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Event Notification Report for November 7, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/04/2005 - 11/07/2005

** EVENT NUMBERS **


42106 42107 42108 42112 42116 42117 42119 42120 42122

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General Information or Other Event Number: 42106
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: AEA TECHNOLOGY QSA
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: MICHAEL P. WHALEN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/01/2005
Notification Time: 15:27 [ET]
Event Date: 10/29/2005
Event Time: [EST]
Last Update Date: 11/02/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLIFFORD ANDERSON (R1)
MICHELE BURGESS (NMSS)
SHERI MINNICK (R1)
TAS (email) ()

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL MISSING IN SHIPMENT

The State provided the following information via facsimile:

A single package originally containing two pigs arrived on 10/29/05 at the FedEx hub at the Memphis Airport damaged, with one of the two pigs missing. The missing pig contains 10 special form capsules of Am-241/Be with a total activity of 500 milliCuries. The pig is small (described as the size of a shotgun shell). The package was being sent by AEA Technology QSA of Burlington, MA to CPN Corp in California. FedEx stated that the package arrived in Memphis on Saturday morning 10/29, however, it was not determined that one of the pigs was missing until the morning of 10/30.

On 11/1/05, the Tennessee Radiation Control Program was at Fed Ex hub to assist in the search for the pig, and AEA Technology QSA (now known as QSA Global, Inc.) confirmed that the container did contain 2 pigs.

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

* * * UPDATE FROM STATES TO M. RIPLEY 1615 EST 11/02/05 * * *

The following information was provided from the States of Tennessee and Massachusetts via email:

"The following is an summary/update from [the Tennessee State inspector's ] visit: The container/sources have not been found. FedEx said they have thoroughly searched and continue to search all possible areas where the source could have been lost. They are tracking all the details of the package from the time it arrived through their system until it was last seen. They are attempting to determine the root cause of the damage to the package and loss of part of its contents. Interviews are being conducted of individuals who played a role in the handling/processing of the package. The damage to the package was such that it looks like a mechanical device (closing metal grate/gate?) was involved in tearing the package. Radiation surveys have been and are being performed by Fed-Ex in any areas that they think the source could have been lost. There is a suspicion that the container and the sources have been swept up and disposed of at the landfill.

AEA Technology (now QSA Global) provided the following information via the State of Massachusetts: "The W1 lead pot (i.e., pig) is 2.5 inches tall X 1 inch diameter, it is painted white and has tape securing the cap. AEA performed measurements on the W1 lead pot and found the surface measurements were: 36 mr/hr gamma and 70 mr/hr neutron. They performed measurements on a pig with the same amount of Am-241/Be lost in TN - 500 mCi of Am241/Be"

Notified R1DO (C. Anderson), NMSS EO (J. Gitter), TAS (L. English).

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General Information or Other Event Number: 42107
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: H AND H CHEVROLET
Region: 4
City: OMAHA State: NE
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: BILL GOTT
Notification Date: 11/01/2005
Notification Time: 15:34 [ET]
Event Date: 11/01/2005
Event Time: [CST]
Last Update Date: 11/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
MICHELE BURGESS (NMSS)
LANCE ENGLISH email (TAS)

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

Hardi Lighting shipped one exit sign model NEXT-1-10WR with serial number C018515 to H and H Chevrolet on April 27, 2005. The sign contained 7.09 Curies of H-3, Tritium. The facility received the sign and paid for it. Upon receiving two letters from the Nebraska Department of Health and Human Services concerning the sign, the facility replied on October 10, 2005 indicating that they did not have the sign. H and H Chevrolet personnel have made three searches of the facility and cannot locate the sign. They believe that the sign was disposed in a trash container and sent to the landfill.

Nebraska Incident Number: NE050008

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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General Information or Other Event Number: 42108
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TURNER INDUSTRIES GROUP LLC
Region: 4
City: PARIS State: TX
County:
License #: L05237-001
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/01/2005
Notification Time: 19:09 [ET]
Event Date: 08/10/2005
Event Time: [CST]
Last Update Date: 11/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
JOSEPH GIITTER (NMSS)
M. BURGESS (email) ()

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The State provided the following information via email:

"[Licensee employee] called RSO to let him know that [a radiographer trainer] had 12.5 rem deep dose equivalent for Quarter 3 - July 1-31, 2005.

