Event Notification Report for July 18, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/17/2005 - 07/18/2005
EVENT NUMBERS
4184841849418504185441905
Power Reactor
Event Number: 41848
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM BRITAIN
HQ OPS Officer: PETE SNYDER
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM BRITAIN
HQ OPS Officer: PETE SNYDER
Notification Date: 07/18/2005
Notification Time: 11:15 [ET]
Event Date: 07/18/2005
Event Time: 09:52 [EDT]
Last Update Date: 07/18/2005
Notification Time: 11:15 [ET]
Event Date: 07/18/2005
Event Time: 09:52 [EDT]
Last Update Date: 07/18/2005
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):
RICHARD CONTE (R1)
RICHARD CONTE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM
"Unit 1 reactor automatically scrammed at 09:52 as a result of an RPS Actuation following a main turbine trip caused by unit protection relaying. All control rods inserted. The plant is stable. No ECCS or SRV actuations occurred. This report is made pursuant to 50.72(b)(2)(iv)(B). An investigation into the cause is currently in progress."
The plant is currently stable in mode 3. No safety relief valves actuated. The current decay heat removal path is normal feedwater to the reactor steaming through the turbine bypass valves to the condenser. No other safety systems actuated. Electric power to the safety busses was supplied via normal offsite power. No bad weather conditions are present. Current reactor pressure is 900 psi with temperature at about 540 degrees. Currently troubleshooting is ongoing to investigate the cause of the trip. The licensee currently plans to stay in mode 3 until the investigation is complete. No safety related systems are currently out of service. There was no estimated restart date.
The licensee notified the NRC Resident Inspector.
"Unit 1 reactor automatically scrammed at 09:52 as a result of an RPS Actuation following a main turbine trip caused by unit protection relaying. All control rods inserted. The plant is stable. No ECCS or SRV actuations occurred. This report is made pursuant to 50.72(b)(2)(iv)(B). An investigation into the cause is currently in progress."
The plant is currently stable in mode 3. No safety relief valves actuated. The current decay heat removal path is normal feedwater to the reactor steaming through the turbine bypass valves to the condenser. No other safety systems actuated. Electric power to the safety busses was supplied via normal offsite power. No bad weather conditions are present. Current reactor pressure is 900 psi with temperature at about 540 degrees. Currently troubleshooting is ongoing to investigate the cause of the trip. The licensee currently plans to stay in mode 3 until the investigation is complete. No safety related systems are currently out of service. There was no estimated restart date.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 41849
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PETRA GEOTECHNICAL
Region: 4
City: YAKAIPA State: CA
County:
License #: 2933-30
Agreement: Y
Docket:
NRC Notified By: R. GREGOR
HQ OPS Officer: MIKE RIPLEY
Licensee: PETRA GEOTECHNICAL
Region: 4
City: YAKAIPA State: CA
County:
License #: 2933-30
Agreement: Y
Docket:
NRC Notified By: R. GREGOR
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/18/2005
Notification Time: 12:52 [ET]
Event Date: 07/18/2005
Event Time: 08:30 [PDT]
Last Update Date: 07/18/2005
Notification Time: 12:52 [ET]
Event Date: 07/18/2005
Event Time: 08:30 [PDT]
Last Update Date: 07/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY GODY (R4)
MICHELE BURGESS (NMSS)
TAS (EMAIL)
MEXICO (CNSNS)
ANTHONY GODY (R4)
MICHELE BURGESS (NMSS)
TAS (EMAIL)
MEXICO (CNSNS)
CALIFORNIA AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGES
The State provided the following information via email:
"At 0830 on July 18, 2005, [NAME DELETED], RSO for the licensee called to report that two model MC-3 gauges (each containing nominally 10 mCi of Cs-137 and 50 mCi of Am-241) were stolen from the secured temporary job storage site in Yucaipa, CA . There were three gauges at this site, but the model MC-1 gauge (an older gauge) was not taken. The licensee last saw these gauges when the job-site was shut down for the weekend, approximately 1700 on July 15, 2005. This morning [07/18/05], in preparation for returning to work, it was noted that two gauges were missing at approximately 0630-0700 hours [PDT]. The RSO is in transit to the job-site, to meet the local police, and will provide more details as he gets them. The licensee intends to post a reward in the Press-Enterprise newspaper in the Riverside area."
