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Event Notification Report for August 17, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/16/2004 - 08/17/2004

** EVENT NUMBERS **


40821 40942 40943 40944 40960 40962

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40821
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN BENEDICT
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 06/16/2004
Notification Time: 15:52 [ET]
Event Date: 06/16/2004
Event Time: 14:00 [EDT]
Last Update Date: 08/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
PATRICK LOUDEN (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

24 HOUR NOTIFICATION OF PLANT EXCEEDING ITS POWER LIMIT

At 1400 hours on June 16, 2004, it was confirmed that the plant had operated in excess of its licensed maximum power limit of 3758 megawatts thermal by about two (2) megawatts thermal. The power limit was determined to have been exceeded due to a feedwater temperature RTD being replaced on May 24, 2004, without having installed a matching transmitter. This error caused a non-conservative input into the core power calculation resulting in a small error. The error allowed the power to be about two (2) megawatts above the limit while indicating that it was within requirements. This condition occurred during two periods on 06/14/04 and 06/15/04. On 06/14/04 the first occurrence lasted for approximately 7 hours. The second occurrence lasted for 16 hours commencing on 06/14/04 and terminating on 06/15/04. The licensee identified this condition on 06/15/04 @ 1130 and the condition was corrected on 06/15/04 @ 1315.

This notification is being submitted in accordance with PNPP Operating License Condition 2.F, as a potential violation of the Maximum Power Level specified in PNPP Operating License

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM K Russell to W Gott at 1356 on 8/16/04 * * *

"A 24 hour notification was made on June 16, 2004, in accordance with [Perry Nuclear Power Plant] PNPP Operating License Condition 2.F, a potential violation of the maximum power level specified in PNPP Operating License Condition 2.C(1). At the time of discovery, maximum licensed power level was determined to have been exceeded by about 2 megawatts thermal as a result of a feedwater resistance temperature detector (RTD) being replaced without installing a matching transmitter. The feedwater temperature provided by this RTD provides an input to the core power calculation and was initially determined to have caused an error in the calculation of about 3.1 megawatts.

"Subsequently, as-found calibration data was taken that determined the RTD loop error was smaller than initially calculated. The resultant error in thermal power was calculated to be 0.1 megawatts. Review of the power history using the recalculated thermal power error resulted in a determination that the maximum licensed power level was not exceeded. Since the maximum licensed power level was not exceeded, this notification retracts ENF 40821. This retraction was discussed with the Resident NRC Inspector."

Notified R3DO (Clayton)

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General Information or Other Event Number: 40942
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES OILFIELD OPERATIONS
Region: 4
City: ODESSA State: TX
County:
License #: L05178-018
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: GERRY WAIG
Notification Date: 08/11/2004
Notification Time: 13:26 [ET]
Event Date: 08/10/2004
Event Time: [CDT]
Last Update Date: 08/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
JOHN HICKEY (NMSS)

Event Text

AGREEMENT STATE REPORT - WELL LOGGING SOURCE LOST IN WELL DURING TRAINING

The following is taken from a facsimile sent by the Agreement State (Texas)

"Event description: After well logging operations on the afternoon of August 10, 2004, the well logger was removing the source from the tool on the training well. The tool was not fully engaged with the source. When the source cleared the logging tool, the well logger bumped the source into the deflector, causing the source to drop from the handling tool. The deflector performed properly and deflected the source, an 18 curie Am/Be (neutron) source downhole. This is the Atlas No. 2 well, an un-cased hard-rock well located on the Baker Hughes property for training of Baker Hughes staff. The source is a GammaTron Model DA20, Serial No 36313. The source is known to be at the bottom of the 5750 foot well. The training well is currently full of fluid. The operator is going to replace the fluid with clear fluid and begin 'fishing' operations. The wellbore is 8-7/8 inches and this source with nose plug is 9 inches in length."

