Event Notification Report for March 30, 2011

AGREEMENT STATE - FIVE TRITIUM EXIT SIGNS DESTROYED

The following information was received via facsimile:

On February 4, 2011, the NC Radiation Protection Section (NCRPS) received notice of a bankruptcy sale for Townsend in Pittsboro, NC. On March 15, 2011, the Radiation Safety Officer (RSO) for Townsend was contacted to check the status of 5 exit light signs they had registered. The Townsend RSO informed NCRPS that Townsend had paperwork for the signs, however, in October 2003 the facility had been changed from a chicken slaughter facility to a chicken process facility. During this construction, the 5 exit signs were destroyed. On March 30, 2011, NCRPS performed an inspection at the facility and no exit signs or evidence of signs containing tritium were found. A total of 71.9 Curies of tritium were destroyed at the facility and NCRPS considers the incident closed. NC Report #11-22.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

AGREEMENT STATE REPORT - EXTREMITY OVEREXPOSURE DURING LABORATORY WORK

The following information was provided via e-mail from the Washington State Department of Health, Office of Radiation Protection:

"A Nuclear Medicine technologist received an overexposure to her extremity dosimeter for March 2011 while working in the basement of the Magnusen Health Sciences Building on the UW Campus. The Extremity Dose was reported as 56,440 mrem. During the month of March, she performed several cell-labeling procedures involving 75mCi, 111mCi, and 108mCi amounts of Y-90. There were also several labeling procedures involving the use of I-131 during the same time frame. However, because the whole body badge showed no significant exposure, it is believed the majority of the exposure came from the technologist's work with Y-90.

"Licensee: University of Washington
"City and State: Seattle, WA
"License Number: WN-C001-1
"Type of License: Broad A
"Date and time of Event: March 1 - March 30, 2011
"Location of Event: UW Magnusen Health Sciences Building

"Investigation is ongoing."

Washington Report #WA-11-030

* * * UPDATE ON 7/19/11 AT 1330 EDT TO HUFFMAN FROM THE STATE OF WASHINGTON VIA E-MAIL * * *

"On 6 June 2011, the department [Washington Division of Radiation Protection] received notification via letter from the University of Washington (UW) that an employee, had received an extremity dose to the left hand of 56,440 mrem from Yttrium 90 for the month of March 2011. The department [Washington Division of Radiation Protection] was notified that the employee retired in May 2011.

"An incident number WA-11-030 was assigned to the event. UW informed the technician of the overexposure and she agreed to meet to discuss the incident.

"On 15 June 2011, a Health Physicist from the Department of Health met with the UW RSO, a UW Health Physicist, and the technician to discuss the incident.

"The Y-90 comes in bulk and must be divided into smaller aliquots based on the desired dose for cell labeling. These aliquots must be handled several times during the cell labeling procedure by the technician. The small size of the aliquot tubes made it too difficult to use tongs or other devices that might have lessened their exposure during these parts of the procedures. Most of this work was done in a hood behind shielding so that the whole body dose remained normal.

"Because the technician is right-handed, she would most often hold the tube containing the Y-90 in the left hand so she could use their right hand to add reagents or pipette the Y-90 solution into another tube. Although the exposure to the right hand did not exceed the annual limit, it was also unusually high for the month of March, 10.85 REM.

"The technician stated that there was no spill or other unusual occurrence during the month of March. It is highly unusual to do multiple labeling procedures in a one month period and March 2011 is the only time she has done three in one month. The amounts received, 75mCi, 111mCi, and 108 mCi were also larger than average. There were also several procedures involving the use of large doses, up to 1 Ci, of I-131 in March. However, this was not out of the ordinary for the technician so it is believed to be more likely that the multiple labeling procedures involving Y-90 contributed to exceeding the annual exposure limit to the left hand.

"Although, the technician is required to do surveys of the lab, the lab only has access to a GM detector and the area readings in the lab are often higher than background because of the large quantities of nuclides on hand. It is difficult for the technician to determine if contamination exists because of these high area readings. No swipe surveys are done by the technician. Swipe surveys are done by the radiation safety office staff. The last survey in which swipes were taken was January 2011. No contamination was noted at that time. The dose reconstruction was done to verify that the technician could in fact have received the reported dose given the time frame the technician was working with the Y-90. The dose reconstruction was also done to eliminate the possibility that the dose recorded by the ring dosimeter could have been caused by the ring being contaminated by Y-90 and that contamination remaining on the dosimeter. It was concluded by the UW RSO and the department [Washington Division of Radiation Protection] that handling these amounts of Y-90 could result in a dose of 56.4 REM in a very short period of time. Therefore, it is the conclusion of this investigation that the reported exposure is real.

"As a result of this investigation, the technician has been informed that she cannot work in an environment which would further contribute to her 2011 radiation dose. Because she is retired and no longer employed as a radiation worker at any facility, this should not be a hardship. It was determined that although the technician received an exposure above the legal limit, it is unlikely to result in any adverse health effects and no medical intervention is warranted.

