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Event Notification Report for April 14, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/13/2005 - 04/14/2005

** EVENT NUMBERS **


41524 41562 41576 41580 41587 41593 41595

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41524
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVID BOWMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/24/2005
Notification Time: 17:50 [ET]
Event Date: 03/24/2005
Event Time: 09:30 [CST]
Last Update Date: 04/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 85 Power Operation 85 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"Minimum Switchyard Voltage Requirements Not Met

"On March 24, 2005, at 0930 hours, Quad Cities was notified that the switchyard voltage was below that required to ensure that offsite power would remain available following a design basis accident. Both sources of off-site power were declared inoperable. The appropriate Technical Specification required actions were taken for both units. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"A preliminary engineering assessment indicates that one source of offsite power was available. Additional confirmatory reviews are being performed to determine if the safety function was preserved.

"At this time, grid/switchyard voltage has been restored."

Minimum switchyard voltage required is 348.4 KV. The analyzed minimum voltage which prompted notification to the NRC was 347.5 KV. Switchyard voltage at the time of this report was ~359 KV.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM C. STEFFES TO M. RIPLEY 1556 EDT 04/13/05 * * *

"The purpose of this report is to retract the following ENS reports: 1) ENS # 41524 on March 24, 2005; 2) ENS # 41562 on April 4, 2005; and 3) ENS # 41587 on April 11, 2005.

"These reports were made following notification to Quad Cities that the switchyard voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident. For each event, both sources of offsite power were declared inoperable, the appropriate Technical Specification required actions were taken for both units, and an ENS notification was made for a condition that could have prevented fulfillment of a safety function.

"The events occurred when Unit 1 was in a refueling outage and Unit 2 was operating at 85% power. Subsequent Engineering analysis has determined that with a unit shutdown, and the large 4 Kv loads on that unit not running, the required minimum post-accident switchyard voltage is reduced to 339.3 kV (for the shutdown unit). Given the new minimum post-accident switchyard voltage, it was confirmed that there was a source of off-site power available to the Station. Specifically for all three events, the projected post-accident switchyard voltage (which ranged between 343 kV to 347.5 kV) was higher than the required minimum post-accident switchyard voltage (339.3 kV) for the shutdown unit. As a result, there was no condition present that could have prevented fulfillment of a safety function, and thus these events are not reportable."

The licensee notified the NRC Resident Inspector. Notified R3 DO (J. Madera)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41562
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DUANE HAAS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/04/2005
Notification Time: 19:51 [ET]
Event Date: 04/04/2005
Event Time: 16:07 [CST]
Last Update Date: 04/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KENNETH O'BRIEN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 85 Power Operation 85 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"On April 4, 2005, at 1607 hours [CDT], Quad Cities was notified that the switchyard voltage was below that required to ensure that offsite power would remain available following a design basis accident. Both sources of off site power were declared inoperable. The appropriate Technical Specification required actions were taken for both units. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"This notification report is similar to the condition reported on March 24, 2005 (reference EN#41524 for additional information)."

Technical Specification minimum switchyard voltage is 348.4 KV. Switchyard voltage at 1607 hrs. was approximately 343.7 KV. Switchyard voltage at the time of NRC notification was 358 KV which is above the Technical Specification minimum.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM C. STEFFES TO M. RIPLEY 1556 EDT 04/13/05 * * *

"The purpose of this report is to retract the following ENS reports: 1) ENS # 41524 on March 24, 2005; 2) ENS # 41562 on April 4, 2005; and 3) ENS # 41587 on April 11, 2005.

"These reports were made following notification to Quad Cities that the switchyard voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident. For each event, both sources of offsite power were declared inoperable, the appropriate Technical Specification required actions were taken for both units, and an ENS notification was made for a condition that could have prevented fulfillment of a safety function.

"The events occurred when Unit 1 was in a refueling outage and Unit 2 was operating at 85% power. Subsequent Engineering analysis has determined that with a unit shutdown, and the large 4 Kv loads on that unit not running, the required minimum post-accident switchyard voltage is reduced to 339.3 kV (for the shutdown unit). Given the new minimum post-accident switchyard voltage, it was confirmed that there was a source of off-site power available to the Station. Specifically for all three events, the projected post-accident switchyard voltage (which ranged between 343 kV to 347.5 kV) was higher than the required minimum post-accident switchyard voltage (339.3 kV) for the shutdown unit. As a result, there was no condition present that could have prevented fulfillment of a safety function, and thus these events are not reportable."

The licensee notified the NRC Resident Inspector. Notified R3 DO (J. Madera)

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General Information or Other Event Number: 41576
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 25-1323-01
Agreement: Y
Docket:
NRC Notified By: PAUL SCHMIDT
HQ OPS Officer: WESLEY HELD
Notification Date: 04/08/2005
Notification Time: 14:07 [ET]
Event Date: 04/08/2005
Event Time: 08:30 [CST]
Last Update Date: 04/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
TOM ESSIG (NMSS)

Event Text

POTENTIAL MEDICAL EVENT INVOLVING A THERAPEUTIC ADMINISTRATION OF YTTRIUM-90

The licensee provided the following information via facsimile (licensee text in quotes):

"On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. [HFS 157.72 (1) (a) 1.]

"On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records.

"The licensee is investigating the incident. The ordering physician has been notified

"HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'.

