Event Notification Report for March 26, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/25/2009 - 03/26/2009
EVENT NUMBERS
4493844934449354493645125
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 44938
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: GARY AHRENS
HQ OPS Officer: PETE SNYDER
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: GARY AHRENS
HQ OPS Officer: PETE SNYDER
Notification Date: 03/26/2009
Notification Time: 19:43 [ET]
Event Date: 03/26/2009
Event Time: 12:26 [CDT]
Last Update Date: 09/09/2009
Notification Time: 19:43 [ET]
Event Date: 03/26/2009
Event Time: 12:26 [CDT]
Last Update Date: 09/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
HIRONORI PETERSON (R3)
HIRONORI PETERSON (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 94 | Power Operation |
NON-FUNCTIONAL STEAM EXCLUSION BARRIER
This event was additionally reported under 10 CFR 50.72(b)(3)(v)(D), 'Mitigate the Consequences of an Accident.'
"On 03/26/2009 at 1226 CDT, an engineering analysis determined that a steam exclusion door would not provide adequate steam exclusion protection. A metal plate, that had been installed over the door's glass window, would fail under the steam overpressure postulated during a high energy line break. The metal plate was replaced with one of a stronger design. Permanent repairs were completed on the door at 1549 on 03/26/2009. While the original plate was installed, the barrier was non-functional. In accordance with TRM 3.0.9, Section A.1 all equipment supported by that steam exclusion barrier was immediately declared inoperable. This zone includes both trains of ECCS and support equipment (i.e., SI, RHR, ICS, CCW, etc.). TS 3.0.c was entered and exited during the time the door issue was identified and repaired.
"All 3 trains of Auxiliary Feedwater were declared inoperable due to AFW low suction pressure trip channels were declared inoperable per TS 3.4.b.5. Power was reduced to less than 1673 MWt per TS 3.4.b.3. All mode changes were suspended per TS 3.4.b.2.
"Therefore, this is reportable under 10 CFR 50.72 (b)(3)(v), 'Any event or condition that at the time of discovery could have prevented the fulfillment of a safety function,' and under 10 CFR 50.72(b)(3)(ii)(B) 'any event or condition that results in the nuclear plant being in an unanalyzed condition that significantly degrades plant safety.'"
Containment Fan Coil Unit A was not operational during this event.
"The licensee notified the NRC Resident Inspector."
* * * RETRACTION FROM JACK GADZALA TO PETE SNYDER ON 9/9/09 AT 1718 * * *
"On March 26, 2009 EN # 44938 provided notification that both trains of ESF equipment (e.g. SI, RHR, ICS, CCW, etc.) were inoperable based on an engineering analysis, which determined that a steam exclusion door in the auxiliary building would not provide adequate steam exclusion protection.
"Subsequent physical pressure testing of equivalent doors and engineering evaluation of the test results determined that the door remained capable of fulfilling its steam exclusion function. A series of pressure tests demonstrated that the door (including a metal plate that had been installed over the door's glass window) would withstand the steam overpressure postulated during a high energy line break.
"Therefore, the door remained functional and the supported ESF equipment in the auxiliary building remain operable. Consequently, this condition did not meet the reportability criteria in 10 CFR 50.72.
"As a result, the notification made on 3/26/09 is hereby retracted.
"This condition was also reported in Licensee Event Report (LER) 2009-005-00 on May 21, 2009." The licensee is planning on retracting this LER.
This event was additionally reported under 10 CFR 50.72(b)(3)(v)(D), 'Mitigate the Consequences of an Accident.'
"On 03/26/2009 at 1226 CDT, an engineering analysis determined that a steam exclusion door would not provide adequate steam exclusion protection. A metal plate, that had been installed over the door's glass window, would fail under the steam overpressure postulated during a high energy line break. The metal plate was replaced with one of a stronger design. Permanent repairs were completed on the door at 1549 on 03/26/2009. While the original plate was installed, the barrier was non-functional. In accordance with TRM 3.0.9, Section A.1 all equipment supported by that steam exclusion barrier was immediately declared inoperable. This zone includes both trains of ECCS and support equipment (i.e., SI, RHR, ICS, CCW, etc.). TS 3.0.c was entered and exited during the time the door issue was identified and repaired.
"All 3 trains of Auxiliary Feedwater were declared inoperable due to AFW low suction pressure trip channels were declared inoperable per TS 3.4.b.5. Power was reduced to less than 1673 MWt per TS 3.4.b.3. All mode changes were suspended per TS 3.4.b.2.
"Therefore, this is reportable under 10 CFR 50.72 (b)(3)(v), 'Any event or condition that at the time of discovery could have prevented the fulfillment of a safety function,' and under 10 CFR 50.72(b)(3)(ii)(B) 'any event or condition that results in the nuclear plant being in an unanalyzed condition that significantly degrades plant safety.'"
Containment Fan Coil Unit A was not operational during this event.
"The licensee notified the NRC Resident Inspector."