"The Y-90 labeling has been halted at UW. No other person has done a labeling of this kind since the technician's retirement. No further work of this kind will take place at UW until a complete reworking of the procedures is completed and submitted to the Department, and their own RSC, for approval.

"This incident is closed."

R4DO (Campbell) and FSME EO (Zelac) have been notified.

EMERGENCY SIRENS OUT OF SERVICE DUE TO INADVERTENT SECURING OF POWER

"City of San Clemente inadvertently secured power to 19 Community Alert Sirens. Trouble alarms were received at 0700 [PDT] but it is not known at what time specifically power was removed. All sirens were functional the day before when an inspection was performed on 3/29/2011 at 1213 [PDT]. Power was restored to the sirens at 1145 [PDT] 3/30/2011. This event resulted in 20 community sirens being non-functional for greater than 1 hour.

"Siren State Parks 4 (SP-4) was also non-functional for unrelated reasons and remains out of service."

Power was restored and all but the state park siren capabilities were declared operable.

The licensee notified the NRC Resident Inspector.

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION (UNUSUAL EVENT)

"An extent of condition review of Braidwood Unit 2 unplanned loss of safety system annunciators Emergency Plan Unusual Event on March 24, 2011 (ENS number 46694) was performed for both Units of Braidwood Station. During this review it was identified that a previous unknown loss of annunciators had also occurred on August 10, 2010 from 1024 to 1136 CT on Unit 2. This condition occurred during planned maintenance on annunciator cabinet 2PA19J power supply capacitors.

"The maintenance performed on August 10, 2010 would normally not cause a loss of all Unit 2 annunciators. During the work, it was expected to lose approximately one third of the annunciators. Latent annunciator system problems identified from the March 24, 2011 event caused a loss of all Unit 2 annunciators and contributed to this condition being unknown to Main Control Room operators. All Unit 2 indications and computer points to the sequence of events recorder remained available and Unit 2 was stable during this timeframe.

"At 1538 CT on 3/30/11, it was determined that the August 10, 2010 condition met the threshold for Emergency Action Level MU6, UNPLANNED loss of most or all safety system annunciation or indication in the control room for greater than 15 minutes. This notification is being made as an undeclared Unusual Event Emergency Plan Classification per 10 CFR 50.72(a)(1)(ii).

"Per NUREG 1022, a 1- hour notification is required when a condition existed which met the emergency plan criteria but no emergency was declared and the basis for the emergency class no longer exists at the time of the discovery."

The licensee notified the NRC Resident Inspector.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN INITIATED

"On March 30, 2011 at 1443 CDT, during a refueling outage, Browns Ferry Unit 2 received an invalid Common Accident Signal (CAS) as a result of maintenance activities. All four Unit 1/2 diesel [generators] auto started and all four Unit 3 diesel [generators] auto started. Unit 2 received a full Reactor SCRAM and Core Spray pumps A, B, C, and D auto started and injected into the reactor. Unit 2 Division I RHR [Residual Heat Removal] system was in Shutdown Cooling with only the C pump in service. The A RHR pump auto started and Shutdown Cooling flow increased, as expected. Unit 2 Division II RHR system was tagged out for maintenance. HPCI [High Pressure Coolant Injection] and RCIC [Reactor Core Isolation Cooling] received auto initiation signals, however the steam isolation valves were tagged closed and the systems did not start. MSIVs [Main Steam Isolation Valves] isolated as a result of the CAS signal.

"Unit 1 was at 100% power when the CAS on Unit 2 occurred. This caused initiation of the Preferred Pump Logic which designates Division I CS [Core Spray] and LPCI [Low Pressure Coolant Injection] pumps on Unit 1 (1A and 1C) and the Division II pumps on Unit 2 (2B and 2D) and prevents Unit 1 Division II pumps from auto starting. This resulted in the Division II RHR and CS pumps [being] inoperable for Unit 1. Unit 1 subsequently entered Technical Specification 3.5.1, Condition H (two or more low pressure ECCS [Emergency Core Cooling System] injection/spray subsystems inoperable) which requires entering LCO 3.0.3 immediately.

"Unit 1 entered LCO 3.0.3 at 1443, which requires that actions shall be initiated within one hour to place the unit in Mode 2 within 10 hours; Mode 3 within 13 hours; and Mode 4 within 37 hours. At 1542 Unit 1 began lowering power in order to comply with LCO 3.0.3.

"CAS logic was reset at 1812 and Unit 1 exited LCOs 3.5.1.H and 3.0.3.

"This condition requires a four hour report in accordance with 50.72(b)(2)(i) - 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'

"The NRC Resident Inspector was notified. Service Request #346544 was initiated in the Corrective Action Program."

CONTRABAND FOUND INSIDE THE PROTECTED AREA

"While cleaning out portable toilets being used at the site, the waste disposal vendor employee discovered a two ounce (shot sized) liquor bottle in one of the units. The unit had been on-site since 2/25/11 and was staged in the Protected Area. The waste disposal vendor indicated that it is unlikely the bottle was in the portable toilet prior to delivery to the site."

The NRC Resident Inspector has been notified.