"DHFS, RPS staff plan to investigate. "

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General Information or Other Event Number: 41580
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SADDLEBACK MEMORIAL HOSPITAL
Region: 4
City: LAGUNA HILLS State: CA
County:
License #: 2652-30
Agreement: Y
Docket:
NRC Notified By: MARK PIETZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/08/2005
Notification Time: 17:42 [ET]
Event Date: 04/08/2005
Event Time: 12:35 [PST]
Last Update Date: 04/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
MELVYN LEACH (NMSS)

Event Text

AGREEMENT STATE REPORT OF POTENTIAL MEDICAL MISADMINISTRATION

The following information was provided by the State of CA via e-mail (text in quotes):

"At 12:35 pm [the] manager of the [Saddleback Memorial Hospital] Imaging Department contacted [the CA Radiological Health Branch] to report a therapy misadministration involving HDR and Ir-192. [The hospital manager] knew few details, other than to report that the source was apparently implanted 8 cm short of its desired location. At this time it is not known how much under treatment there was to the tumor site, nor how much exposure there was to healthy tissue. [It has] not been determined if this is a CA SS&D [Sealed Source and Device]. [The hospital manager] is obtaining this information and will be reporting it back, via fax, as soon as possible. [The CA Radiological Health Branch] has requested narrative as to flow of events.

"This form will be updated and forwarded to NRC Ops Center as information comes in."

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41587
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVE BOWMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/11/2005
Notification Time: 15:39 [ET]
Event Date: 04/11/2005
Event Time: 12:40 [CST]
Last Update Date: 04/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN MADERA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 85 Power Operation 85 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

"At 1240 on April 11, 2005 Quad Cities Station was notified calculated post-LOCA switchyard voltage is below the minimum acceptable value required to ensure offsite power will remain available following a design basis accident. The appropriate Technical Specification Actions have been taken for both Units. The ability of the Emergency Diesel Generators to fulfill their design function is not affected by this condition. This event is being reported in accordance with 10CFR50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"Actual Switchyard voltage at the time of this notification is 361 Kv. The required minimum post-accident switchyard voltage is 348.4 Kv, while the projected post-accident voltage which prompted this notification is 346.3 Kv.

"This notification is similar to the condition reported on March 24, 2005 (EN #41524) and April 4, 2005 (EN #41562)."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM C. STEFFES TO M. RIPLEY 1556 EDT 04/13/05 * * *

"The purpose of this report is to retract the following ENS reports: 1) ENS # 41524 on March 24, 2005; 2) ENS # 41562 on April 4, 2005; and 3) ENS # 41587 on April 11, 2005.

"These reports were made following notification to Quad Cities that the switchyard voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident. For each event, both sources of offsite power were declared inoperable, the appropriate Technical Specification required actions were taken for both units, and an ENS notification was made for a condition that could have prevented fulfillment of a safety function.

"The events occurred when Unit 1 was in a refueling outage and Unit 2 was operating at 85% power. Subsequent Engineering analysis has determined that with a unit shutdown, and the large 4 Kv loads on that unit not running, the required minimum post-accident switchyard voltage is reduced to 339.3 kV (for the shutdown unit). Given the new minimum post-accident switchyard voltage, it was confirmed that there was a source of off-site power available to the Station. Specifically for all three events, the projected post-accident switchyard voltage (which ranged between 343 kV to 347.5 kV) was higher than the required minimum post-accident switchyard voltage (339.3 kV) for the shutdown unit. As a result, there was no condition present that could have prevented fulfillment of a safety function, and thus these events are not reportable."

The licensee notified the NRC Resident Inspector. Notified R3 DO (J. Madera)

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Power Reactor Event Number: 41593
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/13/2005
Notification Time: 10:19 [ET]
Event Date: 04/13/2005
Event Time: 03:50 [EST]
Last Update Date: 04/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN WHITE (R1)

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

Event Text

DURING CORE RELOAD REACTOR TRIP BREAKERS OPENED

"The plant is in Mode 6 (Refueling) and core reload is in progress with the reactor trip breakers open; both trains of solid state protection system are in the operate mode.

"While restoring a line up to place the 'D' steam generator on recirculation, a path was opened that allowed the 'B' steam generator to transfer water to the 'D' steam generator. This alignment lowered the 'B' steam generator to its low-low set point level. This initiated a reactor trip signal (RPS). With the reactor trip breakers open and the reactor core reload in progress, no components actuated as a result of the signal. If the emergency feedwater system had been in service, this would have resulted in equipment actuation. This is an 8-hour report per 10 CFR 50.72 (b)(3)(iv)(A). The resident inspector has been notified."

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Power Reactor Event Number: 41595
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DONALD SMITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/13/2005
Notification Time: 18:19 [ET]
Event Date: 04/13/2005
Event Time: 09:53 [CST]
Last Update Date: 04/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
PAUL FREDRICKSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

VALID RPS ACTUATION DUE TO AN INVALID ATWS LOGIC ACTUATION

"At 0953 [CDT] on 04/13/2005 with Unit 2 in MODE 4 [and] all Control Rods inserted, a valid RPS Actuation (Reactor SCRAM Signal resulting from the filling of the SCRAM DISCHARGE VOLUME) was received as a result of an invalid ATWS initiation. This occurred during the performance of 2-SR-3.3.5.2.4(FT) RCIC SYSTEM LOGIC FUNCTIONAL TEST. Further review of the test revealed that a Volt/Ohm Meter was attached across contacts in the ATWS LOGIC that conflicted with the RCIC Surveillance and apparently resulted in the ATWS initiation and the filling of the SCRAM DISCHARGE VOLUME.

"This event is reportable as an 8-hour Non-Emergency Notification along with a 60-day written report in accordance with 10CFR50.72 (b)(3)(iv)(A) & 10CFR50.73(a)(2)(iv)(A) as 'Any event or condition that results in valid actuation of RPS & PCIS as described in (1) & (2) below.' "

The licensee notified the NRC Resident Inspector.

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