"On Wednesday, 8/10/05, [name deleted], RSO for Turner Industries called DSHS Radiation Control (RC) to report that [licensee employee] has informed him that [name deleted] radiographer trainer for his company, had a 12.5 rem deep dose equivalent reading for Quarter 3-July 1-31, 2005 monitoring period.

"[The radiographer trainer] wrote a statement to RC stating that he has worked as an x-ray radiographer for the last 6 years with Turner Industries, is very conscientious & checks his dosimeter often throughout the work day. He stated that he was closely supervised by the RSO for the monitoring period in question & did training for a new trainee.

"An on-site investigation was conducted by [name deleted], a RAM inspector for RC. [The RAM inspector] interviewed [the radiographer trainer] & [another employee] regarding this investigation. Both [the radiographer trainer and the other employee] felt that this was a result of an altercation [the radiographer trainer] had with a contract radiographer & felt that this was the result of a retaliation against [the radiographer trainer] for not allowing the contract radiographer to enter [the radiographer trainer's] shooting bay. [The radiographer trainer] went on vacation & from 6/27-07/5/05.The RSO & [the radiographer trainer] felt that the contract radiographer had access to [the radiographer trainer's] film badge & a radiography camera & could have easily carried out this retaliation without being noticed.

"The RC inspector reviewed past monitoring records for [the radiographer trainer] & found that his results were consistent with someone receiving 50-60 mrem /month & 500-650 mrem/year in this line of work. The inspector concluded that the overexposure appeared to be very suspicious & agreed that the overexposure be readjusted to reflect the normal monthly results for [the radiographer trainer].

"Additional Documents Supplied:

"Personnel monitoring records for the past year for [the radiographer trainer] were obtained & sent in to RC by the RAM inspector. The investigation determined that the dose appeared to be to the dosimeter only. No violation recommended. RC has issued a letter concurring with the licensee's investigation results & has sent a copy of this letter to DSHS RC."

Texas Incident # I-8250

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General Information or Other Event Number: 42112
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CASCADE TESTING LABORATORY, INC
Region: 4
City: EDMONDS State: WA
County:
License #: WN-L057-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/02/2005
Notification Time: 14:30 [ET]
Event Date: 11/02/2005
Event Time: [PST]
Last Update Date: 11/02/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
JOSEPH GIITTER (NMSS)
CANADA (CNSC) ()
TAS ()

Event Text

AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGE

The State provided the following information via email:

"A portable gauge licensee reported a Troxler Electronics Model 3411 portable moisture/density gauge, serial number 16176 was stolen when the transport vehicle was stolen. The transport vehicle is a 1989 Honda CRX and was parked at the gauge user's residence at the time of the theft. The Licensee reported the gauge was stolen between the hours of 10:00 PM Monday, November 1, 2005 and 7:00 AM Tuesday, November 2, 2005. A police report has been filed by the licensee with the Edmonds police department.

"No media attention to date.

"Isotope and Activity involved: 1.48 GBq (40 mCi) Am-241:Be and a 0.296 GBq (8 mCi) Cs-137 source. Source serial numbers: Cs-137 (50-5267), Am-241Be (47-11584).

"Disposition/recovery: The police have been notified of the theft, the gauge has not yet been recovered.

"Gauge was last leak tested on October 5, 2005. Analysis was done by Troxler and found to be acceptable.

"The licensee reported that all the proper levels of security were being used at the time the vehicle was stolen with two locked cables or chains."

Washington Event report # WA-05-061

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Power Reactor Event Number: 42116
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT KIDDER
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/2005
Notification Time: 03:32 [ET]
Event Date: 11/03/2005
Event Time: 16:00 [EST]
Last Update Date: 11/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (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

TS REQUIRED COMPONENTS INADVERTENTLY RENDERED INOPERABLE DUE TO INADEQUATE REVIEW OF WORK CLEARANCE

"At 0200 on 11/03/05 a clearance was authorized that defeated the DW [Drywell] pressure high and Rx [Reactor] vessel low isolation features to valves in the Nuclear Closed Cooling System and Instrument Air Systems. The required T.S. [Technical Specification] actions after this discovery are that the plant should have been in Mode 3 at 1600 on 11/3/05. The clearance was removed and the circuit restored to operability at 0142 on 11/4/05. The time of discovery for the loss of safety function was 2345 on 11/3/05."

The clearance was to perform pre-planned maintenance activities. The licensee plans on entering this incident into their corrective action program and will issue a Condition Report.

The licensee informed the NRC Resident Inspector.

