Event Notification Report for March 24, 2005

UNANALYZED CONDITION RELATING TO THE INTEGRITY OF THE DIESEL GENERATOR EXHAUST STACKS DURING A TORNADO

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"While evaluating the capability of the plant to withstand a tornado it was identified that the Diesel Generator Exhaust Stacks may not maintain their design structural integrity. This would place the plant in an unanalyzed condition, however expert engineering judgment is that the damage to the Emergency Diesel Generator Exhausts would not reduce the capacity below that required to ensure decay heat removal. Currently the plant is in refueling shutdown and the Emergency Diesel Generators are not required to be operable per Technical Specifications. This condition will be corrected prior to plant startup. Power is still being supplied to the plant from the Reserve and Tertiary Auxiliary Transformers. This event was determined to be reportable per 10CFR50.73(a)(2)(ii)(B) and further review of the reporting criteria identified that if there is any doubt, this condition should be reported under 10CFR50.72(b)(3)(ii)(B).

"At the request of the Plant Manager at approximately 2100 on 3/25/05, the Shift Manger and Shift Technical Advisor independently reviewed the reporting criteria. Based on the statement in NUREG 1022, Rev 2, when applying engineering judgment and there is doubt regarding whether to report or not, the commission's policy is that the licensees should make the report, it was decided to report per 10CFR50.72."

The licensee has notified the NRC Resident Inspector.

REACTOR AUTOMATIC SCRAM DUE TO MAIN STEAM HIGH FLOW ISOLATION SIGNAL

The licensee provided the following information via email (licensee text in quotes):

"On 3/24/05 at approximately 0529 Unit 2 received a Group 1 isolation on main steam line high flow. All Group 1 valves closed as required and the reactor scrammed. The Isolation Condenser was manually initiated to control reactor pressure. Group 2 and 3 Containment Isolations occurred as expected. Investigation as to the cause of the Group 1 isolation is in progress.

"All systems responded as required with no abnormalities noted."

The licensee also indicated that a Main Turbine Generator EHC transient occurred at the time of the isolation. All control rods fully inserted, the electrical grid is stable, and decay heat is being removed via the Isolation Condenser System.

The licensee notified the NRC Resident Inspector.

UNUSUAL EVENT DECLARED DUE TO LOSS OF CONTROL ROOM ANNUNCIATORS

The licensee reported an Unusual Event following a loss of all control room overhead annunciators (per EAL 8.2.1). The cause of the loss of the overhead annunciators is still being investigated. The licensee states that the plant is stable with no other problems. This licensee plans to remain at 100% power while troubleshooting the condition.

The licensee has notified the NRC Resident Inspector, State , and local government agencies.

The NRC Resident Inspector in the control room provided some additional information related to this event (0820 EST). The condition was discovered during a routine lamp check of the annunciators. When the lamps failed to clear after the check, the licensee entered its abnormal operating procedure and discovered the problem. The licensee does have compensatory means of monitoring the alarms through a control room CRT display as well as a printer that registers alarms. The resident stated that the extent of the annunciator loss is unclear.

* * * UPDATE FROM LICENSEE (PRZEKOP) TO NRC (HUFFMAN) AT 10:55 EST ON 3/24/05 * * *

The licensee terminated from the Unusual Event at 10:50 EST. The licensee stated that the annunciator system has been repaired and reset and verified to be operable. No information on the specific nature of the problem or repairs affected to restore the system to operable was provided.

The NRC Resident Inspector, State, and local authorities have been notified by the licensee. R1DO (Rogge), NRR (Benner), IRD (Crlenjak), FEMA (DUNKET), and DHS (EVANS) were notified.

* * * UPDATE FROM LICENSEE (S. SAUER) TO NRC (J. KNOKE) AT 15:21 EST ON 3/24/05 * * *

UNUSUAL EVENT RETRACTED

The licensee faxed the following update:

"Upon further investigation and testing it was determined that the annunciator system was always functional; redundant capability of the annunciators was unavailable. Plant equipment information was always available to Operators during this time period (07:42 to present), and as such the emergency condition did not exist and the Unusual Event is retracted."

The NRC Resident Inspector, State, and local authorities will be notified by the licensee. Notified R1 (Rogge), IRD (Crlenjak), NRR (Berkow), FEMA (Dunket), and DHS (Evans).

MISSING SHIPMENT OF 105 BRACHYTHERAPY (I-125) SEEDS TOTALING 66 MILLICURIES

GE Healthcare, also known as Medi Physics, reported that a package of radioactive material had not been received as expected by Northwest Arkansas Medical Center in Springdale, Arkansas. The package, which contains 105 brachytherapy seeds, was to be delivered on Monday March 21, 2005. The seeds contain approximately 0.63 milliCi of activity each, with a total package activity of 66 milliCi. The maximum radiation level on the surface of the package is less than 0.5 milliR/hr.

