Event Notification Report for November 23, 2004

FAILURE OF UF6 RELEASE DETECTION SYSTEM DUE TO LOSS OF ELECTRICAL POWER

"At 1325 [CST] on 11-23-04, the Plant Shift Superintendent (PSS) was notified of a failure of the C-310 High Voltage UF6 Release Detection System. The High Voltage UF6 detection system was disabled due to loss of power. Power was lost when a circuit breaker was tripped to de-energize an auxiliary substation that faulted and caused a fire. This High Voltage UF6 Release System is designed to activate alarms to alert operators in the event of a UF6 release. The PSS declared the system inoperable and TSR LCO 2.3.4.4.A actions were implemented to post a continuous smoke watch in the affected area. The event is reportable as a 24 hour event, as required by 10 CFR 76.120(c)(2)(i); An event in which equipment is disabled or fails to function as designed when the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a preestablished safe condition after an accident. The equipment was required by TSR to be available and operable and no redundant equipment was available to perform the required safety function.

"In addition, the loss of power caused the Low Voltage UF6 Detection System to isolate the C-310 withdrawal positions as designed. The substation fault and subsequent fire did not result in a release of radioactive material.

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

LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO FAILURE OF SPDS

The Safety Parameter Display System (SPDS) is not transmitting data to the Technical Support Center. The cause of the failure is unknown at the present time. The Computer Support Group is attempting to restore transmission capability.

The licensee will inform the State of Arkansas as a courtesy and has informed the NRC Resident Inspector.

* * * RETRACTION FROM R. SCHELDE TO J. MACKINNON 1523 ET 12/21/04 * * *

"On 11/23/2004, at 1207 EST, Arkansas Nuclear One notified the NRC Operations Center that the Safety Parameter Display System (SPDS) was not transmitting data to the Technical Support Center (TSC) for a time period greater than 1 hour. Subsequent investigation determined that the SPDS was, in fact, operable during the time it was believed to be inoperable. Specifically, the Ramtek display was in service and updating normally during the time that SPDS was suspected to be inoperable. Although the SPDS consoles in the TSC were inoperable during this time, data was retrievable via the SPDS monitor touch screens."

The licensee notified the NRC Resident Inspector.

Notified R4 DO (B. Spitzberg)

AUTOMATIC REACTOR SCRAM DUE TO TURBINE TRIP

"At 1002 on 11/23/2004 with Unit 3 @ 100% power, a full reactor scram signal (RPS) was received due to a Turbine Trip. Unit 2 was also @ 100% power and was unaffected by the event. Reactor water level lowered to approximately -30 [inches] as expected and was recovered with normal feed water flow. All expected PCIS ISOLATIONS, Group 2 (RHR S/D Cooling), Group 3 (RWCU), Group 6 (Ventilation) & Group 8 (TIP) were received along with the auto start of CREVS and the three SBGT Trains. One PCIS Scram Discharge Volume Drain (85-37F) failed to close but the flowpath did isolate. The Unit remains Shutdown and an investigation is underway to determine the cause of the Turbine Trip and resulting Reactor Scram.

"This event is reportable as a 4-hour & 8-hour Non-Emergency Notification along with a 60 day written Report in accordance with 10CFR50.72(b)(2)(iv)(B), 10CFR50.72(b)(3)(iv)(A) & 10CFR50.73(a)(2)(iv)(A) as 'Any event or condition that results in valid actuation of RPS & PCIS . . . "

The licensee informed the NRC Resident Inspector.

