Event Notification Report for September 30, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/29/2009 - 09/30/2009
EVENT NUMBERS
454024539945400453944539545396
Fuel Cycle Facility
Event Number: 45402
Facility: AREVA NP INC RICHLAND
Region: 2 State: WA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
FABRICATION & SCRAP
COMMERCIAL LWR FUEL
NRC Notified By: ROBERT LINK
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: WA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
FABRICATION & SCRAP
COMMERCIAL LWR FUEL
NRC Notified By: ROBERT LINK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2009
Notification Time: 19:49 [ET]
Event Date: 09/30/2009
Event Time: 19:10 [PDT]
Last Update Date: 10/01/2009
Notification Time: 19:49 [ET]
Event Date: 09/30/2009
Event Time: 19:10 [PDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)
24 HOUR REPORT ON PROCESS EXHAUST HEPA FILTER DETERIORATON
"On September 30, 2009 at approximately 1910 (PDT) an Air Balance Tech at AREVA NP's Richland fuel fabrication plant discovered that the primary and secondary HEPA filters servicing the ammonium diuranate (ADU) area showed visible signs of deterioration. The apparent deterioration is being reported in accordance with 10CFR70.50.b.2.
"The K32A HEPA filters were examined at approximately 1910 PDT on September 30, 2009 based on a request to follow up on some observations the previous day of a dusting of powder and very low contamination downstream of the filters. Air flow was diverted to HEPA filters in a parallel upper housing in order to check the filters in the lower housing. Investigation showed apparent deterioration, cracked creases, of both the primary and final HEPA's.
"At approximately 2030 PDT the same day EHS&L personnel were informed of the event. The only processes running at the time were the Mop Water Furnace and Cylinder Wash. EHS&L ordered that these be shut down. Air monitor samples were pulled on the K-32A system. Air monitoring samples showed negligible release levels. A Health Safety Technician survey of the downstream side of the final HEPA housing of K-32A revealed no contamination.
"Potential dose to a member of the public and the effect on the environment are essentially negligible. External conditions are not known to have affected the event.
"A Corrective Action Report was written on October 1, 2009. The cause of the apparent deterioration is under active investigation. Steps to prevent recurrence will be developed as appropriate."
The licensee stated that records indicate that the primary filter was changed out in August and the final filter was changed out in March.
The licensee will notify the State and the NRC regional contact.
"On September 30, 2009 at approximately 1910 (PDT) an Air Balance Tech at AREVA NP's Richland fuel fabrication plant discovered that the primary and secondary HEPA filters servicing the ammonium diuranate (ADU) area showed visible signs of deterioration. The apparent deterioration is being reported in accordance with 10CFR70.50.b.2.
"The K32A HEPA filters were examined at approximately 1910 PDT on September 30, 2009 based on a request to follow up on some observations the previous day of a dusting of powder and very low contamination downstream of the filters. Air flow was diverted to HEPA filters in a parallel upper housing in order to check the filters in the lower housing. Investigation showed apparent deterioration, cracked creases, of both the primary and final HEPA's.
"At approximately 2030 PDT the same day EHS&L personnel were informed of the event. The only processes running at the time were the Mop Water Furnace and Cylinder Wash. EHS&L ordered that these be shut down. Air monitor samples were pulled on the K-32A system. Air monitoring samples showed negligible release levels. A Health Safety Technician survey of the downstream side of the final HEPA housing of K-32A revealed no contamination.
"Potential dose to a member of the public and the effect on the environment are essentially negligible. External conditions are not known to have affected the event.
"A Corrective Action Report was written on October 1, 2009. The cause of the apparent deterioration is under active investigation. Steps to prevent recurrence will be developed as appropriate."
The licensee stated that records indicate that the primary filter was changed out in August and the final filter was changed out in March.
The licensee will notify the State and the NRC regional contact.
