Event Notification Report for May 18, 2005

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION WITH BROKEN PD-103 SEED (1.7 MILLICURIES)

The State provided the following information via facsimile:

"On May 18, 2005, during a prostate brachytherapy procedure, a pre-loaded cartridge containing Pd-103 seeds jammed in a Mick applicator. The jam occurred during a cartridge change, and when the authorized user attempted to remove the stuck cartridge from the applicator, the end of one seed was sheared off. After the authorized user reattached the applicator to the needle, he determined a seed had broken. Pieces of the broken seed were found in a needle and in the cartridge. This needle was removed from the patient and a new needle was inserted. The cartridge was removed from the Mick applicator and no contamination was detected on the applicator itself. The patient treatment was completed without further incident. Contamination was detected on several pieces of equipment as well as on the floor of the operating room. All personnel were surveyed before they were permitted to leave the operating room. Access to the operating room was restricted until the room was decontaminated by the radiation safety officer and the medical physicist. The seed fragments and cartridge were placed in a lead pig and secured in the radioactive waste storage area, where they will be held for decay-in-storage. The activity of the broken Pd-103 seed was 1.7 mCi.

"The licensee notified DHFS on May 18, 2005. The Wisconsin Radiation Protection Section will investigate this event."

The State event report number is 26.

IDENTIFICATION OF DESIGN AND OPERATING PROCEDURE DEFICIENCIES RELATED TO APPENDIX R EVENTS

"During a review of the dedicated shutdown procedure (20.000.18), several possible design and operating procedure deficiencies were identified affecting Appendix R events. BOP Battery Charger 2C-1 is relied upon to feed post fire emergency shutdown loads. It was determined that although a circuit breaker supplying power to battery charger 2C-1 was re-closed by procedure, an additional action was required to place the battery charger in service. The BOP battery charger 2C-1 contactor circuit logic requires the control switch first be returned to the off-reset position, before the contactor can be re-energized. That control switch and associated control wiring is located in the control room envelope that is evacuated in an Appendix R fire scenario. Furthermore, the dedicated shutdown logic does not isolate this control switch circuitry from cables in the fire affected zone which is a requirement of the Appendix R circuit design.

"In addition to the same issues identified for battery charger 2C-1, it was determined that the dedicated shutdown procedure did not provide for closure of the circuit breaker feeding power to battery charger 2C1-2. Battery charger 2C1-2 is required to power 260VDC motor operated valves used by the standby feedwater system to provide reactor cooling water and to control reactor water level after a shutdown due to an Appendix R fire. For both of these problems, power would be initially supplied by the associated batteries, but the batteries are not sized to provide power for the entire duration of the Appendix-R event. Therefore, when the plant must be shutdown from outside of the control room, a safe shutdown cannot be assured using the dedicated shutdown panel. This event is being reported as an unanalyzed condition under 50.72(b)(3)(ii)(B).

"The affected Appendix R equipment was declared inoperable, and procedure changes to address this issue are being considered to address these conditions. The NRC Resident Inspector has been notified."

INADVERTENT DE-ENERGIZATION OF 4160 V SAFETY RELATED A.C. BUS WITH EDG AUTO START

"On 5/18/05 at 20:59 the 1A3 4160 V safety related A.C. bus inadvertently de-energized and the 1A Emergency Diesel Generator [EDG] automatically started and loaded onto the bus. The inadvertent de-energization of the 1A3, 4160 V bus appears to have resulted from testing of the 4160 V under voltage relays. Currently, normal power has been restored to the 1A3, 4160 V bus and the 1A Emergency Diesel Generator has been secured.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(iv)(A) to be completed within 8 hours as a safety systems actuation of the 1A3, 4160 V under voltage relaying and inadvertent start and load of the 1A Emergency Diesel Generator."

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY THE LICENSEE (HURCHALLA) TO NRC (HELD) AT 2207 EDT ON 5/19/05 * * *

"On 5/18/05 at 20:59 the 1A3 4,160 KV safety related AC bus inadvertently de-energized and the 1A Emergency Diesel Generator (EDG) automatically started and loaded onto the bus. This event was initiated during the performance of a plant surveillance 1-OSP-100.07, to test the 1A3 4,160 KV Bus Under Voltage Relay. The 1A EDG loaded and carried the 1A3 bus. The 1B3 4,160 KV bus was unaffected and the 'B' side power remained energized. This update is to provide the following additional information identified during the follow up investigation.

