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Event Notification Report for June 14, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/13/2006 - 06/14/2006

** EVENT NUMBERS **


41377 42627 42628 42632 42635 42637

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41377
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WARNER ANDREWS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/06/2005
Notification Time: 00:43 [ET]
Event Date: 02/05/2005
Event Time: 20:46 [CST]
Last Update Date: 06/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BRUCE BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 88 Power Operation 88 Power Operation

Event Text

4160 VOLT RELAYING AND METERING SINGLE FAILURE VULNERABILITY


"This report is being made pursuant to 10CFR50.72(b)(3)(ii)(B). At 20:46 on 02/05/05 while reviewing Operation Experience from another Nuclear Site, it was discovered that the design of the AC Auxiliary Power System incorporates a common circuit which could result in a bus lockout preventing the re-energization of both unit one safeguards buses from either onsite or offsite power sources due to a single failure in the common portion of the circuitry. This common circuit includes various metering circuits and is also connected to overcurrent devices that feed breaker lockout relays. Should a failure occur on these common circuits, all breakers supplying power to these buses would be opened, locked out, and prevented from reclosure onto the buses.

"Due to the loss of the ability to accommodate a single failure, one offsite power source ( CT11 ) has been declared inoperable and Technical Specification 3.8.1 Condition A, entered. Corrective actions are in progress to isolate the common circuit and eliminate the single point vulnerability."

The licensee notified the NRC Resident Inspector.

See similar events #41362 (Crystal River), #41366 (LaSalle), #41369 (Quad Cities) ,#41370 (Dresden) and #41377 (Monticello).

* * * RETRACTION FROM S. SEILHYMER TO S. ROTTON AT 1140 ON 6/13/06 * * *

"The event reported on February 6, 2005 (4160 volt relaying and metering single failure vulnerability, NRC Event Number 41377) is hereby retracted. Subsequent analysis has concluded that a common mode failure resulting in a simultaneous lockout of both safeguards 4160 volt Bus 15 and Bus 16 due to the common metering circuit was not a credible event in the as-found condition. The analysis showed that the required magnitude of a fire induced fault is much greater than the available fault current in any of the associated circuits. The analysis also showed that dual bus lockout due to an open circuit under non-fire induced conditions is not credible since the imbalance current will be less than the trip setpoint of the affected relays.

"Thus, although the plant had been in an unanalyzed condition, that condition has now been shown to have not significantly degraded plant safety and is, therefore, not reportable under the requirements of 10 CFR 50.72(b)(3)(ii)(B). Additionally, NMC will be submitting a letter to cancel the associated LER 1-05-01."

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

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General Information or Other Event Number: 42627
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: AUBURN REGIONAL MEDICAL CENTER
Region: 4
City: AUBURN State: WA
County:
License #: WN-M0149-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOE O'HARA
Notification Date: 06/08/2006
Notification Time: 15:58 [ET]
Event Date: 05/30/2006
Event Time: [PDT]
Last Update Date: 06/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED SOURCES

The State provided the information via e-mail:

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): A patient received a total of 89 sealed Iodine-125 (half-life of 60 days) seeds implanted on a permanent basis in the prostate, for a total activity of 33.84 millicuries. This was done at Auburn Regional Medical Center (ARMC), Auburn, Washington, on 25 May 2006.

"The patient was seen / rechecked by ARMC personnel on 26 May 2006. Sometime after that visit, on the same day, he was taken by family members to Good Samaritan Hospital (GSH) in Puyallup, Washington, where he subsequently died of a myocardial infarction.

"The body was released to a funeral home in Buckley, Washington where it was cremated on 30 May 2006 (about 31 millicuries). The cremains were then boxed up on 31 May 2006 and buried that same day.

"Although it was reported the patient and the patient's family were given appropriate verbal and written instructions by ARMC; when the patient was treated at GSH it was for the MI only, and had nothing to do with the prior surgical prostate procedure. The family did not, for whatever reason, inform the staff at GSH. The urologists who had treated the patient for the prostate cancer did not work at GSH and had no connection there.

"Therefore, once the patient died, personnel at GSH had no idea they were also dealing with a radioactive source problem. Personnel at ARMC had no way of knowing of the treatment or death of the patient since it did not occur at their facility or in their city.

"The RSO for Tacoma Radiation Oncology Center (who provides medical physics support and treatment planning for sealed source therapy to clients such as ARMC and GSH) visited the funeral home on 7 June 2006 and surveyed the crematorium using a meter with a NaI probe. Background was noted at approximately 0.4 Mr/hr. Readings of approximately 3.0 Mr/hr were noted at the entrance to the retort. A filter in the air exhaust system was noted to be reading approximately 1.0 Mr/hr so it was removed for decay and ultimate disposal by GSH.

"It appears that most retorts operate at 1600 degrees Fahrenheit, or more, and the titanium capsule would melt a few hundred degrees lower than that. The manufacturer confirmed that all seeds had most likely been melted and would not be recovered whole. The crematorium is at this time on standby until the crematorium is declared clean for further use. It appears the most reasonable way to safely handle this cleaning chore is to have a commercial cleaning company, properly informed and equipped, clean and vacuum the retort with ARMC physics personnel in constant attendance to protect workers from any potential radiation hazards and to remove any contaminated material for decay and disposal. This is scheduled to happen 8 June 2006.

"Notification Reporting Criteria: WAC 246-221-240

"Isotope and Activity involved: Iodine 125 / 31 millicuries (at time of cremation)

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): to be determined, likely none.

"Lost, Stolen or Damaged? (mfg., model, serial number): melted I-125 seeds.