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Other Nuclear Material Event Number: 42117
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: NEW ORLEANS State: LA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/04/2005
Notification Time: 09:14 [ET]
Event Date: 08/30/2005
Event Time: [CST]
Last Update Date: 11/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MONTE PHILLIPS (R3)
THOMAS FARNHOLTZ (R4)
JOSEPH GIITTER (NMSS)

Event Text

LOSS OF RADIOACTIVE MATERIAL

"I am calling per 10 CFR 20.2201(a)(ii) to notify you of a possible loss of radioactive material at the VA Medical Center, New Orleans, Louisiana, a permittee under the VA license. This incident occurred on or around August 30, 2005, and was discovered October 7, 2005. This possible incident resulted from the flooding of the radioactive waste storage room at the medical center and involved the loss of radioactive materials.

"The materials which are considered lost are Iodine 131 and Iodine 125. The unsealed materials were in waste containers and may have washed out of the containers when the waste room was flooded. The dilution of the small amount of activity in the floodwaters precludes any possible public dose or health and safety concern.

"These circumstances are considered a possible incident since a technical evaluation to estimate the loss is not based on quantitative measurements or surveys. Also, the tags and waste records attached to the containers were obliterated by the floodwaters. Attempts to estimate the activity began on October 7, 2005, and an estimate of the original activity was submitted by the permittee in a preliminary report to the National Health Physics Program on October 24, 2005.

"A best estimate based on review of storage records, radioactive decay, and observations and measurements in the waste room is that, perhaps, as much as 200 microcuries Iodine 131 and 600 microcuries Iodine 125 in storage August 30, 2005, cannot be specifically located or identified as being present in the waste storage room on October 7, 2005."

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Fuel Cycle Facility Event Number: 42119
Facility: FRAMATOME ANP RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP RECOVERY
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: BENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/04/2005
Notification Time: 14:38 [ET]
Event Date: 11/03/2005
Event Time: 14:00 [PST]
Last Update Date: 11/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
DAVID AYRES (R2)
JOSEPH GIITTER (NMSS)

Event Text

DEFICIENCY FOUND IN INTEGRATED SAFETY ANALYSIS PROGRAM

"BACKGROUND:

"Framatome ANP routinely vacuum transfers LEU powder into 55-gallon drums for storage in the BLEU facility 55-gallon drum warehouse. A change was implemented recently to also vacuum transfer LEU powder from 45-gallon drums into 55-gallon drums, also for storage in the BLEU facility 55-gallon drum warehouse.

"EVENT DESCRIPTION:

"On day shift November 3, 2005 at approximate 2:00 PST, a process operator vacuum transferred LEU powder enriched to (deleted) wt% 235U from a 45-gallon to a 55-gallon drum in the BLEU facility at the Richland site. This transfer was performed according to an approved standard operating procedure (SOP). This was the first such transfer under a recently approved nuclear criticality safety analysis (NCSA) part of the Integrated Safety Analysis (ISA)

"When the operator was preparing the newly filled 55-gallon drum for transfer to and storage in the warehouse, the Nuclear Inventory Management System (NIMS) would not print a label for the drum. Operations personnel contacted an NCS specialist about this issue. While troubleshooting this problem, the NCS specialist discovered that the LEU powder contained hydrogenous additives. He recognized that the Richland site ISA did not implement IROFS to prevent transfer of powder containing hydrogenous additives from 45-gallon to 55-gallon drums.

"At this point, the drum was sampled and locked in place pending further evaluation. The 45-gallon to 55-gallon transfer process was also placed out of service pending further evaluation.


"SAFETY SIGNIFICANCE OF EVENT:

"The safety significance of this event is very low. In accordance with the NCSA a 55-gallon drum filled with LEU powder, enriched to (deleted ) 235U with a bulk density of (deleted ) and containing (deleted ) wt% moisture, that is fully reflected by water has a keff of (deleted). A moisture value of (deleted) wt% is required in such a drum to reach a keff of 1.0.

"The drum involved in this event actually contained 115.4 kg of LEU powder enriched to (deleted) wt% 235U with a bulk density of (deleted) and containing (deleted) total moisture equivalence (moisture and moisture equivalent approved additives determined by follow up laboratory analysis). Based on total moisture equivalent content alone, the material in the drum would have to have more than (deleted) times the limit (deleted) and more than (deleted) times the actual amount (deleted) before criticality could occur in the drum. The actual enrichment and bulk density of the material involved in this event provide additional margin compared to the values required for criticality discussed in the previous paragraph.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR):

"Criticality could only occur if moderation control on the material placed in the drum is lost. This could hypothetically occur if powder containing over (deleted) times the allowed limit (deleted) were placed into the drum.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):

"The process parameter controlled in this portion of the process is moderation.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:

"Within the 1SA the NCSA, E04-NCSA-323 version 3.0 accident sequence 1.4.1 description bounds this event. It states, "UO, powder containing greater than (deleted) wt% H2O equivalent is transferred to a 55-gallon drum from the BLEU powder preparation south addback station."

