Event Notification Report for December 08, 2006

SHIFT OF I-125 SEEDS AFTER IMPLANTATION

On 10/26/06 the licensee implanted a patient with 104 seeds of I-125 (total activity of 42.2 millicuries, manufactured by Bard, Inc.) to treat prostate cancer. The post implant CT performed on 12/08/06 indicated that the distribution of the seeds was inferior to the intended distribution. A percentage of the seeds had shifted approximately 1.5 cm inferior to what was intended. The licensee is still evaluating at this time what percentage of the seeds intended for the prostate were no longer in the prostate . The licensee immediately informed the patient and the prescribing physician. The patient has to this point shown no ill effects from the migration. However, a quantity of the seeds have migrated to the perineum. Due to the unknown quantity of seeds in the perineum the licensee is still investigating the amount of dose received in this area.

The licensee is investigating the cause of the migration. After the cause is determined they will put corrective actions in place to prevent reoccurrence. The licensee has performed multiple implants that were close to 100% successful since this occurrence. The licensee intends to supplement the patients treatment with an external bean in order to achieve the intended dose.

The licensee notified NRC Region 1 (S. Gabriel, P. Lanzisera)

* * * UPDATE TO HUFFMAN FROM TRIPP AT 10:55 EST ON 12/11/06 * * *

Based on discussion with NRC Region 1 (S. Gabriel), the licensee provided the following revision to the initial event report:

"On October 25, 2006, the licensee implanted 104 I-125 seeds into a patient for the treatment of prostate cancer. The total activity of the implanted seeds was 42.4 mCi. A post-implant CT performed on December 8, 2006, indicated that the seed were misplaced approximately 1.5 cm inferior to the intended position. The licensee is still evaluating the details of the post-implant dosimetry.

"Notifications pursuant to 10 CFR 35.3045 were made on December 8, 2006.

"The licensee is still evaluating the cause of the misplacement of the iodine seeds. After the cause(s) has been determined, corrective actions will be put in place.

"The patient will require will require further treatment of the prostate gland. External beam therapy will be used to supplement the dose to prostate."

R1DO (Conte) and NMSS EO (Morell) notified.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

CREFS SYSTEM INOPERABLE

"Control Room Emergency Filtration System (CREFS) was declared inoperable at 1812 on 12/8/06 because the W-14A, F-16 Control Room Charcoal Filter Fan tripped during performance of the monthly technical specification surveillance test, TS-9.

"This fan is required to be operable for operability of the CREFS System. This condition is covered by TS 3.7.9, Control Room Emergency Filtration System and both units have entered action condition A, 'CREFS Inoperable' with a required action to 'Restore CREFS to OPERABLE Status' with a completion time of 7 days.

"CREFS is a single train system. Based on the guidance in NUREG-1022 for single train systems that perform safety functions, this condition was determined to be reportable under 10CFR50.72(b)(3)(v), 'Event or Condition That Could Have Prevented Fulfillment of a Safety Function'."

* * * RETRACTION PROVIDED BY VANDERWARF TO KOZAL ON 12/28/06 AT 0952 * * *

"On December 8, 2006, at 22.42 EST, EN 43040 was made by the Point Beach Nuclear Plant in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition at the time of discovery could have prevented the fulfillment of a system function that is needed to mitigate the consequences of an accident. Control Room Emergency Filtration System (CREFS) fan W-1 4A, F-16 Control Room Charcoal Filter Fan tripped during performance of the monthly Technical Specification surveillance test. CREFS was declared inoperable.

"After further evaluation, it was determined that the safety function of CREFS was not lost. Redundant fan W-14B was operable for the duration of the time fan W-14A was out of service. Single train portions of the system were not affected by the W-1 4A fan trip. Accordingly, this event is not reportable. EN 43040 is, therefore, retracted."

Notified R2DO (Burgess)

INVALID EFW ACTUATIONS DUE TO AN ISSUE IN SG DRYOUT PROTECTION CIRCUIT

"This report is being made per paragraphs 50.73(a)(1) and 50.73(a)(2)(iv)(A) to address two actuations of the Emergency Feedwater (EFW) System on Oconee Unit 1 on 12/8/06 by the Steam Generator (SG) Dry-out Protection Circuit. EFW is a system named in 50.72(b)(3)(iv)(B).

"By design, the SG Dry-out Protection Circuit actuates whenever two Extended Start-up level indications (two of two actuation logic) in either SG are lower than the setpoint (i.e. below 21 inches) for more than 30 seconds. This start circuit is not credited in Oconee safety analyses as performing a required safety function, therefore this signal is considered an INVALID signal with respect to 50.73 (a)(2)(iv)(A). Upon actuation, the circuit starts both Motor Driven Emergency Feedwater Pumps (MD EFWPs) on the affected unit. It does not send a start signal to the Turbine Driven Emergency Feedwater Pump.

