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Event Notification Report for November 26, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/24/2004 - 11/26/2004

** EVENT NUMBERS **


41094 41208 41210 41223 41224 41225 41226

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41094
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: RITA BRADDICK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/05/2004
Notification Time: 18:48 [ET]
Event Date: 10/05/2004
Event Time: 13:34 [EDT]
Last Update Date: 11/25/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICHARD BARKLEY (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


INADVERTENT UNDERVOLTAGE CONDITION INITATED DIESEL LOAD SEQUENCER, ETC. DIESEL DID NOT START.

"At approximately 1334, during realignment from monthly surveillance testing of the normal and alternate power
supply breakers to the 10 A404 vital 4 Kv bus, an inadvertent undervoltage condition appears to have occurred.
This condition resulted in initiation of the diesel load sequencer and tripping of the normal loads supplied by this
bus. The undervoltage condition was momentary in nature, the load sequencer stopped upon restoration of voltage
prior to starting the emergency diesel generator and operators successfully restarted the equipment that had tripped
and restored the load sequencer. The D Emergency Diesel Generator is considered to be operable at this time.

"The cause of the occurrence is under investigation. The plant is stable in Operational Condition 1 at 100% power.

"This event is being reported in accordance with 10CFR50.72(b)(3)(iv)(A) 'Any event or condition that results in
valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) subsection 8', specifically in this case,
Emergency ac electrical power systems." LAC Township notified by licensee.

The NRC Resident Inspector was notified of this event by the licensee.

* * * RETRACTION PROVIDED FROM BRADDICK TO KNOKE AT 1503 ON 11/25/04. * * *

"Upon further review this event was determined to not meet the reportability requirements of 10CFR50.72. The event that caused the momentary interruption to the 10A404 vital bus (i.e., less then a second) did not result in an actuation of a listed system (Emergency ac electrical power systems, including: Emergency diesel generators (EDGs)). Because the event did not meet the NUREG 1022 reporting requirement specified in 10CFR50.72 (b)(3)(iv)(A) it has been determine to not be reportable."

The NRC Resident Inspector was notified of this event by the licensee. LAC Township notified by licensee.

Notified R1DO (Dimitriadis)

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General Information or Other Event Number: 41208
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: H&H X-RAY SERVICES INCORPORATED
Region: 1
City: EAST POINT State: KY
County:
License #: 201-34205
Agreement: Y
Docket:
NRC Notified By: MATT MacKINLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/19/2004
Notification Time: 11:37 [ET]
Event Date: 11/19/2004
Event Time: 10:03 [CST]
Last Update Date: 11/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)
JIM WHITNEY (TAS)
RICHARD WESSMAN (IRD)
JANNIE EVERETTE (DHS)
THOMAS YATES (DOE)
EUGENE LEE (EPA)
SUZANNE RIGBY (USDA)
JOHN ALDAHONDO (HHS)
JIM DUNKER (FEMA)

Event Text

AGREEMENT STATE REPORT OF A STOLEN RADIOGRAPHY CAMERA

The State of Kentucky Radiation Control Branch reported a stolen radiography camera AEA Model 880D with a 40 Curie Ir-192 source (Camera Serial#D1121; Source Model 424-9; Source Serial #16663-B). The Camera is owned and licensed to H&H X-Ray Services that has an office located in East Point, Kentucky. The camera was located in the radiographer's truck which was in the town of Corbin, Kentucky in preparation for a job. The radiographer lent the truck to the assistant radiographer on Wednesday night (11/17/04). The assistant radiographer did not return with the truck all day Thursday. Without any contact with the assistant radiographer since Wednesday night, the radiographer reported the truck and camera stolen this morning (11/19/04). The local police believe they saw the truck parked at a home in the Corbin area. The camera was locked in the truck but the assistant radiographer has a key to the camera so the current status is unknown.

