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Event Notification Report for January 27, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2004 - 01/27/2004

** EVENT NUMBERS **


40359 40460 40461 40464 40466 40472 40476 40477 40478 40480 40481

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40359
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMIE MCCONNELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/28/2003
Notification Time: 01:55 [ET]
Event Date: 11/27/2003
Event Time: 22:55 [EST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEPHEN CAHILL (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling Shutdown 0 Refueling Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

COMPONENT COOLING SYSTEM SURGE TANK SUPPORTS MAY FAIL DURING A SEISMIC EVENT

During an ISI inspection of the component cooling system, it was discovered that several of the surge tank support stiffener plates were missing due to a design change that was never fully implemented. This condition creates a question as to the adequacy of the tanks to withstand a seismic event. This deficiency affects both trains of component cooling on Units 1 and 2. The problem will be corrected on Unit 1 while it is in its refueling outage. Work on the Unit 2 "A" train is currently ongoing, making that train of the component cooling system inoperable, therefore, putting the plant in a 72 hour LCO. When work on the "A" train is completed, they will exit the LCO, but re-enter it when work begins on the "B" train.

Licensee will notify the NRC Resident Inspector, the State and local agencies.

* * * RETRACTION AT 1025 EST ON 01/26/04 BY MIKE HEAVNER TO JOLLIFFE * * *

"The subject EN #40359 was made on 11/28/03. Following additional review by the licensee, this event was determined to not meet the reportability requirements of 10 CFR 50.72. The event was determined to not result in a condition that could have prevented fulfillment of a safety function, as the tank supports were analyzed to withstand a seismic event. In addition, the event did not result in the plant being in an unanalyzed condition. The condition did not prevent the fulfillment of a safety function or system that is needed to remove residual heat or mitigate the consequences of an accident."

The licensee plans to notify the NRC Resident Inspector.

Notified R2DO Caudle Julian.

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General Information or Other Event Number: 40460
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: BOWLING GREEN MEDICAL CENTER
Region: 1
City: BOWLING GREEN State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GRESHAM
HQ OPS Officer: RICH LAURA
Notification Date: 01/21/2004
Notification Time: 16:20 [ET]
Event Date: 01/19/2004
Event Time: [CST]
Last Update Date: 01/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLIFFORD ANDERSON (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

KENTUCKY AGREEMENT STATE REPORT ON A MEDICAL EVENT

A medical event occurred on 1/19/04 at the Bowling Green Medical Center located in Bowling Green, Kentucky. Specifically, an inner vascular Brachytherapy treatment was planned. The catheter ran outside the body through an external valve which was inadvertently partially shut resulting in no dose to the target area. As a result, the doctor administering the treatment received .736 gray at his fingertips. Also, the patient received .736 gray to the thigh area. The source involved was 43.14 curies of strontium-90. There was no significant adverse health effects from this event. A review was initiated by the licensee to determine the cause and to initiate corrective actions.

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General Information or Other Event Number: 40461
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: INDUSTRIAL SERVICES OF AMERICA
Region: 1
City: LOUISVILLE State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GRESHAM
HQ OPS Officer: RICH LAURA
Notification Date: 01/21/2004
Notification Time: 16:28 [ET]
Event Date: 01/16/2004
Event Time: [CST]
Last Update Date: 01/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLIFFORD ANDERSON (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

KENTUCKY AGREEMENT STATE REPORT ON LOSS OF RADIOACTIVE MATERIAL FOUND AT SCRAP YARD

On 1/16/04, the radiation detectors alarmed at the North American Stainless scrap yard, located in Ghent, Kentucky, when a truck entered the scrap yard. The scrap yard radiation detectors indicated 42 microrem per hour. The truck was not accepted and sent back to its origin. The scrap material in the truck came from Industrial Services of America. Investigation determined that a piece of a fixed gauge caused the radiation alarms to set off. Apparently, the gauge went through a shredder. On-contact radiation readings were 35 millirem/hour with the shutter closed and 58 millirem/hour with the shutter open. This was considered a loss of radioactive material and further review will be performed to try to determine the owner of the gauge.

