Event Notification Report for February 02, 2007

LOW PRESSURE INJECTION (LPI) NET POSITIVE SUCTION HEAD FLOW REQUIREMENTS NOT MET FOR CERTAIN ACCIDENT SEQUENCES

"At 1350 hours on February 2, 2007, with the plant at 100% power, it was determined [that] the low pressure injection (LPI) system net positive suction head calculation does not account for the additional flow through the failed LPI pump recirculation line during certain accident scenarios. The additional flow is upstream of the flow element used by control room operators to throttle system flow to maintain net positive suction head flow requirements. The additional flow could result in net positive suction head below required design limits. The system design is not affected in events where both LPI trains perform as designed.

"Emergency operating procedures direct control room operators to open the LPI system discharge flow cross-connect line isolation valves, if accessible, following a LPI pump failure. Operators are then directed to throttle system flow through the operable LPI pump to maintain proceduralized values. These values are designed to provide sufficient design flow and maintain pump NPSH. During a simulator training scenario, operators identified when the discharge cross-connect line isolation valves were opened, the idle Building Spray train indicated flow. Follow-up investigation identified the increased flow was due to back flow through the failed LPI pump minimum flow recirculation line. This additional flow is upstream of the flow element used by operators to maintain adequate net positive suction head for the operable LPI pump. The additional flow could result in not meeting NPSH design requirements.

"The licensee entered the 72 hour Technical Specification limiting condition for operation (LCO) for one inoperable LPI train. The licensee is revising calculations and emergency operating procedures to account for the additional flow.

"This condition is reportable in accordance with 10CFR 50.72(b)(3)(ii) and (b)(3)(v) as an unanalyzed condition, and a condition that could have prevented the fulfillment of the safety function of the LPI system to mitigate the consequences of an accident, respectively. "

The NRC Resident Inspector was notified of this event by the licensee.

*** RETRACTION FROM MILLER TO KNOKE AT 11:11 ON 03/14/07 ***

"The purpose of this report is to retract the ENS report made on February 2, 2007 at 2105 hours ( ENS #43139) under 10CFR50.72(b)(3)(ii) and (b)(3)(v) as an unanalyzed condition, and a condition that could have prevented the fulfillment of the safety function of the Low Pressure Injection (LPI) system to mitigate the consequences of an accident, respectively. The initial report was made when it was determined that the LPI system net positive suction head (NPSH) calculation does not account for the additional flow through the LPI pump recirculation line during certain accident scenarios. The additional flow could result in net positive suction head below required design limits. Due to this condition, it was not certain if the LPI system could have met its design basis requirements. The licensee entered the 72 hour Technical Specification limiting condition for operation (LCO) for one inoperable LPI train. The LCO was exited on February 3, 2007 at 9:25PM following implementation of a procedure change that accounted for the additional flow and ensured that adequate NPSH was maintained. A subsequent engineering evaluation has determined that sufficient LPI pump NPSH would have been available to perform its design basis function prior to the procedure change. The engineering evaluation shows that the LPI pumps remained capable of performing their design basis functions based on the following three independent assessments:

1) the LPI pumps would have operated well beyond their mission time without significant cavitation damage at the available NPSH
2) proceduralized operator actions would have throttled flow to restore required NPSH if signs of cavitation occurred
3) an evaluation using realistic Reactor Building pressures showed that sufficient NPSH would exist."

The licensee notified the NRC Resident Inspector. Notified R1DO (Hott)

RADIOGRAPHY CAMERA WITH POTENTIALLY DEFECTIVE SOURCE CONTROL CABLES

The licensee provided the following information via facsimile:

"RE: U.S. Nuclear Regulatory Commission Radioactive Materials License Number 43-29213-01
Reporting to requirement of 10 CFR 21.21 (d)(3)(i): Concerning Identification of a defect or a failure to comply.

