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Event Notification Report for April 7, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/06/2006 - 04/07/2006

** EVENT NUMBERS **


42020 42343 42470 42474 42481

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Power Reactor Event Number: 42020
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: CHARLES STALZER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/27/2005
Notification Time: 17:15 [ET]
Event Date: 09/27/2005
Event Time: 10:00 [CDT]
Last Update Date: 04/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

POSTULATED FAULTS HAVE ELECTRICAL CURRENT IN EXCESS OF THE MAXIMUM LISTED INTERRUPTING RATINGS.

"NMC (Nuclear Management Company) has identified certain equipment in the PBNP electrical distribution system that will not assure, under certain conditions, interruption of a three phase bolted fault short circuit. These postulated faults have electrical current in excess of the maximum listed interrupting ratings for designated circuit breakers and associated bus bar bracing. This condition affects the 13.8 Kv, 4.16 Kv, and 480 V power panels, motor control centers (MCCs), and switchgear. Although the probability of bolted faults is considered low, the Point Beach bolted fault analysis is based on the worst case assumption of three phases firmly tied together and grounded. A postulated bolted fault itself would only impact equipment in a single safety train. However, the PBNP Appendix R analysis relies on breaker coordination and fault current interruption to prevent loss of safe shutdown equipment due to common enclosure/power supply associated circuit concerns. The degraded breaker coordination resulting from a bolted fault condition does not satisfy the requirements of the Appendix R safe shutdown analysis.

"This condition is reportable because the PBNP Appendix R analysis is based on the occurrence of a single fire in a single fire area. The postulated condition could result in a loss of safe shutdown equipment functionality beyond that previously analyzed.

"Compensatory measures (i.e., fire rounds - 6 times per day) have been implemented for cases where the unprotected cable length was routed beyond the original fire area. As part of the long-term corrective action, transformer tap setting changes to reduce bus voltages are being evaluated."

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

* * * UPDATE RECEIVED FROM RYAN RODE TO JOE O'HARA AT 1855 ON 04/06/06 * * *

"This is a supplemental emergency notification based on additional information identified regarding degraded voltage conditions at PBNP. On 09/27/2005 NMC reported a condition where certain equipment in the PBNP electrical distribution system would not assure, under certain conditions, interruption of a three-phase bolted fault short circuit. Licensee Event Report (LER) 266 & 301/2005-005-00 was subsequently submitted on November 18, 2005. The original Event Notification Report was associated with bolted fault conditions that potentially resulted in
additional unanalyzed fire losses due to direct fire damage or uncleared faults on associated circuits. The synopsis of the LER addressed these issues, and also identified:

"1. A non-conservative Technical Specification for degraded voltage time delay relay settings and their setting tolerance range in calibration procedures that could have resulted in certain safety system motors and switchgear tripping on overcurrent. Such an event could have prevented the fulfillment of the motors' safety function to mitigate the consequences of an accident.

"2. Under a design basis loss of coolant accident concurrent with a reduced voltage condition, safety-related motors and switchgear may trip their protective devices on overcurrent without the degraded voltage relays being actuated. Affected equipment included certain safeguards 480V AC switchgear, 480 V AC motor control centers, both auxiliary feedwater pump motors, and one component cooling water pump motor.

"Corrective actions for the above issues included placing calibration procedures on administrative hold, implementation of compensatory measures consisting of fire rounds for affected zones, and administrative controls to assure that a more restrictive limit for the degraded voltage allowable value was in place for the affected Technical Specification (s), as well as implementing administrative controls on the management of 480 V loads.

"Long-term corrective actions are evaluation and implementation of analytical changes resulting from the completed analysis, plant modification changes as needed to address minimum bus voltage and submittal of a license amendment request.

