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Event Notification Report for February 11, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/08/2008 - 02/11/2008

** EVENT NUMBERS **


43836 43894 43960 43964 43965 43966 43971 43972 43973 43974 43976

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43836
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/11/2007
Notification Time: 17:28 [ET]
Event Date: 12/11/2007
Event Time: 08:55 [CST]
Last Update Date: 02/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JOHN MADERA (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

LOSS OF RHR ROOM COOLER

"At 08:55 on 12/11/07 the division 1 RHR room cooler, V-AC-5 would not start. At approximately 10:00, troubleshooting determined that the cause of the failure was a blown line fuse on the B phase of the 480 VAC supply breaker. In accordance with plant procedures, a loss of this room cooler requires that the associated division 1 core spray pump and both division 1 LPCI pumps be declared inoperable. The result is entry into Technical Specification 3.5.1 Condition M due to having two or more ECCS injection/spray subsystems inoperable. This requires entry into LCO 3.0.3. At 10:53 on 12/11/07 the blown line fuse was replaced, the unit was tested and operability was restored. LCO 3.0.3 was exited at this time.

"The Technical Specification bases for Technical Specification 3.5.1 Condition M states that when multiple ECCS subsystems are inoperable, as stated in Condition M, the Plant is in a condition outside of the accident analyses. As described in this bases section the plant is in an unanalyzed condition and pursuant to 10 CFR 50.72(b)(3)(ii) an 8 hour report is being made.

"At this time, the station believes there was no loss of safety function. Further review of the event is in progress at the station.

"The station has informed the NRC resident inspector of this event."

* * * UPDATE AT 1710 EST ON 02/08/08 FROM RANDY SAND TO S. SANDIN * * *

After further review, the licensee is retracting this report based on the following:

"The notification was initiated due a TS Bases that stated the plant was outside of its accident analyses with multiple ECCS subsystems are inoperable. This was considered an unanalyzed condition.

"Further evaluation by plant staff has determined that for the conditions present at the time of the event the station was bounded by the accident analysis and therefore the event was not an unanalyzed condition. A review of Section 14 of the Updated Safety Analysis Report (USAR) determined that with one low-pressure ECCS division inoperable, the plant was not outside the ECCS accident analysis as described in the SAFER GESTR ECCS licensing topical report for Monticello and reflected in Chapter 14 of the USAR."

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

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43894
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GREG EVANS
HQ OPS Officer: PETE SNYDER
Notification Date: 01/11/2008
Notification Time: 15:46 [ET]
Event Date: 01/11/2008
Event Time: 15:10 [EST]
Last Update Date: 02/08/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
76.120(a)(4) - EMERGENCY DECLARED
Person (Organization):
MALCOLM WIDMANN (R2)
MARY JANE ROSS-LEE (NRR)
JEFFREY CRUZ (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

DISCOVERY OF AN AFTER THE FACT UNUSUAL EVENT

At 1510, "[Watts Bar Nuclear (WBN)] had identified RCS leakage in excess of 25 gallons per minute (gpm). The leakage was estimated at 105 gpm. This is a report notification only and not a declaration. The EAL that was exceeded was 2.6, RCS identified leakage. While placing a mixed bed demineralizer in service VCT level was observed to have dropped 10%. The demineralizer was immediately removed from service. This terminated the drop in VCT level. In accordance with WBN EPIP-1 Emergency Classification Flowchart, section 3.0 step 3.3.7, if an EAL was exceeded but the emergency has been totally resolved (prior to declaration), the emergency condition that was appropriate shall not be declared but reported only. The duration of the leakage was approximately 15 minutes. The unit remains at mode 1 and 100% power. The cause for the unexpected level decrease is under investigation at this time. There were no radiological releases associated."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE FROM MICHAEL BRANDON TO JOE O'HARA AT 1327 ON 1/15/08 * * *

The original report contains a typographical error. The leak duration was reported as 15 minutes. The correct time period is 1.5 minutes.

Notified R2DO(Moorman)

* * * RETRACTION ON 2/8/2008 AT 1710 FROM MICHAEL BRANDON TO MARK ABRAMOVITZ * * *

"On January 11, 2008, TVA notified the NRC of the discovery of an after the fact unusual event. The reported event described potential RCS leakage in excess of 25 GPM that was approximately 1 and 1/2 minutes in duration. The estimated magnitude of this leak was based on a step change in Volume Control Tank (VCT) level that occurred when placing the 1A Mixed Bed Demineralizer in service. TVA's post-event investigation concluded the cause of the VCT level change was the filling of a void in the 1A Mixed Bed Demineralizer. The cause of the void was a procedural deficiency in the flush methodology used when returning the demineralizer to service. Based on the evaluation of this event, TVA has concluded that no actual RCS leakage occurred. The RCS pressure boundary remained intact throughout this evolution.

"Based on the result of this evaluation and the subsequent successful alignment of the demineralizer without incident, TVA is retracting this event.

"The licensee has notified the NRC Resident of this retraction."

Notified the R2DO (Munday) and NRR EO (Brown).

