Event Notification Report for February 19, 2009

POWER SUPPLY FAILURE RESULTING IN A TECH SPEC REQUIRED SHUTDOWN

"The plant was operating in MODE 1 at 100% power. At 0228 on 2/19/09, a power supply to cabinet SA036D, Channel 1 of the Engineered Safety Features Actuation System (ESFAS) failed. As a result of the failure, both trains of control room ventilation isolation signal (CRVIS), containment purge isolation signal (CPIS), and fuel building isolation signal (FBIS) inadvertently actuated. The cause of the failure of SA036D is under investigation. Technical Specification (TS) Action 3.3.2.Q was entered which requires the plant to be in MODE 3 in 6 hours and MODE 4 in 12 hours. Load reduction began at 0530. MODE 2 was entered at 0750. MODE 3 was entered at 0817.

"All systems functioned properly.

"The NRC Resident Inspector has been notified."

The licensee is replacing the entire power supply and will investigate the cause.

UNUSUAL EVENT DECLARED DUE TO MAIN GENERATOR HYDROGEN GAS LEAK

"An Unusual Event was declared at 1021 CST due to toxic, corrosive, flammable gasses in amounts that have or could adversely affect normal plant operations. Licensee estimated that a plume of hydrogen gas 20 feet high was leaking in the Turbine Building at the North Generator Bearing. Licensee entered EAL HU3.1. There was no release above normal operating limits (0.1 Mr/hr at EAB). No offsite response required. Gas is being dissipated via emergency degassing of Main Generator. Presently, the Main Generator degas has been completed and no flammable environments remain. The Unusual Event will stay in effect until the area is accessible to personnel, as evaluated by chemistry."

There was no fire or personnel injury related to this event. The Plant was already in Mode 3 due to an earlier event requiring a Technical Specification Action 3.3.2.Q shutdown.

The licensee has notified the NRC Resident Inspector, and local, state and other government agencies. No media press release was anticipated.

* * * UPDATE FROM DAVID HURT TO JOHN KNOKE AT 1255 EST ON 02/19/09 * * *

"The hazard was eliminated by 1055 on 2/19/2008. The Unusual Event was closed out at 1115. The state and counties (Callaway, Gasconade, Montgomery, and Osage) were notified of the event closeout at 1126. A news release will be made by Ameren Corporate Communications."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Powers), DHS ( Cassandra McKentry) and FEMA (Mike Eaches).

INJURED WORKER TRANSPORTED TO OFFSITE MEDICAL FACILITY

"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 February 19, 2009, at approximately 11:20 Mountain Standard Time (MST), an employee of Arizona Public Service (APS) was injured while working at the Palo Verde Independent Spent Fuel Storage Installation (ISFSI) which is considered to be a radiologically controlled area (RCA). The ISFSI is located within the owner controlled area but outside the plant's protected area. The ISFSI has been evaluated as having a very low probability for contamination, so administrative controls are used to allow workers access into the ISFSI and return to the appropriate Unit RCA egress point located in the protected area where personnel monitoring for contamination is performed prior to leaving the site. Upon exiting the ISFSI area, the individual was initially transported to the Palo Verde Medical Clinic to attend to the injury. Subsequently, the individual was transported to an offsite medical facility for further evaluation. The individual was not monitored for contamination prior to being transported offsite. The individual and the transporting vehicle were frisked offsite and found to be free of contamination. There were no exposures from licensed material and no consequence to the public or environment."

Injured person was an employee of licensee. Employee was transported to the hospital via private owned vehicle.

The NRC Resident Inspector was notified.

IMPROPERLY PACKAGED RADIOACTIVE MATERIAL

The following was provided by the state via email:

"A single Cs-131 Brachytherapy seed was put back into the 'mick' cartridge by Banner Baywood Medical Center in Mesa, AZ, - the medical customer and end-user - and then returned to the manufacturer, IsoRay, a Washington State seed manufacturing licensee. When the shipping container, holding the mick container, arrived at IsoRay, contamination was found on the inside of the shipping container but not on the outside. There was no damage to the shipping container.

"While unpacking the seed, a technician noticed there was visible damage to the seed. The tech monitored the packing material and found contamination. The RSO determined that a few microcuries of radioactive material leaked onto the packing material. The remaining millirem of material was in the damaged source and the pig. No material was missing. IsoRay called Washington State, Office of Radiation Protection, and reported the event that day.

"There was no contamination found at the customer's site. IsoRay's Radiation Safety Officer reported that the seed had been visibly damaged, as if sheared. This may have happened when it was returned to the mick container or when the mick cartridge was re-inserted into the pig. Since all the contamination was inside the shipping container, it is doubtful that any personnel exposure was received.

"The cartridge was a Mick Radio-Nuclear Instruments, Inc catalog number 0216-DS. The SS&D registration for the seed is WA-1220-S-101-S."

Incident Number: WA-09-006

AGREEMENT STATE REPORT - EQUIPMENT FAILURE / RADIOGRAPHY SOURCE DISCONNECT

The following was received from the Commonwealth via e-mail:

"DEP [Department of Environmental Protection] received a letter dated March 9, 2009 from Acuren describing the incident. It was received March 16, 2009.

"Event Description: A technician was performing radiography in Erie, PA (Booth #2) at 8:55am. A few seconds after his fourth exposure, the technician heard the spool piece fall off the table. He immediately tried to retract the source but was unsuccessful. The RSO traveled to the facility, calculated the exposure rates and executed a safe retrieval of the source. He received 35 mrem of exposure during the retrieval. The damaged guide tube was disposed. A 1.75" lead sheet was used to shield the source while the guide tube was reshaped to allow a safe retrieval to the secured position. A whole body dose of 32 mrem was received by retrieval technician.

"Causes of the event: Spool piece was not properly secured in a safe position on the table. Piece was not properly blocked or braced, and located too close to the end of the table, so any movement would result in a fall. The jack stands that were available were not used, nor was shooting the parts on the floor considered. Guide tube and camera were not properly positioned to avoid contact with falling spool piece."

Event Report ID No, PA090016