TX Incident # I-8152

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General Information or Other Event Number: 40943
Rep Org: NY STATE DEPARTMENT OF HEALTH
Licensee:
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/12/2004
Notification Time: 17:12 [ET]
Event Date: 08/10/2004
Event Time: [EDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED BRACHYTHERAPY SEEDS

"A New York State Department of Health licensee reported on 8/10/04 that prostate seed implant needles were found to be contaminated during a post implant radiological survey in the operating room. Two post implant urine samples from the patient were saved and were found to be contaminated as well. Radiograph of the prostate post implant indicated all seeds were implanted. Hospital staff believed that the contamination was attributable to the implant procedure as the patient had not received a diagnostic nuclear medicine procedure and there was no evidence of any other source for the contamination. The radiation oncologist contacted the patient and was able to administer KI [Potassium Iodide] later in the day, and he will evaluate the need for ongoing treatment with KI.

"New York State Department of Health staff went to the hospital on 8/11/04 to investigate this incident. Confirmatory measurements were made and the plastic needle packing tray, needles, lead pouch and urine samples were found to be contaminated. A third urine sample was obtained from the patient on 8/11/04, which also is contaminated. The radiation oncologist who performed the procedure stated that there were no problems with the needles or the implant procedure. The needles were examined and no bends, crimps or damage were observed. The hospital, has notified the pharmacy that had provided the preloaded sterile needles. NRC Region 1 staff were contacted by phone and were given the name of the pharmacy.

"The Radiation Safety Officer took the initial urine sample to another New York State Department of Health licensee on 8/11/04 for nuclide identification and rough quantification using a HPGe detector. The isotope in the urine was identified as I-125 and the activity was estimated to be 34 nanocuries per cc (volume of urine sample collected was 200 cc). The patient's urine samples will be sent to DOH Wadsworth Laboratories for analysis. Future samples are expected to be collected and analyzed.

"The brachytherapy seeds were manufactured by Mills Biopharmarmaceuticals, Inc., sold by Mentor MBI (Oklahoma City, OK) and loaded into needles by the pharmacy. Brachytherapy seed specifics are:
Model: 125SL
Lot Number: 042814
Batch Number: IB040142N
Seed activity on 8/10/04: 0.405 millicuries"

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General Information or Other Event Number: 40944
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WYATT ENGINEERING - USKH
Region: 4
City: SPOKANE State: WA
County:
License #: WN-I0409-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/12/2004
Notification Time: 18:13 [ET]
Event Date: 07/27/2004
Event Time: [PDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

Taken in part from email sent from Washington Department of Health

"The licensee reported that a Troxler moisture/density gauge, Model 3430, Serial Number 19736 was damaged while in use. The gauge was backed over by a water truck while the source rod was extended into the road surface. The gauge contained two sealed sources, (Cs-137, 0.296 GBq (8 milliCuries) and Am-241:Be 1.48 GBq (40 milliCuries). The licensee stated the gauge had been placed on the surface with the source rod in a test hole. The licensee was looking for a new test location when the truck damaged the gauge.

"The licensee attempted to retract the Cs-137 source into its shielded position but could not. The operator placed the end of the probe back in the test hole and waited for help. A manufacturer's representative arrived at about 10:30 a.m. to assist the licensee. He surveyed the area and found that the highest reading was 50 mR/hr directly beside the gauge with the rod in the ground. A second attempt was made to retract the source rod into the shielded position. This resulted in moving all but the last inch inside the shield. At this point the source rod with shield was placed in a five gallon bucket and filled with dirt and rock while the transport box was made ready.

" Both the Cs-137 and Am-241:Be sources appeared to be intact and undamaged. The representative attempted again to move the Cs-137 source into the shielded position. This attempt was successful. The Cs-137 source rod/shield assembly and Am-241:Be source were placed into the transport box and more dirt and rock were added. The box was then locked and chained inside the licensee's truck.