The material was sent via FedEx on Friday March 18 and received at the FedEx facility in Tulsa, Oklahoma on March 19. No further information has been logged since. Medi Physics' customer service group has begun their investigation.

The Arkansas Division of Radiation Control has been advised of the situation.

IL report number: IL050022


*** UPDATE FROM STATE OF IL (G. VINSON) TO (J. KNOKE) AT 15:14 EST ON 3/25/05 ***

The State of IL, Division of Nuclear Safety, called to indicate the missing package containing 105 brachytherapy seeds was located in the Fed Express facility in Arkansas. The package, which was estimated to be found about 11:30 EST on 3/25/05, was intact and in its original condition. The licensee believes the missing package was in the possession of Fed Ex at all times, with no third party intervention. The brachytherapy seeds are being returned to G.E. Healthcare to determine that all seeds are accounted for and to further investigate how the package was lost within the Fed Ex system.

Notifications were given to R3 (Kozak), NMSS (Moore), and TAS (Sandler).

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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EQUIPMENT PIECE FOR STORAGE RACK NOT IN PLACE FOR SAFE STORAGE OF SNM

The following information was faxed by Nuclear Fuels Services:

"ACTUAL OR POTENTIAL HEALTH AND SAFETY CONSEQUENCES TO THE WORKERS, THE PUBLIC, AND THE ENVIRONMENT, INCLUDING RELEVANT CHEMICAL AND RADIATION DATA FOR ACTUAL PERSONNEL EXPOSURES TO RADIATION OR RADIOACTIVE MATERIALS OR HAZARDOUS CHEMICALS REPRODUCED FROM LICENSED MATERIALS

"There were no actual health and safety consequences to workers, the public, or the environment. There were also no personnel exposures to radiation, radioactive materials, or hazardous chemicals produced from licensed materials. The potential Nuclear Criticality Safety (NCS) consequences for workers were very low given the actual material storage conditions. No additional containers of SNM above the approved limit were stored in the storage racks and additional containers were specifically evaluated and determined to be subcritical.

"THE SEQUENCE OF OCCURRENCES LEADING TO THE EVENT, INCLUDING DEGRADATION OR FAILURE OF STRUCTURES, SYSTEMS, EQUIPMENT, COMPONENTS, AND ACTIVITIES OF PERSONNEL RELIED ON TO PREVENT POTENTIAL ACCIDENTS OR MITIGATE THEIR CONSEQUENCES:
"On March 24, 2005, a Nuclear Criticality Safety Engineer (NCSE) inspected a storage rack and observed that a piece of Configuration Controlled Equipment (CCE) was not in place. The piece of equipment is credited for preventing containers of SNM from being stored between approved storage positions. A posted Station Limit Card (SLC) instructs the operations personnel on the number and location where containers of SNM may be stored in the racks.

"DISCUSS WHETHER REMAINING STRUCTURES, SYSTEMS, EQUIPMENT COMPONENTS, AND ACTIVITIES RELIED ON TO PREVENT POTENTIAL ACCIDENTS OR MITIGATE THEIR CONSEQUENCES ARE AVAILABLE AND RELIABLE TO PERFORM THEIR FUNCTION:
"The remaining activities relied on to prevent potential accidents are available and reliable to perform their function. The storage requirements are posted via a Station Limit Card on the storage rack and no containers were observed to be stored in unapproved locations.

"ACTIONS TAKEN IN RESPONSE TO THE EVENT:
"The bottom two storage positions that could be involved were covered by signs instructing the operations personnel to not use them. The process engineer for the area was instructed to install the needed equipment to bring the storage rack into compliance. The event was entered into the PIRCS system (PIRCS ID 4704).

"SAFETY SIGNIFICANCE OF THE EVENT:
"The safety significance was very low for the event given that no violation of container storage was found. Containers of SNM were not stored in unapproved locations in the storage rack. More than one failure would have been necessary to be outside of the normal case configuration modeled in the Nuclear Criticality Safety Evaluation. The risk index could very easily have been written to credit additional limits and requirements that would have made this report unnecessary.

"BRIEF SCENARIO OF HOW A CRITICALITY COULD OCCUR:
"For a criticality to occur, multiple containers (more than two) would have had to have been stored incorrectly.

"WHAT ARE THE CONTROLS OR CONTROL SYSTEMS AND THE FAILURES OR DEFICIENCIES?
"The controls were equipment design to prevent containers of SNM from being stored between approved storage locations in a storage rack. The bottom of the storage rack had not been modified to prevent a container from being stored between approved storage locations.

