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Event Notification Report for December 3, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/30/2007 - 12/03/2007

** EVENT NUMBERS **


43689 43805 43806 43811 43814 43815 43817

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43689
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ANDREW SMOLINSKI
HQ OPS Officer: JOE O'HARA
Notification Date: 10/03/2007
Notification Time: 23:38 [ET]
Event Date: 10/03/2007
Event Time: 15:30 [CDT]
Last Update Date: 11/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
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 100 Power Operation

Event Text

POTENTIAL UNAVAILABILITY OF TWO WAY RADIO SYSTEM TO SUPPORT SAFE SHUTDOWN

"In response to Self-Assessment Report SA014668 and preparation for the 2008 Triennial Fire Protection Inspection, a Fire Protection Improvement Plan implementation is in progress. Preliminary analysis of the major equipment, power supplies and cables associated with the two-way radio communication system (DCR-3341) indicates the potential for the plant two-way radio system to be adversely impacted and potentially unavailable to support post-fire safe shutdown operator actions and/or fire brigade fire fighting activities for a fire location in:
- Fire Zone AX-35 (Control Room and AC Equipment Room)
- Fire Zone TU-22 (Turbine Room) at the mezzanine elevation just outside Battery Room 1B
- Fire Zone TU-98 (Battery Room 1B)

"This review has identified discrepancies regarding the credited means of communication required for use by Operators in response to an Appendix R fire. The safe shutdown procedures E-O-06 and E-O-07, and the Manual Action Feasibility Study (Fire Protection Engineering Evaluation FPEE-003) only credit the plant two-way radio system.

"However, upper tier program documents (e.g., Fire Protection Program Plan, Appendix R Design Description) do not consistently contain the same requirements. For example, the Fire Plan, Rev 7, Section 12.9 requires both the 5-channel Gai-Tronics system between key shutdown locations AND the multi-channel portable radio communications equipped with repeaters and provided for use by the plant fire brigade shall be operable at all times. The Appendix R Design Description. Rev. 5 is silent on safe shutdown communications.

"It is not clear at this time whether the 5-channel Gai-Tronics should also be credited in the safe shutdown procedures. If so, then the cables supporting operation of the Gai-Tronics would need to be identified and located by fire zone to determine their availability in lieu of two-way radio communications for a fire in any of the three fire zones identified above.

"Until this is verified, the Appendix R timeline for achieving sate shutdown may not be able to be met. Therefore, this is reportable under 10 CFR 50.72 (b)(3)(V)(A), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to:
(A) shutdown the reactor and maintain it in a safe shutdown condition,
(B) remove residual heat,
(C) control the release of radioactive material, OR
(D) mitigate the consequences of an accident."

The licensee will notify the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY JACK GADZALA TO JEFF ROTTON AT 1527 EST ON 11/30/07 * * *

"EN# 43689 provided notification that the Appendix R timeline for achieving safe shutdown may not be achievable due to potential loss of the credited two-way radio communication system due to fire and consequent need for face-to-face communications between the Operators. This position was adopted pending verification of the availability of the Gai-Tronics paging system.

"A subsequent engineering analysis of the major equipment, power supplies and cables associated with the Fire Protection/Appendix R two-way radio communication system, the Gai-Tronics plant paging system and the dedicated Emergency Gai-Tronics System, determined that adequate communications would have been available during a fire in the subject fire zones. Operators are familiar with and skilled in the use of the Gai-Tronics system as part of their job function. Interviews with on-shift Operators confirmed that operations would use the two-way radios; and if they failed, would then use the nearest Gai-Tronics handset station and then Emergency Gai-Tronics at specific locations for an Appendix R Dedicated Shutdown scenario. Where Operator manual actions are in close proximity to the Dedicated Shutdown panel, face-to-face communications would be achievable and timely.

"Consequently, the assumption of only face-to-face communications described in the Event Report would not have been necessary for all safe shutdown actions. Use of redundant communications systems (Gai-Tronics and Emergency Gai-Tronics) would have been available for fires in the subject fire zones such that the Appendix R safe shutdown time requirements would not have been significantly impacted. The loss of the two-way radio system for the identified fire zones would not have prevented the fulfillment of the safety function of systems that are needed to shut down the reactor and maintain it in a safe shutdown condition. As such, this condition is not reportable under 10CFR50.72(b)(3)(v)(A) as previously stated.

"Consequently, the notification made on 10/03/2007 (EN 43689) is hereby retracted."

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

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General Information or Other Event Number: 43805
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NUCLEAR ONCOLOGY S.C.
Region: 3
City: WINFIELD State: IL
County:
License #: IL-01641-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/26/2007
Notification Time: 10:18 [ET]
Event Date: 11/19/2007
Event Time: [CST]
Last Update Date: 11/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - PATIENT RECEIVED 10% OF PRESCRIBED DOSE

"Medical physicist for the licensee called to advise that on Wednesday November 21, it had come to his attention that a medical event had occurred at their Winfield, IL facility. He reported that on beginning Monday November 19, the delivered dose per fraction was only one tenth that which was originally prescribed by the oncologist. The original written directive was to have a post surgical total dose of 3400 cGy delivered in 10 fractions over the course of 5 days (2 per day). However when reviewed by the medical physicist, the treatment protocol instead indicated that each fraction was 34 cGy instead of the 340 cGy per fraction. The attending oncologist we immediately notified and treatments suspended. As a result the dose administered was well below 20% of the intended dose as well as less than 50% per each fraction.