General Information or Other
Event Number: 45399
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL COMPANY
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Licensee: CHEVRON PHILLIPS CHEMICAL COMPANY
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/01/2009
Notification Time: 15:43 [ET]
Event Date: 09/30/2009
Event Time: 18:00 [CDT]
Last Update Date: 10/01/2009
Notification Time: 15:43 [ET]
Event Date: 09/30/2009
Event Time: 18:00 [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WERNER (R4DO)
GLENDA VILLAMAR (FSME)
GREG WERNER (R4DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE
The following was received via E-mail:
"On October 1, 2009, the Agency [TX Dept. of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting a routine shutter check on an Ohmart/Vega Corp. SHF1 nuclear gauge containing 20 millicuries of Cesium (Cs) 137, the shutter failed to close. The RSO stated that the gauge had been installed on the vessel in June of 2009. He was performing the check now to get this gauge into the same inspection schedule as the other gauges they use. He stated that the gauge is stuck open in the normal operating position and a survey conducted in the area indicated that dose rates were normal. He stated that there was no other damage to the gauge. He stated that he thought the mechanism may have become fouled from work conducted on a piece of equipment in the area. The manufacturer was contacted and is scheduled to perform repairs and training on October 21, 2009. The gauge is currently tagged 'Do Not Operate.' Additional information will be provided as it is received."
See similar event report EN# 45400 involving an Ohmart gauge with a stuck open shutter.
Texas Incident #: I-8675.
The following was received via E-mail:
"On October 1, 2009, the Agency [TX Dept. of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting a routine shutter check on an Ohmart/Vega Corp. SHF1 nuclear gauge containing 20 millicuries of Cesium (Cs) 137, the shutter failed to close. The RSO stated that the gauge had been installed on the vessel in June of 2009. He was performing the check now to get this gauge into the same inspection schedule as the other gauges they use. He stated that the gauge is stuck open in the normal operating position and a survey conducted in the area indicated that dose rates were normal. He stated that there was no other damage to the gauge. He stated that he thought the mechanism may have become fouled from work conducted on a piece of equipment in the area. The manufacturer was contacted and is scheduled to perform repairs and training on October 21, 2009. The gauge is currently tagged 'Do Not Operate.' Additional information will be provided as it is received."
See similar event report EN# 45400 involving an Ohmart gauge with a stuck open shutter.
Texas Incident #: I-8675.
General Information or Other
Event Number: 45400
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: EQUISTAR CHEMICALS LP
Region: 3
City: MORRIS State: IL
County:
License #: IL-01737-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Licensee: EQUISTAR CHEMICALS LP
Region: 3
City: MORRIS State: IL
County:
License #: IL-01737-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2009
Notification Time: 16:19 [ET]
Event Date: 09/30/2009
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2009
Notification Time: 16:19 [ET]
Event Date: 09/30/2009
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JULIO LARA (R3DO)
TERRENCE REIS (FSME)
JULIO LARA (R3DO)
TERRENCE REIS (FSME)
AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE
The following information from the State of Illinois Emergency Management Agency via e-mail:
"On September 30, the facility's radiation safety officer contacted the Agency to advise that a fixed gauge had failed to operate as intended. While performing routine safety and shutter condition checks, attempts to close the shutter on the level gauge were not successful. The gauge is operated in an elevated, open environment on a polymer process vessel and there are no occupiable workstations in the area. The safety officer reports that they believe the shutter could be rotated to the closed position if additional force were applied to the shutter arm. However, previous experience has shown such actions could result in the arm becoming sheared from the shutter. Attempts to apply additional lubricant and remove debris from the pathway not otherwise readily observed, did not improve the extent of closure.
"The process vessel involved is continuously operated and not scheduled for any routine maintenance at this time. The licensee continues to operate the line at this time with the shutter open. Warning notices have been posted near the gauge regarding the shutter operation and all operational supervisors and personnel responsible for the line have been made aware of the condition. Should an emergency condition exist the licensee is prepared to remove the gauge from the vessel and apply additional shielding. Arrangements are pending with the manufacturer to come on-site to perform an evaluation of the three year old device and make the necessary repairs or replace the device as necessary. Similar failures of this device have been noted in the past. The manufacturer states the common cause for those failures is poor or non-existent maintenance, operation of the gauge outside of its approved conditions and/or attempting to force operation of the shutter handle.
"The licensee indicated the necessary written report would be filed within the next 30 days. "
The gauge involved is an Ohmart Model SHF2 (S/N 74932) with a 80 millicurie Cs-137 source.
See similar event report EN#45399 involving an Ohmart gauge with a stuck open shutter.
Illinois Report Number IL0900075.
