United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2006 > March 10

Event Notification Report for March 10, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/09/2006 - 03/10/2006

** EVENT NUMBERS **


42388 42391 42399 42400 42403

To top of page
General Information or Other Event Number: 42388
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: VIA CHRISTI CANCER CENTER
Region: 4
City: PONCA CITY State: OK
County:
License #: OK-14046-02
Agreement: Y
Docket:
NRC Notified By: M. BRODERICK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/06/2006
Notification Time: 10:30 [ET]
Event Date: 03/01/2006
Event Time: 12:00 [CST]
Last Update Date: 03/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
MICHELE BURGESS (NMSS)

Event Text

INCORRECT DOSE GIVEN TO PROSTATE PATIENT

The State provided the following information via facsimile:

"The medical physicist for the Via Christi Cancer Center reported that a medical event had occurred the day before. A patient was treated for prostate cancer with I-125 seeds. An activity of 0.4 air kerma units per seed was ordered. The seeds were received with an activity of 0.4 millicuries per seed. The difference in activity units was not detected until after the surgery was completed. The patient received a total dose of 12,850 centigray rather than the prescribed 10,000 centigray; a 28% difference. The radiation oncologist has determined that this larger dose should not cause any untoward harm to the patient. The referring urologist and the patient have been notified of the dose discrepancy. As corrective action, the licensee plans to introduce a new form to be used as part of the procedure followed during permanent implant preparation. This form will be used to record seed activity, including the units, used in treatment planning, listed on the shipping form as well as the seed activity observed at the time of implant."

OK Item # - OK060004

To top of page
General Information or Other Event Number: 42391
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COTTER CORP URANIUM MILL
Region: 4
City: CANYON CITY State: CO
County:
License #: 369-01
Agreement: Y
Docket:
NRC Notified By: PHILIP EGIDI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/06/2006
Notification Time: 20:00 [ET]
Event Date: 03/01/2006
Event Time: 01:00 [MST]
Last Update Date: 03/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SCOTT FLANDERS (NMSS)
MELVYN LEACH (IRD)

Event Text

YELLOW CAKE DRUM EVACUATED INTO ENCLOSED ROOM

At approximately 14:00 on 2/28/2006, an employee noticed that a drum of soluble yellow cake had a bulging lid and bottom cap. At 01:00 on 3/1/06, an employee in full protective clothing entered the calciner to release the lid. When the lid was released, approximately half of the barrel's contents evacuated the barrel. Some of the yellow cake went under the employee's hood.

The employee will undergo testing 3/7/06.

To top of page
Power Reactor Event Number: 42399
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MICHAEL COEN
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/08/2006
Notification Time: 22:38 [ET]
Event Date: 03/08/2006
Event Time: 15:53 [EST]
Last Update Date: 03/09/2006
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
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

VALID ACTUATION OF EMERGENCY DIESEL GENERATORS

"While restoring power to the 3C 480V Load Center following planned maintenance, the 3A safety related 4KV Bus was deenergized by the 3A Sequencer. This resulted in a valid actuation of the emergency diesel generator. The plant was in Mode 5, depressurized, with reactor coolant system level at approximately the vessel flange level. This resulted in a temporary loss of residual heat removal flow which was restored within approximately seven (7) minutes. Reactor coolant system temperature increased from 113 degrees F to 140 degrees F.

"Reactor coolant system level and temperature were stabilized at pre-event values."

At this time the licensee is preparing to restore off-site power to the 3A Bus and put the emergency diesel generator in standby. The licensee is also investigating the cause of the power loss to the 3A safety related 4KV Bus.

The licensee will notify the NRC Resident Inspector.

* * * UPDATE FROM G. RICHARDSON TO M. RIPLEY 2248 EST 03/09/06 * * *

"In response to questions regarding the cause of the loss of the 3A 4KV bus, the following information is provided:

"The 3C 480 volt Load Center was de-energized for maintenance and was being restored at the time of the event. One of the maintenance activities associated with the 3C Load Center involved replacement of the 480V feeder breaker for the load center. A rotating cam inside the auxiliary switch for the replacement breaker was misaligned. The misaligned cam caused the switch contacts to operate in reverse, such that normally open contacts would be normally closed and vice versa. One of the auxiliary contacts on the 3C Load Center 480V feeder breaker provides input to the A-train Emergency Diesel Generator (EDG) Load Sequencer. With this contact operation reversed (closed vs. open with the breaker open), the Load Sequencer sensed undervoltage on the 3C Load Center, when the 4kV feeder breaker for the load center was closed. The contact being open would normally block the undervoltage signal, until the 480V feeder breaker was closed and the bus was energized. Once the A-train Load Sequencer sensed the undervoltage condition, the 3A 4kV bus was stripped and then re-energized from the 3A EDG."