The State has notified NRC Region 1 (Sheri Minnick). In addition to the other Federal agencies notified above, contacted the National Response Center (Ms. Jones).


* * * UPDATE 1420 EST ON 11/21/04 FROM CLYDE SLAUGHTER (RSO - H&H X-RAY SERVICES, INC.) TO S.SANDIN * * *

The abandoned vehicle containing the radiography camera was recovered in Wise, VA after the assistant radiographer contacted another company employee providing information as to its location. Mr. Slaughter inspected the camera and found no indication of tampering. The camera is enroute to the East Point, KY office and will later be returned to the West Monroe, LA main facility. The licensee informed the KY Department of Homeland Security (Lt. Joe England).

Notified R1DO(Dimitriadas), NMSS(Gillen), IRD(Wessman), TAS Duty Officer(Whitney), NSIR(Weber, Zimmerman), Chairman Diaz(Fragoyannis), EDO(Hsia), DHS(Evans), DOE(Smith), EPA(Baumgartner), USDA(Comeau), HHS(Miller), FEMA(Caldwell) and FBI.

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General Information or Other Event Number: 41210
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI
Region: 1
City:  State: MS
County:
License #: MS-232-02
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/19/2004
Notification Time: 12:36 [ET]
Event Date: 11/18/2004
Event Time: [CST]
Last Update Date: 11/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A THERAPY MISADMINISTRATION

The following information was provided via email from the Radioactive Materials Branch Director, Division of Radiological Health, MS State Dept. of Health:

"On November 18, 2004, licensee's RSO notified Division of Radiological Health/MS State Dept. of Health, of a Iodine-125 therapy misadministration. The prescribed treatment was for 145 gray to the prostate gland; however, due to an error concerning the coordinates, the treatment area was partially missed and resulted in a greater than 10 gray treatment to the rectum. The isotope was Iodine -125, 88 seeds with average activity of .300 millicuries, total activity of 26.8 millicuries. The patient was notified of the error and agreed to have the treatment performed again with no problems occurring. The RSO notified DRH after discussing the error with the authorized user and agreeing on corrective actions to prevent reoccurrence. At the present time, this is all the information we have received. I will update as soon as possible."

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Fuel Cycle Facility Event Number: 41223
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: CALVIN PITTMAN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/24/2004
Notification Time: 13:39 [ET]
Event Date: 11/23/2004
Event Time: 13:25 [CST]
Last Update Date: 11/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
CHARLIE PAYNE (R2)
PATRICIA HOLAHAN (NMSS)

Event Text

FAILURE OF UF6 RELEASE DETECTION SYSTEM DUE TO LOSS OF ELECTRICAL POWER

"At 1325 [CST] on 11-23-04, the Plant Shift Superintendent (PSS) was notified of a failure of the C-310 High Voltage UF6 Release Detection System. The High Voltage UF6 detection system was disabled due to loss of power. Power was lost when a circuit breaker was tripped to de-energize an auxiliary substation that faulted and caused a fire. This High Voltage UF6 Release System is designed to activate alarms to alert operators in the event of a UF6 release. The PSS declared the system inoperable and TSR LCO 2.3.4.4.A actions were implemented to post a continuous smoke watch in the affected area. The event is reportable as a 24 hour event, as required by 10 CFR 76.120(c)(2)(i); An event in which equipment is disabled or fails to function as designed when the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a preestablished safe condition after an accident. The equipment was required by TSR to be available and operable and no redundant equipment was available to perform the required safety function.

"In addition, the loss of power caused the Low Voltage UF6 Detection System to isolate the C-310 withdrawal positions as designed. The substation fault and subsequent fire did not result in a release of radioactive material.

"The Senior NRC Resident Inspector has been notified of this event."

