Event Notification Report for June 13, 2002

STATE LICENSEE REPORTED THAT THREE OF TEN I-125 SEEDS WERE LOST IN THE SEWER DRAIN

At 2:30pm on June 13, 2002 the radiation safety officer (RSO) for City of Hope National Medical Center reported that during the course of an iodine-125 prostate permanent implant procedure, three of the ten seeds were lost down the autoclave sink located in the operating room.

The initial report from the preliminary investigation was that the operating room technician wanted to wash off the three seeds prior to autoclaving them. They were not going to be used in the procedure. During this process they ended up being washed down the drain of the autoclave sink. Although this occurred at approximately 5:00pm on June 12, 2002, the RSO was not notified until approximately noon on June 13, 2002. They requested the RSO investigate the reason(s) for the delay in reporting the incident. The activity of the iodine -125 seeds was 0.344 mCi each (for a total of 1.032 mCi) at 5:00pm on June 12, 2002. At noon on June 13, 2002 the activity was 0.340 mCi (for a total of 1.02 mCi).

On June 14, 2002 a request was made to remove the sink trap and piping in an effort to locate the seeds. At approximately 10:00am it was reported that the seeds were not located, even with the use of a NaI probe and visual examination. This information was forwarded to ICE Supervisor for reporting to the NRC.

Investigation # 061402

24 HOUR REPORT ON LICENSE CONDITION 2F

" At 1130 hours on 6/13/02 it was discovered that the Safety Relief Valve (SRV) Position Indication Channel for one of the SRVs controlled from the Remote Shutdown Panel was inoperable. The inoperability was due to both alarm card inhibit switches for associated acoustic monitoring channel being found to be in the inhibit position. These switches are normally in the "alarm" position. With the switches in the "inhibit" position the SRV position indication from a high vibration condition would not provide an open position indication for the SRV in the Control Room or at the Remote Shutdown Panel. Immediate Action was to return the switches to the alarm position and all other SRV acoustic monitoring switches were verified to be in the correct "alarm" position.

"Technical Specification LCO 3.3.3.2 requires that the Remote Shutdown System Functions shall be OPERABLE. With this channel inoperable, Required Actions require restoration to OPERABLE status within 30 days OR placing the Unit in Mode 3 within the following 12 hours. Since the potential exists that this condition has existed in excess of the 30-day requirement this event may be considered a Condition Prohibited by Technical Specifications.

"This report is being made in accordance with Section 2F of Operating License NPF-69 for Nine-Mile Point Unit 2. Section 2F requires that the initial notification of a violation of any requirement contained in Section 2C to the Operating License (License Conditions) be reported to the NRC Operations Center via the Emergency Notification System within 24 hours with written follow-up with 30 days. License Condition 2C requires that Nine Mile Point Nuclear Station, LLC shall operate the facility in accordance with the Technical Specifications."

The NRC Resident Inspector has been notified.

****Retraction on 07/08/02 at 1634 ET by Mr. Cigler taken by MacKinnon ****


"A subsequent investigation concluded that there is no firm evidence that the switches were in the wrong position in excess of 30 days. Based on the guidance of NUREG 1022, Rev 2, section 3.2.2, the previous report made is being retracted." R1DO (Brian McDermott)

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

OFFSITE NOTIFICATION MADE TO LOCAL FIRE DEPARTMENT FOR ASSISTANCE


A fire in the owner controlled area 1/2 mile outside the protected area occurred at their training facility and a call for offsite assistance was made. The fire turned out to be a lot of black smoke coming from a burned out fan motor in the training facilities ventilation system. Everything was under control within a half hour and the licensee logged out of their procedures at 1237.

The NRC Resident Inspector was notified along with state and local agencies. A press release may be made.

LOSS OF EMERGENCY NOTIFICATION NETWORK (ENN) TO STATES OF ALABAMA AND GEORGIA

"The ENN (Emergency Communications Equipment) [was] declared inoperable at 1230 central on 13 June 2002 due to [the] inability to communicate with the states of Alabama and Georgia. Action has been initiated to correct [the] problem. All other communication equipment is available including the designated backup capability provided by the Southern Link Radio System."

The licensee will inform the states of Alabama and Georgia and the NRC Resident Inspector.


* * * UPDATE ON 6/13/2002 @ 1723 BY HOBSON TO GOULD * * *

At 1414 CDT they restored capability to contact one state agency in both Alabama and Georgia.

The NRC Resident Inspector will be informed

LICENSEE NOTED THAT A 4160 VOLT BUS MAY NOT HAVE BEEN ADEQUATELY PROTECTED FROM A POTENTIAL MODERATE ENERGY SPRAY INTERACTION

During a plant walk down as a corrective action for a previous issue, it was noted that 4160 volt vital bus 2ETA may not have been adequately protected from a potential moderate energy spray interaction. It was noted that a section of fire protection system piping was identified as a potential source for moderate energy spray onto 2ETA. Engineering performed a review of both the spray distances assumed in the moderate energy spray criteria and the requirement to postulate moderate energy cracks in piping at every weld location. The fire protection system in question is low pressure, low temperature. This review concluded that a moderate energy pipe rupture (crack) in the fire protection system piping could lead to a loss of the vital 4160 volt bus 2ETA. A concurrent single failure of the opposite train vital 4160 volt bus (2ETB) could prevent the fulfillment of safety function of systems or structures. UFSAR section 3.6 describes the requirements for protection against dynamic effects associated with the postulated rupture of piping. Specifically the general design requirements for postulated piping breaks other than reactor coolant system requires that the design be of a nature that to mitigate the consequences of the break so that the reactor can be shutdown safely and eventually maintained in a cold shutdown condition. Maintenance has placed a spray deflector on the affected area of piping to preclude postulated spray interaction with 2ETA. Engineering has reviewed the other safety related 4160 volt bus on Unit 2 and both safety related 4160 volt buses on Unit 1 and determined that they do not have any spray interaction issues. The root cause of this issue is still under investigation.


The NRC Resident Inspector, States and local agencies will be notified.