"At the time of the assessment only 6 fractions had been conducted and a total dose of 192 cGy had been delivered. After notifying the oncologist and the patient the same day the error was noted, it was determined that the treatment provided to date was an ineffective post surgical procedure and the patient should be retreated. A revised treatment plan was prepared and the first six fractions of a revised 10 fraction treatment have been completed at this time. The oncologist believes there is no end medical effect that will be noticed from this event.

"Upon review, the treatment team determined that the dosimetrist who entered the data for the treatment plan had failed to enter the proper dose per fraction after applying a dose optimization plan. Nor was the error caught during a routine review of the plan by the treatment team prior to loading the plan from the planning system. The confusion may have arisen from the fact that this was the first multi-fractionated treatment that the dosimetrist had prepared as all previous treatments they had been involved with were all single fractions.

"Due to the nature of this event it will be reported to the U.S. Nuclear Regulatory Commission Operations Center. The licensee is aware of the requirement to file a written report within the next 15 days. This item will remain open an under investigation until receipt of that report.

"Corrective Actions:
1 New procedure written
2 Personnel received additional training"

The patient has been informed of the incident and has re-commenced radiation treatment.

The state has no follow-up intentions for this event.

Illinois event number: IL070062

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 BY FSME (FLANNERY) TO KOZAL AT 0950 ON 11/27/07* * *

"This event (EN43805) has been reviewed and determined to be a reportable medical event."

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Fuel Cycle Facility Event Number: 43806
Facility: BWX TECHNOLOGIES, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: BARRY COLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/26/2007
Notification Time: 14:31 [ET]
Event Date: 11/22/2007
Event Time: 15:47 [EST]
Last Update Date: 11/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
JAY HENSON (R2)
MICHELL BURGESS (FSME)
FUELS OUO email ()

Event Text

OFFSITE NEWS PRESS RELEASE

"This concurrent report is being made to the NRC as a result of a media inquiry from [a reporter] of the Virginian Pilot for an article concerning the closure of Barnwell and its impact on the BWXT operations. The Virginian Pilot is a newspaper in the Hampton Roads, Virginian area. The information was provided to [the reporter] by [Deleted], BWXT's Communications Specialist."


The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 43811
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: UNKNOWN
Region: 4
City: GLENDALE State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: AUBRY GODWIN
HQ OPS Officer: PETE SNYDER
Notification Date: 11/28/2007
Notification Time: 15:22 [ET]
Event Date: 11/27/2007
Event Time: 18:11 [MST]
Last Update Date: 11/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
DENNIS RATHBUN (FSME)
ILTAB (e-mail) ()
MEXICO ()

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

Event Text

AGREEMENT STATE REPORT - NATURALLY OCCURRING RADIOACTIVE MATERIAL FOUND AT A SCHOOL

The Agreement State submitted the following information via e-mail:

"At approximately 6:11 PM November 27, 2007, the Agency was informed that the Washington Elementary School District had found some radioactive material and had called the Glendale Fire Department. The material was found when the District was cleaning out some chemicals. The Glendale and Phoenix Fire Departments responded and they detected radiation with their instrumentation. At that point the Agency was contacted.

"The radioactive material was identified as radium 226 and read 220 microrad at 3 inches from the container. Wipes and alpha surveys checks made in field were negative. Laboratory results pending. Based on the radiation reading at 3 inches, we estimate that a total of between 0.5 to 5 microcuries of radium may be present. The material was secured until a waste broker can remove it. The form of the radium was not determined.

"The [Arizona Regulatory] Agency continues to investigate this event."

Arizona Report First Notice Number: 07-013

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Fuel Cycle Facility Event Number: 43814
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: SEAN GOUGH
HQ OPS Officer: JOE O'HARA
Notification Date: 11/30/2007
Notification Time: 14:20 [ET]
Event Date: 11/30/2007
Event Time: 11:00 [EST]
Last Update Date: 11/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
JOEL MUNDAY (R2)
DENNIS RATHBUN (FSME)

Event Text

POTENTIAL LOSS OF ITEM RELIED ON FOR SAFETY (IROFS)

"Reason for Notification: On 11/30/07, during a routine NCS facility walkthrough assessment performed by a qualified NCS Engineer, it was discovered that the SNM mass balance maintained for the Chemical Process Development Laboratory (CPD Lab) had been performed incorrectly. Specifically, although the applicable inventory form and associated mass limit for the lab was in terms of grams of SNM (i.e., grams of UO2), cans of archive pellets brought into the lab had been recorded in terms of grams of 235U (underestimating the total lab mass).

