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Event Notification Report for January 22, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/18/2008 - 01/22/2008

** EVENT NUMBERS **


43903 43905 43908 43914 43916 43918 43919 43920 43921 43922

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 43903
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: TONY HUDSON
HQ OPS Officer: JOE O'HARA
Notification Date: 01/14/2008
Notification Time: 15:36 [ET]
Event Date: 01/13/2008
Event Time: 15:12 [CST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MALCOLM WIDMANN (R2)
ROBERT PIERSON (NMSS)

Event Text

FAILURE OF UF6 RELEASE DETECTION SYSTEM

"At 1512 CST, on 01-13-08 the Plant Shift Superintendent (PSS) was notified that the C-333 Unit 6 Cell 7 UF6 Release Detection (PGLD) System failed to function when performing the twice per shift test firing. Test firing of the PGLD detector heads is required per TSR SR 2.4.4.1-1. TSR 2.4.4.1 also requires that at least the minimum number (three) of detector heads in the cell and in each defined section of the cell bypass are operable where UF6 systems are above atmospheric pressure. The C-333 Unit 6 Cell 7 PGLD System contains detectors that covers the cell and Sections 3 and 4 of the cell bypass piping. At the time of this failure some areas of Section 3 of the cell bypass were operating above atmospheric pressure. Since Unit 6 Cell 7 was operating below atmosphere, the cell was not in an applicable TSR mode. However, Section 3 of the cell bypass was above atmosphere and in an applicable TSR mode which required at least three operable PGLD heads. With the Unit 6 Cell 7 PGLD system inoperable only two of the required three heads in Section 3 of the cell bypass were operable. This PGLD System was declared inoperable, and system pressure in the affected operating area was reduced to less than atmospheric pressure within one hour, thus placing the operating system in a non-applicable TSR mode. This event is being reported as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Resident Inspector has been notified of this event.

"PGDP Assessment and Tracking Report No. ATR-08-0122; PGDP Event Report No. PAD-2008-01; Worksheet No. 43903

"Responsible Division: Operations"

The licensee is investigating the cause of the event, and will make appropriate notifications to the Department of Energy.

* * * RETRACTION PROVIDED BY TONY HUDSON TO JASON KOZAL AT 1403 ON 1/18/08 * * *

"On January 13, 2008 the C-333 U/6 C/7 PGLD system failed during testing. This affected all the PGLD heads in the cell area and two of the four heads in section 3 of the cell by-pass. A review of operating pressures in the affected area determined that the cell was operating below atmospheric pressure, but that piping in section 3 of the cell by-pass was operating above atmosphere. Thus, three of four heads in section 3 of the Cell by-pass were required by the TSR to be operable. Given the recent failure in November and indications that the failure modes may be similar, the PSS reported the event to the NRC per 10CFR 76.120(c)(2)(i), In-Service Safety System Failure. Subsequent to the event, the pressures in C-333 U/6 CR, section 3 in the cell by-pass area associated with the event were reviewed. Using Engineering Notice EN-C-821-05-090, Rev, 3, it was determined that section 3 of the cell by-pass was actually not operating above atmosphere and thus, the PGLD system was not required to be operable at the time of the failure. Since the failure only affected detectors in an area operating in a non-TSR mode, the PGLD system is not required to be operable and reporting under 10 CFR 76.120(C)(2) is not required."

The licensee notified the NRC Resident Inspector. The licensee made appropriate notifications to the Department of Energy.

R2DO (Moorman) and NMSS EO (Kokajko) notified.

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General Information or Other Event Number: 43905
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OWENSBORO MEDICAL HEALTH SYSTEMS
Region: 1
City: OWENSBORO State: KY
County:
License #: 202-161-26
Agreement: Y
Docket:
NRC Notified By: KENTUCKY DEPT OF RAD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/15/2008
Notification Time: 11:35 [ET]
Event Date: 12/20/2007
Event Time: [CST]
Last Update Date: 01/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT - MISPLACED SEEDS DURING PROSTATE TREATMENT

The State provided the following information via facsimile:

"On January 10, 2008, a 4-week follow up CT-based post prostate seed implant plan was created and reviewed by the prescribing physician. Upon completion of the review it was determined that the seeds had been implanted approximately 2.5cm interior to the base of the prostate. The prescription dose was for 145 Gy to be implanted into the prostate gland using 74 lodine -125 seeds with an average activity of 0.300 milliCuries

"The post plan dosimetry showed that prostate was under-dosed by greater than 20% from the prescription dose of 145 Gy. The nearby organs at risk, namely the bladder and rectum, were not affected by the misplacement of the seeds.