REPORT OF THEFT OR LOSS OF LICENSED MATERIAL

The following information is excerpted from an email submitted by the licensee describing in detail the circumstances and conclusions concerning the missing rad material:
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II. DESCRIPTION OF LOSS OF LICENSED MATERIAL

Radioisotope: Phosphorous-32

Chemical Form: Deoxycytidine 5'-Triphosphate [alpha-32P]

Physical Form: Aqueous Solution

Amount: Xenogen appears to be missing material from 2 separate vials as outlined below:

1. 150 µCi (15 µl of material at 10 µCi/µl) from a vial sent from GE HealthCare (formerly Amersham Biosciences) to Xenogen Biosciences on November 4, 2004. This vial was received at Xenogen Biosciences on Friday, November 5, 2004. The supplier's catalog number for the material is AA0005-1 mCi and the lot number for the material received is AC0445. The quantity requested was 1000 µCi (37 MBq) under Purchase Order No. 36348. This vial was designated internally within Xenogen Biosciences as vial No. 491.

2. 100 µCi (10 µl of material at 10 µCi/µl) from a vial sent from GE HealthCare (formerly Amersham Biosciences) to Xenogen Biosciences on November 11, 2004. This vial was received at Xenogen Biosciences on Friday, November 12, 2004. The supplier's catalog number for the material is AA0005-1 mCi and the lot number for the material received is AC0446. The quantity requested was 1000 µCi (37 MBq) under Purchase Order No. 36348. This vial was designated internally within Xenogen Biosciences as vial No. 492.

Activity: 3000 Ci (111TBq)/mmole
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V. PROBABLE DISPOSITION OF THE LICENSED MATERIAL INVOLVED

As of November 23, 2004, our current hypothesis is that the volume discrepancies (loss) of material in vials 491 and 492 were due to two conditions. First, the material appears to be evaporating in the vials. Second, any evaporated moisture that condensed on the lid of the vial is not being concentrated through centrifugation prior to removal of material by research associates. Evidence that supports this conclusion is listed below:

1. We have found that when this material is separated into 5 µl aliquots, placed in screw cap tubes with o-rings, and stored at 4°C for several days, the liquid evaporates and a dried and visible red pellet forms (concentrated dye). In addition, the volume of the pellet appears to be less than 1 µl (visual inspection). However, when the tube is centrifuged after storage, the full volume reappears in the bottom of the tube and can be confirmed by using a pipetting device. The experiment mentioned above was performed using one vial of 1000 µCi of Redivue[TM] [alpha-32] deoxycytidine 5'-Triphosphate (dCTP) from GE Healthcare that was received at Xenogen Biosciences on Friday, November 19, 2004. This vial was designated internally as vial 493. Volume discrepancies were first noticed on Monday, November 22, 2004.

2. The occurrence of volume discrepancies in vial 491 and 492, along with a similar incident involving vial 486, which was reported to the U.S NRC on October 13, 2004, coincides with the recent switch (July 2004) by Xenogen from [alpha -32P] dCTP supplied by PE Life Sciences to material supplied by GE Healthcare. Unlike the material supplied by PE Life Sciences, the material from GE Healthcare is not kept frozen during transit and storage, but rather at 4 degrees Celsius. Hence, the material is subject to evaporation and condensation at the top of the vial.

3. Upon arrival, we have found that these vials need to be centrifuged in order to collect the material at the bottom of the vial. If the vials are not centrifuged, we are unable to verify that the volume sent is correct. Because it was determined that the volume of both vials was correct prior to any removal of material, we have eliminated the possibility that an incorrect volume was shipped to our facility by GE Healthcare.

4. During the November 18 meeting with the researchers, one employee notified [the RSO] with the EHS department, that he failed to make a log entry for which he removed 50 µCi from vial 492. Other than this particular instance, there is no further evidence that a research associate or scientist removed material from vial 491 and 492 and failed to record this removal in the Isotope Inventory Log. Importantly, this discrepancy has been accounted for in the total amount of material missing from vial 492 as detailed in this report.

5. There appears to be no evidence that the volume discrepancies are due to inaccurate pipetting devices. Last month, all three P-20 pipetman that are used by users to remove radioactive material from P-32 vials were checked for accuracy by [the RSO]. Importantly, this evidence does not rule out the possibility a user had the pipettor accidentally set to a higher volume prior to removal or that the user did not use the pipetting device correctly.