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Power Reactor Event Number: 41224
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID OAKES
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/24/2004
Notification Time: 20:01 [ET]
Event Date: 11/24/2004
Event Time: 12:20 [MST]
Last Update Date: 11/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEFFERY CLARK (R4)

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

ECCS LOOPS DECLARED INOPERABLE IN SUPPORT OF LOG TERM ACCIDENT MITIGATION

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On November 24, 2004, at approximately 12:20 Mountain Standard Time (MST), Palo Verde Nuclear Generating Station Unit 3 was operating at 0% power at approximately normal operating temperature and pressure when 3 of the 4 ECCS injection check valves were identified to be in a degraded condition. While performing normal torque verifications on the bonnet bolts for these check valves, it was identified that the graphoil seals were degraded in that the seal material had extruded past the retaining ring. Although there was no evidence of actual leakage associated with these valves, the long term integrity of the valves during post accident operation could not be assured. As a result, the Operators conservatively declared both trains of ECCS inoperable per LCO 3.5.3 and 3 of 4 Safety Injection Tanks inoperable per LCO 3.5.1, requiring entry into LCO 3.0.3. Operations also declared both RCS loops inoperable per LCO 3.4.5. A cooldown and depressurization of the RCS is in progress to Mode 5.

"Unit 3 was preparing for Mode 2 entry following a refueling outage when the degraded check valve seals were identified.

"Engineering continues to evaluate this condition.

"There were no RPS/ESF actuations, and none were required.

"There were no structures, systems or components that were inoperable at the start of event that contributed to the event.

"This condition did not result in any challenges to the fission product barrier or result in any releases of radioactive materials. There were no adverse safety consequences or implications as a result of this event. This condition did not adversely affect the safe operation of the plant or health and safety of the public.

"The NRC Resident Inspector has been notified of this condition and this ENS notification."

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Power Reactor Event Number: 41225
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: NICOLE KEENE
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/25/2004
Notification Time: 16:50 [ET]
Event Date: 11/25/2004
Event Time: 15:45 [CST]
Last Update Date: 11/25/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVE PASSEHL (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation
2 N Y 85 Power Operation 85 Power Operation

Event Text

LOSS OF SAFETY PARAMETER DISPLAY SYSTEM

"On November 25, as of 1545 hours, the Station's Plant Process Computer (PPC) had been in a failed state for greater than eight hours. Previous to this, at 0745 hours, the PPC experienced an unexpected hardware failure. This computer feeds the Safety Parameter Display System (SPDS) for both Units. This failure is considered a major loss of emergency assessment capability. Troubleshooting and repairs are in progress."

This failure affects the transmission of ERDS data and applicable emergency response personnel have been notified of the change in their reporting status if an emergency event is declared due to the loss of ERDS.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41226
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ETHAN TREPTOW
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/26/2004
Notification Time: 03:22 [ET]
Event Date: 11/26/2004
Event Time: 00:25 [CST]
Last Update Date: 11/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVE PASSEHL (R3)

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

Event Text

SAFETY INJECTION ACCUMULATOR ISOLATION VALVES FOUND CLOSED AND THEIR BREAKERS LOCKED OFF.

"During plant startup following a Refueling Outage, the Reactor Coolant System was pressurized greater than 1000 psig with the Safety Injection Accumulator Isolation Valves (SI-20A and SI-20B) closed and their breakers locked off. This is contrary to the plant Technical Specification requirement to open the valves and lock out their breakers prior to the Reactor Coolant System exceeding 1000 psig. The Safety Injection Accumulators are required to inject into the Reactor Coolant System to mitigate the consequences to a LOCA. This is conservatively being reported under 10CFR50.72(b)(3)(v)(D) as "Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident."

"At the time of discovery, Reactor Coolant System pressure was approximately 1090 psig and Reactor Coolant System temperature was approximately 440 deg. Fahrenheit. Approximately three minutes after the condition was discovered, the SI Accumulator Isolation Valves were opened and their power breakers were locked out."

The STA discovered the problem while reviewing Technical Specification's and Plant Conditions.

The NRC Resident Inspector was notified of this event by the licensee.

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