"On January 11, 2008, the prescribing physician, [DELETED], notified the attending urologist, [DELETED] of this medical event. The urologist has requested that he notify the patient himself."

Item Number: KY082

* * * UPDATE FROM CYNTHIA FLANNERY TO JOE O'HARA VIA E-MAIL AT 0651 ON 1/16/08 * * *

"EN43905 has been reviewed and determined to be a reportable medical event."

Notified R1DO(Cobey) and FSME(Flannery)


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.

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General Information or Other Event Number: 43908
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LAHEY CLINIC FOUNDATION
Region: 1
City: BURLINGTON State: MA
County:
License #: 44-0015
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/16/2008
Notification Time: 16:47 [ET]
Event Date: 01/15/2008
Event Time: [EST]
Last Update Date: 01/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
EUGENE COBEY (R1)
KEITH McCONNELL (FSME)
ILTAB via email ()

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

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT - MISSING BRACHYTHERAPY SEEDS

"The Licensee's RSO reports that a total of five (5) I-125 brachytherapy seeds, each containing 0.395 millicuries (assayed January 15, 2008) (total activity of 1.975 millicuries) are missing. The Licensee's RSO reports that the seeds were likely lost during or after a procedure performed in the Licensee's operating room on January 15, 2008. The seeds were discovered to be missing on January 16, 2008 and the seeds likely were disposed of in regular trash.

"The Licensee's RSO reports that the missing seeds are Oncura Echo seed Model 6733 seeds.

"The Licensee continues to search and survey for the seeds."

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: 43914
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/17/2008
Notification Time: 23:48 [ET]
Event Date: 01/17/2008
Event Time: 18:00 [EST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
JAMES MOORMAN (R2)
JIM WHITNEY (ILTA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N Y 98 Power Operation 98 Power Operation

Event Text

CONTROLLED SUBSTANCE FOUND IN LOCATION OUTSIDE PROTECTED AREA

"At approximately 1800 EST, a controlled substance and paraphernalia were discovered by a supplemental employee, who then reported the discovery to his supervision. Plant Security was contacted, who then notified Local Law Enforcement. All supplemental personnel who were in-processing in the area at the time of discovery were interviewed and sent for FFD testing. All immediate results were negative; lab results are still pending. A drug detection dog was brought in by the Local Law Enforcement Agency to clear the area where the substance was found and nothing additional was found. This notification is being made as a courtesy as a result of the potential newsworthiness of the event."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE FROM LICENSEE (POPE) TO NRC (HUFFMAN) AT 0925 EST ON 01/18/08 * * *

"The building in which the substance was found was located outside the Plant Vogtle Protected Area."
The licensee notified the NRC Resident Inspector. R2DO (Moorman) notified.

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Power Reactor Event Number: 43916
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: GLENN KRAUSE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2008
Notification Time: 11:53 [ET]
Event Date: 01/18/2008
Event Time: 10:15 [CST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BLAIR SPITZBERG (R4)

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

Event Text

OFFSITE NOTIFICATION OF TRITIUM IDENTIFIED IN WATER SAMPLES FROM PIPING LEAK

"This is a report of a situation, related to the protection of the environment, for which a notification to other government agencies is being made, as described in 10CFR50.72(b)(2)(xi).

"On January 17, 2008, at approximately 1300 hours, site environmental monitoring personnel at River Bend Station completed analysis which confirmed the presence of tritium in water samples taken from a piping leak that occurred on January 16, 2008, on plant property. The source of the tritium was from water that had been treated in the liquid radwaste system and was suitable for release. The Louisiana Department of Environmental Quality and other state and local officials are being notified in accordance with the voluntary NEI groundwater protection initiative.

"The following is a summary of the events that led up to the identification of tritium in the water sample.