State 5010 Report No.: 071805
* * * UPDATE FROM STATE (GREGOR) TO M. RIPLEY 1839 EDT 07/18/05 * * *
The State provided the following information via email:
" The window in which the gauges were stolen was 7/16-18/05 instead of 7/15-18/05 as indicated on our form. Also, we have been informed that there was other construction equipment stolen in addition to the two gauges. We have been informed in the past by law enforcement in the area that there is a ring who apparently raids construction sites stealing construction materials for resale in Mexico. Don't know if this is the situation in this case."
Notified R4 DO (L. Smith), NMSS EO (Dan Gillen), TAS and Mexico CNSNS (email)
The State provided the following information via email:
"At 0830 on July 18, 2005, [NAME DELETED], RSO for the licensee called to report that two model MC-3 gauges (each containing nominally 10 mCi of Cs-137 and 50 mCi of Am-241) were stolen from the secured temporary job storage site in Yucaipa, CA . There were three gauges at this site, but the model MC-1 gauge (an older gauge) was not taken. The licensee last saw these gauges when the job-site was shut down for the weekend, approximately 1700 on July 15, 2005. This morning [07/18/05], in preparation for returning to work, it was noted that two gauges were missing at approximately 0630-0700 hours [PDT]. The RSO is in transit to the job-site, to meet the local police, and will provide more details as he gets them. The licensee intends to post a reward in the Press-Enterprise newspaper in the Riverside area."
State 5010 Report No.: 071805
* * * UPDATE FROM STATE (GREGOR) TO M. RIPLEY 1839 EDT 07/18/05 * * *
The State provided the following information via email:
" The window in which the gauges were stolen was 7/16-18/05 instead of 7/15-18/05 as indicated on our form. Also, we have been informed that there was other construction equipment stolen in addition to the two gauges. We have been informed in the past by law enforcement in the area that there is a ring who apparently raids construction sites stealing construction materials for resale in Mexico. Don't know if this is the situation in this case."
Notified R4 DO (L. Smith), NMSS EO (Dan Gillen), TAS and Mexico CNSNS (email)
Power Reactor
Event Number: 41850
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: MIKE RIPLEY
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/18/2005
Notification Time: 15:53 [ET]
Event Date: 07/18/2005
Event Time: 11:30 [EDT]
Last Update Date: 07/18/2005
Notification Time: 15:53 [ET]
Event Date: 07/18/2005
Event Time: 11:30 [EDT]
Last Update Date: 07/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAUL FREDRICKSON (R2)
PAUL FREDRICKSON (R2)
| 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 |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
ELECTRICAL ALIGNMENT RESULTS IN SINGLE FAILURE VULNERABILITY
"Event: Keowee Hydro Station provides emergency power to the three Oconee units via two independent emergency power paths designated as the Overhead Path and the Underground Path. Either of the two Keowee Hydro Units (KHU) can be dedicated to either path, and Keowee Operations rotates which unit is aligned to which path, nominally on a monthly basis. On 7-18-05, as part of a corrective action from a previous event, Oconee reviewed power configurations for Keowee components/circuits with alternate power sources and discovered an alignment which presented a single failure vulnerability which could impact both paths.
"A review of Keowee Operating Procedures revealed that KHU-1 was designated as the normal source for control relays associated with the overhead path regardless of which unit was aligned to the underground path. KHU-1 was currently aligned to the underground path. It was determined that a postulated single failure of that DC power source would prevent KHU-1 from starting (which would affect the underground path) and would also prevent the main output Air Circuit Breakers from closing in the overhead path.
"As a result, Operations declared entry at 1130 hours [EDT] into Technical Specification (TS) 3.8.1 condition C for the Overhead power path being inoperable (a 72 hour allowed completion time). A review of available information indicates that this condition has existed whenever KHU-1 was dedicated to the underground path. This condition is being reported as an unanalyzed condition per guidance in NUREG 1022 section 3.2.4.
"Initial Safety Significance: The postulated single failure has not occurred. If the postulated single failure occurred during a design basis event, it is expected that, without credit for Operator intervention, both KHUs would fail. Operations would have been able to realign the KHU-2 to the Underground path and/or to have started and aligned a combustion turbine at Lee Steam Station. Such actions would be adequate for LOOP and station blackout scenarios, but would not be adequate for LOCA/LOOP scenarios. Therefore, the potential single failure condition being reported could have potentially resulted in a loss of safety function.
