Event Notification Report for June 30, 2009

AGREEMENT STATE REPORT - POTENTIAL WORKER OVEREXPOSURE

The following information was received via facsimile:

"A worker was working in a hot cell when a F-18 [radio-isotope] was mistakenly delivered to the hot cell. [The] initial estimated worker dose [was] 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. [The] worker has been taken off Rad work and is being monitored"

A Commonwealth of Massachusetts investigation is pending.

* * * UPDATE ON 8/13/2009 AT 1130 FROM TONY CARPENITO TO MARK ABRAMOVITZ

The following report was received via e-mail:

"On 6/30/09, 1.6 Curies of Fluorine-18 was mistakenly delivered to a shielded vial within the cyclotron facility hot cell while a worker was performing routine maintenance within the hot cell. Delivery was intended for a different hot cell. The total worker exposure time was less than 3 minutes. The worker was removed from radiation work and dosimeters were sent out for immediate processing. Same day notification was made from the licensee to the Agency [Massachusetts Radiation Control Program]. The licensee submitted an independent consultant written report, dated 7/8/09, to the Agency [Massachusetts Radiation Control Program] on 7/27/09. The worker's effective dose equivalent was conservatively determined to be not more than 0.170 Rem, the maximum extremity not more than 26.9 Rem, and the eye dose equivalent not more than 1.2 Rem. These dose values were assigned to the worker. The worker was returned to radiation work with cumulative dose closely monitored.

"Licensee's formal descriptions of cause, contributing and precipitating factors, and corrective actions are pending.

"The Agency [Massachusetts Radiation Control Program] considers this situation to still be OPEN."

Notified the R1DO (Cook) and FSME (McIntosh).

* * * UPDATE ON 9/17/2009 AT 0949 FROM CARPENITO TO HUFFMAN * * *

The following update was received via e-mail:

"9/16/09 Update: A subsequent on-site Agency inspection was performed. On 8/27/09, the licensee submitted report of cause, contributing and precipitating factors, and corrective actions.

"Cause: Pre-event re-configuration of transport tubing during an earlier calibration effort was not returned to original configuration and operators were not aware of the routing change.

"Precipitating and Contributing Factors: Licensee procedures related to use of personnel dosimeters, functioning survey instruments, and hot cell door closure, were not followed.

"Corrective Actions: Licensee to implement procedural changes and retraining of staff.

"The Agency considers this situation to be closed."

Notified the R1DO (Jackson) and FSME (McIntosh).

AGREEMENT STATE REPORT - SAFETY FUNCTION FAILURE

The following information was received via facsimile:

"The electronics are not working on a [thickness] gauge on the Z-34 press. The equipment is out of use. The [Integrated Industrial Systems] gauge [is a Model #SS-3A] with a serial number [of] #9834LX; 1000 milliCurie Am-241. A potential cause is the source moved."

The licensed contractor RSI (Radiometric Services and Instruments) was contacted to fix the thickness gauge.

A Commonwealth of Massachusetts investigation is pending.

POTENTIAL MEDIA INTEREST DUE TO FORCED OUTAGE

"On June 30, 2009, at 1513 PDT, Unit 2 commenced a ramp[-down] in accordance with the annunciator response guidance to enter Operating Procedure (OP) Abnormal Procedure AP-25 due to loss of forced cooling to main transformer bank (MTB) C-Phase transformer. At 1538, Unit 2 was separated from the grid in accordance with plant OP AP-25 initiation of a main generator unit trip. At 1554 PDT, the Reactor Trip Breakers (RTBs) were manually opened per OP AP-25 Step 24.j. [Reactor] power was being held in Mode 2 at about 3% reactor power per the procedure when the RTBs were opened.

"The investigation into the cause is continuing.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi), Offsite Notification, as Pacific Gas and Electric plans to make a news release regarding the event that may raise media interest."

The licensee notified the NRC Resident Inspector.

SAFETY EQUIPMENT FAILURE OF THE CRITICALITY ALARM SYSTEM

"The public address system (criticality accident alarm) was impaired for a portion of the Building 310 warehouse and a subcontractor trailer. The cause of the impairment was determined to be the result of a contractor drilling into a public address system speaker wire while installing fire protection components in the Building 310 warehouse. This created an electrical short which rendered the speakers inoperable for a portion of the Building 310 warehouse and a subcontractor trailer. The speaker wire was obscured from view by a structural beam. The system was repaired, tested, and placed back into service by 1721 hours (EDT) on 6/30/2009."

The NRC Resident Inspector was notified.

PART 21 - RADIATION MONITOR DEFECT

"The defect is contained in the General Atomics Electronic Systems, Inc (GA-ESI) radiation monitoring system model RM-80 firmware. The RM-80 firmware anomaly was initially identified at the St. Lucie Nuclear Power Plant. The radiation monitor was part of the control room outside air intake ventilation radiation monitors.

"More specifically, if the radiation monitor is already in a high and or alert alarm state, and subsequently suffers a loss of power, then upon restoration of power to the unit, the RM-80 high and or alert alarm relays are not reenergized by the RM-80 firmware. This in turn prevents the relays that are located in the [RM]-80 from performing their safety related function.

"This error in the firmware only affects those plant sites that connect annunciator panels or other safety related equipment to the RM-80 Alert and High Alarm relays.

"Plant sites that use RM-80 radiation monitors will be advised to test their systems for this anomaly. When so requested, GA-ESI will provide all necessary information to plants on how to test their RM-80 radiation monitors, and how to receive firmware upgrades if the condition is found during testing."

General Atomics will notify the following affected plants: Beaver Valley, Braidwood, Byron, Callaway, Indian Point 2 &3, Limerick, River Bend, Shearon Harris, South Texas, St. Lucie, Waterford, and Wolf Creek.


* * * UPDATE FROM KEITH E. ASMUSSEN TO C. TEAL AT 1900 ON 8/31/2009 * * *

"This notification is an update to a notification made on 1506 Hrs. EST on August 25, 2009 regarding the existence of a defect. This notification is being provided in compliance with the requirements of Title 10 Code of Federal Regulations Part 21.21.

"In the initial notification, under the section titled 'Locations affected by the reported condition,' General Atomics Electronic Systems, Inc. (GA-ESI) provided a table (Table1) that listed sites and corresponding firmware sets having safety related RM-80 software that had been found to contain the reported firmware anomaly. GA-ESI has now identified one additional firmware set that should be included in Table 1. The site is Braidwood and the firmware set is bhr165/01.

"Accordingly, Table 1 has been revised to include this firmware set for the Braidwood site. The revised Table 1 is attached to this update notification.

"Also, please note that earlier today, August 31, 2009, GA-ESI emailed a notification letter to its customer contact at the Braidwood site.

"All other information remains the same as was initially reported on August 25, 2009"

Notified R3DO (Lipa). Also notified NRR and NRO via email.