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Event Notification Report for October 1, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/30/2004 - 10/01/2004

** EVENT NUMBERS **


40982 41027 41075 41077 41078 41081

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General Information or Other Event Number: 40982
Rep Org: GENERAL ELECTRIC COMPANY
Licensee: GENERAL ELECTRIC COMPANY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JASON S. POST
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/24/2004
Notification Time: 17:36 [ET]
Event Date: 08/24/2004
Event Time: [EDT]
Last Update Date: 09/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
EUGENE COBEY (R1)
JOEL MUNDAY (R2)
ERIC DUNCAN (R3)
WILLIAM JOHNSON (R4)
VERN HODGE (NRR)

Event Text

PART 21 REPORTABLE CONDITION AND 60-DAY INTERIM REPORT NOTIFICATION: NON-CONSERVATIVE SAFETY LIMIT MINIMUM CRITICAL POWER RATIO

Global Nuclear Fuel (GNF) and GE Nuclear Energy (GENE) have determined that the current GNF process for determination of the Safety Limit Minimum Critical Power Ratio (SLMCPR) can result in a non-conservative SLMCPR. GENE has historically used a non-conservative SLMCPR impact of 0.01 as the threshold for reportability under 10CFR21. A preliminary screening evaluation has been completed for all plants operating with a SLMCPR calculated by GNF to determine those that have a nonconservative impact of 0.01 or greater. Verification has been completed for those plants that the screen showed to have a non-conservative SLMCPR impact of 0.01 or greater. Verification has not been completed for the plants that the screen showed had an impact of less than 0.01 or were unaffected, thus requiring a 60-Day Interim Report notification pending verification completion.

The plants for which GNF calculates the SLMCPR are identified [below]. Those plants for which the preliminary screen indicated that the current SLMCPR is unaffected are identified as a 60-Day Interim Report. Upon completion of verification (assuming the results of the screen are confirmed) the status of these plants will be changed to Not Reportable. GENE will provide a follow-up report to the NRC by September 29, 2004. The plants for which the current SLMCPR is non-conservative by 0.01 or greater are identified as a Reportable Condition under 10CFR21.21(d). These plants will take action to address the Reportable Condition.

GNF has notified all plants that have been confirmed to be affected. The plants that have a non-conservative SLMCPR for current plant operation will take action to mitigate the potential impact. Depending on the specific circumstances, mitigating actions to protect the SLMCPR may include increasing the OLMCPR to assure compliance with the low flow calculated SLMCPR. In some cases sufficient conservatism may exist in the OLMCPR at low flow to bound the increased SLMCPR. Each affected plant will notify the NRC and take appropriate action if their Technical Specifications are affected.

There are no actions necessary for the plants that are unaffected pending completion of verification. If, in the course of verification, GNF determines that there is an impact, the affected utility will be notified immediately. GNF will complete the verification and GENE, will provide a follow-up letter to the NRC by September 29, 2004.

Affected and 60-Day Interim Notification Plants:

60-Day Interim Report: Clinton, Oyster Creek, Brunswick 1, Brunswick 2, Nine Mile Point 2, Fitzpatrick (60-Day interim report for current operation, Reportable Condition for SLMCPR licensing submittal), Pilgrim, Vermont Yankee, Dresden 2, Dresden 3, LaSalle 1, LaSalle 2, Limerick 1, Limerick 2, Peach Bottom 2, Peach Bottom 3, Quad Cities 1, Quad Cities 2, Perry 1, Duane Arnold, Monticello, Hope Creek, Hatch 1, Hatch 2, Browns Ferry 2

Reportable Condition: Nine Mile Point 1, Fermi 2, Fitzpatrick (60-Day interim report for current operation, Reportable Condition for SLMCPR licensing submittal), Cooper.

* * * UPDATE FROM JASON POST (VIA FAX) TO CROUCH @ 2354 HRS. EST ON 09/29/04 * * *

In part, the update reads:

"The evaluation for the potentially unaffected plants has now been completed. The results of the screening calculation have been confirmed: this is not a reportable condition for the plants that were previously identified as a 60-Day Interim Report notification in MFN 04-081" (See above).