CONTROL ROD MALFUNCTION DURING ROD TESTING RESULTS IN OPERATORS MANUALLY OPENING TRIP BREAKERS

"Rod L-13 did not function as expected during control rod movement test. This rod is in Shutdown Bank C. When withdrawing this bank, rod L-13 did not withdraw and when the bank was manually inserted, rod L-13 began to withdraw. The [operating] crew went to Enclosure 13.2 of the procedure to deal with the misaligned rods. This enclosure has procedural guidance to open the reactor trip breakers, if desired. The reactor trip breakers were opened and all 211 rods are fully inserted. The reactor was not critical. This activity was performed twice [at the request of reactor engineering]."

The licensee will remain in Mode 5 (Cold Shutdown) until troubleshooting and repair is completed.

The licensee will be notifying the NRC Resident Inspector.

* * * RETRACTION AT 1528 ON 4/26/2011 FROM JAMES DAIN TO MARK ABRAMOVITZ * * *

"This notification pertains to Event Number 46709. Based on further investigation, this event is being retracted.

"The event described in Event Number 46709 involved a control rod malfunction on Unit 2 while in Mode 5, during RCCA movement testing. Specifically, Control Rod 'L-13' in Shutdown Bank 'c' did not move with the bank when the bank was withdrawn from the bottom of the core. When the bank was reinserted to the bottom of the core, L-13 was observed to be 12 steps withdrawn. This condition was corrected by opening the reactor trip breakers which placed L-13 at the bottom of the core. The subsequent troubleshooting plan involved further manipulation of Shutdown Bank 'C' with additional instrumentation on the rod control cabinets. The same anomaly occurred and the reactor trip breakers were again opened.

"This event (both openings of the reactor trip breakers) was reported to the NRC on 3/30/11 as a valid RPS actuation (8-hour report; 10 CFR 50.72(b)(3)(iv)(A)). The event in question did not result in any consequences, given that the plant was in Mode 5 and not critical. NUREG-1022, Revision 2 states that actuations that need not be reported are those initiated for reasons other than to mitigate the consequences of an event (e.g., at the discretion of the licensee as part of a preplanned procedure). Notwithstanding the issue of whether opening the reactor trip breakers was to mitigate the consequences of an event, NUREG-1022 cites one valid example of actuations that need not be reported, namely if the actuation was 'at the discretion of the licensee as part of a preplanned procedure'. The purpose of the test being conducted was to identify issues with the control rod system. The malfunction that occurred is one of a host of possible issues that could reasonably be expected to occur. Although the test personnel did not go into the test expecting the need to open the reactor trip breakers, the malfunction that occurred resulted in a desire to open the reactor trip breakers in order to restore the plant to the desired configuration. This action was a choice as allowed by the test procedure, and the personnel involved were aware of the result of the action before it occurred. Therefore, the event constituted a 'pre-planned sequence during testing', and was 'at the discretion of the licensee as part of a preplanned procedure.'

"Based upon the above considerations, the event does not meet the aforementioned criteria for an 8-hour report, and Event Number 46709 is therefore retracted. The licensee has notified the NRC Resident Inspector of this update."

Notified the R2DO (Seymour).

60-DAY TELEPHONIC NOTIFICATION OF INVALID RPS SIGNAL DUE TO LOSS OF VARIABLE LEG OF LEVEL TRANSMITTER

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv) and 10 CFR 50.73(a)(1) to describe an invalid RPS (SCRAM) actuation.

"On March 30, 2011, at 1443 hours Central Daylight Time (CDT), during a refueling outage, Browns Ferry Unit 2 received an invalid Common Accident Signal (CAS) as a result of maintenance activities.

"The CAS caused a full Unit 2 Reactor SCRAM and associated system initiations. The CAS was initiated due to invalid indications on both Channels A and B of low-low-low reactor water level, which did not exist; therefore, the actuation was invalid.

"The affected equipment responded as designed. All four Unit 1/2 Emergency Diesel Generators auto started and all four Unit 3 Emergency Diesel Generators auto started. Unit 2 received a full Reactor SCRAM and Core Spray Pumps A, B, C, and D auto started and injected into the reactor. Unit 2 Division I Residual Heat Removal (RHR) System was in Shutdown Cooling with only the C pump in service. The 'A' RHR pump auto started and Shutdown Cooling flow increased, as expected. Unit 2 Division II RHR System had been tagged out for maintenance and did not respond. High Pressure Coolant Injection and Reactor Core Isolation Cooling received auto initiation signals; however, their steam isolation valves were tagged closed and the systems did not start. The Inboard Main Steam Isolation Valves (MSIVs) isolated as a result of the CAS signal. The outboard MSIVs had been previously closed and tagged for refueling outage purposes.

"This event was entered in the Corrective Action Program as Service Request (SR) 346544, which generated Problem Evaluation Report (PER) 346568.

"There were no safety consequences or impact on the health and safety of the public as a result of these events.

"The NRC Senior Resident Inspector has been notified."

The shutdown reactor water level transmitters share a common variable leg. When maintenance unrelated to the transmitters was performed, the variable leg was lost causing the low-low-low reactor water level SCRAM signal to be generated.