"Dose-rate measurements were taken and noted to be 10 mR/hr at 6 inches from the box. The driver's side of the cab measured about 2 mR/hr. The licensee was instructed to park the vehicle, not to leave it unattended and not to drive it until additional shielding could be located. The representative took possession and transported the gauge to a storage area where it was secured. A leak test was performed and found to be negative. The representative will ship the gauge for disposal."

Washington State event report #WA 04-044.

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Power Reactor Event Number: 40960
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIMMY BURGESS
HQ OPS Officer: BILL GOTT
Notification Date: 08/16/2004
Notification Time: 12:18 [ET]
Event Date: 08/16/2004
Event Time: 10:28 [EDT]
Last Update Date: 08/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CAUDLE JULIAN (R2)

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

Event Text

TRANSFER EMPLOYEE OFFSITE DUE TO ELECTRICAL SHOCK

An employee received an electrical shock while working on temporary power on the north side of the unit 2 turbine building. He was transported to the Carolina Medical Center.

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 40962
Rep Org: GENERAL ELECTRIC NUCLEAR ENERGY
Licensee: GENERAL ELECTRIC NUCLEAR ENERGY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JASON S. POST
HQ OPS Officer: BILL GOTT
Notification Date: 08/16/2004
Notification Time: 16:04 [ET]
Event Date: 08/16/2004
Event Time: 16:00 [EDT]
Last Update Date: 08/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
TODD JACKSON (R1)
CAUDLE JULIAN (R2)
BRENT CLAYTON (R3)
WILLIAM JONES (R4)
VERN HODGE (NRR)

Event Text

PART 21 60-DAY INTERIM NOTIFICATION: NARROW RANGE WATER LEVEL INSTRUMENT LEVEL 3 TRIP

This letter provides a 10CFR21(a)(2) 60- Day Interim Report notification regarding a potential issue with the Level 3 trip from the narrow range water level instruments that initiate reactor scram. A conservative evaluation by GE Nuclear Energy (GENE) has determined that water level instruments may indicate high by as much as 8 inches, should the reactor water level drop below the dryer seal shirt. At issue is whether with the actual water level as much as 8 inches lower than indicated, the top of active fuel (TAF) will be uncovered for the limiting loss of feedwater event due to

1. Actual water level being lower than indicated when the Level 3 trip occurs, or

2. Failure of the Level 3 trip to occur if water level drops below the narrow range instrument variable leg tap prior to reaching the Level 3 trip setpoint.

Because TAF is a Technical Specification Safety Limit, TAF uncovery for a loss of feedwater event would be a Reportable Condition. However, it would not lead to a significant safety hazard due to multiple automatic and passive protection features of a BWR.

GENE has completed analysis for BWR 2/3 plants and determined that this is not a reportable condition (i.e., the TAF safety limit is protected). GENE has not completed the analyses for BWR /4-/6 plants. For these plants, GENE has determined that actual water level being lower than indicated by up to 8 inches when the Level 3 trip occurs does not lead to TAF uncovery. However, for these plants GENE has not determined if water level could drop below the narrow range instrument variable leg tap prior to reaching the Level 3 trip setpoint.

Therefore, this letter is issued as a 60 - Day Interim Notification under 10 CFR21.21(a)(2) to the BWR/4-/6 plants listed in Attachment 1. The potentially affected plants are being concurrently notified of this situation by a GENE Safety Communication letter. GENE is committed to complete the evaluation by October 11, 2004.


Attachment 1 Plants List Below: (Affected Plants - Evaluation incomplete)

Clinton, Brunswick Units 1 & 2, Nine Mile Point Unit 2, Fermi Unit 2, Columbia, Fitzpatrick, Grand Gulf, River Bend, La Salle Units 1&2, Limerick Units 1 & 2, Peach Bottom Units 1 & 2, Perry, Cooper, Duane Arnold, Susquehanna Units 1 & 2, Hope Creek, Hatch Units 1 & 2, Browns Ferry Units 1 (plant is in an extended shutdown),2 & 3.

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