"Additional reviews into the extent of condition of this issue have revealed additional potential concerns associated if a station battery charger load test is conducted under reduced or degraded grid voltage conditions. If a battery charger load test is conducted during a degraded grid voltage condition and a loss-of-coolant accident occurs with a coincident safety injection signal but a loss of off-site power does not occur, the battery chargers are not stripped from their alternating current supply. The additional potential electrical load on the AC supply has not been analyzed.

"Compensatory measures, in the form of administrative controls associated with battery charger testing, are being implemented. A supplement to LER 266(301)/2005-005-00 will be submitted.

"The senior resident inspector has been informed of this supplemental report."

Subsequent conversations between the Headquarters Operations Officer and the Shift Manager and Shift Technical Advisor at Point Beach have confirmed that this is not an "emergency" notification as quoted in the first paragraph of the event update. This is an event notification only.

R3DO (Stone) notified.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42343
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC POWELL
HQ OPS Officer: JOE O'HARA
Notification Date: 02/16/2006
Notification Time: 06:38 [ET]
Event Date: 02/15/2006
Event Time: 23:45 [EST]
Last Update Date: 04/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PAUL KROHN (R1)

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

Event Text

POTENTIAL UNCONTROLLED RADIOLOGICAL RELEASE

"This is an 8-hour notification being made to report exceeding the design basis for reactor coolant leakage outside of containment. The normal daily RCS leakrate was completed at 2345 on 2/15/06. This leakrate indicated a step change in unidentified leakrate to .8 gpm from .09 gpm. This leakage value is within the 1 gpm allowed by Technical Specifications. Investigation is on going, and the source of the leak has not been determined at this time, however preliminary conclusion is that the leakage is outside of containment and related to the centrifugal charging pumps. The design requirement ECCS leakage outside of containment is 3840 cc/hour ( .1 gpm) to support GDC-19 limits for control room habilitability.

"No safety system actuation occurred or were required. No injuries have occurred due to this event."

The licensee has performed troubleshooting to identify the source of the leak and to narrow down the portion of the charging system where they believe the leak to be located. The licensee believes the leak is in a relief valve or hard pipe system to the waste tanks, and that the leak is not external to the system.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM PAUL ABBOTT TO JOE O'HARA AT 2119 ON 4/6/06 * * *

"On February 16, 2006, PSEG made an 8-hour report (event number 42343) in accordance with 10CFR50.72(b)(3)(v) because of exceeding the design basis limits for ECCS leakage outside containment. The leakage was determined to be approximately 0.8 gpm with a limit of 3840 cc/hour.

"Further investigation into this event determined that the leakage was not in the ECCS recirculation flow path. The cause of the elevated RCS unidentified leakrate was the failure of the automatic three-way high level divert valve (2CV35), which prevents a high level from occurring in the Volume Control Tank (VCT). This valve failed to fully isolate flow to the Chemical Volume Control (CVC) Hold-Up Tanks (HUTs) after VCT level dropped below the divert setpoint of 77% . This conclusion is based on the VCT level being at the divert setpoint a number of times during the shift, the increased use of the valve to control level, and valve performance to fully isolate flow to the CVC HUT'S.

"Because this flow path is automatically isolated on a Safety Injection signal by other means (valves), the leakage through this valve is not considered part of the ECCS recirculation flow path and therefore is not included in the calculation for ECCS leakage outside containment.

"The event is being withdrawn."

The licensee will notify the NRC Resident Inspector.

R1DO(Finney) notified.

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General Information or Other Event Number: 42470
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GLOBAL GEO ENGINEERING, INC.
Region: 4
City: TUSTIN State: CA
County: ORANGE
License #: 6899
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/04/2006
Notification Time: 17:08 [ET]
Event Date: 03/17/2006
Event Time: [PDT]
Last Update Date: 04/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
WILLIAM RULAND (NMSS)
MEXICO (via fax) ()
ILTAB (via email) ()

Event Text

AGREEMENT STATE REPORT INVOLVING THE POSSIBLE LOSS OF A TROXLER MOISTURE DENSITY GAUGE

At 1430 PDT on 4/4/06, the CA Rad Control Program Office was notified by Global Geo Engineering, Inc. that one of their Troxler Moisture Density Gauges, a Model 3430 - S/N 32401 containing 8 mCi Cs-137 and 40 mCi Am-241/Be, was missing and could not be accounted for. The last known log out occurred on 3/17/06 when the gauge had been used by a temporary worker at a jobsite. The licensee, unable to locate the temporary worker for a work assignment, reported the gauge as missing to both the State of CA and their local police department. CA will conduct an investigation into the circumstances involving this incident.