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General Information or Other Event Number: 43960
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: U C DAVIS MEDICAL CENTER
Region: 4
City: SACRAMENTO State: CA
County:
License #: 1334-34
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/04/2008
Notification Time: 16:03 [ET]
Event Date: 01/31/2008
Event Time: [PST]
Last Update Date: 02/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
MICHELE BURGESS ()

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT RADIATION TREATMENT NOT ADMINISTERED PER INTENTION

The following report was made by e-mail:

"In Radiation Oncology, a treatment was ordered for an HDR cylinder gynecological treatment of 2 fractions of 600 cGy to 5 mm past the surface of the cylinder. The treatment form was most likely filled out by a resident and was signed by both the resident and the attending radiation oncologist as stated by Environmental Health & Safety staff. When the radiation oncologist typed the official written directive into the IMPAC system, (Information for Management, Planning, Analysis and Coordination System), her intention was to treat 2 fractions of 600 cGy to the surface of the cylinder. The treatment was planned according to the written form to 5 mm past the surface of the cylinder. This plan was checked and signed off by the treating physician and was the treatment given to the patient. The radiation oncologist states that there should be no medical impact to the patient, as prescription to 5 mm past the surface of the cylinder is also an acceptable and standard treatment. The radiation oncologist has changed the prescription in IMPAC to reflect the dose that was given. The treating physician has notified both the referring physician and the patient."

A 'medical event' indicates potential problems in a medical facility's use of radioactive materials. It does not result in harm to the patient.

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Power Reactor Event Number: 43964
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DALE SHELTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/06/2008
Notification Time: 12:56 [ET]
Event Date: 02/06/2008
Event Time: 11:33 [CST]
Last Update Date: 02/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 27 Power Operation 27 Power Operation

Event Text

FLOOD WATCH DUE TO SNOW MELT AND HEAVY RAIN

"On February 6, 2008 at 1119 hours, Clinton Lake level reached 694 feet 0 inches (mean sea level). Normal lake level is 690 feet 0 inches. Per Clinton Power Station (CPS) procedure 4303.02, 'Abnormal Lake Level,' the CPS Main Dam - Emergency Action Plan requires that a 'Flood Watch' be declared. This resulted in a notification to the DeWitt County Sheriff's Department that occurred at 1133 hours. Lake level continues to slowly rise due to the melting snow and heavy rains received in the area for the past several days. Expected peak is approximately 694 feet 6 inches. Mitigating measures are currently being instituted as a precautionary measure in the screen house, per CPS procedures.

"The NRC Resident has been notified."

High lake level only affects the plant intake structure.

* * * UPDATE AT 1248 EST ON 02/09/08 FROM DALE SHELTON TO S. SANDIN * * *

"On February 8, 2008 at 1655 hours, Clinton Lake level reached 693 ft-0 inches (mean sea level). Clinton Power Station (CPS) Procedure 4303.02, 'Abnormal Lake Level', and the CPS Main Dam - Emergency Action Plan allow termination of the 'Flood Watch.' This resulted in a notification to the DeWitt County Sheriff's Department that occurred on February 8, 2008 at 2043 hours when the Offnormal procedure was exited. Maximum lake level observed was 694 ft-4 inches (mean sea level). Lake level is currently 692 ft-6 inches (mean sea level) and lowering. Inspections have identified no damage due to the heavy rainfall or associated elevated lake level."

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

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General Information or Other Event Number: 43965
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ANAZAO HEALTH CORPORATION
Region: 1
City: TAMPA State: FL
County: HILLSBOROUGH
License #: 2975-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/06/2008
Notification Time: 13:09 [ET]
Event Date: 02/06/2008
Event Time: [EST]
Last Update Date: 02/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - EXTREMITY OVEREXPOSURE TO TWO INDIVIDUALS

"Anazao Health contacted [the Florida Bureau of Radiation Control] Licensing and Materials Office by fax concerning an over exposure to two individuals on 28 January 2008. Initial determination was on 27 December 2008. During routine facility audit on 6 February 2008 inspector found documentation concerning over exposure. No verbal communication was sent by Anazao Health to state officials. One individual received 105.3 [REM] to right extremity TLD finger ring, and 82.3 [REM] to his left extremity TLD finger ring. Both are shallow dose equivalent for calendar year 2007. Second individual received 53.186 [REM] to right extremity TLD finger ring, and 80.066 [REM] to his left extremity TLD finger ring. Florida is investigating."

Florida Incident number FL08-018

* * * UPDATE AT 1423 EST ON 02/07/08 FROM STEVE FURNACE TO S. SANDIN * * *

The following information was received as an update via email:

"Anazao Health compounds radiopharmaceutical drugs. The company makes capsules of concentrated doses normally one quarter the size of standard capsules. The company primarily accomplishes these tasks by hand.

"Both employees worked with I-131 liquid in the preparation of nuclear medicine capsules. The I-131 stock contained up to 3 Curies and the individuals removed stock liquid into other vials for diagnostic or therapy capsule production. Operations were conducted within a fume hood. A buffer solution was added to vials in order to dilute the I-131 to required activity levels. The individuals removed liquid from these vials to make capsules.

