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Event Notification Report for June 20, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/17/2005 - 06/20/2005

** EVENT NUMBERS **


41768 41778 41782 41783 41784

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General Information or Other Event Number: 41768
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: FORSYTH MEMORIAL MEDICAL CENTER
Region: 1
City: WINSTON-SALEM State: NC
County:
License #: 034-0878-3
Agreement: Y
Docket:
NRC Notified By: CLIFFTON R. HARRIS
HQ OPS Officer: ARLON COSTA
Notification Date: 06/13/2005
Notification Time: 17:20 [ET]
Event Date: 05/27/2005
Event Time: [EDT]
Last Update Date: 06/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
KERRY LANDIS (R2)
PATRICIA HOLAHAN (NMSS)
TAS (Email) ()

Event Text

NC AGREEMENT STATE REPORT ON HDR SOURCE MISSING IN TRANSIT

A Varian Medical Systems technician replaced a source from a high dose rate (HDR) brachytherapy unit at the Forsyth Memorial Medical Center on 5/26/05. The technician then shipped the replaced source on 5/27/05 in a type A package via Federal Express to Excel Logistics (Freight Forwarder for Varian) in Sterling, Virginia. The shipped source contains 3.3 Curies of Iridium-192. The source was not received at Excel Logistics Sterling, VA. The Varian Radiation Safety Officer contacted the Federal Express on 6/10/05. The package was reported missing with its last known location at the Federal Express hub in Memphis, Tennessee. The search for the package is ongoing.


* * * UPDATE FROM DR. C. HARRIS TO W. GOTT AT 1152 ON 06/17/05 * * *

The missing source was located at 1030 on 06/17/05. It had been misrouted to Paris, France, found, and then rerouted to Memphis, TN. It will be forwarded to Excel Logistics in Sterling, VA. Varian Medical Systems is sending a technician to Excel Logistics to inspect the package before it is forwarded to Belgium.

Notified R1DO (Krohn), NMSS (R. Correia), and emailed to TAS.

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General Information or Other Event Number: 41778
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NDS SOLUTIONS/LAMCO & ASSOCIATES
Region: 4
City: BRYAN State: TX
County:
License #: L05879/L05152
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 06/15/2005
Notification Time: 18:21 [ET]
Event Date: 06/08/2005
Event Time: [CDT]
Last Update Date: 06/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

RADIOGRAPHY SOURCE DISCONNECT/ RETRIEVAL AND POTENTIAL OVEREXPOSURE

"Consultant for Lamco was conducting a source retrieval on June 8, 2005 and personnel monitor fell near the 70 Curie radiography source. She picked it up when she realized it and had it returned to the supplier for processing. After receiving the results on June 13, 2005, she called to report the results. The personnel monitor received 9.477 rem, deep dose equivalent. The consultant estimated she received 1.5 rem based on her direct reading dosimeter after the source recovery was completed."


Texas Incident # I-8236

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Power Reactor Event Number: 41782
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JIM STORTZ
HQ OPS Officer: BILL GOTT
Notification Date: 06/17/2005
Notification Time: 15:02 [ET]
Event Date: 06/17/2005
Event Time: 11:20 [CDT]
Last Update Date: 06/17/2005
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):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 85 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO EHC MALFUNCTION

"At 1120 hours (CDT) on June 17, 2005, the Unit 1 reactor automatically scrammed from 85% power due to a valid high reactor pressure signal. The maximum reactor pressure was approximately 1044 psig during the event. All control rods inserted to their full-in position. Initial indications are that the reactor pressure increase was caused by a malfunction in the Electro-Hydraulic Control (EHC) system, which resulted in closure of the main turbine control valves. The main turbine bypass valves (nine) opened as expected in response to the pressure increase. No reactor pressure vessel safety or relief valves were required to actuate during the event. Reactor water level decreased to approximately -20 inches, which resulted in automatic Group 2 and 3 isolations as expected. All systems responded properly to the event. Unit 1 is in Mode 3 with a cooldown in progress and reactor water level in the normal level band. An investigation into the Unit 1 scram is in progress.