"Defense 1 for this accident sequence states, 'Moderation control: Any 45-gallon drum of UOX powder that does not have at least two independent determinations that it has (deleted) wt% or less moisture must be stored in a specially designated, locked storage grid to prevent accidental drum movement.' This is IROFS 1105 and was maintained throughout this event. At HRR, per SOP, if a drum contains greater than (deleted) wt% moisture and/or > (greater) wt% moisture equivalent additives, it is locked in a storage location. Only trained key custodians may unlock these storage locations for further processing or handling of the drum, Based on the moisture and moisture equivalent approved additive content of the powder, the drum involved in this event was not such a drum.

"Defense 2 for this accident sequence states, 'Moderation control: The programmable controller interfaces with NIMS to verify acceptable moisture content before it permits transfer valve to open.' This is IROFS 6002 and was maintained throughout this event for moisture content of the powder. As implemented, this IROFS does not verify that the powder to be transferred contains no hydrogenous additives. However, as an uncredited defense, before permitting the transfer valve to open, NIMS does verify that the powder contains s (deleted) wt% AZS and (deleted) wt% ALS, which is (deleted) wt% moisture equivalent approved additives. Therefore, on a total moisture and moisture equivalent basis, NIMS does verify that the powder contains less than (deleted) wt% total moisture equivalence. This is approximately (deleted) times less than the (deleted) wt% total moisture equivalence required to approach a keff value of (deleted).

"Defense 3 for this accident sequence states, Moderation control provided by an AEC [active engineered control]. An in-line moisture monitor is interlocked to shut off the vacuum blower and stop the rotary valve to prevent a significant amount of Uox powder containing greater than (deleted) wt% H2O from being transferred to the drum. This is IROFS 4704 and was maintained throughout this event for moisture content of the powder. This IROFS, however, will not detect dry hydrogenous additives.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

"After discovery of the deficiency, the drum was sampled and locked in place pending further evaluation. The 45-gallon to 55-gallon transfer process was also placed out of service pending further evaluation."

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Power Reactor Event Number: 42120
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL PLETCHER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/04/2005
Notification Time: 22:20 [ET]
Event Date: 11/04/2005
Event Time: 16:08 [EST]
Last Update Date: 11/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CLIFFORD ANDERSON (R1)

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

Event Text

TEMPORARY LOSS OF THE RUNNING RHR PUMP DURING A BUS TRANSFER

"PCIS Group 4 isolated during Reactor Protection Power Supply bus transfer. The isolation was not expected by control room operators prior to the power supply transfer. The isolation resulted in the trip of the running RHR pump.

"Operators verified proper isolation and reset the power supply. Shutdown cooling was re-established. The total time out of service was 18 minutes. The time to boil was calculated to be 68 hours prior to the event."

The temperature at the RHR heat exchanger inlet at the beginning of the event was 90 degrees. The temperature at 22:20 was 92 degrees. The other RHR pump was available during this event. The plant is in refueling with the cavity flooded.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42122
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: LARRY MOFFATT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/06/2005
Notification Time: 12:45 [ET]
Event Date: 11/06/2005
Event Time: 09:35 [EST]
Last Update Date: 11/06/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2)

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

Event Text

TEMPORARY LOSS OF OFFSITE NOTIFICATION SIRENS

"At 0935 on November 6, 2005, all offsite notification sirens for Crystal River Unit 3 were lost. One siren failed and sent a feedback signal which in turn disabled all remaining sirens. The failed siren was bypassed at 1124, thereby restoring the remaining 39 sirens to service. The failed siren will be repaired promptly. During the loss of siren function, backup means of notifying the public were available, including route alerting using local law enforcement and use of the Code Red autodialing system. This is reportable as an immediate notification (eight-hour report) in accordance with 10CFR50.72(b)(3)(xiii)."

The siren system is maintained by the county. Compensatory measures for the remaining area is either: dispatching a police car, or fire truck, or using the Code Red autodialing system for the affected area.

The licensee notified the NRC Resident Inspector.

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