may be inadequate if subjected."

An Extent of Condition investigation of High Energy Line Break (HELB) barriers determined that a barrier separating two adjacent areas (upper and lower) in the turbine building may not withstand a 0.6 psid due to a postulated heated feedwater line break. This could result in the loss of both trains of equipment controlled by 480 volt MCCs. The licensee will develop appropriate corrective action.

The licensee informed the NRC resident inspector.

NRC BULLETIN 91-01 - 24 HOUR REPORT

The following is taken from the faxed report:

ON 3/12/01 AT 1745 HOURS X-705 OPERATIONS PERSONNEL WERE CONDUCTING ROUTINE INSPECTIONS OF THE TUNNEL BASEMENT AREA WHEN THEY IDENTIFIED THAT THE SCAVENGER SYSTEM WOULD NOT OPERATE IN THE 'AUTOMATIC' OR THE 'MANUAL' MODE. NCSA-0705_035.A05 REQUIREMENT 5d STATES "THE SCAVENGER PUMP SWITCH VERIFIED NOT TO BE IN THE 'MANUAL' MODE WHILE UNATTENDED." THE STATUS OF THE SCAVENGER PUMP SWITCH WAS IN 'AUTOMATIC' MODE BUT IT WAS IDENTIFIED WHEN TESTED THAT THE PUMP WOULD NOT OPERATE IN THE 'AUTOMATIC' OR THE 'MANUAL' MODE BUT WOULD OPERATE IN THE 'MANUAL BY-PASS' MODE. THIS VIOLATES THE INTENT OF THE NCSA REQUIREMENT WHEREBY THE PUMP WOULD NOT START AUTOMATICALLY NOR WAS THE PUMP MANNED IN THE 'MANUAL' MODE. THE FACT THAT A TIME FRAME EXISTED WHEN THE PUMP WOULD NOT START IN THE 'AUTOMATIC' MODE AND DURING THIS SAME TIME FRAME THE PUMP WAS NOT MANNED IN THE 'MANUAL' MODE CONSTITUTES A LOSS OF ONE CONTROL WHICH IS RELIED ON TO MEET THE DOUBLE CONTINGENCY PRINCIPAL,

SAFETY SIGNIFICANCE OF EVENTS:

LOW = The failure of the Scavenger Pump to operate In the automatic mode represents the loss of one control (5d) relied upon for double contingency. The failure of the Scavenger Pump to operate in the automatic mode would allow the Scavenger System Storage Tank to overflow and solution to collect on the floor of the basement The size of the floor area and the remaining control on the amount of solution transferred make a criticality nearly non-credible.

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

Six of eight Fissile Solution Storage Banks fail in such a way that all of the Fissile Solution collects in the tunnel basement floor. This is sufficient Fissile Solution to exceed the safe depth of 1.5 inches for solutions containing greater than 100 wt.% U-235.

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

Volume Control was lost when the Scavenger Pump failed. Geometry Control was maintained throughout this event.

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

The Tunnel Storage System receives Fissile Solution for various operations in the X-705 Facility. The most likely form is UO2F2 in solution with a maximum enrichment of 100 wt.% U-235.

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

Automatic Mode of Scavenger Pump failed. Pump not manned in Manual Mode, 5d Control lost. Note: Pump would operate in the Manual By-Pass Mode but the pump was unmanned. Since no Fissile Solution leaked and allowed >1.5 inches of solution to collect on the floor the second control was maintained.

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

Entered Anomalous Condition. Assigned Operator to man the system until facility status was verified. Immediately verified no evolutions in progress that could challenge the Scavenger System. Tagged out the power supplies to all facility equipment that could challenge the Scavenger System. Emergent Work authorized by Plant Shift Superintendent for repairs to Scavenger System. Called in off-duty Nuclear Criticality Safety Staff to assess compliance, create Anomalous Condition Report and oversee the efforts to establish the lost control. Control established at 2038 hours by manning the pump controls.

The licensee notified the NRC Resident Inspector as well as the DOE representative.

* * * UPDATE 1808EST ON 3/14/01 FROM JOE HALCOMB TO S. SANDIN * * *

The following update was submitted to clarify the above report:

"03/14/01 - Update #1 - The Nuclear Criticality Safety (NCS) Group performed a follow up assessment of the above event. A revision to the NCS Anomalous Condition Report was issued and it determined that the malfunction of the scavenger system did not constitute a loss of an NCS control and that double contingency was maintained. The previous issue would not have been reported based on the revised NCS Anomalous Condition Report."

The licensee informed the NRC resident inspector and DOE site representative. Notified R3DO(Wright) and NMSS(Hickey).

ACTUATION OF DIVISION 1 BALANCE-OF-PLANT OUTBOARD ISOLATION VALVES - INVALID SYSTEM ACTUATION

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

"On March 12, 2001, at approximately 0030 hours, the Perry Nuclear Power Plant experienced an actuation of Division 1 Balance-of-Plant (BOP) outboard isolation valves. At the time of the event, the plant was in Mode 5 (Refueling), and had been subcritical for approximately 23 days. The reactor pressure vessel (RPV) head was removed and the refuel cavity and upper containment pools were flooded; no core alterations were in progress at the time. Shutdown cooling was being provided by the Fuel Pool Cooling and Clean-up system (FPCC), which was aligned to the upper containment pool. The isolation signal closed one or more valves in each of the following Division 1 subsystems: FPCC, Containment Drywell purge, Two-Bed Demineralized Water System, Fire Protection, Liquid Radwaste Sumps, Liquid Radwaste Disposal, Instrument Air, Containment Vessel Chilled Water, Condensate Transfer and Storage. In addition, the isolation signal caused a temporary interruption of shutdown cooling flow through the FPCC system, until it was re-established by on-shift Operations personnel."

"The event is considered an invalid system actuation, and is reportable under 10 CFR 50.73(a)(2)(iv)(A). The isolation was not initiated in response to actual plant conditions or parameters, and was not a manual initiation. It meets the criteria specified in 10 CFR 50.73(a)(2)(iv)(B)(2) as a general containment isolation signal affecting containment isolation valves in more than one system. Therefore, notification is being provided via 60-day optional phone call in accordance with 10 CFR 50.73(a)(1). All systems functioned as expected for a partial BOP (outboard) isolation."

"The interruption of shutdown cooling lasted for 111 minutes, from 0030 hours to 0221 hours on March 12, 2001. During this time, the reactor water temperature increased approximately 3 degrees, from 99 to 102 degrees. The estimated time to boil was conservatively calculated at 28 hours. The affected Fire Protection (drywell CO2) isolation valve was not required to be open, since the fire-protected equipment was secured during the refueling outage. Repositioning of the other valves did not present operational concerns; they were re-opened per restoration procedures. The cooling flow path was available immediately with manual operator action."

"The BOP isolation was attributed to scheduled maintenance activities being conducted in the Control Room. The replacement of a bayonet-socket-style relay caused two fuses to blow in the BOP manual initiation logic circuit. The apparent cause was an inadvertent ground from the seismic strap of the new relay during installation that resulted in the required logic for the isolation."

"This event was documented in the Corrective Action Program. Remedial actions include review of the event with instrumentation and control technicians, and evaluation of depowering valves which could interrupt shutdown cooling during maintenance activities."

The licensee notified the NRC resident inspector.