Notified R1DO(Rogge), R2DO(Lesser), R3DO(Kozak), R4DO(Howell) and NRREO(Hodges).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41027
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: JON HUECKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/08/2004
Notification Time: 18:23 [ET]
Event Date: 09/08/2004
Event Time: 14:45 [EDT]
Last Update Date: 09/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CAROLYN EVANS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby

Event Text

EMERGENCY FEEDWATER SYSTEM ACTUATION

"At 1445 on September 8, 2004, while in Mode 3 after an unplanned reactor trip during tropical storm Frances, Crystal River Unit 3 experienced a re-actuation of the B-Train of the Emergency Feedwater System. The Emergency Feedwater System had previously actuated during a Loss of Offsite Power experienced during Hurricane Frances and the B-Train actuation had procedurally been bypassed as part of the plant recovery. While In the process of restoring a Main Feedwater Pump to an operating condition, the signal bypassing the B-Train Emergency Feedwater actuation was momentarily removed due to unusual plant conditions present during recovery from the loss of power This resulted in the re-actuation of the B-Train of Emergency Feedwater. This condition is 8-Hour reportable per 10CFR50.72(b)(3)(iv)(B)(6). The re-actuation of the B-Train of Emergency Feedwater did not have a significant impact on plant operation and the associated equipment has been returned to a standby condition."

The licensee informed the NRC Resident Inspector.

* * * RETRACTION FROM JOHN ADDISON TO BILL HUFFMAN AT 1402 EDT ON 9/30/04 * * *

The following information was provided by the licensee via facsimile:

"At 1823 [hrs. EDT] on 9/8/04, Crystal River Unit 3 made an 8-hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 50.72(b)(3)(iv)(B)(6) concerning re-actuation of the B-train of the Emergency Feedwater System. The Emergency Feedwater System had previously actuated during a Loss of Offsite Power experienced during Hurricane Frances and the B-Train actuation had procedurally been bypassed as part of the plant recovery. While in the process of restoring a Main Feedwater Pump to an operating condition, the signal bypassing the B-Train Emergency Feedwater actuation was momentarily removed due to unusual plant conditions present during recovery from the loss of power. This allowed for a re-actuation of the B-Train of Emergency Feedwater based on a loss of Main Feedwater Pump signal. However, the two Main Feedwater Pumps had not been operating since the loss of offsite power that occurred on 9/6/04. The A-Train Emergency Feedwater System had been operating continuously since the initial actuation on the loss of offsite power and continued to operate during and after the re-actuation of the B-Train. Re-actuation of the B-Train has been determined to be an invalid actuation in accordance with the guidance of NUREG-1022, and therefore EN 41027 is retracted."

The licensee has informed the NRC resident inspector. R2DO (Lesser) notified.

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General Information or Other Event Number: 41075
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: PROFESSIONAL SERVICE INDUSTRIES, INC.
Region: 1
City: Haines City State: FL
County: Polk County
License #: 0022-17
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/27/2004
Notification Time: 11:25 [ET]
Event Date: 09/27/2004
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
TOM ESSIG (NMSS)
MATTHEW HAHN (TAS)

Event Text

STOLEN TROXLER MOISTURE DENSITY GAUGE

"Metal ship container was broken into and the gauge was stolen. It was last seen close of business on Friday the 24th and discovered stolen Monday the 27th. The keys were not taken. The Haines City PD has been notified. Owner will offer a $500 reward. Florida is investigating."

Incident Location: HWY 27, 5 miles south of I-4 (Polk County near Haines City) Temp work storage site.

Troxler: Model number 3430 [containing] 8 millicuries of cesium-137 and 40 millicuries of Am-241/Be. Serial number of the gauge is 27404.

License type: Specific; 3L(1).

* * * UPDATE ON 09/29/04 AT 1514 EDT FROM CHARLES ADAMS TO GERRY WAIG VIA EMAIL * * *

"Stolen Troxler gauge & case were recovered undamaged by the licensee this afternoon. The source rod was still locked. A teenage boy claimed the reward and stated that he had found it Saturday night (during the hurricane) beside the side of road which runs along the orange grove right behind the storage container. When his mother saw the radiation sticker she told him to get it out of the house. He then opened up the case and found the contact information and called the licensee. He claimed that the case lock was gone when he found it."