"Unit 2 remains at 94% power.

"This report is being made in accordance with 10CFR 50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A)."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41783
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAN MARKS
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/17/2005
Notification Time: 18:39 [ET]
Event Date: 06/17/2005
Event Time: 11:00 [MST]
Last Update Date: 06/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JACK WHITTEN (R4)

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

Event Text

POTENTIAL DEGRADED CONDITION DUE TO PRESSURIZER HEATER ELEMENT NON-CONFORMANCE

"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 June 15, 2005, Palo Verde Nuclear Generating Station was informed by Framatome that Thermocoax pressurizer heater elements provided for, and installed in Unit 3, were in non-conformance with specifications. Specifically, the active heating portion of the element was approximately 8 inches lower than design. The result of this error is that the active (heating) portion of the element extended into the nozzle area of the pressurizer heater sleeve and the heating effect on the pressurizer sleeve exceeded design, and possibly code-allowable temperature.

"Unit 3 operators entered Technical Requirements Manual LCO 3.4.103, Structural Integrity, Condition A for a ASME Code Class 1 component not conforming with requirements. The pressurizer can not be isolated and RCS temperature was already more than 50 degrees F above the minimum temperature required by NDT consideration when the condition was discovered. TLCO 3.0.100.3 is not applicable in Mode 5 and Technical Specification 3.4.9, Pressurizer, is not applicable in Mode 5. The RCS is in Mode 5 at approximately 190 degrees F and 350 psia.

"Engineering personnel are evaluating the code acceptability and potential for significant degradation resulting from the temperatures experienced by the pressurizer heater sleeves. On June 17, 2005, at approximately 11:00 AM MST, Palo Verde was informed that based on x-ray results of a PVNGS failed Thermocoax heater that revealed the active portion of the heater is longer than previously assumed, the metal temperatures exceeded ASME code allowable values. Stress levels are still under evaluation.

"This report is conservatively being placed per 10CFR50.72(b)(3)(ii)(A) based on the potential that the RCS pressure boundary may be seriously degraded, and 10CFR21(d)(3)(i) based on a defect in the pressurizer heater, a basic component, that may affect its safety function necessary to assure the integrity of the reactor coolant pressure boundary.

"An investigation of this condition will be conducted in accordance with the PVNGS corrective action program."

The Thermocoax heater elements were installed in November 2004, when all heaters in the Unit 3 pressurizer were replaced. Due to the increased failure rate all Thermocoax heater elements have been replaced in the last 30 days with General Electric style pressurizer heater elements that were used previously.

The heaters, which were also provided to SONGS 2&3 and Waterford 3, had a design variance (480 VAC single phase instead of 480 VAC 3-phase) which made them unique to Palo Verde. The impact of this variance is currently being evaluated.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 41784
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: KEITH MERIWETHER
HQ OPS Officer: BILL GOTT
Notification Date: 06/17/2005
Notification Time: 19:25 [ET]
Event Date: 06/17/2005
Event Time: 16:54 [CDT]
Last Update Date: 06/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JACK WHITTEN (R4)

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

LOSS OF SAFETY PARAMETER DISPLAY SYSTEM

"On 6/17/2005, at 08:54 am CDT, the Wolf Creek Generating Station experienced an unexpected loss of the safety parameter display system (SPDS). Troubleshooting efforts have been, at this time, unsuccessful in restoring functionality of the SPDS. Because SPDS has been lost for longer than a short period of time, the Wolf Creek Nuclear Operating Corporation is making this ENS notification pursuant to the criteria within 10 CFR 50.72(b)(3)(xiii). There is no other loss of emergency assessment capability concurrent with the ongoing loss of SPDS. Plant personnel have entered the applicable off-normal procedure and are taking local readings of equipment normally monitored by SPDS.

"It is unknown at this time when SPDS is expected to be restored."

The licensee notified the NRC Resident Inspector.

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