"On January 16, 2008, at approximately 1750 hours with the plant shutdown in Mode 5 (Refueling), River Bend Station personnel identified a water leak from a cooling tower blowdown line. The design of this system takes water from the plant's cooling tower basin. This water mixes with treated water being discharged from the liquid radwaste system. The diluted blowdown is then discharged to the Mississippi River.

"Plant operators received a low blowdown line flow alarm and immediately terminated the discharge of water from the liquid radwaste system. The cooling tower blowdown pumps were also subsequently stopped. The leak was caused by a failure of the blowdown piping.

"The leak was located inside the owner controlled area near the plant's cooling towers. Based on the location of the leak, the water drained to a nearby storm drain and into East Creek (Outfall 3). East Creek exits the plant site and discharges to the Mississippi River. The volume of the spill as been estimated to be less than 720 gallons of water from the radwaste system. This water had been treated and was suitable for release. Additional clean water from the cooling tower basin mixed with the water from the liquid radwaste system and was released. The analysis of a water sample, taken at the discharge point to East Creek determined that the samples contained 28,042 Pico Curies per liter (pCi/I) tritium. The NRC reporting level for a non-drinking water pathway is 30,000 pCi/I. Samples taken directly at the location of the leak contained 129,456 pCi/I tritium. The release has no potential to impact the health and safety of the public. RBS personnel are investigating the cause of the leak and will not restore blowdown until action is taken to prevent further occurrence."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 43918
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: TODD CREASY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2008
Notification Time: 17:54 [ET]
Event Date: 01/18/2008
Event Time: 17:03 [EST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
EUGENE COBEY (R1)
KEITH McCONNELL (FSME)

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

OFFSITE NOTIFICATION DUE TO RECEIPT OF PACKAGE THAT EXCEEDED ALLOWABLE CONTACT DOSE RATE

"At 1703 EST on 1/18/2008, Susquehanna LLC personnel became aware that a shipment received from GE Hitachi Nuclear Energy exceeded the allowable limit of 200 mr/hr contact dose rate. The external radiation limit of 200 mrem/hr was exceeded on one of the two boxes comprising the shipment. The limit per NDAP-QA-0648 is 200 mrem/hr on contact for a shipment type for a transport vehicle which is not designated exclusive use. The actual value was determined to be 350 mrem/hr, therefore reportable per the requirements of 10CFR20.1906(d)(2).

"The NRC Resident Inspector and the Shipper (GE Hitachi Nuclear Energy) were notified. The transport vehicle left Wilmington NC on 1/17/2008 at 1435 and was received by SSES [Susquehanna Steam Electric Station] on 1/18/2008 at 0800. There was no surface contamination noted on the shipment. The original survey completed prior to shipment noted the highest on contact dose rate was 170 mr/hr.

"This item is reportable under 50.72(b)(2)(xi) for offsite notification of an event of public interest."

The boxes contained various pieces of equipment that GE uses to support refueling.

The licensee has notified the NRC Resident Inspector and will be notifying the Pennsylvania Emergency Management Agency.

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Power Reactor Event Number: 43919
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID FUNK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2008
Notification Time: 18:44 [ET]
Event Date: 01/18/2008
Event Time: 17:44 [EST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAMES MOORMAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO TWO INOPERABLE ROD POSITION INDICATORS IN THE SAME ROD GROUP

"At 1744 [EST] on 1/18/08, [the licensee] entered Technical Specification (TS) 3.0.3 on Unit 3 due to observed Rod Position lndicator (RPI) F-14 dropping from 228 steps to 135-145 steps and behaving erratically. This RPI is in the same bank as currently inoperable RPI F-2. TS 3.1.3.2 has actions for a maximum of one RPI per bank inoperable. Since there are two inoperable in one bank, an entry into TS 3.0.3 is required.

"Power reduction [was] initiated at 1835 [hrs.].

"Repairs [are] currently in progress [and the licensee] anticipate[s] correction prior to completion of power reduction."

