Event Notification Report for July 21, 2011

AGREEMENT STATE REPORT INVOLVING A PATIENT RECEIVING AN INCORRECT DOSAGE OF I-131

The following report was received from the State of Wisconsin via fax:

"The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on July 22, 2011 that a patient received the wrong dose of I-131 on July 21, 2011. The patient was scheduled for a diagnostic procedure involving 8 mCi of I-131, but instead received a 150 mCi therapeutic dose of I-131.

"DHS will be conducting an investigation on July 26, 2011 and the licensee will be submitting a 15 day written report concerning the medical event."

Wisconsin Event Report ID No.: WI10010

* * * RETRACTION ON 7/26/11 AT 1405 EDT VIA FAX TO HUFFMAN FROM TIMMERMAN * * *

"This is an update to [the State of Wisconsin] Event Notification WI-10010. On July 26, 2011, the licensee informed [the Wisconsin Department of Health Services] that the reported medical event on July 22, 2011 involving a patient that received 150 mCi dose of I-131 on July 21, 2011, was an internal miscommunication. Upon review of the written directive and speaking with UW-Madison staff, DHS has verified that the patient received an I-131 therapeutic dose as prescribed on the written directive.

"This medical event is retracted."

R3DO (Giessner) and FSME EO (McIntosh) notified.

POTENTIAL ADVERSE EFFECT ON ESW TRAIN DURING A POSTULATED CONTROL ROOM FIRE

"On July 21, 2011 at 1100 [CDT] Callaway Plant staff determined that a design deficiency could adversely affect the 'B' Train of Essential Service Water (ESW) in the event of a Control Room fire. 'B' Train is the credited train for completion of a post-fire safe shutdown as a result of a Control Room evacuation.

"As a result of this deficiency, normally closed valve EFHV0060 could spuriously open during a postulated control room fire. EFHV0060 is located on the ESW return line from the 'B' Component Cooling Water (CCW) heat exchanger. If EFHV0060 spuriously opened as a result of this postulated fire, the flow balance in the 'B' Train of the ESW system would be affected. In this scenario, cooling water flow to other essential components could be reduced to below the minimum requirements.

"A fire watch has been imposed as a compensatory measure for this condition. Additionally, EFHV0060 has been closed and de-energized to preclude spurious opening in the event of a postulated control room fire.

"This condition is reported in accordance with 10 CFR 50.72 (b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.

"The NRC Resident Inspector has been notified."

VULNERABILITY FROM A POTENTIAL CONTROL ROOM FIRE ON "A" SAFEGUARDS BUS

"A potential scenario has been identified that has not been analyzed in the Comanche Peak Nuclear Power Plant Fire Safe Shutdown Analysis (FSSA). This situation is described below for Unit 1, but also applies to Unit 2. Listed below is the configuration for 1EA1. The basic configuration is typical for 1EA2, 2EA1 and 2EA2 as well (ref. E1-0001)

- Safeguard Bus 1EA1 is a 6.9 kV switchgear with a Main-Tie-Main configuration.
- The normal lineup has one feeder breaker closed, the other feeder breaker open and the tie breaker closed.
- 1EA1 receives normal power from the secondary side of Startup Transformer XST2 through breaker 1EA1-1.
- 1EA1 receives alternate power from the secondary side of Startup Transformer XST1 through breaker 1EA1-2.
- 1EA1 receives emergency power from diesel generator 1EG1 through breaker 1EG1.
- An alternate source of power for 1EA1 is also available from Train C through breaker 1EA1-3.

"The control wiring for the 1EA1-1 circuit breaker contains the following attributes that are important to understand the issue:

- Switch 43/1EA1-1, located in the Shutdown Transfer Panel (STP) is used to transfer control of 1EA1-1 from the Control Room (1-CB-11 switch CS-1 EA1-1) to the Hot Shutdown Panel (HSP) switch CS-1 EA-1 L. (Ref. E1-0031-01&02)
- There is a trip circuit fuse located in the 6.9 kV switchgear compartment for 1EA1-1 for control of the trip circuit when the breaker is controlled at 1CB-11 and a separate fuse for the trip circuit when the breaker is controlled by the HSP.
- The trip circuit for 1EA1-1 has a contact routed through the Control Room to the Solid State Protection System (SSPS) Cabinet. This contact is in the trip circuit when control is from the Control Room or when control is from the HSP. (Ref. E1-0031-01)