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General Information or Other Event Number: 40464
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: HILLCREST HOSPITAL
Region: 3
City: MAYFIELD HEIGHTS State: OH
County:
License #: OH02120180042
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/22/2004
Notification Time: 09:29 [ET]
Event Date: 01/16/2004
Event Time: 16:10 [EST]
Last Update Date: 01/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
ROBERTO TORRES (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING AN ABNORMAL OCCURRENCE (AO)

On 11/20/03 a 19 year old female patient received 140.1 millicuries I-131 for thyroid carcinoma as prescribed. At the time she was unaware and had completed the required forms indicating she was not pregnant. On 12/5, 12/8 and 12/11/03 quantitative tests confirmed that she was pregnant. The results were provided to her endocrinologist who recommended that a fetal dose calculation be performed. The hospital was notified and their consultant informed the endocrinologist that the fetus would have received 19.6 rads. The Endocrinologist sent the results to the Center for Human Genetics at University Hospital in Cleveland where as assessment was performed that the pregnancy could safely continue.

The Ohio Bureau of Radiation was informed on 1/16/04 and submitted the information to the NRC Region III office. NRC Region III (Lynch) recommended making a telephonic notification due to the incident meeting the criteria of an AO even though Ohio is not required to conform with the revised reporting requirements for a period of three years (October 2005) after the final rule is issued.

Hillcrest Hospital has implemented pregnancy testing for child bearing age female patients receiving radiation therapy.

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General Information or Other Event Number: 40466
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: AMERSHAM/MEDI PHYSICS
Region: 3
City: ARLINGTON HTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH KLINGER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/22/2004
Notification Time: 17:29 [ET]
Event Date: 01/21/2004
Event Time: [CST]
Last Update Date: 01/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
LAWRENCE KOKAJKO (NMSS)
CLIFFORD ANDERSON (R1)

Event Text

MEDICAL SOURCES MISSING IN TRANSIT

"The Director of Nuclear Regulatory Assurance of Amersham/Medi Physics (IL-01109-01) called late yesterday to report that a package of small activity sources intended for medical use had not arrived at its intended destination. The details are as follows:

"On January 9, a package containing sixty-six sealed iodine-125 sources was sent from the Arlington Heights, IL facility intended for the St. John's Riverside Hospital in Yonkers, New York. The sources are stainless steel encapsulations of I-125, each originally 0.942 millicuries of activity. The total activity at the time of packaging was 62 millicuries. The sources are about the size of a grain of rice and designed for implantation in cancerous tumors of the prostate gland via a needle. The package was shipped in a standard 'Type A' box and had a surface dose rate of less than 0.5 millirem/hr. The package was due to arrive in Yonkers on the 12th of January for a treatment on the 14th. As part of Medi Physics customer service, a routine call to the client revealed that the package had not arrived as of the end of the day on the 12th. When the carrier, Federal Express, was queried by the licensee, Federal Express claimed that the package had been accidentally set aside at their Newark, New Jersey facility with some other packages and would be delivered the next day. Additional tracking by Medi Physics on subsequent days showed that the package never left the Federal Express sorting facility in Newark, New Jersey. To date, efforts by Medi Physics and those reported by Federal Express have not located the missing package.

"As of this time, the activity of each source is 810 microcurie for a total package activity of 53.5 millicuries. Although in the past such packages have been located and recovered and returned to Medi Physics by the carrier, the extended length of time from the date of expected delivery to now is unusual. Both Medi Physics and Federal Express have indicated they will continue monitoring this situation. The U.S. NRC Region III Liaison Officer has been made aware of the situation and has indicated he will contact his U.S. NRC Region I counterpart to advise him of the situation.

"Form of Radioactive Material: SEALED SOURCE
Radionuclide: I-125; Source Use: BRACHYTHERAPY; Activity: 53.5E-3 Curies
Manufacturer: MEDI+PHYSICS, Model Number: 6711; Serial Number: NA"

* * * UPDATE ON 01/23/04 AT 10:27 FROM JOE KINGLER TO ARLON COSTA * * *
Federal Express has located the package containing sixty-six sealed iodine-125 sources in Newark, NJ. Federal Express is in the process of returning the package back to Amersham/Medi. Notified R1DO (Anderson), R3DO (Lanksbury) and NMSS EO (Kokajko).

