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Event Notification Report for October 29, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/26/2007 - 10/29/2007

** EVENT NUMBERS **


43602 43692 43743 43746 43749 43750 43752 43753

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43602
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ELLIS VANN
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2007
Notification Time: 20:26 [ET]
Event Date: 08/27/2007
Event Time: [CDT]
Last Update Date: 10/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTINE LIPA (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

ONE CHANNEL OF LOW MAIN STEAM LINE PRESSURE SIGNAL MISTAKENLY REMOVED FROM SERVICE FOR 33 MINUTES

"On 8/27/07 at approximately 12:05, during performance of STP 3.3.6.1-02 step 7.7.2 the jumper was installed on contacts 1 and 2 of relay A71B-K4A PCIS TRIP CHANNEL A1 A MAIN STEAM LINE LO PRESSURE. The jumper should have been installed on contacts 1 and 2 of relay A71B-K4C PCIS TRIP CHANNEL A2 C MAIN STEAM LINE LO PRESSURE.

"The incorrectly installed jumper on contacts 1-2 of relay A71B-K4A resulted in the channel A1 not being able to trip on a low main steam line pressure signal of 850 psig (PS1014) thus making the function of PS1014 inoperable. At the same time PS1016 was being tested for channel A2 thus making the function for pressure switch PS1016 inoperable. Per Technical specification 3.3.6.1 'Primary Containment Isolation Instrumentation' function 1b 'Main Steam Line pressure - Low' with both PS1014 and PS1016 inoperable, the tripping capability for channel A for Main steam Line Pressure - Low would be lost. This would be a automatic function with isolation capability not maintained per TS 3.3.6.1 condition B. Required action B.1 requires isolation capability to be restored in 1 hour. The I&C techs entered the AOT time for PS1016 at 11:32 AM and exited the AOT at 12:05 PM. Therefore, the isolation capability was lost for 33 minutes of the 1 hour.

"There was no violation of Technical Specification 3.3.6.1 function 1b.

"This event is reportable under 10 CFR 50.72(b)(3)(v), 'Any event or condition that alone at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (D) Mitigate the consequences of an accident."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION AT 09:10 ON 10/26/2007 FROM ROBERT MURRELL TO MARK ABRAMOVITZ * * *

"An UFSAR review has determined that the Main Steam Line Low Pressure isolation is intended to mitigate a transient event. Specifically, the isolation is a safety feature intended to mitigate the consequences of an EHC Pressure Regulator Failure - Open. This transient is not a Design Basis Accident (DBA). Therefore this event resulted in a loss of a Safety Feature, not a loss of a Safety Function. This event is not reportable under 10CFR50.72(b)(3)(v)(D) because the event did not result in a condition that would have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident."

Notified the R3DO (Hills).

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43692
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BOB MURRELL
HQ OPS Officer: JOE O'HARA
Notification Date: 10/05/2007
Notification Time: 11:30 [ET]
Event Date: 10/05/2007
Event Time: 04:08 [CDT]
Last Update Date: 10/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 96 Power Operation

Event Text

LOSS OF BOTH EMERGENCY SERVICE WATER PUMPS

"On October 5, 2007, at approximately 0408, while attempting to open 480 VAC breaker 1B4234A/B for preplanned maintenance, a loss of bus 1B42 occurred. The preliminary cause of the bus trip was arcing of the bucket stabs/bus bars when opening the door to breaker 1B4234A/B. The arcing was a result of the breaker bucket inadvertently pulling away from the bus. At the time of this event, the 'A' Emergency Service Water (ESW) pump was out of service for preplanned maintenance. The loss of 1B42 resulted in a loss of the 'B' ESW pump. The 'A' ESW pump was subsequently returned to service at 0458 on October 5, 2007. Note that power was conservatively lowered approximately 4% at 0512. At the time of this power reduction, the plant was not in a Technical Specification that would require a plant shutdown.

"In addition to the loss of the 'B' ESW pump, the loss of 1B42 resulted in invalid Group 1-5 isolations on the 'B' side of PCIS (not including Main Steam Line Isolation Valves).

