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Event Notification Report for April 28, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2006 - 04/28/2006

** EVENT NUMBERS **


42521 42522 42523 42525 42530 42531 42533 42534

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General Information or Other Event Number: 42521
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL X-RAY AND TESTING CORP
Region: 4
City: WEST CAMERON` State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: BILL GOTT
Notification Date: 04/24/2006
Notification Time: 10:14 [ET]
Event Date: 04/20/2006
Event Time: [CDT]
Last Update Date: 04/24/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE

The State provided the following information via facsimile:

"On April 20, 2006, Global X-Ray had a source that failed to return to the shielded position. The source is a 105 Ci source of Ir-192 manufactured by SPEC with model #G-60 and serial #NC-1506. The source was in a SPEC 150 radiography camera with serial number 905. The RSO was dispatched to the Lonestar Horizon barge at West Cameron 165 to retrieve the source. The source was retrieved at approximately 11:37AM on April 20, 2006. No excessive exposures were reported. The badges were sent in for processing. The RSO picked up approximately 430 millirem while performing retrieval activity."

Event Report number: LA060006

This was reported by Global X-Ray and given NRC Event Number 42516

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General Information or Other Event Number: 42522
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DRASH CONSULTING ENGINEERS
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L04724
Agreement: Y
Docket:
NRC Notified By: SONIA SIMMONS
HQ OPS Officer: BILL GOTT
Notification Date: 04/24/2006
Notification Time: 10:42 [ET]
Event Date: 04/23/2006
Event Time: 07:30 [CDT]
Last Update Date: 04/24/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
GREG MORELL (NMSS)
ILTAB (email) ()
Mexico (email) ()

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

A Troxler Moisture Density Gauge (sn 25459; 40 millicuries Am-241/Be and 8 millicuries Cs-137) was stolen from the operator's truck which was parked at his home. This was reported to the police and a reward was offered.

Texas Incident No.: I-8327

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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General Information or Other Event Number: 42523
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CENTRAL ARKANSAS RADIATION THERAPY INSTITUTE
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK654BP12-08
Agreement: Y
Docket:
NRC Notified By: KIM WIEBECK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/24/2006
Notification Time: 14:11 [ET]
Event Date: 04/21/2006
Event Time: [CDT]
Last Update Date: 04/24/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via email:

"On April 21, 2006, the Radioactive Materials Program of Arkansas Department of Health and Human Services was notified by Central Arkansas Radiation Therapy Institute, ARK-654-BP-12-08, located in Little Rock, of a possible misadministration (medical event), which had been identified during the post-implant CT of a prostate implant patient. Based upon the CT scan, the facility determined that the I-125 seeds had been implanted in the incorrect area. The post-implant treatment plan generated on April 24, 2006, indicated that a dose greater than 50 Rem had been delivered to an unintended area of tissue.

"The licensee and Department will continue to investigate this event. A final written report regarding this misadministration (medical event) will be submitted within 15 days.

"NRC Region IV was notified of the potential misadministration on April 21, 2006."

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General Information or Other Event Number: 42525
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: MILLER BREWING COMPANY
Region: 1
City: ALBANY State: GA
County:
License #: GA546-1
Agreement: Y
Docket:
NRC Notified By: CYNTHIA SANDERS
HQ OPS Officer: PETE SNYDER
Notification Date: 04/25/2006
Notification Time: 12:45 [ET]
Event Date: 04/20/2006
Event Time: [EDT]
Last Update Date: 04/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST PROCESS INSTRUMENT SOURCE

On 4/20/06 the licensee Radiation Safety Officer called the State of Georgia to report the loss of a process instrument source. The instrument contained a 100 millicurie Americium-241 source as part of an Industrial Dynamics Model CI-2 case inspector serial number 00224. The source serial number is 3139 and model number is 06765.

The instrument was installed in a conveyor system that was removed and salvaged between March 20 and 25 of this year. The licensee contacted the Albany recycling facility to notify them of possible disposal at their facility but the recycling center said that their radiation detectors did not alarm. The recycling company also sends their scrap to IPSCO and ELG recycling operations in Mobile, AL. The licensee continues its search for the lost source. The licensee is currently reviewing their procedures for handling radioactive devices and the entire plant population will be retrained.

The Georgia State ERC report number is 38364.

