Event Notification Report for May 02, 2005

MEDICAL EVENT: BRACHYTHERAPY UNDER DOSE ADMINISTRATION

On May 2, 2005 to May 3, 2005 during a planned 1 day 5 hour 22 minute brachytherapy vaginal dose a calculated 27% under dose of 1825 cGy dose was administered in a 2.5 cm solid vaginal cylinder. Two 19.56 mg Ra equivalent Cs-137 sources were used. This event was discovered on May 4, 2005 at 10 am, during a summary review, when the licensee discovered that the wrong size applicator cylinder was used. A 1.93 cm cylinder was planned to have been used to apply a 2500 cGy total dose.

The licensee contacted the patient about the under dose and plans to administer the rest of the dose on May 5, 2005. The licensee is formulating a plan to administer additional training to the hospital staff to prevent future events of this type.

AGREEMENT STATE - PERSONNEL OVEREXPOSURE

"On 5/2/2005 at 4:00 p.m., Texas Department of State Health Services was notified by [the] Radiation Safety Officer [RSO] with Testmasters, Inc. in Houston. [The RSO] stated that he had just received the Occupational Radiation Exposure Report for Testmasters during the period of 3/20/05 through 4/19/05 with a monthly whole body exposure of 4.665 Rem to one of his radiographers. This puts the radiographer's annual exposure at 6.395 Rem. He stated that this radiographer works the night shift and usually works in the dark room where there is no source. There is however one portable gage that is used on night shift at Testmasters for radiography. It is an Amersham 660B with an Ir-192 source. The source activity is 140 Ci. The radiographer thinks he left his badge in his tool box which is located in the radiography bay area. Testmasters plans to make a badge storage area in the front office where all employees can keep their badges when not in use. An investigation will follow."

The employee's badge has been rescinded until this investigation is completed.

State report number: I-8228

* * * UPDATE FROM STATE (K. VERSER) TO P. SNYDER 1200 EDT 5/5/05 * * *

The State provided the following information via email:

The fourth sentence of the original text above should read as follows: "There is however one industrial radiography camera that is used on night shift at Testmasters for radiography."

Notified NMSS (Hickey) and R4DO (Pruett).

* * * UPDATE FROM STATE (K. VERSER) TO HUFFMAN 0940 EDT 5/6/05 * * *

The State provided the following information via email:

"On 5/5/05 DSHS was notified by the licensee that the monthly whole body exposure during the period of 4/20/05 through 5/2/05 had been reported for the affected radiographer. He had received 65 mrem during that period. That brings his annual exposure to 6.45 Rem. He has been restricted from radiological work by the licensee."

R4DO (Pruett) and NMSS (Cox) have been notified.

FITNESS FOR DUTY

A non-licensed contract employee was determined to be under the influence of illegal drugs during a random test. The employee's access to the plant has been terminated. Contact the Headquarter Operations Officer for additional details.

DURING STEAM GENERATOR TUBE INSPECTION - GREATER THAN 1% (106 TUBES) OF THE TUBES WERE FOUND DEFECTIVE

"On May 2, 2005, with Waterford 3 in Mode 6, it was determined that Steam Generator 1 In-Service Inspection had identified more than 1 % defective tubes. Per Technical Specification table 4.4.2-C. this percentage of defective tubes is characterized as "C-3" and should be reported to the NRC. Accordingly, this event is being reported pursuant to 10CFR50.72(b)(3)(ii) as an 8-Hr Non-Emergency Degraded Condition.

"In addition, per Technical Specification 4.4.4.5, the final results of the Steam Generator tube inspection, which fall into category C-3, shall be reported in a special report within 30 days and prior to resumption of plant operation."

Defective tubes will be plugged.

The NRC Resident Inspector was notified.

SUSPICIOUS SUBSTANCE FOUND ON FLOOR OF MAINTENANCE BUILDING

An employee discovered a substance wrapped in paper lying on the floor of the Maintenance Building. The substance is being submitted to the state laboratory for further analysis.