"This update is to identify that HVS-1B, Containment Fan Cooler, did not start as expected after the 1A EDG automatically loaded on the 1A3 4,160 KV Bus. The HVS-1A and HVS-1B were both load shed from the bus prior to closure of the 1A EDG output breaker. The HVS-1A did start as expected following closure of the EDG output breaker. The HVS-1B is on the three (3) second load block for the 1A EDG to restart, but did not start.

"A Root Cause Team has been formed to identify the cause of the initiating event and the auto-start failure of HVS-1B. A Condition Report was generated and a troubleshooting plan has been developed to determine the cause of the initiating event and failure of the HVS-1B to automatically restart.

"The 1B3 4,160 KV safety related AC bus and associated EDG were not affected by this event and remained operable during and following the event. Troubleshooting for the subject failed equipment is ongoing."

The licensee notified the NRC Resident Inspector.

The R2DO (Ogle) was notified.

LOSS OF BALANCE OF PLANT POWER DUE TO TRANSFORMERS LOCKOUT

"At 0154, 5/18/2005, during performance of relay testing, differential lockout 86T3 was manually actuated resulting in lockout of transformers XTF 31 and XTF 32. This resulted in a loss of all balance of plant (BOP) buses, loss of vital bus 1DB, an auto start of 'B' Diesel Generator (DG), and the sequencing of required ESF loads.

"At 0154, during relay testing, the 86T3 differential lockout was actuated. This resulted in a total isolation of XTF0031/32 which de-energized all of the BOP power to the plant and the XSW1 DB switchgear.

"Plant Engineered Safeguards Features (ESF) systems responded per design as the 'B' DG started and sequenced ESF loads. There were no major problems due to the event; however, the Diesel Fire Pump did not start as expected on a loss of BOP bus 1 C2.

"The Control Room entered AOP-304.3, 'Loss of All Balance of Plant Buses' and SOP-306, Section B, 'Operation of Diesel Generator 'B' After An Automatic Start And Load'.

"Preliminary review of plant response shows the RHR flow was in the process of coasting down and was restored to full flow within 20 seconds. The inlet temperature of the Residual Heat Removal (RHR) Heat Exchanger increased approximately 0.3 °F due to this event. There was no change in Reactor Coolant System level. V. C. Summer is currently shutdown in Mode 5 during Refueling Outage 15."

All plant systems are currently restored to normal configuration for Mode 5 refueling activities and there were no reported reactivity issues associated with this incident.

The licensee notified the NRC Resident Inspector and will notify the State, local and other government agencies.

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"A Ford F-150 with the CO license plate #225ALO was stolen at approximately 88th and Washington Street in Thornton (at approximately 11:00 am). A Troxler model 3430, gauge serial # 33250 was inside a DOT approved container, which was chained in the back truck bed and the container/box, was also locked. The keys for those locks were with the truck keys, with the individuals who have stole the truck; per Mr. D.

"Per Mr. D, he is waiting for the Thronton Police to arrive to document such. Further information will be forwarded to us upon learning."

* * * UPDATE FROM STATE (BONZER) VIA FAX RECEIVED AT 1348 EDT ON 5/19/05 * * *

The stolen truck was recovered with gauge in the truck bed. The licensee retrieved the truck and gauge at 0115 MDT on 5/19/05 with no evidence that the gauge had been tampered with or disturbed. The licensee intends on leak testing the gauge and will keep the gauge out of service until results are obtained.

R4DO (Nease) and NMSS (Correia) have been notified. TAS (Hahn) informed via e-mail.

EIGHT IODINE-125 SEEDS LOST DOWN A SINK

Radiation Safety Officer for Boone Hospital located in Columbia, MO., reported the following event:

A pre-loaded cartridge containing 15 Iodine-125 seeds, activity of each seed is 0.31 millicuries, was sent to the sterilization room of the hospital. Upon arrival the person handling the pre-loaded cartridge, not familiar with handling the cartridge, unscrewed the cap to the cartridge and the 15 seeds inside the cartridge fell out. Some of the seeds went down the drain of the sink and the rest ended up inside a tray or on the counter around the sink. Seven of the Iodine-125 seeds were recovered. Eight of the seeds that went down the sink were not recovered. Radiation surveys were performed in the sterilization room and no other seeds were found. Total activity of the missing eight Iodine-125 seeds is 2.48 millicures.

The person opening the pre-loaded cartridge did not receive any dose according to the Radiation Safety Officer.