"This event is reportable under 10 CFR 50.72(b)(3)(v), Any event or condition that alone at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (D) Mitigate the consequences of an accident.

"The licensee notified the NRC Resident Inspector."

The licensee has not yet determined if this is a mechanical failure of the breaker or a human error. However, they are looking at OE associated with this issue.

* * * UPDATE AT 1324 EDT ON 10/26/07 FROM BOB MURRELL TO S. SANDIN * * *

The licensee provided the following information as an update:

"In addition to the ESW loss of safety function that occurred, it has been determined that from 0408 till approximately 0715 on 10/05/07, a loss of both onsite emergency AC power sources occurred. Specifically, at the time of the event, the 'A' Emergency Diesel Generator (EDG) was out of service for preplanned maintenance. When bus 1B42 was lost, this resulted in a loss of 'B' ESW. The loss of 'B' ESW resulted in the 'B' EDG being incapable of performing its safety function. Therefore, this is another example of an event or condition that could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident."

The licensee informed the NRC Resident Inspector. Notified R3DO (Hills).

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General Information or Other Event Number: 43743
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: WINGERTER LABS, INC.
Region: 1
City: MIAMI State: FL
County:
License #: 0673-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNANCE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/24/2007
Notification Time: 16:48 [ET]
Event Date: 10/24/2007
Event Time: 15:30 [EDT]
Last Update Date: 10/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
LAWRENCE KOKAJKO (FSME)
ILTAB (EMAILED) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

FLORIDA AGREEMENT STATE REPORT - STOLEN/LOST TROXLER MOISTURE DENSITY GAUGE

"Licensee called 10/24/07 at 1640 hours and reported that a Troxler gauge is missing. It was last seen on 10/24/07. Troxler gauge was sitting on tailgate while operator was writing paperwork in vehicle cab. Operator drove off with gauge on tailgate. Wingerter employees searching area for gauge. It was reported missing to the North Miami PD. The Radioactive Materials Office is investigating. No further action will be taken by this office."

Incident Location: Intersection of Curtiss Drive and Pervis Avenue Opalocka, FL

Isotope(s) Cs-137; Be:Am-241 Activity(s): 8mCi; 40mCi

Material Form: Chemical Form; Physical Form: By-product; Special Form

Probable Disposition of Material: Material stolen and not recovered.

Emergency Groups at Scene: North Miami PD

Incident Number: FL07-163

* * * UPDATE PROVIDED BY STEVE FURNACE TO JASON KOZAL ON 10/25/07 AT 1308 * * *

The lost Troxler was recovered by the licensee at the intersection of NW 103rd St and NW 27th Ave Opalocka, FL. The device appears to have fallen off the vehicle tailgate at this location. The case was damaged but the source remained unharmed and locked in the shielded position. Surveys taken revealed no external contamination or indication of leakage. The device will be returned to the manufacturer for repair.

Notified R1DO (Caruso), ILTAB (Via E-mail) and NMSS EO (Morell).

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: 43746
Rep Org: KARMANOS CANCER CENTER
Licensee: KARMANOS CANCER CENTER
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/25/2007
Notification Time: 11:40 [ET]
Event Date: 10/24/2007
Event Time: 14:00 [EDT]
Last Update Date: 10/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3)
GREG MORELL (FSME)

Event Text

GAMMA KNIFE TREATMENT TO WRONG SIDE OF BRAIN

"On October 24, 2007, a medical event occurred at Leksel Gamma Knife facility which resulted in the total dose delivered differing from the prescribed dose by more than20%.

"1. Licensee's name: Karmanos Cancer Center.

"2. Name of prescribing physician: [DELETED]

"3. Brief description of the event:

"Due to a left - right reversal of the treatment planning MRI images, the patient's left side was targeted and treated rather than the right side. The error resulted in an 18 mm shift of isocenter across midline of the brain. The collimator diameter selected for the treatment was 18 mm, thus resulting in some overlap of the delivered 50% isodose volume with the correct intended target lesion volume. The event resulted in approximately 7% of the lesion volume receiving the prescribed dose of 18 Gy to the 50% isodose, rather than the preferred 95% of the lesion volume.