Notified R1DO (John Rogge) and NMSS EO (M. Wayne Rogers)

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General Information or Other Event Number: 41077
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PORT TOWNSEND PAPER
Region: 4
City: PORT TOWNSEND State: WA
County:
License #: WN-I041-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL GOTT
Notification Date: 09/28/2004
Notification Time: 12:51 [ET]
Event Date: 05/17/2004
Event Time: [PDT]
Last Update Date: 09/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE LOST OHMART DENSITY GAUGE

"The licensee reported that an Ohmart density gauge (Model SH-F2, Serial Number 2479GK) had last been seen during an inventory and shutter check on November 17, 2003. The gauge contained a 1.85 GBq (50 mCi), Cs-137 sealed source. Facility records indicate the device's electrical signal was lost on December 12, 2003, at 4:30 pm. At that time, a physical investigation, to investigate the signal loss, was not performed. The next routine inventory was attempted on May 17, 2004. At this time the gauge was found to be missing.

"The missing gauge had measured 'weight rejects' at a remote part of the facility. Rejects are routinely sent to an eastern Washington landfill by truck. The gauge seems to have been dislodged from its angle-iron attachment, by large reject material, and then inadvertently taken to an eastern Washington landfill by the rejects truck.

"Gauge measurements were not vital to operations, so the loss of signal had gone ignored until the May 17th inventory attempt.

"CORRECTIVE ACTION TAKEN by licensee:

1. A special training session will be given, during the licensee's next monthly safety meeting, for those employees associated with fixed gauge operations. The training will emphasize the importance for employees to investigate when gauge process measurements are lost.

2. Special informational postings will be placed at key locations within the facility, near process control equipment receiving fixed gauge electrical signals, so facility employees shall be reminded to immediately investigate the loss of a gauging device's signal.

"Isotope and Activity Involved: Cs-137, 1.85 GBq (50 mCi)

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None likely.

"Lost, Stolen or Damaged? (mfg., model, serial number): Lost (or Stolen) Ohmart density gauge (Model SH-F2, Serial Number 2479GK)

"DISPOSITION/RECOVERY: Searches by licensee with the assistance of department staff were performed with Ludlum Model 19, Micro R meters and other detection instrumentation. These searches were unsuccessful.

"A search at the Licensee's facility in Port Townsend, Washington was conducted on May 25, 2004. A search at the landfill was performed on July 29, 2004."

Event Report Number: WA-04-028

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General Information or Other Event Number: 41078
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL GOTT
Notification Date: 09/28/2004
Notification Time: 15:08 [ET]
Event Date: 09/24/2004
Event Time: [PDT]
Last Update Date: 09/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT

"Per Swedish Medical Center policy, post thyroid treatment patients are prescribed 74 mBq (2mCi (milliCuries)) for the treatment follow-up scan, and 185 mBq (5 mCi) for subsequent treatment if necessary. On 24 September 2004 a patient was prescribed 74 mBq (2 mCi) of NaI (Iodine-131) for a post treatment scan. Instead, 191 mBq (5.16 mCi) of NaI (Iodine-131) were administered. The prescribing physician realized that a misadministration had occurred on 27 September 2004 when the patient underwent the scan. A viable follow-up scan was able to be performed even though the misadministration had occurred.

"There are multiple procedural checks in place to assure medical technicians administer the prescribed dose. Human error appears to have lead to checks not being performed prior to this event.

"The Radiation Safety Officer for Swedish Medical Center notified the State of Washington, of the misadministration, on 27 September 2004.

"The treating physician notified the patient on Monday, 27 September 2004, when the physician discovered the patient had been administered 191 mBq (5.16 mCi) of NaI (Iodine-131) instead of the prescribed 74 mBq (2 mCi) of NaI (Iodine-131)."

Event Report Number WA-04--57

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Power Reactor Event Number: 41081
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: JOHN ADDISON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/30/2004
Notification Time: 14:02 [ET]
Event Date: 09/08/2004
Event Time: 14:45 [EDT]
Last Update Date: 09/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK LESSER (R2)

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

Event Text

INVALID EMERGENCY FEEDWATER ACTUATION

The following information was provided by the licensee via facsimile:

"At 1445 [hrs. EDT] on September 8, 2004 Crystal River Unit 3 experienced an invalid actuation of the B-Train of the Emergency Feedwater System. This occurrence is being reported in accordance with 10CFR50.73(a)(2)(iv)(A) and 50.73(a)(2)(iv)(B)(6) using the optional process described in 50.73(a)(1). A complete actuation of the B-Train of Emergency Feedwater occurred and the train started and functioned successfully. The A-Train of Emergency Feedwater was operating at the time, and it continued to operate successfully during and after the B-Train actuation."

The licensee has notified the NRC resident inspector.

See retraction of Event #41027 for related information.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012