* * * RETRACTION FROM JACK GADZALA TO PETE SNYDER ON 9/9/09 AT 1718 * * *
"On March 26, 2009 EN # 44938 provided notification that both trains of ESF equipment (e.g. SI, RHR, ICS, CCW, etc.) were inoperable based on an engineering analysis, which determined that a steam exclusion door in the auxiliary building would not provide adequate steam exclusion protection.
"Subsequent physical pressure testing of equivalent doors and engineering evaluation of the test results determined that the door remained capable of fulfilling its steam exclusion function. A series of pressure tests demonstrated that the door (including a metal plate that had been installed over the door's glass window) would withstand the steam overpressure postulated during a high energy line break.
"Therefore, the door remained functional and the supported ESF equipment in the auxiliary building remain operable. Consequently, this condition did not meet the reportability criteria in 10 CFR 50.72.
"As a result, the notification made on 3/26/09 is hereby retracted.
"This condition was also reported in Licensee Event Report (LER) 2009-005-00 on May 21, 2009." The licensee is planning on retracting this LER.
Power Reactor
Event Number: 44934
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Notification Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVEN VIAS (R2)
MARY JANE ROSS-LEE
ANTHONY McMURTRAY (IRD)
STEVEN VIAS (R2)
MARY JANE ROSS-LEE
ANTHONY McMURTRAY (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 97 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP AND AUX FEED WATER START DUE TO LOSS OF AN OFF SITE POWER SOURCE
"At approximately 0452 on 03/26/09, Sequoyah Unit 1 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 1B and 1D Unit Boards. The 1B and 1D unit boards are the 6.9Kv electrical feeds to the 1-2 and 1-4 RCPs, respectively. RCPs 1-1 and 1-3 are running.
"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 1A Shutdown Board is being powered from the 1A EDG.
"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.
"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."
All rods inserted as expected. No safety related equipment is out of service. Unit 1 has no known Steam Generator Tube leaks.
The licensee notified the NRC Resident Inspector.
"At approximately 0452 on 03/26/09, Sequoyah Unit 1 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 1B and 1D Unit Boards. The 1B and 1D unit boards are the 6.9Kv electrical feeds to the 1-2 and 1-4 RCPs, respectively. RCPs 1-1 and 1-3 are running.
"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 1A Shutdown Board is being powered from the 1A EDG.
"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.
"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."
All rods inserted as expected. No safety related equipment is out of service. Unit 1 has no known Steam Generator Tube leaks.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 44935
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Notification Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVEN VIAS (R2)
MARY JANE ROSS-LEE (NRR)
ANTHONY McMURTRAY (IRD)
STEVEN VIAS (R2)
MARY JANE ROSS-LEE (NRR)
ANTHONY McMURTRAY (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP AND AUX FEED WATER START DUE TO LOSS OF AN OFF SITE POWER SOURCE
"At approximately 0452 on 03/26/09, Sequoyah Unit 2 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 2B and 2D Unit Boards. The 2B and 2D unit boards are the 6.9Kv electrical feeds to the 2-2 and 2-4 RCPs, respectively. RCPs 2-1 and 2-3 are running.
"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 2A Shutdown Board is being powered from the 2A EDG.
"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.
"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."
All rods inserted as expected. No safety related equipment is out of service. Unit 2 has no known Steam Generator Tube leaks.
The licensee notified the NRC Resident Inspector.
"At approximately 0452 on 03/26/09, Sequoyah Unit 2 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 2B and 2D Unit Boards. The 2B and 2D unit boards are the 6.9Kv electrical feeds to the 2-2 and 2-4 RCPs, respectively. RCPs 2-1 and 2-3 are running.
"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 2A Shutdown Board is being powered from the 2A EDG.
"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.
"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."
All rods inserted as expected. No safety related equipment is out of service. Unit 2 has no known Steam Generator Tube leaks.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 44936
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: HILL BROTHERS CONSTRUCTION COMPANY, INC.
Region: 4
City: TALLULAH State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: PETE SNYDER
Licensee: HILL BROTHERS CONSTRUCTION COMPANY, INC.
Region: 4
City: TALLULAH State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/26/2009
Notification Time: 14:58 [ET]
Event Date: 03/26/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/26/2009
Notification Time: 14:58 [ET]
Event Date: 03/26/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL OKEEFE (R4)
ANGELA MCINTOSH (FSME)
NEIL OKEEFE (R4)
ANGELA MCINTOSH (FSME)
TROXLER MOISTURE DENSITY GAUGE DAMAGED AT CONSTRUCTION SITE
The following information was received from the State of Louisiana by Fax:
"On March 21, 2009, a soil moisture/density gauge operated by the licensee under radioactive material (RAM) reciprocity was struck by the axle of a moving pick-up truck while the source was fully extended into the soil and while soil measurements were being performed. During an initial phone interview with the gauge operator, he stated that the gauge plunger handle had been damaged. The operator stated that the source rod might have been bent during this incident.