"4. Why the event occurred:

"During the pre-treatment setup and simulation MRI imaging, a 'feet first' scan technique was used with the patient positioned in the MRI scanner head first. This had the effect of reversing the axial images left to right. The standard of practice in gamma knife radiosurgery is to position the patient in the MRI scanner head first, and to use the 'head first' scan technique. The gamma knife authorized medical physicist (AMP) failed to recognize the scanning error when importing the MRI images into the Gamma Knife treatment planning computer, and subsequently registered them as head first. This resulted in the wrong side of the patient being targeted and treated, i.e. the left cerebellum was targeted and treated rather than the right cerebellar lesion.

"5. The effect on the individual who received the administration:

"To be determined.

"6. What actions have been taken or are planned to prevent recurrence:

"For all future gamma knife cases, left/right alignment of the MRI images will be inspected by the AMP by using the Leksel anterior face plate with fiducial markers visible in the MRI images. A Gamma Knife MRI protocol will be written and posted in the MRI department and in the Gamma Knife suite. The protocol will clearly indicate the patient and scan orientation required for Gamma Knife planning and delivery, which are patient on table head first, with head first scanning protocol.

"7. Certification that the licensee notified the individual, and if not, why not:

"The referring neurosurgeon will be notified this evening after he finishes with surgery."

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * * UPDATE AT 08:13 ON 10/26/2007 FROM GREG MORELL TO MARK ABRAMOVITZ * * *

This event has been reviewed and determined to be a reportable medical event.

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Power Reactor Event Number: 43749
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JASON LANIER
HQ OPS Officer: JASON KOZAL
Notification Date: 10/26/2007
Notification Time: 12:06 [ET]
Event Date: 10/26/2007
Event Time: 11:49 [EDT]
Last Update Date: 10/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ROBERT HAAG (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 87 Power Operation 87 Power Operation

Event Text

PRESS RELEASE ISSUED DUE TO TRAIN DERAILMENT

"Harris Nuclear Plant has issued a press release at 1149 EDT today related to the events previously reported to the NRC on 10/25/07. Plant operation has not been affected."

The following is the content of the licensee's press release:

"Rail incident on Harris Plant property reported.

"The wheels of a caboose and part of an empty flatbed car came off the train tracks while accompanying a spent fuel shipping container on Harris Plant property. No injuries occurred and all rail cars remained upright and sustained no damage.

"The wheels of the rail car carrying the shipping container remained on the tracks, fully upright and fully intact the entire time. There was no damage or impact to the shipping container, and there was no danger to the health and safety of the plant or the public. The rail car was moved safely into its storage location and the shipping container was not affected.

"This occurred on Harris Plant property. According to procedure, the NRC and local law enforcement were immediately notified.

"Plant officials report that the rail cars came off the tracks when individuals inaccurately communicated about whether the tracks were prepared for the train's movement."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43750
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ROBERT BROCK
HQ OPS Officer: JASON KOZAL
Notification Date: 10/26/2007
Notification Time: 14:19 [ET]
Event Date: 10/25/2007
Event Time: 19:30 [CDT]
Last Update Date: 10/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

BOTH LOW TEMPERATURE OVERPRESSURE PROTECTION SYSTEMS OUT OF SERVICE

"This 8 hour report is being made pursuant to 10 CFR 50.72(b)(3)(v). On 10/25/2007 at 1930 CDT Point Beach Nuclear Plant (PBNP) Unit 1 and Unit 2 low temperature overpressure protection systems (LTOP) were declared inoperable as a result of the determination that the current LTOP actuation setpoint was non-conservative based on updated calculations. Specifically,

"1) The mass input from the Safety Injection Pumps has significantly increased based on the use of a Point Beach Nuclear Plant specific system flow model.

"2) The setpoint calculation does not consider instrument delay times during (PORV) Pilot Operated Relief Valve actuation.

"3) The updated Calculation changes instrument uncertainties.

