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Event Notification Report for May 12, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/11/2004 - 05/12/2004

** EVENT NUMBERS **


40596 40732 40741

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40596
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVE DEES
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/17/2004
Notification Time: 21:25 [ET]
Event Date: 03/17/2004
Event Time: 14:57 [CST]
Last Update Date: 05/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEFFERY CLARK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

SWITCHGEAR ROOMS FLOODING ANALYSIS CONCERNS

"At 1457 on 3-17-2004, Wolf Creek Generating Station Fire Protection Engineering submitted information to the Control Room that there was a flooding analysis concern in the Engineered Safety Features Switchgear (NB) Rooms regarding the 2 inch fire protection header that is located in the rooms. The capability of the floor drain system in the room is indeterminate in regards to draining all the water that could be expected to accumulate in the rooms if the fire main were to rupture during a seismic event.

"Compensatory actions have been put in place in the form of additional fire suppression equipment and administrative isolation of the fire protection header that is located in the NB switchgear rooms. Investigation continues into the assumptions used in the flooding and seismic analysis. The Senior Resident Inspector has been notified. "


* * * RETRACTION ON 05/11/04 AT 1555 EDT FROM C. SIBLEY TO A. COSTA * * *

"On March 17, 2004, at 2125 EST, Wolf Creek Nuclear Operating Corporation (WCNOC) made an event notification regarding a flooding analysis concern related to a 2 1/2 Inch fire protection header located in the Engineered Safety Features Switchgear (NB) Rooms (EN40596). This notification identified that the analysis with regards to draining all the water from the room in the event that the fire protection header pipe were to rupture during a seismic event was indeterminate.

"Subsequent evaluation has determined that the fire protection header piping located in the subject NB switchgear rooms is built to seismic Il/I requirements, and is therefore not subject to a pipe rupture in the event of a seismic event. Therefore, WCNOC is retracting the March 17, 2004 event notification.

"The NRC Senior Resident Inspector has been notified."

Notified R4DO (L. Smith).

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General Information or Other Event Number: 40732
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NEW ORLEANS CANCER INSTITUTE MEMORIAL MEDICAL CENTER
Region: 4
City: New Orleans State: LA
County:
License #: LA-10853-LO1
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/07/2004
Notification Time: 15:21 [ET]
Event Date: 05/07/2004
Event Time: [CDT]
Last Update Date: 05/07/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM FARNHOLTZ (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the Louisiana Department of Environmental Quality via facsimile:

"There was a Medical Event reported on April 7, 2004 concerning an incident that occurred on March 31-April 1, 2004. In the process of constructing a computer generated treatment plan for prostate Brachytherapy, a default switch that changes the source position calculation orientation from 'Connector End' to 'Catheter tip' was not adjusted to the correct orientation (Catheter/Needle tip). This led to the sources stopping short of the target and the total prescribed dose was not delivered. The facility was using a Nucletron Micro Selectron with a 7.315 [Curie] source of Ir-192. There was a total of three fractions for the treatment. One on March 31, 2004 and two on April 1, 2004. The total dose that was delivered was 1800 cGy to the wrong location. The misadministration is being compensated by external beam therapy. [There] are two causes for this event. The design of the default switch automatically selects an orientation that is not used at this facility and cannot be adjusted to default to the correct position. The other cause is operator error in not assuring that the orientation had been changed to read correctly. The patient is self-[referred] from Guatemala. The patient was informed immediately of the misadministration and received further external beam treatment. According to the Radiation Oncologist, no detrimental effects are expected. Actions taken to prevent further recurrence will be the addition of a visible check and documentation that the treatment plan was done with the source positions calculated from the tip end of the catheter or needle. This will be added to the pretreatment checklist which is performed and signed by the Radiation Oncologist, the Physicist, and the Dosimetrist. This checklist will be performed prior to initial treatment and at plan changes and is part of the patient's permanent record. There will also be a written notification to Nucletron regarding the potential danger of misadministration due to inability to change the default on the orientation 'switch'. The design should be that if the connector end is selected, the [planner] should be warned that this will change the source placement."

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Power Reactor Event Number: 40741
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVEN JOBE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/11/2004
Notification Time: 18:07 [ET]
Event Date: 05/11/2004
Event Time: 10:55 [CDT]
Last Update Date: 05/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA SMITH (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO LOSS OF NORMAL POWER TO TSC

The following information was obtained from the licensee via facsimile:

"A loss of emergency assessment capability occurred due to a loss of normal power to the Cooper Nuclear Station Technical Support Center [TSC]. At 1055 [CDT], power loss occurred due to a ground fault on the feeder to the motor control center [supplying] power to the TSC. Power was transferred to the alternate feeder for the TSC at 1214 [hrs]. Alternate power was available during the entire time, however due to the nature of the ground fault, transfer was not performed until source of ground was known: (during 'bump' checking of a chiller compressor, the compressor internally shorted causing the ground fault protection circuitry to activate for the feeder breaker [Electrical Panel designated OBFP].) The source of fault has been identified and has been isolated.

"Normal power was restored to the TSC at 1443.

"The emergency offsite facility and the main control room were unaffected by the ground fault.

"The NRC Senior Resident Inspector has been notified of this event."

No other safety systems were affected by the loss of the feeder circuit. Prior to finding the fault, the system was undergoing maintenance. The 'bump' check involves momentarily powering the chiller compressor to verify proper and free rotation.

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