The licensee notified the NRC Resident Inspector. Notified R2DO (Fredrickson)

To top of page
Power Reactor Event Number: 42400
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MICHAEL MURPHY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/09/2006
Notification Time: 09:20 [ET]
Event Date: 03/09/2006
Event Time: 05:55 [EST]
Last Update Date: 03/09/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
PAUL FREDRICKSON (R2)

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

Event Text

TECHNICAL SPECIFICATION 3.8.1.1 ENTRY DUE TO LOSS OF UNIT 3 STARTUP TRANSFORMER

"While the Unit 3 Startup Transformer was inoperable for planned maintenance, it was discovered that both the 3A and 3B Emergency Diesel Generators were inoperable. The Emergency Diesel Generators were inoperable due to a configuration that resulted in the Emergency Diesel Generators being in the Droop mode versus the Isochronous mode. This configuration was improperly established when offsite power was supplied to Unit 3 via the Main and Auxiliary Transformers (Backfeed).

"Upon discovery, jumpers were installed to place both [Unit 3] Emergency Diesel Generators in the proper Isochronous mode correcting this condition at 0615 on March 9, 2006. Unit 4 was identified to be in a condition where one of its required Startup Transformers [from Unit 3] and one of its required Emergency Diesel Generators [from Unit 3] were out of service. Both [Unit 3] Emergency Diesel Generators were restored to an operable condition approximately twenty (20) minutes after discovery."

Technical Specification 3.8.1.1 Action c entered due to inoperable Unit 3 Startup Transformer and one inoperable Unit 3 EDG and requires a 4 hour notification report to the NRC.


The licensee notified the NRC Resident Inspector.

* * * * UPDATE AT 1301 EST ON 3/9/06 FROM M. MURPHY TO P. SNYDER * * * *

"As reported in Event Notification # 42400, with Unit 4 at 100% power in Mode 1, and the Unit 3 Startup Transformer out of service for planned maintenance, both the 3A and 3B Emergency Diesel Generators were declared inoperable due to a configuration that placed both Emergency Diesel Generators in the droop mode versus the normal isochronous mode. This placed Unit 4 in a Technical Specification Action Statement for one of its required Startup Transformers and one of its required Emergency Diesel Generators being inoperable.

"This EN# 42400 supplement documents that, although the 3A and 3B Emergency Diesel Generators were declared inoperable, the droop mode condition is bounded within previous analyses that demonstrate that the Emergency Diesel Generators and required electrical loads would operate to satisfactorily perform their safety function at the resulting reduced electrical frequency. Refer [to] Turkey Point LER 2004-001-01, dated 10/18/04."

The licensee notified the NRC Resident Inspector. Notified R2DO (Fredrickson).

To top of page
Power Reactor Event Number: 42403
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ANTHONY PETRELLI
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/10/2006
Notification Time: 00:58 [ET]
Event Date: 03/09/2006
Event Time: 22:14 [EST]
Last Update Date: 03/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JOHN WHITE (R1)

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

Event Text

AUTOMATIC REACTOR SCRAM DUE TO LOSS OF CONDENSER VACUUM TURBINE TRIP

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B) RPS Actuation (scram) for Nine Mile Point Unit 2 which states 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' On 03/09/2006 at 2214 while operating at approximately 85 % reactor power (coast down to refueling) a condenser low vacuum condition resulted in a turbine trip and a subsequent reactor scram. A loss of sealing steam most probably caused the loss of condenser vacuum and an investigation is in progress. Special Operating procedure N2-SOP-101 C was entered. All control rods inserted [fully] as expected. Condenser vacuum has been stabilized and the main steam isolation valves are open. The plant is stable and recovery actions are in progress."

Decay heat is being removed via the turbine bypass valves to the main condenser. The condensate and feedwater system is in operation maintaining reactor vessel level. The electric plant is in a normal shutdown lineup and there was no effect from this transient on Unit 1.

The licensee notified the NRC Resident Inspector.

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