"Per the startup procedure, Condensate Booster Pumps (CBP) feed the SGs until a main Feedwater pump (FDWP) is placed in service. Operators begin startup of a FDWP when the Reactor Coolant System (RCS) temperature is between ~395 degrees to 475 degrees. The Unit is then maintained at ~ 475 degrees RCS temperature and 500 - 550 psig SG pressure until a FDWP is in service.

"On 12/8/06, a Unit 1 startup from a refueling outage was in progress. RCS temperature was approximately 475 deg. (Mode 3) when the RCS heat-up was suspended due to issues with the 1A FDWP Turbine which delayed placing it in service. Steam pressure was being maintained approximately 530 psig (in the procedural band of 500-550 psig) per the unit startup procedure. In addition, a 'SG Hot Soak' was in progress. For this evolution, SG level was raised to 75% (Operating Range) then Operators took manual control to individually blow down 1A and the 1B SGs to low levels (25 inches) while attempting to maintain level above 21 inches.

"During this evolution, 1B SG levels decreased below minimum level. Operators initiated actions to recover level but at 2143 the 1A and the 1B MD EFW Pumps auto-started on dry-out protection. From their observation of the level displays, the Operators thought that the actuation logic had not been met (i.e. level had not been less that 21 inches for 30 seconds). Therefore they considered the actuation to be spurious. Based on this understanding and concerns about possible overfeeding and RCS overcooling (due to the relatively low decay heat load starting up from a refueling outage), EFW was secured and reset at 2144.

"SG Blowdown activities continued per procedure. At 2207, in response to lowering 1A SG levels, the dry-out protection feature again initiated an auto start of the 1 A and 1 B MD EFW Pumps. Based on his review of SG levels, the CR SRO believed that the second EFW actuation was invalid and directed that EFW be secured. EFW was secured and reset at 2208. At 2241 hrs SG outlet pressure was lowered and maintained within a band of 490-520 psig.

"Subsequent review of computer data indicated that a dry-out condition (i.e. less than 21 inches SG level for 30 seconds) did exist for both actuations. Therefore both actuations were valid in that actual plant conditions satisfied the initiation criteria, but, as stated above, the SG Dry-out Protection signal is considered an INVALID signal with respect to 50.73 (a)(2)(iv)(A).

"Additional review by Mechanical-Civil Engineering personnel determined that the Unit 1 CBPs operate at approximately 15 psig lower discharge pressure than the Unit 2 and 3 CBPs, apparently due to lower discharge pressures on the Unit 1 Hotwell pumps. That being the case, the Unit 2 and 3 CBPs, apparently due to lower discharge pressures on the Unit 1 Hotwell pumps. That being the case, the Unit 1 CBPs in service could not develop sufficient head pressure to maintain adequate flow to the SGs over the full operating operating band of 500 - 550 psig allowed by current operating procedure guidance. As steam pressures approached or exceeded 535 psig, the ability to feed the SGs using the CBPs was reduced, ultimately leading to the dry-out condition.

"The issue of these pump discharge pressures being slightly lower than expected had not been recognized previous to this event. The event investigation noted that during past startups, a main FDWP was normally placed into service promptly, which may have avoided using the CBPs to feed the SG above 535 psig. In this case, alignment of a main FDWP was delayed, which led to the event.

"Specific Information Required per NUREG 1022:
"(a) The specific train(s) and system(s) that were actuated.
"The specific train(s) and system(s) that were actuated were the 1 A and 1 B Motor Driven (MD) Emergency Feedwater (EFW) Pumps and the associated A and B trains of EFW. The Turbine Driven EFW pump does not receive this signal and was not challenged by the event.
"(b) Whether each train actuation was complete or partial.
"Both actuations were considered complete (i.e. all necessary components responded to the start signal and associated control signals to provide EFW to the SG(s)).
"(c) Whether or not the system started and functioned successfully.
"In both cases, the system started and operated successfully until secured by Operations personnel.

"Initial Safety Significance: None, there was no significant transient.

"Corrective Action(s): As stated above, EFDW was secured and reset at 2208. At 2241 hrs SG outlet pressure was lowered and maintained within a band of 490-520 psig. Unit 1 continued startup and subsequently reached Mode 1. This event has been entered into the site corrective action program for resolution."

The licensee notified the NRC Resident Inspector.