The licensee notified the NRC Resident Inspector.

Contact Headquarters Operations Officer for additional details.

STOLEN HUMBOLT DENSITY GAUGE

"Sometime between Friday afternoon (4/29/05) and 07:00 Monday morning (5/2/05), a Humbolt density gauge was stolen from the HDR job site. The gauge was stored in a shed located at 10 N Atlantic Ave, Daytona Beach, FL 32115. The Florida Bureau of Radiation Control is investigating the case."

Humbolt density gauge model: H-5001EZ
Serial number: 4360
Source activity: Cs-137 10 mCi, Am:Be-241 40 mCi
Police Report Number from Daytona Beach Police: 2005-05-0073
Florida Report: FL05-69

* * * UPDATE PROVIDED BY ADAMS TO GOULD AT 1545 EDT ON 05/03/05 * * *

"[State of Florida] investigator inspected the temp work site storage area and interviewed licensee rep's and found no discrepancies.

"The gauge was found by Daytona PD mid afternoon on 3 May behind an abandoned house near Lincoln Street in Daytona Beach. The gauge was in its box undamaged, locks were intact and it was working fine. Licensee has taken possession of the gauge The State office will take no further action on this incident."

Notified R1DO (McDermott) and NMSS EO (Holahan)

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - REACTOR VESSEL LEVEL INSTRUMENTATION

"On 5/1/05 at 19:16, the plant entered MODE 2 and began a reactor startup. After withdrawing control rods, but prior to criticality, perturbations were noticed on reactor vessel level indications and control rod withdrawal was halted.

"At 22:32 control rods were inserted in reverse order to maintain the reactor subcritical. At that time, level instrumentation associated with the 'A' level reference leg was declared inoperable. All control rods were inserted at 23:02 in Mode 2.

"At 23:32 on 5/1/05 a 12 hour shutdown statement was entered due to the inoperable level instrumentation. Efforts were underway to troubleshoot and restore the level Instrumentation.

"On 5/2/05 at 06:11 the reactor mode switch was placed in shutdown - level instrumentation will not be restored within the time allowed by Technical Specifications. Instrument fill and vent procedures are being implemented at this time. The plant expects to enter Mode 2 later today."

Technical specification 3.3.6.1 requires restoration within one hour, shutdown within 12 hours. This reference leg level affects both the wide and narrow range level instruments and feed into the Reactor Protective System, Emergency Core Cooling System Instrumentation, and Isolation Instrumentation systems.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 6/3/05 AT 12:02 FROM PERRY'S COMPLIANCE SUPERVISOR (KEN MEADE) TO ABRAMOVITZ * * *

"Update to Event Notification (EN 41657) Retraction:

"A 4-hour notification was made on May 2, 2005, in accordance with 10CFR50.72(b)(2)(i), for a shutdown required by Technical Specifications. The report was made due to inserting all withdrawn control rods during a startup, prior to criticality, for Technical Specification 3.3.6.1 required actions. Technical Specification 3.3.6.1 was entered as a result of level perturbations determined to have been caused by reference leg keep-fill system operation when the reactor pressure vessel (RPV) was under vacuum conditions with minor component compression fitting leaks. Actions were taken to fix the minor leaks in the reference leg keep-fill panel. Additionally, the reference leg keep-fill system was removed from service until the RPV was pressurized.

"It was subsequently determined that since the reactor had not yet been taken critical, the reactor was in a shutdown condition. Per NUREG-1022, rev 2, section 3.2.1 'Plant Shutdown Required by Technical Specifications,' the 'initiation of any nuclear plant shutdown' does not include mode changes required by TS if initiated after the plant is already in a shutdown condition. Since the plant remained in a shutdown condition, this issue is not reportable.

"Since the condition is not reportable. EN 41657 is retracted."

The licensee notified the NRC Resident Inspector. The R3DO (Burgess) has been notified.