"Disposition/recovery: clean and hold material for decay

"Leak test? NA

"Vehicle: NA

"Release of activity? Yes

"Activity and pharmaceutical compound intended: NA

"Misadministered activity and/or compound received: NA

"Device (HDR, etc.) Mfg., Model; computer program: I-125 seeds

"Exposure (intended/actual); consequences: minimal, likely no consequences

"Was patient or responsible relative notified? Yes

"Was written report provided to patient? Yes

"Was referring physician notified? Yes

"Consultant used? Yes"

Event Report No.: WA-06-042

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General Information or Other Event Number: 42628
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NATIONAL INSPECTIONS SERVICES
Region: 4
City: LAFAYETTE State: LA
County:
License #: LA-11160-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/08/2006
Notification Time: 18:14 [ET]
Event Date: 03/15/2006
Event Time: [CDT]
Last Update Date: 06/08/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SCOTT MOORE (NMSS)

Event Text

LOUISIANA AGREEMENT STATE REPORT - EXCESSIVE EXPOSURE

Louisiana Agreement State Report was faxed to the NRC Operation Center.


"National Inspection Services reported on June 6, 2006 that a trainee, [deleted], received an excessive exposure. The film badge for [deleted] had an exposure of 5.879 Rem for the March 2006 wear period. This individual is no longer working for National Inspection Services. His employment ran from February 23, 2006 to April 26, 2006. The facility is performing an investigation and will report their findings to the Louisiana Department of Environmental Quality. [Deleted], Radiation Safety Officer, stated that the daily pocket dosimeter records do not reflect an excessive exposure."

Event Report ID No.: LA060011

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Power Reactor Event Number: 42632
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: MARTIN WOLF
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/12/2006
Notification Time: 11:38 [ET]
Event Date: 06/12/2006
Event Time: 10:56 [EDT]
Last Update Date: 06/13/2006
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVID AYRES (R2)
THOMAS BLOUNT (IRD)
MARY JANE ROSS-LEE (NRR)
MIKE INZER (DHS)
JIM DUNKER (FEMA)

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

Event Text

UNUSUAL EVENT DUE TO A POSTING OF HURRICANE WARNING AT THE SITE

"Crystal River 3 is in a Hurricane Warning area. The site is evaluating the need for a plant shutdown at this time."

The declaration of NOUE is per the licensee's Emergency Action Guidelines due to posting of the hurricane warning. There are currently no significant equipment problems or LCOs that might be impacted by the impending weather conditions. The licensee will provide updates as appropriate if weather conditions change or a decision to shutdown is made.

The licensee notified the NRC Resident Inspector, State, and Local authorities.

* * * UPDATE FROM M. WOLF TO M. ABRAMOVITZ AT 1530 ON 06/13/06 * * *

The hurricane warning necessitating the entrance by the site into the Unusual Event was exited by the state this morning at 11 am. The site waited until high tide passed and exited the Unusual Event at 1511.

The licensee notified the NRC Resident Inspector. Notified R2DO (Ayers), NRR EO (Jung), IRD (Blount), DHS (S. York) , and FEMA (E. Casto).

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Power Reactor Event Number: 42635
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: EDWIN TAYLOR
HQ OPS Officer: PETE SNYDER
Notification Date: 06/12/2006
Notification Time: 18:00 [ET]
Event Date: 06/12/2006
Event Time: 15:56 [CDT]
Last Update Date: 06/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY GODY (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 SPDS DURING PLANNED COMPUTER MAINTENANCE

"On 6/12/06 at 07:54 am CDT, the Wolf Creek Generating Station removed the Nuclear Plant Information System (NPIS) computer from service for planned maintenance. Following this maintenance, one of the NPIS multiplexers (MTJX 'D') failed to re-establish communications with the computer, and efforts to restore the computer to service have been unsuccessful. The failure to restore the NPIS computer has resulted in a loss of functionality of the Safety Parameters Display System (SPDS). Efforts continue to restore the NPIS computer to service, which will restore SPDS functionality. Due to SPDS being lost for longer than a short period of time, Wolf Creek Nuclear Operating Corporation is making this ENS notification pursuant to the criteria of 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 appropriate Off-Normal procedure and are obtaining local readings for the equipment that is normally monitored by SPDS and NPIS. It is unknown at this time when NPIS/SPDS will be restored."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM T. DAMASHEK TO P. SNYDER AT 1735 ON 6/13/06 * * *

SPDS has been restored as of 1605 CDT.

The licensee will notify the NRC Resident Inspector. Notified R4DO (Bywater).

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General Information or Other Event Number: 42637
Rep Org: NAK ENGINEERING INC
Licensee: NORDBERG
Region: 4
City: WINDSOR State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NAK ENGINEERING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/13/2006
Notification Time: 15:29 [ET]
Event Date: 06/13/2006
Event Time: [PDT]
Last Update Date: 06/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID AYRES (R2)
THOMAS BLOUNT (IRD)
IAN JUNG (NRR)

Event Text

10 CFR PART 21 NOTIFICATION - DEFECTIVE NORDBERG EMERGENCY DIESEL GENERATOR VALVE SEAT INSERTS

The manufacturer provided the following information via facsimile:

"Significant Safety Hazard regarding the potential of Nordberg Valve Seat Inserts (VSI) to 'drop' from the bore of the cylinder head into the cylinder with probable resulting damage to the cylinder head, power valves, piston, cylinder liner, exhaust manifold and turbocharger which could result in the loss of the intended 'Safety Function' of the EDG.

"There exists a potential problem with the original specification for the specified value of interference fit of the inlet and exhaust Valve Seat Insert (VSI) in the area between the cylinder head bore and the VSI."

Two sites, Brunswick and McGuire, had the defective parts with Brunswick already having changed out the affected parts.

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