"WHAT ARE THE CORRECTIVE ACTIONS TAKEN AN WHEN WAS EACH IMPLEMENTED?
"The storage positions involved at the bottom of the storage rack were taken out of service immediately on 3/24/2005. The process engineer for the area was immediately notified of the necessary modification to the equipment. The event was entered into the PII2CS system."


There was no exposure to personnel with this event.

The licensee notified the NRC Resident Inspector. No other notifications were issued.

* * * UPDATE 1030 EDT ON 4/6/05 FROM RANDY SHACKELFORD TO JEFF ROTTON * * *

NFS Erwin is retracting this report based on the following:

"On 3/24/2005, NFS made a 24-hour report to the operations center based on l OCFR70, Appendix A, Paragraph (a)(2). L OCFR70, Appendix A, Paragraph (a)(2) requires a 24hour report for loss or degradation of items relied on for safety (IROFS) that results in failure to meet the performance requirement of Sec. 70.61. The report was made because it was observed that a piece of configuration controlled equipment for a storage rack was not in place that would prevent containers from being stored between approved storage positions.

"The storage of containers between approved storage positions was bounded by the normal case Nuclear Criticality Safety (NCS) model; and, it was later determined that other IROFS listed in the ISA Summary were in place such that the performance requirements were met. This information was discussed and reviewed with an NRC Nuclear Criticality Safety (NCS) Inspector during the week of March 28, 2005. Based on this information and discussion with the NRC Inspector, it is requested that this event report be retracted."

Notified R2DO (Rodgers) and NMSS (Burgess).

* * * UPDATE ON 05/11/08 BY J KOZAL * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"Minimum Switchyard Voltage Requirements Not Met

"On March 24, 2005, at 0930 hours, Quad Cities was notified that the switchyard voltage was below that required to ensure that offsite power would remain available following a design basis accident. Both sources of off-site power were declared inoperable. The appropriate Technical Specification required actions were taken for both units. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"A preliminary engineering assessment indicates that one source of offsite power was available. Additional confirmatory reviews are being performed to determine if the safety function was preserved.

"At this time, grid/switchyard voltage has been restored."

Minimum switchyard voltage required is 348.4 KV. The analyzed minimum voltage which prompted notification to the NRC was 347.5 KV. Switchyard voltage at the time of this report was ~359 KV.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM C. STEFFES TO M. RIPLEY 1556 EDT 04/13/05 * * *

"The purpose of this report is to retract the following ENS reports: 1) ENS # 41524 on March 24, 2005; 2) ENS # 41562 on April 4, 2005; and 3) ENS # 41587 on April 11, 2005.

"These reports were made following notification to Quad Cities that the switchyard voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident. For each event, both sources of offsite power were declared inoperable, the appropriate Technical Specification required actions were taken for both units, and an ENS notification was made for a condition that could have prevented fulfillment of a safety function.

"The events occurred when Unit 1 was in a refueling outage and Unit 2 was operating at 85% power. Subsequent Engineering analysis has determined that with a unit shutdown, and the large 4 Kv loads on that unit not running, the required minimum post-accident switchyard voltage is reduced to 339.3 kV (for the shutdown unit). Given the new minimum post-accident switchyard voltage, it was confirmed that there was a source of off-site power available to the Station. Specifically for all three events, the projected post-accident switchyard voltage (which ranged between 343 kV to 347.5 kV) was higher than the required minimum post-accident switchyard voltage (339.3 kV) for the shutdown unit. As a result, there was no condition present that could have prevented fulfillment of a safety function, and thus these events are not reportable."

The licensee notified the NRC Resident Inspector. Notified R3 DO (J. Madera)

REACTOR COOLANT LEAKAGE OUTSIDE CONTAINMENT EXCEEDING DESIGN BASIS

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"This is an 8-hour notification being made to report exceeding the design basis for the reactor coolant leakage outside of containment. The event is being reported under paragraph (b)(3)(v) of 10CFR50.72. An event or condition that could have prevented mitigating the consequences of an accident.

"On 03/24/05 at 2015 operators discovered that a closed manual discharge valve for the positive displacement charging pump was leaking through allowing Reactor Coolant System to leak back to the refueling water storage tank. The leakage was 0.34 gallons per minute. This leakage is greater than the UFSAR limit for ECCS leakage outside containment.

"With leakage greater than the UFSAR allowed limits (greater than 3800 cc/hr), GDC-19 limits for control room habitability cannot be assured.

"Actions were taken and the leakage was stopped at 2040. The affected positive displacement charging pump is not a safety related pump and is not required for accident mitigation; however it is in the ECCS recirculation flow path during the cold leg injection phase of the accident mitigation.

"The licensee will notify the NRC Resident Inspector of this event."

The licensee will be notifying local authorities. The licensee reported that the event had no impact on Unit 1.