"LCO 3.4.12 for the LTOP system is not applicable at this time for either unit (both units in Mode 1/100% power). LCO 3.4.12 is only applicable in Mode 5, Mode 6 when the reactor vessel head is on, and Mode 4 when any cold leg temperature is at or below the temperature specified in the Pressure Temperature Limits Report (270 deg F).

"Changes to operating procedures to delineate operation of reactor coolant pumps and charging pumps during low temperature conditions are in progress. Implementation of these procedure changes will permit LTOP to be returned to service."

The licensee stated that this issue was discovered as part of the on going calculation reconstitution initiative at the plant.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY RYAN RODE TO JASON KOZAL AT 2135 ON 10/26/07 * * *

"The following is an update to the 8 hr report made to the NRC via EN#43750:

"On 10/26/07 at 17:51 procedure changes which identify requirements for operation of reactor coolant pumps and charging pumps during low temperature conditions have been made. These procedures provide the guidance required to ensure that the current LTOP setpoints remain conservative. Based on the issuance of these procedures with the required guidance, LTOP is returned to service for both Unit-1 and Unit-2."

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

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Power Reactor Event Number: 43752
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVE RICHARDSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/28/2007
Notification Time: 03:24 [ET]
Event Date: 10/28/2007
Event Time: 00:59 [EDT]
Last Update Date: 10/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN CARUSO (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL SCRAM DUE TO LOWERING INTAKE LEVEL

"High winds (in excess of 40 MPH) resulted in significant debris at the plant intake. Traveling screens had been placed in 'Fast' speed and continuous wash on the previous shift in anticipation of predicted high wind conditions. As the debris entered the intake, high traveling screen differential pressure and lowering intake level prompted the operating crew to enter the appropriate Abnormal Operating Procedure (AOP).

"Efforts to manually clean the screens were ineffective, and at 0059 hours, the crew inserted a manual scram as directed by procedure at 240 foot intake level.

"On scram, as expected, reactor vessel level lowered to the low level scram setpoint (177 inches above top of active fuel). At this point, as expected, an automatic Reactor Protection System (RPS) actuation, and a Group 2 Primary Containment Isolation System (PCIS) isolation occurred with no anomalies noted.

"During plant cooldown reactor level lowered to 177 inches above TAF. This resulted in a valid RPS actuation and a PCIS Group 2 isolation signal. All systems responded as expected.

"Operators were able to maintain reactor vessel level above the actuation setpoint for High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) systems, and these systems were not required to operate.

"The cause of the failure of the traveling screens to maintain intake level is under investigation.

"All control rods are fully inserted and the plant is stable in Mode 3, Hot Shutdown."

Decay heat is being removed via the turbine bypass valves to the main condenser. No SRVs lifted during the transient. The plant is in a normal shutdown electric plant lineup.

The licensee notified the NRC Resident Inspector and the New York Public Service Commission.

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Power Reactor Event Number: 43753
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BERNIE LITKETT
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2007
Notification Time: 02:12 [ET]
Event Date: 10/28/2007
Event Time: 22:03 [EDT]
Last Update Date: 10/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN CARUSO (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

REFUEL FLOOR EXHAUST HI-HI RADIATION ALARMS DURING REACTOR REASSEMBLY

"On 10/28/07 at 2203 in Operational Condition 5, two of three Refuel Floor Exhaust Radiation Monitors actuated on HI-HI Radiation during the Moisture Separator lift for Reactor Pressure Vessel Reassembly. Reactor Building Ventilation was procedurally secured at the time of the actuation to minimize the potential for airborne contamination. The cause of the elevated radiation levels at the Refuel Floor Exhaust Radiation Monitors is currently attributed to the lifting of the Moisture Separator closer to the surface of the water to obtain an unobstructed underwater path to the Reactor Pressure Vessel. The resulting ESF signal yielded an automatic start of the 'A' and 'D' Station Service Water Pumps, the Filtration Recirculation and Ventilation System, and load-shed of non-1E breaker loads. All systems responded as expected. Systems and components actuated by the condition have been restored to a normal stand-by alignment as required. No other systems were affected and the plant is stable in Operational Condition 5."

The licensee will notify the NRC Resident Inspector. The licensee notified the Lower Alloways Creek Township.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012