If the RPI is not corrected, the licensee will be required to be in Mode 3 by 0044 hrs. EST on 01/19/08. This is an ongoing issue. See Event Notifications 43896 and 43888.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY DAVE FUNK TO JASON KOZAL AT 2041 0N 1/18/07 * * *

"Repairs are complete. RPI F-14 has been restored to service on Unit 3, exited Technical Specification 3.0.3 at 2027. Return to 100% power on Unit 3 [is] in progress."

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Moorman).

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Power Reactor Event Number: 43920
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL REED
HQ OPS Officer: JASON KOZAL
Notification Date: 01/19/2008
Notification Time: 16:13 [ET]
Event Date: 01/19/2008
Event Time: 11:52 [EST]
Last Update Date: 01/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
EUGENE COBEY (R1)

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

'A' AND 'B' RECIRCULATION PUMP MOTOR GENERATOR OVERSPEED STOPS FOUND SET HIGH (NON-CONSERVATIVE) DURING SURVEILLANCE TESTING

"During the Performance of the 18 month surveillance requirement to demonstrate operability of the reactor recirc pump motor set scoop tube mechanical and electrical stop over-speed set points to be less than or equal to 109 percent and 107 percent, respectively, the 'A' and 'B' MG set stops were found non-conservatively high. The electrical and mechanical stops have been adjusted to meet surveillance requirements as of 1538 [on] 1/19/2008.

"The potential impact of this condition would be a function of the reactor recirc 'run-out' transient. If that analyzed transient were to have occurred, the potential existed for the flow dependent Minimum Critical Power Ratio to have been exceeded. This could result in exceeding the safety limit (MCPR) under the most limiting postulated conditions.

"Evaluation of the potential cause of the improper settings is underway.

"The 'A' Recirc Pump and Motor were replaced during the last refueling outage. [November 2007]"

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

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Power Reactor Event Number: 43921
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MATT FORREST
HQ OPS Officer: PETE SNYDER
Notification Date: 01/20/2008
Notification Time: 02:55 [ET]
Event Date: 01/19/2008
Event Time: 23:02 [EST]
Last Update Date: 01/20/2008
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):
EUGENE COBEY (R1)

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

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING TURBINE TRIP

"Initiating alarm received was a Turbine Trip. All on site buses 1, 2, 4, 5 and 6 swapped to the Reserve Auxiliary Transformer power supplies. Bus 3 did not swap as expected. The station has entered a Technical Specification 3.8.1.1 (a) 72 hour action statement for offsite power distribution with 345 kV Bus 3 unavailable.

"All safety systems operated correctly. The station continues to troubleshoot the initiating cause of the Turbine Trip. The plant is stable in Mode 3."

During the swap of non safety buses to the Reserve Auxiliary Transformer the Reactor Coolant Pumps (RCP) tripped. Following the loss of power to the RCPs the reactor stabilized in natural circulation. A Pressurizer PORV cycled following the trip. One RCP was restarted to restore forced circulation. Auxiliary Feedwater Pumps started as expected on the trip and were subsequently secured.

All control rods fully inserted on the trip. The current decay heat removal path is Start-up Feedwater supplying water to the Steam Generators steaming to the Condenser Steam Dumps.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 0348 ON 1/20/08 FROM FORREST TO HUFFMAN * * *

The licensee has indication of a differential voltage fault on the C phase of the 345 kV line that feeds the Unit Auxiliary Transformer and the generator step-up transformers. The licensee also wanted to ensure that the report reflected the specified system actuation of Auxiliary Feedwater.

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Power Reactor Event Number: 43922
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TOM FOWLER
HQ OPS Officer: JASON KOZAL
Notification Date: 01/21/2008
Notification Time: 12:26 [ET]
Event Date: 01/21/2008
Event Time: 09:52 [EST]
Last Update Date: 01/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE COBEY (R1)
MICHELE EVANS (NRR)
THOMAS BLOUNT (IRD)

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

ON-SITE FATALITY

"A supplemental employee associated with the Salem Steam Generator Replacement Project died this morning from an apparent heart attack. The death was not the result of any industrial safety issue and did not occur in a contaminated area. The individual was treated by the onsite EMI's who administered CPR and AED (automatic external defibrillator). He was transported via ambulance to Salem Memorial hospital where he was pronounced dead. This is considered to be a common report for both Salem and Hope Creek Generating Stations."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012