"The gauge operator was able to retract the source into the shielded position. Radiation readings were taken through the entire process. The gauge operator stated that he succeeded in padlocking the source rod plunger handle with the source rod in the fully upright position even though the plunger handle had been partially damaged. The operator then secured the gauge in its transportation case and performed a survey of the transportation case.
"The operator stated that he got a highest reading of 1 mR/hr at the case surface on the side next to the base of the gauge. The gauge case was resurveyed before placing the gauge back into storage in the licensee's source vault. A leak test was performed but the results are not available at this time.
"The gauge is a Troxler Model 3440, serial #31096, containing 8 mCi of Cs-137, serial # 750-5735 and a 40 mCi source of AmBe241,serial #47À3180.
"Additional information will be forwarded once it is received. An inspector was sent to the temporary jobsite on March 25, 2009 to verify this information."
Louisiana Event Report ID: LA090010.
The following information was received from the State of Louisiana by Fax:
"On March 21, 2009, a soil moisture/density gauge operated by the licensee under radioactive material (RAM) reciprocity was struck by the axle of a moving pick-up truck while the source was fully extended into the soil and while soil measurements were being performed. During an initial phone interview with the gauge operator, he stated that the gauge plunger handle had been damaged. The operator stated that the source rod might have been bent during this incident.
"The gauge operator was able to retract the source into the shielded position. Radiation readings were taken through the entire process. The gauge operator stated that he succeeded in padlocking the source rod plunger handle with the source rod in the fully upright position even though the plunger handle had been partially damaged. The operator then secured the gauge in its transportation case and performed a survey of the transportation case.
"The operator stated that he got a highest reading of 1 mR/hr at the case surface on the side next to the base of the gauge. The gauge case was resurveyed before placing the gauge back into storage in the licensee's source vault. A leak test was performed but the results are not available at this time.
"The gauge is a Troxler Model 3440, serial #31096, containing 8 mCi of Cs-137, serial # 750-5735 and a 40 mCi source of AmBe241,serial #47À3180.
"Additional information will be forwarded once it is received. An inspector was sent to the temporary jobsite on March 25, 2009 to verify this information."
Louisiana Event Report ID: LA090010.
General Information or Other
Event Number: 45125
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: MERCY FITZGERALD HOSPITAL
Region: 1
City: DARBY State: PA
County:
License #: PA-0082
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Licensee: MERCY FITZGERALD HOSPITAL
Region: 1
City: DARBY State: PA
County:
License #: PA-0082
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/11/2009
Notification Time: 21:00 [ET]
Event Date: 03/26/2009
Event Time: 00:00 [EDT]
Last Update Date: 06/11/2009
Notification Time: 21:00 [ET]
Event Date: 03/26/2009
Event Time: 00:00 [EDT]
Last Update Date: 06/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1DO)
ANDREA KOCK (FSME)
RONALD BELLAMY (R1DO)
ANDREA KOCK (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN UNDERDOSE DUE TO TECHNICIAN ERROR
The following information was received via fax:
"Event Report ID No: PA090015
"License No: PA-0082
"Licensee: Mercy Fitzgerald Hospital
"Event date and time: March 26, 2009/time unknown
"Event location: Mercy Fitzgerald Hospital Lansdowne & Baily Rds., Darby, PA
"Event type: Medical Event
"Notifications: A letter dated April 9, 2009 was sent to DEP
"Event description: Under dose for a Sr-90 eye applicator
"City, State: Darby, PA
"Description: PA DEP Bureau of Radiation Protection was notified in writing, dated April 9, 2009, by the Radiation Safety Officer for Mercy Fitzgerald Hospital. An ADCL calibrated Sr-90 ophthalmic applicator was used on a patient for an external eye application for the treatment of pterygium. The guard ring needed to be removed before treatment and was not, hence only delivered 5% of the prescribed dose to the patient.
"The State has an inspection scheduled and will continue to keep NRC informed of the status of our investigation."
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 via fax:
"Event Report ID No: PA090015
"License No: PA-0082
"Licensee: Mercy Fitzgerald Hospital
"Event date and time: March 26, 2009/time unknown
"Event location: Mercy Fitzgerald Hospital Lansdowne & Baily Rds., Darby, PA
"Event type: Medical Event
"Notifications: A letter dated April 9, 2009 was sent to DEP
"Event description: Under dose for a Sr-90 eye applicator
"City, State: Darby, PA
"Description: PA DEP Bureau of Radiation Protection was notified in writing, dated April 9, 2009, by the Radiation Safety Officer for Mercy Fitzgerald Hospital. An ADCL calibrated Sr-90 ophthalmic applicator was used on a patient for an external eye application for the treatment of pterygium. The guard ring needed to be removed before treatment and was not, hence only delivered 5% of the prescribed dose to the patient.
"The State has an inspection scheduled and will continue to keep NRC informed of the status of our investigation."
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.