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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Power Reactor Event Number: 42530
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: JONATHAN ROBB
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/26/2006
Notification Time: 22:39 [ET]
Event Date: 04/26/2006
Event Time: 20:49 [CDT]
Last Update Date: 04/27/2006
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HIRONORI PETERSON (R3)
PETER WILSON (IRD)
MIKE WEBER (NRR)
MARY JANE ROSS-LEE (NRR)
JIM CALDWELL (RA)
SWO (DHS)
SWO (FEMA)
CREWS (NRC)
TIMMONS (USDA)
WILLIAMS (HHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A Y 35 Power Operation 0 Hot Standby

Event Text

FAILURE OF RPS SIGNAL TO INITIATE REACTOR TRIP

"At 2043 [CDT] on 4-26-06, during a plant shutdown with the reactor at approximately 35% power, the operating crew manually initiated a reactor trip. The operating crew had just stopped one of the two condensate pumps and then the remaining feedwater pump tripped unexpectedly. The operating crew recognized the turbine did not trip, as it is expected to automatically trip when no feedwater pumps are running. The automatic turbine trip would have automatically tripped the reactor. Therefore, the operating crew manually initiated a reactor trip.

"Because the reactor did not automatically trip (i.e., failure of RPS to initiate and complete a reactor trip), the Shift Manager declared an Alert, at 2049, based on Chart F of Table 2-1 EPIP-AD-02. Therefore, this is a one-hour notification in accordance with 10CFR50.72(a)(1)(i) 'The declaration of any of the emergency classes specified in the licensee's approved Emergency Plan.'

"The manual reactor trip is reportable (4-hour) in accordance with 10CFR50.72(b)(2)(iv)(B) 'Any event or condition that results in an 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.'

"All systems functioned as expected following the manual reactor trip. Service Water Train B is inoperable because of a one-gallon per minute leak."

All rods inserted fully. Decay heat is being removed with the steam dump and secondary PORVs. The condenser is losing vacuum due to the turbine trip. Auxiliary Feedwater Pumps started as required.

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM JERRY RISTE TO JOHN KNOKE AT 01:45 EDT ON 04/27/06 * * *

"At 2049 on April 26, 2006, Kewaunee Power Station staff declared an Alert emergency classification (reference EN# 42530). The Kewaunee Power Station staff has assessed this event. There was no affect on the health and safety of the general public and no release of radiation. No plant personnel were injured and the only plant equipment problem was with the failure of a trip of both feedwater pumps to cause the main turbine to trip. The Kewaunee Power Plant staff has conducted a preliminary investigation of the control room indications and sequential events recorder, which indicates that before the manual reactor trip there was no automatic reactor trip signal present and a failure of the reactor trip breakers did not occur. The Alert was terminated at 0024 CDT [on 04/27/06]. The unit is currently in the Hot Shutdown Mode with plans to cool the plant to less than 350 degrees Fahrenheit."

The licensee notified the NRC Resident Inspector and will be notifying State and local government and issuing a press release. Notified NRR EO (MJ Ross-Lee), IRD Mgr (P. Wilson), R3DO (H. Peterson), DHS (Holz ), FEMA (Steindurf), NRC/EPA (Crews), DOE (Wyatt), USDA (Timmons), HHS (Peagler).

* * * UPDATE ON 04/27/06 AT 1718 EDT FROM JERRY RISTE TO ARLON COSTA * * *

"When performing a review of the event reported on April 26, 2006 (EN# 42530), the Kewaunee Power Station staff determined another reporting criterion was met. An eight-hour report is required to be made per 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of 10 CFR 50.72 except when the actuation results from and is apart of a pre-planned sequence during testing or reactor operation.' 10 CFR 50.72(b)(3)(iv)(B)(6) is PWR auxiliary or emergency feedwater system.

"As described in EN# 42530, a manual reactor trip of the Kewaunee Power Station was initiated at 2043 on April 26, 2006. The manual reactor trip was initiated when the plant experienced a loss of both feedwater pumps. With a loss of both feedwater pumps and a manual reactor trip, the narrow range water level in both steam generators decreased to the actuation setpoint value for starting the Auxiliary Feedwater Pumps, causing all three Auxiliary Feedwater Pumps to start as designed. Because the steam generator water level was below the actuation setpoint, this was a valid actuation of the auxiliary feedwater system. As a valid actuation of the auxiliary feedwater system, this condition is reportable under 10 CFR 50.72(b)(3)(iv).

"The untimeliness of the report has been entered into the Kewaunee Power Station's corrective action program."

The licensee notified the NRC Resident Inspector. Notified R3DO (H. Peterson).