"Corrective Action(s): The immediate corrective action was to realign the affected DC control circuit power source to KHU-2, which was aligned to the overhead Path. The TS condition was exited at 1200 hours [EDT] when this realignment was complete."
The licensee notified the NRC Resident Inspector.
"Event: Keowee Hydro Station provides emergency power to the three Oconee units via two independent emergency power paths designated as the Overhead Path and the Underground Path. Either of the two Keowee Hydro Units (KHU) can be dedicated to either path, and Keowee Operations rotates which unit is aligned to which path, nominally on a monthly basis. On 7-18-05, as part of a corrective action from a previous event, Oconee reviewed power configurations for Keowee components/circuits with alternate power sources and discovered an alignment which presented a single failure vulnerability which could impact both paths.
"A review of Keowee Operating Procedures revealed that KHU-1 was designated as the normal source for control relays associated with the overhead path regardless of which unit was aligned to the underground path. KHU-1 was currently aligned to the underground path. It was determined that a postulated single failure of that DC power source would prevent KHU-1 from starting (which would affect the underground path) and would also prevent the main output Air Circuit Breakers from closing in the overhead path.
"As a result, Operations declared entry at 1130 hours [EDT] into Technical Specification (TS) 3.8.1 condition C for the Overhead power path being inoperable (a 72 hour allowed completion time). A review of available information indicates that this condition has existed whenever KHU-1 was dedicated to the underground path. This condition is being reported as an unanalyzed condition per guidance in NUREG 1022 section 3.2.4.
"Initial Safety Significance: The postulated single failure has not occurred. If the postulated single failure occurred during a design basis event, it is expected that, without credit for Operator intervention, both KHUs would fail. Operations would have been able to realign the KHU-2 to the Underground path and/or to have started and aligned a combustion turbine at Lee Steam Station. Such actions would be adequate for LOOP and station blackout scenarios, but would not be adequate for LOCA/LOOP scenarios. Therefore, the potential single failure condition being reported could have potentially resulted in a loss of safety function.
"Corrective Action(s): The immediate corrective action was to realign the affected DC control circuit power source to KHU-2, which was aligned to the overhead Path. The TS condition was exited at 1200 hours [EDT] when this realignment was complete."
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 41854
Rep Org: ALABAMA RADIATION CONTROL
Licensee: INLAND DREDGING
Region: 1
City: JACKSON State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER
HQ OPS Officer: MIKE RIPLEY
Licensee: INLAND DREDGING
Region: 1
City: JACKSON State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/19/2005
Notification Time: 10:04 [ET]
Event Date: 07/18/2005
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2005
Notification Time: 10:04 [ET]
Event Date: 07/18/2005
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD CONTE (R1)
MICHELE BURGESS (NMSS)
RICHARD CONTE (R1)
MICHELE BURGESS (NMSS)
ALABAMA AGREEMENT STATE REPORT - IMPROPER USE AND SHIPMENT OF NUCLEAR GAUGE
The State provided the following information via facsimile:
"Description of Event: A dredging company using GL devices in Alabama illegally, removed and shipped a device containing a 200 milliCuries cesium 137 source to Ronan Engineering Company in Kentucky for repair. The shutter was not locked in the closed position. The owner had painted over the marking and labeling on the source holder so that they were illegible. The dredging company has hired a consultant to reconstruct the incident and try to determine any possible exposures received.
"Additional information will be submitted after the investigation is completed."
The following, additional information was obtained from the State via telephone:
Dredging Company: Inland Dredging, Co. based in Dyersberg, TN, doing work in the vicinity of Jackson, AL
The gauge is currently at Ronan Engineering Co., Florence, KY
Event date is unknown, but the State was notified on the evening of 7/18/05.
* * * UPDATE PROVIDED BY DAVID WALTER (STATE OF ALABAMA) TO JEFF ROTTON VIA FAX AT 1623 EDT ON 08/05/05 * * *
The State provided the following information via facsimile:
"The general licensee stated that they had closed the shutter and placed a bolt through the mechanism to lock it closed. [The general licensee] then removed the device and prepared it for delivery to Ronan Engineering Company via truck. [The general licensee] contends that the shutter handle was broken during shipping. [The general licensee] further states that they had removed the paint from the identification placard on the source head. When [the general licensee] prepared the unit, they stated they bolted the source head to the detector head. This resulted in minimal access to the beam port. Ronan performed a survey of the device, and found maximum exposure readings of 1.5 mrem/hour at 1 meter.