"1. Description of the equipment problem:

"Alpha Testing Labs purchased a new exposure device with new associated equipment and new source from Source Production & Equipment Company (SPEC).
Exposure device model No. 150, S/N 1030
Source Model No. G-60, SIN OA 1704
The first use of the new equipment was of a field job site location in Casper, Wyoming February 2, 2007. Source strength - 4995 GBq

"The radiographer successfully cranked out the source for 10 exposures. On the 11th exposure, he experienced difficulty retracting the source back into the locked position. They did an inspection of the equipment (guide tubes and crank cable) and found no visible defects. They informed the RSO of the difficulty. They tried another exposure with the same results. Then they checked the drive cable and gear in the crank outs, replaced the safety stop spring on the drive cable and made 108 exposures with no problems. RSO called SPEC and reported the problem. They said they would overnight a new set of controls and related equipment.

"Dosimeter readings: Radiographer-40 mr, Assistant radiographer-45 mr, Assistant radiographer- 12 mr

"The next day, February 3, 2007, they made 2 exposures and the problem happened again. They informed the RSO and did not use the equipment again. SPEC sent a new set of associated equipment by overnight delivery and there have been no problems.

"2. Corrective action taken:

The equipment was returned to the manufacturer, Source Production & Equipment Company (SPEC). SPEC personnel will evaluate the equipment problem and submit a written reply.

"3. Place, Date and time of incident:

Field site location: Toromont Energy Systems (Wyoming) Inc., 2289 Renauna Ave., Casper, WY 82601 Dates: February 2 and 3rd 2007 at approximately 6:30 PM.

"4. Qualifications of personnel involved in incident:

Contact the HOO for details."

The licensee was operating a brand new SPEC Model 150 S/N 1030 radiography camera containing a 147 Curie source of Ir-192 when the operator experienced some binding while retracting the source control cable. The operator suspended the radiography operation, contacted SPEC, and performed an inspection of the guide tube and cables. The licensee operator noticed some raised metal in the guide tube and guide spring. SPEC provided replacement source guide cables and guide tubes and those components were replaced. The licensee replaced the control cables and guide tubes and no further binding problems were noticed. There were no personnel overexposures and the potentially defective cables are being inspected by the manufacturer. The licensee believes this is a manufacturers defect given that the equipment is brand new and being used for the first time. Additionally, the licensee has four other SPEC cameras and has not experienced any difficulties. The licensee has discussed this issue with Mr. Montgomery in Region IV.

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"Patient was scheduled for administration of 30 millicuries of 90Y [Yttrium-90] microspheres. The delivery catheter developed a leak during the administration. Leakage was mostly contained within the Plexiglas box containing the vial of microspheres. There was very minimal contamination outside of the box.

"Licensee performed bremsstrahlung measurements of the patient and the Plexiglas box. Based on differences, the administered dose was determined to be only 66% of the prescribed dose.

"Licensee noted that this was the first of a two part administration of the microspheres and the dose at the next treatment will be adjusted to compensate for the 'missing' activity.

"The device manufacturer (Sirtex) traced the leaky units to one operator who had deviated from the normal assembly procedure. Sirtex destroyed the remainder of that lot number and replaced them with a new, tested lot."

NC Event Report ID number: NC-07-02


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.

* * * UPDATE FROM C. FLANNERY TO P. SNYDER AT 1436 ON 5/02/07 * * *

The NRC's medical events review committee has determined that this report is a medical event. Notified R1DO (Holody) and FSME (Morell) via e-mail.

AGREEMENT STATE REPORT - CONTAMINATION FROM LEAKING SEALED SOURCE

The following information was provided by the state via facsimile:

On 02/05/07, the licensee notified the Louisiana Department of Environmental Quality that one of its Electron Caption Detectors (ECD) had a removable activity above 0.005 microcuries as a result off a recent "wipe test". The ECD is a Agilent Technologies, Inc. model number: 19233-69570, serial number YA353 with an estimated activity of 15 millicuries of Ni-63. Leak test results from a test performed on 01/26/07 were 0.024 microcuries. The wipe test results were reported to the licensee on 02/02/07.

On 02/07/07 an onsite inspection was performed by licensee corporate personnel. On 02/07/07 the ECD was returned to the manufacturer's location in Wilmington, DE for disposal.

LA Event Report ID No.: LA070002