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Power Reactor Event Number: 42531
Facility: COOK
Region: 3 State: MI
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DALE TURINETTI
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/27/2006
Notification Time: 09:18 [ET]
Event Date: 04/27/2006
Event Time: 02:07 [EDT]
Last Update Date: 04/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HIRONORI PETERSON (R3)

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

LOW PRESSURE STEAM LINE PRESSURE SAFETY INJECTION SIGNAL INADVERTENTLY INITIATED

"On 4/27/06 at 02:00, with D.C. Cook Unit 2 in Mode 5 and the Control Rod Drive System de-energized under clearance and incapable of withdrawal, Instrumentation and Controls Technicians were beginning Instrumentation Channel Operational Test and Trip Actuating Device Operational Tests. The block for Main Steam Line Low Pressure Safety Injection was inadvertently removed. This allowed the existing low steam generator pressure (0 psig) and low RCS temperature (186 degrees F) to initiate a Low Steam Line Pressure Safety Injection and a Steam Line Isolation signal.

"At 02:07 Unit 2 had a Main Steam Line Low Pressure Safety Injection signal on both Trains. The following components automatically started:
Unit 2 West Centrifugal Charging Pump (on minimum flow recirc path with injection path isolated for LTOP -- no injection to RCS)
Unit 2 South Safety Injection Pump (on minimum flow recirc path with injection path isolated for LTOP - no injection to RCS)
Unit 2 East Residual Heat Removal Pump
Unit 2 East Component Cooling Water Pump
Unit 2 CD Emergency Diesel Generator
Both Trains of Unit 2 Control Room Pressurization
Both Trains of Unit 2 Phase A Containment Isolation signal
Both Trains of Unit 2 Containment Ventilation Isolation.
Both Trains of Unit 1 Control Room Pressurization Fans
Unit 1 West Essential Service Water Pump

"All available equipment actuated as expected for this condition.
(The Unit 2 Boron Injection Tank was isolated under clearance for LTOP. The Unit 2 East Centrifugal Charging Pump, Unit 2 West Residual Heat Removal Pump, and Unit 2 West Component Cooling Water Pump were already running. The Unit 2 AB Emergency Diesel Generator was under a clearance for maintenance. The Unit 2 North Safety Injection Pump was under an administrative clearance for LTOP. The Unit 1 East Essential Service Water Pump was already running.)

"After diagnosing the event, operators manually blocked the Steam Line Isolation and manually reset Safety Injection signals for both trains. Components were returned to normal status for plant conditions."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42533
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: JOEL STODOLA
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/28/2006
Notification Time: 03:20 [ET]
Event Date: 04/27/2006
Event Time: 22:30 [CDT]
Last Update Date: 04/28/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
HIRONORI PETERSON (R3)

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

Event Text

BOTH SAFETY INJECTION TRAINS DECLARED INOPERABLE

At 22:30 on 04/27/2006 the Kewaunee Power Station declared both trains of Safety Injection (SI) inoperable. SI Pumps A & B were declared out of service per Surveillance Procedure SP 87-125 (Shift Instrument Channel Checks-Operating) due to SI Accumulator B level change of greater than or equal to 3%. SI Accumulator B level indicator (LI-935) indicated 30%. Previous indication recorded for SI Accumulator B was 33%. Per SP-87-125 'If the SI pumps are not vented prior to a level decrease of greater than or equal to 3%, the SI pumps become INOPERABLE.' TS 3.0.c (Standard Shutdown Sequence) was entered. At 0130 on 4/28/2006, venting of both SI Pumps was completed. SI Pump A was returned to service and SI Pump B remains out of service due to SW Train B inoperability.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42534
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: JOEL STODOLA
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/28/2006
Notification Time: 03:25 [ET]
Event Date: 04/27/2006
Event Time: 19:29 [CDT]
Last Update Date: 04/28/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
HIRONORI PETERSON (R3)

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

Event Text

TWO TRAINS OF SHIELD BUILDING VENTILATION INOPERABLE

At 19:29 on 04/27/2006 the Kewaunee Power Station declared two trains of Shield Building Ventilation (SBV) inoperable. Train B SBV was declared inoperable on 4/25/2006 at 17:25 when SW Train B was declared out of service for a leak that developed on the branch header to Diesel Generator B and TS 3.3.e.2 was entered. On 4/27/2006 at 19:29 QA typing discrepancies in RR-119 were discovered. QA-2 components were used in a QA-1 system, which could potentially cause a failure of some safety related equipment powered from this relay rack. As a result, all safety related equipment powered from RR-119 were declared inoperable and the appropriate technical specifications entered. SBV Train A Damper Control is powered from RR-119 and was declared inoperable at 19:29 on 4/27/2006 resulting in two trains of SBV being inoperable and TS 3.6.c.1 entered. The QA-2 components that may have an adverse affect on QA-1 safety related components in RR-119 have been removed and both trains of SBV were declared operable at 00:29 on 4/28/2006.

The licensee notified the NRC Resident Inspector.

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