Event Notification Report for June 25, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/24/2009 - 06/25/2009
Power Reactor
Event Number: 45162
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: ERIC HORVATH
HQ OPS Officer: BILL HUFFMAN
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: ERIC HORVATH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/25/2009
Notification Time: 11:44 [ET]
Event Date: 06/25/2009
Event Time: 00:49 [EDT]
Last Update Date: 06/25/2009
Notification Time: 11:44 [ET]
Event Date: 06/25/2009
Event Time: 00:49 [EDT]
Last Update Date: 06/25/2009
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
ANN MARIE STONE (R3DO)
MARK SATORIUS (R3 D)
FREDERICK BROWN (NRR)
JIM WIGGINS (NRR)
JEFFERY GRANT (IRD)
ANN MARIE STONE (R3DO)
MARK SATORIUS (R3 D)
FREDERICK BROWN (NRR)
JIM WIGGINS (NRR)
JEFFERY GRANT (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
DISCOVERY OF AN AFTER-THE-FACT ALERT DUE TO CATASTROPHIC FAILURE OF CCPD
"A transitory ALERT [condition was determined to have existed] based on Emergency Action Level 7.D.2 - 'Onsite Explosion Affecting Plant Operation'. At time 0049 on 06/25/09 a catastrophic failure-explosion of the Constant Current Potential Device (CCPD) on 'J' Bus near Air Circuit Breaker (ACB) 34563 resulted in a loss of switchyard 345 KV Bus 'J'. This event de-energized Startup Transformer 01 which is a tie from offsite sources to the Unit 13.8 KV Busses. The unit entered [Technical Specification] LCO 3.8.1, Condition A [due to the loss of one offsite power source]. The Unit remains stable and in operation at 100% RTP [reactor thermal power]. A problem solving decision making team is working on [the] troubleshooting/repair/restoration activities. This event did not impact any plant safety systems or result in any release of radioactive material."
Failure of the CCPD caused automatic opening of the breakers on both sides of the 'J' bus which was configured as part of a switchyard ring bus at the time of the event. This resulted in the loss of one of the offsite power ties. However, startup Transformer 02 is still energized from offsite power and remains available for plant operations. Other than the de-energized startup transformer, onsite electrical configurations are normal including availability of emergency diesel generators. The licensee is in a 72 hour LCO per Tech Spec 3.8.1, Condition A, to restore the lost offsite power source. The licensee is inspecting the switchyard for collateral damage to other equipment from the failure of the CCPD. The licensee believes the CCPD failure is likely a result of equipment failure and not the result of any equipment tampering.
The licensee stated that initially, the severity of the CCPD failure was not recognized because of the night time conditions and minimal lighting in the area. After daylight examination of the location of the event, it was determined that the failure of the CCPD should have been classified as an explosion affecting plant operation under EAL 7.D.2. Consequently, the licensee made the after-the-fact declaration.
Licensee has notified the NRC Resident Inspector, and will be notifying State and local authorities.
"A transitory ALERT [condition was determined to have existed] based on Emergency Action Level 7.D.2 - 'Onsite Explosion Affecting Plant Operation'. At time 0049 on 06/25/09 a catastrophic failure-explosion of the Constant Current Potential Device (CCPD) on 'J' Bus near Air Circuit Breaker (ACB) 34563 resulted in a loss of switchyard 345 KV Bus 'J'. This event de-energized Startup Transformer 01 which is a tie from offsite sources to the Unit 13.8 KV Busses. The unit entered [Technical Specification] LCO 3.8.1, Condition A [due to the loss of one offsite power source]. The Unit remains stable and in operation at 100% RTP [reactor thermal power]. A problem solving decision making team is working on [the] troubleshooting/repair/restoration activities. This event did not impact any plant safety systems or result in any release of radioactive material."
Failure of the CCPD caused automatic opening of the breakers on both sides of the 'J' bus which was configured as part of a switchyard ring bus at the time of the event. This resulted in the loss of one of the offsite power ties. However, startup Transformer 02 is still energized from offsite power and remains available for plant operations. Other than the de-energized startup transformer, onsite electrical configurations are normal including availability of emergency diesel generators. The licensee is in a 72 hour LCO per Tech Spec 3.8.1, Condition A, to restore the lost offsite power source. The licensee is inspecting the switchyard for collateral damage to other equipment from the failure of the CCPD. The licensee believes the CCPD failure is likely a result of equipment failure and not the result of any equipment tampering.
The licensee stated that initially, the severity of the CCPD failure was not recognized because of the night time conditions and minimal lighting in the area. After daylight examination of the location of the event, it was determined that the failure of the CCPD should have been classified as an explosion affecting plant operation under EAL 7.D.2. Consequently, the licensee made the after-the-fact declaration.
Licensee has notified the NRC Resident Inspector, and will be notifying State and local authorities.
General Information or Other
Event Number: 45165
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ST. JOSEPH
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-1288-01
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: JOHN KNOKE
Licensee: WHEATON FRANCISCAN HEALTHCARE - ST. JOSEPH
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-1288-01
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/26/2009
Notification Time: 12:11 [ET]
Event Date: 06/25/2009
Event Time: 00:00 [CDT]
Last Update Date: 06/26/2009
Notification Time: 12:11 [ET]
Event Date: 06/25/2009
Event Time: 00:00 [CDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT INVOLVING MEDICAL EVENT
The following information was provided by the State of Wisconsin via email:
"On June 26, 2009, the Radiation Safety Officer (RSO) notified DHS of a probable medical event that occurred on June 25, 2009 involving an HDR treatment to the esophagus. The authorized user intended to insert the applicator 2 cm past the distal part of the esophageal tumor. A GI specialist verified the location prior to treatment using a scope. Post treatment location of the applicator was reviewed using an AP lateral film. It was then realized that the applicator went 10 cm too far. The prescribed dose was 500 cGy. Therefore, a dose was given to a organ or tissue other than the intended treatment site that exceeds 0.5 Sv (50 rem) to an organ or tissue, and was 50% or more of the dose expected from the administration defined in the written directive (DHS 157.72(1)(a)(3.). DHS inspectors will investigate June 29, 2009."
Wisconsin Incident Number: WI090005
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 provided by the State of Wisconsin via email:
"On June 26, 2009, the Radiation Safety Officer (RSO) notified DHS of a probable medical event that occurred on June 25, 2009 involving an HDR treatment to the esophagus. The authorized user intended to insert the applicator 2 cm past the distal part of the esophageal tumor. A GI specialist verified the location prior to treatment using a scope. Post treatment location of the applicator was reviewed using an AP lateral film. It was then realized that the applicator went 10 cm too far. The prescribed dose was 500 cGy. Therefore, a dose was given to a organ or tissue other than the intended treatment site that exceeds 0.5 Sv (50 rem) to an organ or tissue, and was 50% or more of the dose expected from the administration defined in the written directive (DHS 157.72(1)(a)(3.). DHS inspectors will investigate June 29, 2009."
Wisconsin Incident Number: WI090005
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.