Event Notification Report for February 15, 2002

MEDICAL MISADMINISTRATION DUE TO AN EQUIPMENT MALFUNCTION

A BetaCath Systems device containing strontium-90 produced by Novoste was being used to treat a patient. On sending the active sources to the target area, a fluid leak occurred which slowed the movement of the seeds into the target vessel/position (Left Anterior Descending Artery). Not able to see the active seeds on the fluoroscopy monitors, a decision to have the active seeds returned to the holding device was made. A total time of 17 seconds elapsed from the time of delivery until the active seeds were returned to the holding device.

On close inspection of the treatment catheter/device, one of the sealing O-rings was found to be ruptured. This was the ultimate cause of the fluid leak and consequently the slow movement of the active seeds to the target position.

With a dose rate of 0.095 Gy/s at 2 mm, the artery wall along the approximately 1 m track over which the source traveled out and back for its 17 sec would be calculated as:

Speed equals 2 * (100 cm)/17 s = 11.8 cm/s

Time wall was exposed to the 4 cm source = 4 cm / 11.8 cm/s = 0.34 s, but this time is doubled since it is exposed coming and going, to 0.68 s.

Dose to the wall = 0.68 s * 0.095 Gy/s = 0.0646 Gy = 6.5 rads.

The normal dose to the wall (assuming an 8 s round trip) would be 3.0 rads.

A new catheter was tested with the non-active device and the treatment was continued. The treatment was timed, checked for the return of the active sources and surveyed the patient/room post treatment. No problems were encountered with the new treatment catheter.

* * * UPDATE 1745EST ON 2/19/02 FROM ABDUL BEN-ZIKRI TO S. SANDIN VIA E-MAIL * * *

The following is a portion of an e-mail received at hoo1@nrc.gov:

"I am retracting my event report (Event # 38708). I took a conservative action and reported this event based on preliminary written information.

"Our Hospital staff followed all standard operating & emergency procedures, and retracted the source when they realized that they did not arrive to the area of clinical interest as indicated in the report below. Based on the investigation analysis, we conclude that there was no misadministration to report."

Notified R3DO(Jorgensen) and NMSS(Brach).
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DISCOVERY OF A NON-CONSERVATIVE LO-LO LEVEL TRIP SETPOINT DUE TO A DIFFERENTIAL PRESSURE PHENOMENA THAT CAUSES STEAM GENERATOR NARROW RANGE LEVEL CHANNELS TO READ HIGHER THAN ACTUAL WATER LEVEL AT HIGH STEAM FLOWS

"Based on the review of [Operating Experience (OE)] 13294 from Diablo Canyon regarding unexpected response of Steam Generator [(SG)] Narrow Range level trip not responding as expected, an assessment was performed of the narrow range (NR) Steam Generator level channels at Salem 1 and 2. This assessment determined that the current 9% lo-lo level trip setpoint did not account for the uncertainties associated with the differential pressure (dP) created by the steam flow past the mid-deck plate in the moisture separator section of the steam generator. This dP phenomena will cause the SG NR level channels to read higher than actual water level at high steam flows. Thus the lo-lo level trip setpoint is non-conservative."

"In the unlikely event of a Loss of Main Feedwater to the Station Auxiliaries, or a Main Feedwater Rupture, the potential exists that a required reactor trip on lo-lo steam generator level may be delayed or may not be received at all. In this scenario, other trip functions such as overtemperature delta-T would be expected to actuate in response to the initiating event. However, these would arrive in a different sequence, and the net effect on the UFSAR Chapter 15 accident analysis results is unknown. Thus, a condition exists in that a safety function could have been prevented."

The licensee stated that operators were in the process of decreasing power on Unit 1 to below 38% based on engineering information. The licensee plans to maintain Unit 2 operations at 78% power.

The licensee plans to notify the NRC resident inspector and the Lower Alloways Creek Township.

(Refer to event #38697 for a similar issue reported by Diablo Canyon.)

