Event Notification Report for June 18, 2006

DAMAGED MOISTURE DENSITY GAUGE

While performing back-scatter measurements at a construction site on I-75 between Davison Freeway and I-94 in Wayne County, MI, a Model 3440 Troxler moisture density gauge (8 millicuries Cs-137, 40 millicuries Am-241:Be) belonging to the department was damaged when it was run over by a truck. The gauge was returned to the department office and survey results, pending a leak test on Monday 06/19, were negative indicating the sources remained intact. The licensee notified the NRC Resident Inspector.

LOSS OF ONSITE EMERGENCY SAFETY FUNCTION - "B" EDG FAILED TO START DURING TEST RUN

"The following event description is based on information currently available. If through subsequent reviews of this
event, additional information is identified that is pertinent to this event or alters the information being provided at this
time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On June 18, 2006, at approximately 1455 Mountain Standard Time (MST), Palo Verde Nuclear Generating Station
Unit 1 was operating at 0% power in Mode 6 with the 'A' Emergency Diesel Generator (EDG) inoperable for troubleshooting of the train 'A' load sequencer, The 'B' EDG failed to start during a test run resulting in a loss of the onsite emergency power safety function required by General Design Criterion (GDC) 17. The offsite power source safety function remains available to the plant.

"The unit entered Technical Specification 3.8.2, AC Sources - Shutdown Condition B for one required DG inoperable.
There was no movement of irradiated fuel assemblies, therefore the unit remained in compliance with the Required
Actions. The offsite electrical grid is stable.

"At 1810 MST the 'A' EDG was declared operable, exiting Technical Specification 3.8.2. With the 'A' EDG operable,
the safety function for the onsite emergency power was also restored.

"There were no structures, systems or components that were inoperable at the start of event that contributed to the
event. This condition did not result in any challenges to the fission product barrier or result in any releases of
radioactive materials. There were no adverse safety consequences or implications as a result of this event. This
condition did not adversely affect the safe operation of the plant or health and safety of the public.

"The NRC Resident Inspector has been notified of this condition and this ENS notification."


* * * RETRACTION RECEIVED VIA E-MAIL FROM DAN HAUTALA TO JOE O'HARA AT 1702 ON 7/5/06 * * *

" Further evaluation has determined that this event is not reportable. In the 'test' mode, an 'Incomplete Sequence' trip is enabled and functions on an engine start to trip the engine if starting air is not terminated within 15 seconds. Due to a delay in opening the engine fuel racks by the test mode pneumatic control valve loop, the 'Incomplete Sequence' trip actuated. During an emergency start, the electrically operated emergency fuel solenoids control the operation of the engine fuel racks and the 'Incomplete Sequence' trip function is bypassed. Engineering evaluation found none of the equipment required to operate the 'B' EDG in the emergency mode degraded or malfunctioning. The 'B' EDG was still capable of performing its design function and was 'OPERABLE'. Additionally, it was determined that the 'A' EDG was fully functional and in a standby condition, capable of performing its design function at the time the 'B' EDG test run trip occurred.

"Therefore, this condition is not reportable per 10CFR50.72(2)(b)(v)(B) or (2)(b)(v)(D)."

The licensee notified the NRC Resident Inspector. R4DO(Pick) has been notified.

RADIATION MONITOR SPIKED THREE TIMES

"At 2319 on 06/18/2006, the 'A' Plenum Radiation Monitor spiked high which resulted in the closure of the Drywell CAM (Continuous Air Monitor) and the Oxygen Analyzer Primary Containment Isolation Valves. The spike's (3) of approx. 30 Mr/HR occurred during this event. The valves isolated once, the Reactor Building Ventilation trip was reset once and re-isolation occurred several minutes later from another spike on the Rad Monitor. Trip setpoint is 26 Mr/hr. The Plenum high Rad signal also resulted in Reactor Building isolation (twice), start of 'A' Standby Gas Treatment, and transfer of the Control Room Ventilation to the high Rad Mode. The 'B' Plenum Rad Monitor remained constant at 1.3 Mr/hr. The Reactor Building Ventilation and Control Room Ventilation have been reset and Standby Gas Treatment has been secured. The 'A' Plenum Radiation Monitor has been declared inoperable."