6. There is no evidence that an employee or visitor intentionally stole licensed material from vial 491 and 492. Because of the number of employees (approximately 65) at the facility, employees, in general, know one another and work in an environment where they are likely to observe any unusual behavior. In addition, there are relatively few visitors come to the facility. Furthermore, the refrigerator that is used to store the vials of P-32 material is locked with a combination lock. Only users of radioactive material have access to this combination. Moreover, the room (Radioisotope Laboratory) is locked by a punch combination lock. Only users of radioactive material have access to this combination. All employees, whether they are a user or nonuser of radioactive material, receive training that explicitly informs them that it is a crime to remove radioactive material from the facility.

7. There is no evidence that a research associate or scientist recorded an inaccurate amount of material withdrawn from vial 491 or 492 because all employees who used vial 491 and 492 verified, through interviews conducted by [the RSO], that the amount of material indicated on the Isotope Inventory Log is the amount that was intended to be used.

8. There is no evidence that the loss was due to spillage because:

a. There were no reports of a spillage by anyone who worked with the material;

b. The amount of material presumed missing would have easily been detected through our weekly monitoring program by swipe analysis using a Liquid Scintillation Counter. Furthermore, 100 µCi would have easily been detected from monitoring conducted with a GM survey meter by other employees who used the Radioisotope Laboratory over the time in question.

VI. EXPOSURE OF INDIVIDUALS TO RADIATION

Following an intensive survey of the laboratory area and other sections of the building, there is no indication of radiation exposure to individuals due to the unaccounted material.

VII. ACTIONS TAKEN TO RECOVER MATERIAL

At this time, our current hypothesis is that the volume discrepancies with vials 491 and 492 are due to two conditions: 1) evaporation of material within the vial and 2) lack of centrifugation of vials prior to removal of material. Hence, it is not anticipated that the material will be found. More importantly, if it is true that the lost volume was due to evaporation, then radioactivity may not be actually missing. Again, the Radiation Safety Officer does not believe that any employee, or non-employee, unlawfully removed licensed material from vial 491 and 492. . . . .

VIII. PROCEDURES OR MEASURES THAT WILL BE ADOPTED TO ENSURE AGAINST A RECURRENCE OF THE LOSS OR THEFT OF LICENSED MATERIAL.

The company has implemented the following Standard Operating Procedures immediately to insure that 1) the material is not being removed by a user without correct documentation; 2) the material is not being taken or removed for purposes other than those purposes outlined in Materials License 29-30350-01; and 3) the proper amount of material is being used in each experiment.

1. Every commercial vial of P-32 entering the facility and which will be used for DNA/RNA labeling experiments will be separated into 5 µl aliquots (or the volume typically used for one reaction) at the time the package is surveyed and its contents verified. The aliquots will be consecutively numbered for tracking purposes. Aliquots will be stored in Eppendorf tubes and these tubes will be stored in shielded centrifuge test tube racks. The rack will be made of acrylic and will be a solid-block design with drilled wells. One rack will hold aliquots from only one source vial (e.g. Shielded rack reads "vial no. 500" . Eppendorf tubes within read 1-20).

2. A user should use the lowest consecutive numbered aliquot when removing an aliquot from the rack for use.

3. [The RSO] (or his designee) will check daily the supply of P-32 aliquots and determine if there are any inconsistencies with the number of aliquots versus the number used by researchers based on the Isotope Inventory Log (or equivalent).

In addition, all pipetting devices used during the handling or dispensing of P-32 will be calibrated immediately by a commercial vendor, unless recently calibrated in the last 2 months. As mentioned earlier, [the RSO and another individual] met with all users of P-32 at the Cranbury Facility on November 18, 2004 to make them aware of the problem, to review pipetting techniques, and to train them on the new SOPs.

HOO Note: See similar Event Report #41126.