OFFSITE NOTIFICATION REGARDING A SCHEDULED UNIT SHUTDOWN FOR A PLANNED REFUELING OUTAGE

The licensee notified the State Department of Environmental Protection and local county that the unit is in the process of reducing power to enter a planned refueling outage. The licensee also notified the NRC resident inspector.

SAFETY EQUIPMENT FAILURE - PROCESS GAS LEAK DETECTION FAILURE

"At 2200 CST, on 02-15-02 the Plant Shift Superintendent (PSS) was notified of a failure of the Process Gas Leak Detector (PGLD) system in the C-333 building. During above atmospheric operation a PGLD alarm was received in the Area Control Room [ACR] on C-333 Unit 4 Cell 4. An operator responded to the local cell panel to investigate according to the alarm response procedure. Upon arriving at the cell panel the operator discovered that the Ready light was not Illuminated on the PGLD panel. At this time the operator attempted to test fire the PGLD system, however the system would not respond. The Front Line Mgr. and the PSS were immediately notified of the system failure. At this time, required TSR 2.4.4.1 LCO continuous smoke watches were put in place in the affected areas until repair of the system was completed. Following replacement of the power supply by Instrument Maintenance and testing by Operations, ten Unit 4 Cell 4 PGLD system was declared operable by the PSS at 2340 CST. At this time the TSR required smoke watches were discontinued.

"The PGLD system is designed to detect the leakage of process gas from the process system and is required to be operable while operating in Cascade Mode 2 (Above Atmospheric Pressure). Due to the failure of this TSR required system; the PSS has determined that this is reportable as a 24 hour Event Report.

"The NRC Resident inspector has been notified of this event."

* * * RETRACTED AT 0346 EST ON 02/22/02 BY ERIC WALKER TO FANGIE JONES * * *

"This event has been retracted. Even though the power loss causes the system to be incapable of annunciating additional alarms from this system in the ACR, the same is true when a PGLD head actuates in response to smoke. The system Is designed to alert operators of a release or loss of system power. Operator response and the initiation of a smoke watch provide the safety function after the initial alarm is annunciated. The NRC resident inspector has been notified of this update."

The R3DO (Bruce Jorgensen) and NMSS EO (E. William Brach) have been notified.

* * * UPDATED AT 1750 EST ON 3/4/02 BY TOM WHITE TO FANGIE JONES * * *

"Following discussions with NRC Region III and the PGDP NRC Senior Resident Inspector. USEC has determined that a rescission of the retraction made on 2/21/02 will be necessary in response to NRC concerns related to this matter. Therefore, USEC hereby rescinds the subject retraction and will be submitting the written report required by 10CFR76.120(d)(2). The NRC Senior Resident Inspector has been notified of the rescission."

Notified the R3DO (John Madera) and NMSS EO (C. W. Reamer).

MEDICAL MISADMINISTRATION

The West Valley Medical Center reported that during the preparation for a patient's lung scan, 5 millicuries of technetium-99 MAA was inadvertently injected into an artery instead of a vain. The patient and physician were notified and no adverse affects occurred. The lung scan was performed the same day following a second injection of technetium into the vain.

This was discovered during their Radiation Safety Committee meeting.

DISCRETIONARY DECLARATION OF UNUSUAL EVENT DUE TO "INCREASED PLANT AWARENESS"

During a dewatering evolution of the Spent Resin Storage Tank, some spent resin entered the tank vent header. This caused an elevated reading of 263 mrem on a single area radiation monitor (RM-081). The licensee declared an Unusual Event in accordance with EAL 11.4, "Increased Plant Awareness." Additional personnel are being called in to the site to assist in devising a plan to flush the resin from the affected piping. The licensee estimates that it will take two to three hours to complete this evolution. The NRC resident inspector and state and local government agencies have been informed of this event by the licensee.

* * * UPDATE 1045 2/15/02 FROM LUIKENS TAKEN BY STRANSKY * * *

The licensee has terminated the UE as of 0945 CST. The licensee has developed a plan to flush the resin from the inappropriate areas and will be commencing the activity shortly. The affected areas have been properly surveyed and posted. The NRC resident inspector has been informed of this update. Notified R4DO (Smith), NRR (Koshy), FEMA (Zapata).