"As a result, the total inventory of the lab was actually at approximately 39 kg UO2 (assuming the 2007 annual nominal plant enrichment of 4.38 wt%). This value exceeds the lab mass limit of 15.9 kg UO2, designated an Item Relied on for Safety (IROFS) in the Laboratory ISA Summary (CHMDEV-101).

"Notification is being made based on the potential for Loss or degradation of IROFS that result in failure to meet the performance requirements of 10CFR70.61, reference Appendix A, Section (b)(2) to Part 70 of 10CFR70.

"Safety Basis: The total inventory of the lab was at approximately 39 kg UO2 (assuming the 2007 annual nominal plant enrichment of 4.38 wt%). This value exceeds the lab mass balance limit of 15.9 kg UO2 (based on the single parameter mass limit for UO2 and water). Although criticality in the lab is judged to be incredible, a mass limit was established for the lab, and a mass balance was initiated to enforce it. This mass balance was designated an IROFS in the Laboratory ISA Summary (CHMDEV-101).

"Criticality in the CPD Lab is judged to be an incredible event because no routine process operations are performed in the lab, and special evolutions (for testing or product development) require explicit Criticality Safety Evaluations. The vast majority of SNM currently in the lab is in the form of mounted archive pellets in small (~1 gallon) metals cans stored on the floor of the lab. These cans are being stored there temporarily until a new grinder can be installed to dispose of them.

"Although the mass limit was exceeded in the lab, no potential for criticality existed, as the SNM was stored in sealed metal cans with limited moderation (provided by plastic mounting material). In addition, per CN-CRI-06-30, it requires more than 27 fully loaded and optimally moderated pellet cans to challenge the CFFF acceptance criterion of 0.98, even with multiple stacked cans and optimal spacing. In reality, there are only 15 pellet cans in the lab, and these are stored in a single planar array with 12 inch surface-to-surface spacing.

"Summary of Activity: The archive pellet cans have been removed from the lab, such that the total mass balance in the lab is now below the mass limit for the lab. The event was documented in the plant Corrective Action Process (CAPs #07-334-C025). A new Criticality Safety Evaluation for the CPD Lab (CSE-18-D) was issued on October 16, 2007, and is scheduled for implementation during December 2007. Although this new CSE still concludes that criticality in the lab is incredible, it established additional controls on maintaining the mass balance and special periodic Assessments of the mass balance by the NCS Function.

"Conclusions: Problem was self identified by Westinghouse personnel during a scheduled NCS Facility Walkthrough Assessment. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. A causal analysis will be performed.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 43815
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIMOTHY BOLAND
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/30/2007
Notification Time: 17:50 [ET]
Event Date: 11/30/2007
Event Time: 10:52 [CST]
Last Update Date: 11/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

MANUAL HPCI ISOLATION DUE TO STEAM LEAK INCREASE

"At 1052 on 11/30/2007 while in Mode 3 for a maintenance outage, a previously identified steam leak on the packing of valve 3-FCV-073-0006A, HPCI Steam Line Condensate Inboard Drain Valve, increased. The room temperatures were not rising at the time of the increased leakage, alleviating the potential automatic isolation of the system. Upon review of the condition, the Operations staff closed the steam isolation valves and declared HPCI INOPERABLE to minimize the spread of contamination in the area. After HPCI was isolated, inspection of the valve identified a Code Class 2 piping through wall leak on a tee upstream of 3-FCV-073-0006A which contributed to the increased leakage observed prior to isolation of the system.

"This event is reportable as an 8-hour Non-Emergency Notification in accordance with 10CFR50.72 (b)(3)(v)(B) as; 'Any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to: Remove Residual Heat'; and 10CFR50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to: mitigate the consequences of an accident.'

"This event also requires a 60 day written report in accordance with 10CFR 50.73(a)(2)(v)(B) and 10CFR 50.73(a)(2)(v)(D)."

The Code Class 2 piping leak was on a tee for the steam trap bypass valve upstream of the HPCI Steam Line Condensate Inboard Drain Valve.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43817
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: HANS OLSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/01/2007
Notification Time: 18:25 [ET]
Event Date: 12/01/2007
Event Time: 14:35 [CST]
Last Update Date: 12/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHRISTINE LIPA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

AUTOMATIC EDG STARTS ON 161 KV LINE TRANSIENT

"This report is being made under 10CFR50.72(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 this section' due to the Auto Start of the 'A' and 'B' Standby Diesel Generators.

"The Auto start of the 'A' and 'B' Standby Diesel Generators occurred on a valid bus undervoltage condition caused by a transient on the 161 kV Fairfax line. The Standby Diesel Generator Feeder Breakers did not close onto their respective Essential buses. The Essential buses were not required to load onto either diesel as they remained powered from the 1X003 Start-up Transformer during and after the event. Offsite power remained fully operable during and following the event. The Standby Diesel Generators have been returned to the standby/ready condition.

"The RWCU pump tripped which removed RWCU from service. The system has been returned to service. The 'D' Well Water Pump also tripped and auto restarted."


The licensee notified the NRC Resident Inspector.

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