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Power Reactor Event Number: 40472
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID FRYE
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/23/2004
Notification Time: 17:45 [ET]
Event Date: 01/23/2004
Event Time: 15:29 [EST]
Last Update Date: 01/26/2004
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
Person (Organization):
CLIFFORD ANDERSON (R1)
HERB BERKOW (NRR)
RICHARD WESSMAN (DIRO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP WITH SAFETY INJECTION ACTUATION SIGNALS

"At 1529 ET the reactor was manually tripped due to low steam generator level as a result of the loss of the 22 SGFP (Steam Generator Feed Pump). When the reactor was tripped, the turbine bypass and atmospheric dump valves went full open and did not shut. This lead to a SIAS (Safety Injection Actuation Signal) and SGIS (Steam Generator Isolation Signal). At 1718 ET, a second SIAS actuation occurred while reestablishing pressurizer level. The cause of the SGFP trip is unknown. The cause of the over steaming on turbine bypass valves and atmospheric dump valves is unknown."

All control rods fully inserted. Auxiliary Feedwater initiated normally. The licensee stated that there was no actual ECCS injection to the RCS. The plant electrical system responded normally and all emergency diesel generators remain operable. All ECCS systems remain operable. There are no primary to secondary leaks. Decay heat is currently being removed via the steam-driven auxiliary feedwater pump and the atmospheric steam dumps. As of 1830 ET, primary pressure is approximately 2103 psi and pressurizer level is at 242 inches. Plant conditions are being stabilized at normal hot standby values . The licensee notified the NRC Resident Inspector who responded to the Control Room.


* * * UPDATE FROM PACE TO GOTT ON 1/26/04 AT 1438 EST * * *

The licensee reported that their post trip review determined that the reactor received an automatic trip about 2 seconds before the manual trip. The automatic trip was due to low steam generator water level.

The licensee notified the NRC Resident Inspector.

Notified NRR (Reis) and R1DO (Meyer)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40476
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN REYMER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/25/2004
Notification Time: 15:26 [ET]
Event Date: 01/25/2004
Event Time: 11:10 [CST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROGER LANKSBURY (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

INOPERABLE REFUELING INTERLOCK

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(A) and 10CFR50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to Maintain Safe Shutdown and Mitigate the Consequences of an Accident. During Unit 1 refueling operations, it was discovered at 1110 hours 1/25/04 CST that the Refuel Position One-Rod-Out Interlock was inoperable. Because this interlock is credited for mitigating the 'Control Rod Removal Error During Refueling' event evaluated in the UFSAR, this is reportable as an 8 hour ENS notification.

"With the Unit 1 Mode Switch in REFUEL, the one-rod-out interlock function was tested per LaSalle Operating Surveillance LOS-RD-SR4. Since the acceptance criterion of this surveillance was not met, the interlock was declared inoperable and the required actions of Technical Specification 3.9.2 entered. Currently all control rod withdrawals are suspended and all control rods are fully inserted in core cells containing fuel assemblies. The Unit 1 Mode Switch is in Shutdown. Actions are in progress to restore the One-Rod-Out Interlock to an operable status."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM BAILEY TO GOTT AT 1617 EST ON 1/26/04 * * *

"During further investigation, it was determined that the system design is such that whenever the Mode Switch is placed in the REFUEL position with a rod withdrawn, no select block is received but a rod withdrawal block is generated. This design feature allows control rods to be inserted should the Mode Switch be placed in REFUEL with any rod out. The LaSalle Operating Surveillance (LOS-RD-SR4) used to demonstrate operability of the Refuel Position One-Rod-Out Block does not currently recognize this design feature and its acceptance criteria is based solely on receipt of the select block. The subject procedure will be revised to ensure all rods are fully inserted prior to performing the surveillance thereby ensuring the logic initial conditions are met to satisfactorily demonstrate the select block function. With these initial conditions satisfied, the Refuel Position One-Rod-Out Interlock was satisfactorily tested on 1/25/04 at 1935 hours CST. Therefore, the Refuel Position One-Rod-Out interlock performed as designed and was capable of performing its safety function. Thus, this occurrence was not reportable under 10CFR50.72(b)(3)(v)(A) and 10CFR50.72(b)(3)(v)(D)."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Louden).