"The scenario is based on a fire in the Control Room. If the fire in the Control Room causes a ground in the wiring routed in the Control Room to the SSPS cabinet, the fuse for the 1E1-1 trip circuit would open. In the event of a fire in the Control Room, control of the plant is transferred to the HSP. When the control of breaker 1EA1-1 is transferred to the HSP and the ground condition in the SSPS wiring still exists, the second 1EA1-1 trip circuit would open. At this time there would be no way to remotely trip open 1EA1-1. The breaker could still be tripped mechanically at the breaker. Therefore, if 1EA1-1 is closed, 1EA1 could remain energized if off-site power is available. If off-site power is not available, but 1EA1-1 remains closed, bus 1EA1 would remain electrically connected to XST2. As part of the transfer of control from the Control Room to the HSP, operators start up the diesel generator and close 1EG1 to place 1EA1 loads on the generator. If 1EG1 is closed and 1EA1-1 breaker is still closed with off-site power available, the generator will be immediately connected to grid power through XST2 without synchronizing. If 1EG1 is closed and 1EA1-1 breaker is still closed with off-site power not available, the generator will be immediately connected to XST2 and attempt to energize XST2. This large current draw associated with energizing XST2 would likely stall and damage diesel generator 1EG1.

"Compensatory Action is being implemented through procedure revisions to preclude damage to the diesel generator during this scenario."

The licensee will notify the NRC Resident Inspector.

* * * RETRACTION FROM TOM RUCKER TO PETE SNYDER AT 1713 ON 9/8/11 * * *

"At 1939 central daylight time on July 21, 2011, Luminant Power notified the NRC (Event No. 47086) of a Unanalyzed Condition per 50.72(b)(3)(ii)(B) regarding the vulnerability from a potential control room fire on 'A' Safeguards bus. The event report described a portion of a cable running from the Hot Shutdown Panel (HSP) to the Solid State Protection System (SSPS) cabinet in the Control Room (CR) that was not protected from a CR fire scenario for which a worst case Control Room/Cable Spreading Room fire induced short could result in the 1EA1-1 circuit breaker, connecting the 345 kV Startup Transformer to the grid, not tripping and damaging the EDG.

"Upon further review it has been determined that the Fire Safe Shutdown Analysis (FSSA) modeled that cable in the analysis since CPNPP began commercial operation. Additionally, the FSSA accounted for the fire-induced circuit ground on this cable and one of the specified manual actions is to trip the 1EA1-1 circuit breaker to assure the EDG would load the 'A' Safeguard bus to support the required fire scenario. The EDG output breaker is designed to auto close once the 1EA1-1 circuit breaker is tripped open. The previous version (prior to compensatory actions) of ABN-803A/B, the procedure used should a fire occur in the Control Room, directed the Reactor Operator to trip 1EA1-1 circuit breaker once the diesel was verified running, then ensure the EDG breaker closed. There is no procedural step directing personnel to manually close the EDG breaker. Since, in this scenario, indication for the 1EA1-1 circuit breaker at the Hot Shutdown Panel would be lost, it would be expected that the RO would direct the RRO to verify 1EA1-1 circuit breaker position.

"Based on the above, Luminant Power has concluded that the FSSA adequately modeled the plant and procedures were written which would not direct any action that would have caused the condition stated in the CR description. Based on the above, the conclusion is that CPNPP did not have an unanalyzed condition that significantly degraded plant safety per 50.72 (b)(3)(ii)(B) regarding the vulnerability from a potential control room fire on 'A' Safeguards bus. Therefore, this event is retracted."

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Lantz).

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING EXPOSURE LESS THAN PRESCRIBED


The following information was received from the State of Pennsylvania Department of Environmental Protection Bureau of Radiation Protection via e-mail:

"Event Type: A medical event (ME) where the patient was being treated via [Yttrium - 90] TheraSphere for disease of the liver and received 64% of the intended dose, which is reportable under 10CFR35.3045.

"Notifications: On July 22, 2011, at 1541 [EDT] the department's [PA Bureau of Radiation Protection] Southeast Regional Office received notification via email about a ME that was identified during a routine internal audit.

"Event Description: As noted, the event was identified on July 21, 2011, during a routine internal audit by U Penn. The patient was being treated for disease of the liver and received 64% of the intended dose. No harm to the patient is expected. The treating physician notified the patient. No more information is available at this time.

"Cause of the Event: The cause of the event is currently under investigation by the licensee.

"Actions: The licensee will be submitting a written report within 15 days. The department [PA Bureau of Radiation Protection] plans to do a reactive inspection."

The actual event date is unknown based on the state's report.

PA Event Report: PA110019

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.