Instrument & Control Technicians are currently troubleshooting the problem associated with the 'A' Plenum Radiation Monitor.

The NRC Resident Inspector's have been left messages by the licensee.

* * * UPDATE AT 10:15 ON 8/3/2006 FROM ROBERT SCHREIFELS TO ABRAMOVITZ * * *

This report is being reclassified by the licensee from a 50.72(b)(3)(iv)(A) [valid system actuation] to 50.73(a)(2)(iv)(A) [invalid system actuation].

"Based on further investigation, Monticello has determined that the actuation signal was due to a failed microswitch and therefore was not a valid signal. Because the actuation signal was not valid, Monticello is retracting the initial event report and instead reporting this event as an unplanned system actuation under 50.73(a)(2)(iv)(A). This report will be made in lieu of reporting the event as an LER.

"In accordance with 50.73(a)(2)(iv)(A):

"This report is not considered an LER and the report is being made under 50.73(a)(2)(iv)(A). The original event report (ENS #42652) detailed the systems affected, whether the actuation was complete or partial and whether each affected system started and functioned successfully.

"The cause of the invalid signal was the failure of the trip check pushbutton [micro]switch due to age related degradation. The switch has been replaced and the 'A' Plenum Radiation Monitor was returned to service."

The licensee notified the NRC Resident Inspector.

Notified the R3DO (O'Brien).

AGREEMENT STATE - MISPLACED SOURCE

"At 0634 hrs on June 20, 2006, [the Director of the Texas Department of Health] received a call on the way to the office from the Director of Radiology for Ben Taub General Hospital in Houston, TX. He relayed brief details of a recovered source that was either taken out of a patient or never placed in an after loading appliance utilized for the treatment of a cervical cancer patient. In the words of the Radiation Safety Officer with proper names redacted:

"On Sunday, June 18, 2006 at 4:40 am a Cesium-137 source, 3M model 6501(6D6C-CA), serial # 06965, with an activity of approximately 17 mCi [milliCuries] was noted to be missing from a patient who was undergoing a tandem and ovoid implant for cervical cancer. The patient had applicator placement (uterine tandem and two Fletcher ovoids) at Ben Taub General Hospital (BTGH), on Friday 6/16/2006. The Cesium sources (4 in all; 2 in the tandem and 1 each in the ovoid) had been placed in the patient by the Radiation Oncologist at 3:40 pm for a 37 hour implant. When the right ovoid source was noted to be missing at the time of unloading; the patient, room, Nursing Unit 6B of the hospital, and the route of transport of the sources from the BTGH Radiotherapy Department to the patient's room were surveyed using both a sodium iodide detector and a conventional air-ionization type survey meter by both the Radiation Oncologist and Medical Physicist. The BTGH Radiation Safety Officer was notified at 8:20 am Sunday morning of the apparent missing source. Upon further investigation, it was learned that the bed sheets of the patient had been changed at 3 pm on Saturday, 6/17/2006, and this dirty linen was placed in the linen cart on 6B. It was subsequently taken to a truck at the BTGH loading dock and transported to the Texas Medical Center Laundry facility. On Monday morning, 6/19/06, the director of this facility was contacted and subsequently the facility was surveyed. The Cs-137 source was recovered at 10:30 a.m., from the third floor and transported back to the BTGH Radiotherapy Department using an appropriately shielded container.

"The names of all the persons who potentially may have come into contact with the Cesium source were obtained and notified. This list included thirty-five [35] individuals of both hospital and laundry services personnel.

"Upon further review by staff in assembling the documents for the incident file, the attachments to the June 26, 2006 e-mail was examined at 1400hrs on July 7, 2006. At that time DSHS staff realized that this was a lost/found source with quantities >1,000 X Appendix C value requiring immediate reporting to NMED. However, staff reviewed the operational setting and in the absence of the licensee's report demonstrating an exposure exceeding of 100mrem to a member of the public, the incident may not be reportable. Further investigation is on-going."

Texas Incident: I-8350