The following information from the State of Illinois Emergency Management Agency via e-mail:
"On September 30, the facility's radiation safety officer contacted the Agency to advise that a fixed gauge had failed to operate as intended. While performing routine safety and shutter condition checks, attempts to close the shutter on the level gauge were not successful. The gauge is operated in an elevated, open environment on a polymer process vessel and there are no occupiable workstations in the area. The safety officer reports that they believe the shutter could be rotated to the closed position if additional force were applied to the shutter arm. However, previous experience has shown such actions could result in the arm becoming sheared from the shutter. Attempts to apply additional lubricant and remove debris from the pathway not otherwise readily observed, did not improve the extent of closure.
"The process vessel involved is continuously operated and not scheduled for any routine maintenance at this time. The licensee continues to operate the line at this time with the shutter open. Warning notices have been posted near the gauge regarding the shutter operation and all operational supervisors and personnel responsible for the line have been made aware of the condition. Should an emergency condition exist the licensee is prepared to remove the gauge from the vessel and apply additional shielding. Arrangements are pending with the manufacturer to come on-site to perform an evaluation of the three year old device and make the necessary repairs or replace the device as necessary. Similar failures of this device have been noted in the past. The manufacturer states the common cause for those failures is poor or non-existent maintenance, operation of the gauge outside of its approved conditions and/or attempting to force operation of the shutter handle.
"The licensee indicated the necessary written report would be filed within the next 30 days. "
The gauge involved is an Ohmart Model SHF2 (S/N 74932) with a 80 millicurie Cs-137 source.
See similar event report EN#45399 involving an Ohmart gauge with a stuck open shutter.
Illinois Report Number IL0900075.
Power Reactor
Event Number: 45394
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: JOHN KNOKE
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/30/2009
Notification Time: 14:11 [ET]
Event Date: 09/30/2009
Event Time: 11:09 [EDT]
Last Update Date: 09/30/2009
Notification Time: 14:11 [ET]
Event Date: 09/30/2009
Event Time: 11:09 [EDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JULIO LARA (R3DO)
JULIO LARA (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
MANUAL REACTOR SHUTDOWN DUE TO HYDROGEN IN-LEAKAGE TO STATOR WATER COOLING SYSTEM
"At 11:09 EDT 09/30/09, the reactor mode switch was taken to shutdown and the main turbine generator was manually tripped in response to hydrogen gas in-leakage into the stator water cooling system from the main turbine generator. The scram was uncomplicated, and all control rods fully inserted into the core. The lowest reactor vessel water level reached was 122 inches, and as expected, HPCI & RCIC did not actuate. No safety relief valves (SRV) actuated. Reactor water level is being controlled in the normal band using the control rod drive and reactor feedwater systems. All isolations and actuations for reactor water level 3 occurred as expected.
"The cause of the increased hydrogen gas in-leakage into the stator water cooling is under investigation. At the time of the manual scram all Emergency Core Cooling Systems and Emergency Diesel Generators were operable, and no significant safety related equipment was out of service. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), as an event that results in actuation of the reactor protection system (RPS) when the reactor is critical."
The licensee has notified the NRC Resident Inspector.
"At 11:09 EDT 09/30/09, the reactor mode switch was taken to shutdown and the main turbine generator was manually tripped in response to hydrogen gas in-leakage into the stator water cooling system from the main turbine generator. The scram was uncomplicated, and all control rods fully inserted into the core. The lowest reactor vessel water level reached was 122 inches, and as expected, HPCI & RCIC did not actuate. No safety relief valves (SRV) actuated. Reactor water level is being controlled in the normal band using the control rod drive and reactor feedwater systems. All isolations and actuations for reactor water level 3 occurred as expected.