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Power Reactor Event Number: 40477
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: CURTIS CASTELL
HQ OPS Officer: ARLON COSTA
Notification Date: 01/26/2004
Notification Time: 03:50 [ET]
Event Date: 01/25/2004
Event Time: 22:36 [EST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CAUDLE JULIAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF EMERGENCY RESPONSE COMMUNICATIONS DUE TO FAILED UNINTERRUPTIBLE POWER SUPPLY

"At approximately 22:36 hours EST, on January 25, 2004, the H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, Emergency Response Facility Information System (ERFIS) computer system became inoperable due to a loss of the uninterruptible power supply (UPS). The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, FAX modems for Emergency Preparedness functions, and the Inadequate Core Cooling Monitor (ICCM). The loss of ERFIS requires alternate methods as described in plant procedures to be used for these functions, as necessary. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still have been made as necessary, if required, during the time that the ERFIS was inoperable. The ERFIS computer system was restored at approximately 01:47 hours EST on January 26, 2004, using a back-up power supply. The cause of the loss of the ERFIS UPS has not yet been determined. Plant personnel are continuing to investigate the loss of the power supply and are in the process of repairing the UPS. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As previously stated, alternate means remained available to assess plant conditions, make notifications, and accomplish required communications, as necessary."

The Licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40478
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: FRED RINGWALD
HQ OPS Officer: ARLON COSTA
Notification Date: 01/26/2004
Notification Time: 11:15 [ET]
Event Date: 01/26/2004
Event Time: 09:41 [EST]
Last Update Date: 01/26/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
CLIFFORD ANDERSON (R1)
SUSAN FRANT (DIRO)
TERRY REIS (NRR)
TOM YATES (DHS)
KEN SWEETSER (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 90 Power Operation

Event Text

UNUSUAL EVENT (TRANSITORY) DUE TO LOW INTAKE BAY LEVEL CAUSED BY ICING

"This is a notification of a transitory Notification of Unusual Event. Nine Mile Point Unit 1 experienced a transitory low intake bay level due to icing. This condition was resolved by shifting circulating water flow from reverse flow to normal flow. This met Emergency Action Level 8.4.3 for low fore bay level less than 238.8 feet. The duration of this event was from 0941 (EST) to 0943.

"While returning reactor power to 100%, an unrelated problem [plant computer] halted power ascension at 92.4% [from a stable 90% reactor power]."

The licensee notified the NRC Resident Inspector and the state and local government through their "warning point" emergency notification system.

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Power Reactor Event Number: 40480
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOSEPH SHISLER
HQ OPS Officer: BILL GOTT
Notification Date: 01/26/2004
Notification Time: 17:11 [ET]
Event Date: 01/25/2004
Event Time: 17:00 [EST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GLENN MEYER (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH DIFFERENTIAL PRESSURE IN AUXILIARY BUILDING

"On January 25, 2004, during troubleshooting of high differential pressure in the Unit 1 Auxiliary Building, the 1ABF13 fire damper was found closed at approximately 1700 (EST) hours. The 1ABF13 fire damper was re-opened and system flows and differential pressure were verified to be normal at approximately 1950 hours."

"On January 26, 2004, at 1500 hours, a determination was made that with the 1ABF13 fire damper closed, filtration of the effluents from the pipe chase and RHR areas could not be processed through the HEPA-Charcoal absorber. This condition did not meet the assumptions of the Salem dose analysis and is being reported under the requirement of 10CFR50.72(b)(3)(v)(D)."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40481
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: BILL GOTT
Notification Date: 01/26/2004
Notification Time: 20:20 [ET]
Event Date: 01/26/2004
Event Time: 14:30 [CST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRUCE BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

RECIRCULATION FAN ALTERATION AFFECTS ACCIDENT MITIGATION

"V-ERF-11 ('A' Emergency Filtration Train (EFT) recirculation fan) was found to have an improper alteration affecting the fan's shaft speed, and 'A' EFT was declared inoperable. Concurrently, the #12 Emergency Diesel Generator (EDG) was inoperable for planned maintenance, making 'B' EFT inoperable. This condition is a loss of safety function during a design basis accident, and impacts the ability of the plant to mitigate the consequences of an accident."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 1/26/04 AT 2112 EST FROM RASK TO GOTT * * *

At 1958 CST the licensee declared the #12 EDG operable and thus the #12 ("B") EFT was also operable. Additionally, at 2010 the licensee declared the #11 ("A") EFT operable.

Notified R3DO (Burgess).

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Friday, March 30, 2012