* * * UPDATE ON 04/05/06 AT 1548 EDT FROM DONELLE KRAJEWSKI, STATE OF CALIFORNIA, TO MACKINNON * * *

Gauge was returned to licensee today, 04/05/06. The temporary worker had the gauge in his possession.

R4DO (Linda Smith) and NMSS (Greg Morell). E-mailed to Mexico and ILTAB.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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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Hospital Event Number: 42474
Rep Org: COMMUNITY HOSPITALS OF INDIANA
Licensee: COMMUNITY HOSPITALS OF INDIANA
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 130600901
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: JOE O'HARA
Notification Date: 04/05/2006
Notification Time: 13:31 [ET]
Event Date: 11/08/2005
Event Time: [CST]
Last Update Date: 04/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ANNE MARIE STONE (R3)
GREG MORELL (NMSS)

Event Text

NOTIFICATION OF A MEDICAL EVENT - DOSE TO INCORRECT AREA OF BODY

Community Hospitals of Indiana reported that a high dose rate (HDR) remote afterloader treatment field was incorrectly performed. On November 8, 2005, Community Hospital East in Indianapolis, Indiana performed a HDR treatment on a terminally ill lung cancer patient. Community Hospital East applied the correct dose to the patient. However, a catheter used to carry the source into the patients body was inserted into the patients airway without a cap on the end. As a result of the cap not being in its proper place on the catheter, the source was placed approximately 7 mm higher than originally intended per the physicians written directive. As a result, the field which was irradiated was greater by approximately 7 mm. Immediately following the treatment, the error was noted and the physician was informed. The physician noted that the area which was irradiated was within her area of concern and that everything was "o.k." This treatment was conducted to relieve patient symptoms rather than cure the disease. The patient succumbed to the disease approximately two weeks later. The treatment and its results were documented by the licensee in its Radiation Safety Committee Meeting minutes.

During a routine inspection of its records on 4/4/06, a Region III NRC Inspector noted that this event appeared to be a medical event and should be reported. As a result of that guidance, the licensee is reporting the event.

* * * UPDATE FROM K STEFFEN TO J. KNOKE AT 1610 ON 04/06/06 * * *

The licensee provided the doses for the above event. Due to the catheter cap not being in its proper place the airway area above the lung received an actual dose 500 rads, whereas the prescribed dose was to be 200 rads. The area of treatment in the lung received an actual dose 200 rads, whereas the prescribed dose was to be 500 rads.

Notified R3DO (Anne-Marie Stone) and NMSS (Greg Morell)

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Power Reactor Event Number: 42481
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DENNIS FRANCIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/06/2006
Notification Time: 14:44 [ET]
Event Date: 04/06/2006
Event Time: 10:39 [CDT]
Last Update Date: 04/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANNE MARIE STONE (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 97 Power Operation 97 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

At 10:39 AM on 4/6/06, Unit 2 HPCI was declared inoperable due to circuit breaker 16 failure on the ESS bus. Circuit breaker 16 opened as a result of temporarily shorting the power supply lead while installing a new HPCI temperature recorder. Trouble shooting is in progress as a result of the failure and restoration will follow. Since circuit breaker 16 provides ESS power to HPCI flow controller, HPCI was declared inoperable. This event is reportable under 1OCFR 5.72(b)(3)(v)(D).

The licensee notified the NRC Resident Inspector.

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