"The cause of the increased hydrogen gas in-leakage into the stator water cooling is under investigation. At the time of the manual scram all Emergency Core Cooling Systems and Emergency Diesel Generators were operable, and no significant safety related equipment was out of service. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), as an event that results in actuation of the reactor protection system (RPS) when the reactor is critical."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 45395
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE BRUBAKER
HQ OPS Officer: JOHN KNOKE
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE BRUBAKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/30/2009
Notification Time: 15:38 [ET]
Event Date: 09/30/2009
Event Time: 15:21 [EDT]
Last Update Date: 09/30/2009
Notification Time: 15:38 [ET]
Event Date: 09/30/2009
Event Time: 15:21 [EDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MIKE ERNSTES (R2DO)
MIKE ERNSTES (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION TO VARIOUS GOVERNMENT AGENCIES
"Voluntary notifications, a press release, and a webinar are being made to various government agencies and the media to provide information regarding the installation of temporary structures on top of earthen embankments of the Fort Loudoun, Tellico, Cherokee and Watts Bar dams. These dams are on the Tennessee River System. Recent upgraded flood modeling indicates that there is a possibility for overtopping to occur on these dams during a hypothetical extreme flooding scenario in the winter/spring period. As a precautionary measure, TVA is effectively raising the height of some of the dams in certain areas. These precautionary measures ensure that the TVA nuclear sites (Sequoyah, Watts Bar and Browns Ferry) will remain within their original licensing basis.
"Currently, Sequoyah Units 1 & 2 (DPR-77 & 79) and Browns Ferry Units 1 & 3 (DPR-33 & DPR-68) are operating at 100% power, Browns Ferry Unit 2 (DPR-52) is in Mode 4. Watts Bar Unit 1 (NPF-90) is shutdown for refueling."
The licensee has notified the NRC Resident Inspectors at each of these sites. The licensee's corporate management is issuing a press release.
"Voluntary notifications, a press release, and a webinar are being made to various government agencies and the media to provide information regarding the installation of temporary structures on top of earthen embankments of the Fort Loudoun, Tellico, Cherokee and Watts Bar dams. These dams are on the Tennessee River System. Recent upgraded flood modeling indicates that there is a possibility for overtopping to occur on these dams during a hypothetical extreme flooding scenario in the winter/spring period. As a precautionary measure, TVA is effectively raising the height of some of the dams in certain areas. These precautionary measures ensure that the TVA nuclear sites (Sequoyah, Watts Bar and Browns Ferry) will remain within their original licensing basis.
"Currently, Sequoyah Units 1 & 2 (DPR-77 & 79) and Browns Ferry Units 1 & 3 (DPR-33 & DPR-68) are operating at 100% power, Browns Ferry Unit 2 (DPR-52) is in Mode 4. Watts Bar Unit 1 (NPF-90) is shutdown for refueling."
The licensee has notified the NRC Resident Inspectors at each of these sites. The licensee's corporate management is issuing a press release.
General Information or Other
Event Number: 45396
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MARTHA JEFFERSON HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-137-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: JOE O'HARA
Licensee: MARTHA JEFFERSON HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-137-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: JOE O'HARA
Notification Date: 09/30/2009
Notification Time: 15:41 [ET]
Event Date: 09/30/2009
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2009
Notification Time: 15:41 [ET]
Event Date: 09/30/2009
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARIE MILLER (R1DO)
GLENDA VILLAMAR (FSME)
MARIE MILLER (R1DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - PATIENT GIVEN A THERAPEUTIC DOSE VICE A DIAGNOSTIC DOSE
The following information was received from the Commonwealth of Virginia by facsimile:
"On September 30, 2009 a patient was given a therapeutic dose of I-131(100 mCi) instead of a diagnostic dose as prescribed (4 mCi). The patient was previously given a therapeutic dose in August of 2008 and a follow up diagnostic visit was scheduled for September 30, 2009. During scheduling, the dose was incorrectly entered as therapeutic instead of diagnostic. The licensee notified the patient's physician and consulted with the patient. The licensee notified their risk management group and has begun an investigation into the event. The licensee was informed to provide RMP [Radioactive Materials Program] with a written report within 15 days.
"Event Report Number: VA-09-04."
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.
The following information was received from the Commonwealth of Virginia by facsimile:
"On September 30, 2009 a patient was given a therapeutic dose of I-131(100 mCi) instead of a diagnostic dose as prescribed (4 mCi). The patient was previously given a therapeutic dose in August of 2008 and a follow up diagnostic visit was scheduled for September 30, 2009. During scheduling, the dose was incorrectly entered as therapeutic instead of diagnostic. The licensee notified the patient's physician and consulted with the patient. The licensee notified their risk management group and has begun an investigation into the event. The licensee was informed to provide RMP [Radioactive Materials Program] with a written report within 15 days.
"Event Report Number: VA-09-04."
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.