"During shipping, the device went through five transport terminals, and appears to have been transferred to different trucks in each terminal.
"An Alabama licensee authorized to service industrial gauges has been contracted to investigate the incident. This company is traveling to Ronan to obtain further information, and has set up interviews with personnel at the transport terminals."
Notified the R1DO (Gray) and NMSS EO (Moore).
The State provided the following information via facsimile:
"Description of Event: A dredging company using GL devices in Alabama illegally, removed and shipped a device containing a 200 milliCuries cesium 137 source to Ronan Engineering Company in Kentucky for repair. The shutter was not locked in the closed position. The owner had painted over the marking and labeling on the source holder so that they were illegible. The dredging company has hired a consultant to reconstruct the incident and try to determine any possible exposures received.
"Additional information will be submitted after the investigation is completed."
The following, additional information was obtained from the State via telephone:
Dredging Company: Inland Dredging, Co. based in Dyersberg, TN, doing work in the vicinity of Jackson, AL
The gauge is currently at Ronan Engineering Co., Florence, KY
Event date is unknown, but the State was notified on the evening of 7/18/05.
* * * UPDATE PROVIDED BY DAVID WALTER (STATE OF ALABAMA) TO JEFF ROTTON VIA FAX AT 1623 EDT ON 08/05/05 * * *
The State provided the following information via facsimile:
"The general licensee stated that they had closed the shutter and placed a bolt through the mechanism to lock it closed. [The general licensee] then removed the device and prepared it for delivery to Ronan Engineering Company via truck. [The general licensee] contends that the shutter handle was broken during shipping. [The general licensee] further states that they had removed the paint from the identification placard on the source head. When [the general licensee] prepared the unit, they stated they bolted the source head to the detector head. This resulted in minimal access to the beam port. Ronan performed a survey of the device, and found maximum exposure readings of 1.5 mrem/hour at 1 meter.
"During shipping, the device went through five transport terminals, and appears to have been transferred to different trucks in each terminal.
"An Alabama licensee authorized to service industrial gauges has been contracted to investigate the incident. This company is traveling to Ronan to obtain further information, and has set up interviews with personnel at the transport terminals."
Notified the R1DO (Gray) and NMSS EO (Moore).
General Information or Other
Event Number: 41905
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: BILL GOTT
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: BILL GOTT
Notification Date: 08/09/2005
Notification Time: 15:57 [ET]
Event Date: 07/18/2005
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2005
Notification Time: 15:57 [ET]
Event Date: 07/18/2005
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN CARUSO (R1)
JOHN HICKEY (NMSS)
JOHN CARUSO (R1)
JOHN HICKEY (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via facsimile:
"Treatment delivered to two (2) of seven (7) lesions on a patient on 18 July 2005, were discovered to be 50 percent less dose than that prescribed. (15 Gy (Grey) per lesion prescribed; two lesions received only 7.5 Gy each) This was discovered [on 3 August 2005], during an internal audit of treatments, conducted by medical physicist not originally involved with treatment. To date the investigation does not identify a problem with the equipment or the dose programs involved in planning. Initial indicators point to a potential communication problem between the original medical physicist and oncologist. At this time the investigation is pending due to the unavailability of the medical physicist due to vacation. Resumption of the investigation is to commence on or about 9 August 2005 when persons involved have returned from vacation."
RI Event Report ID: RI-05-003
The State provided the following information via facsimile:
"Treatment delivered to two (2) of seven (7) lesions on a patient on 18 July 2005, were discovered to be 50 percent less dose than that prescribed. (15 Gy (Grey) per lesion prescribed; two lesions received only 7.5 Gy each) This was discovered [on 3 August 2005], during an internal audit of treatments, conducted by medical physicist not originally involved with treatment. To date the investigation does not identify a problem with the equipment or the dose programs involved in planning. Initial indicators point to a potential communication problem between the original medical physicist and oncologist. At this time the investigation is pending due to the unavailability of the medical physicist due to vacation. Resumption of the investigation is to commence on or about 9 August 2005 when persons involved have returned from vacation."
RI Event Report ID: RI-05-003