"The individuals stood outside the flume hood behind lead shielding, while the forearms and hands were placed inside the fume hood in order to manually work with I-131 liquid vials and to prepare capsules of required activity. Employees wore double latex gloves, plastic sleeves and a disposable lab coat.

"Manually working with significant amounts of I-131 in the preparation of diagnostic and therapy capsules from liquid inside a fume hood caused both employees extremity finger rings to exceed State of Florida limits. Syringe shields were not used by the individual when extracting liquid I-131 from vials. There are no written procedures for this operation for the individual to follow. No remote tools were used during the preparation process.

"Florida is investigation this incident."

Notified R1DO (Cahill) and FSME (Burgess).

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General Information or Other Event Number: 43966
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH SCIENCES UNIVERSITY
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: OR-90731
Agreement: Y
Docket:
NRC Notified By: DARRELL YOUNG
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/06/2008
Notification Time: 14:58 [ET]
Event Date: 02/06/2008
Event Time: [PST]
Last Update Date: 02/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE GREATER THAN 25 REM

The 4Q07 dosimetry badge reading results indicated an exposure of 261,067 mrem shallow dose, beta, probably from P-32. It is believed that this reading may be a result of leaving a contaminated glove in a lab coat pocket following work, and then placing the badge in the same pocket, and the two remaining together for a period of over a month. The worker has been withdrawn from all radiation work. An investigation is in progress.

"02/06/08 - Radiation Safety officer [REDACTED] of OHSU (License #OR-90731) notified [OREGON PUBLIC HEALTH] at the Agency that while reviewing dosimetry reports from Global Dosimetry Co., he discovered one user who had a 261,067 mrem shallow dose. [OREGON PUBLIC HEALTH] contacted [RSO] regarding the high dose and found that the dose was reported on a whole body badge for 4Q07. Further, it was found through this discussion that the isotope was P-32 and the user told [RSO] that he placed a contaminated glove in the pocket of his lab jacket and later placed his whole-body badge in the pocket with the glove. This was done approximately after 1 month into 4Q07 and the dosimetry and jacket were not used for 2 months. Unknown dose to the user during the first month from the glove. The glove was checked when found in the pocket and found to have 1100cpm (3400dpm) at that time. The user has been suspended from using radioactive material until an investigation (both OHSU and State Radiation Protection Services) can be performed and results determined. [RSO] is writing a preliminary report to be sent to [OREGON PUBLIC HEALTH] and [OREGON PUBLIC HEALTH] this afternoon or tomorrow.

"02/06/08: SA-300 consulted, potential dose exceeds 250 rem shallow dose level. Notified NRC Operations Center by phone per significant reportable event requirements at 14:58 EST (11:58 PST) and received Event number 43966. Relayed preliminary information as acquired so far, will follow with fax of this information as well. Licensee to issue preliminary investigative report sometime this afternoon or early tomorrow."

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Power Reactor Event Number: 43971
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD ELLIOT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/08/2008
Notification Time: 14:02 [ET]
Event Date: 02/08/2008
Event Time: 14:02 [EST]
Last Update Date: 02/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RANDY MUSSER (R2)

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

PH MONITORING PROBE EFFLUENT BYPASSES THE WASTE HOLDUP POND

"As part of the on going investigation of the final holdup pond (NRC Notification #43958), McGuire has identified a discharge path from the pH monitoring and adjustment system that has existed since plant startup. This discharge path has been secured. The North Carolina Department of Environmental and Natural Resources will be notified."

The effluent from the pH monitoring probe had been routed to a pit which drains into the river i.e. bypassing the holdup pond.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43972
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAUL TRENT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/08/2008
Notification Time: 19:59 [ET]
Event Date: 02/08/2008
Event Time: 18:12 [EST]
Last Update Date: 02/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOEL MUNDAY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

CONTROL ROD POSITION DEVIATION

"While withdrawing shutdown bank rods in preparation for a North Anna Unit 2 startup, a Rod Control system Urgent Failure alarm was received in the main control room. Further investigation revealed group step counters for Shutdown Bank 'A' deviated by 3 steps from demand. TRM 3.1.3 was entered and the Reactor Trip breakers were opened within the 15 minute requirement."

The licensee notified the NRC Resident Inspector.

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General Information or Other Event Number: 43973
Rep Org: NUTHERM INTERNATIONAL, INC
Licensee: NUTHERM INTERNATIONAL, INC
Region: 3
City: MT VERNON State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LEONARD HINSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/09/2008
Notification Time: 09:11 [ET]
Event Date: 02/09/2008
Event Time: [CST]
Last Update Date: 02/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
THOMAS KOZAK (R3)
JOEL MUNDAY (R2)
CHRISTOPHER CAHILL (R1)
PART 21 GROUP ()

Event Text

PART 21 NOTIFICATION - POWER SUPPLY UNIT IS LIMITED AT ELEVATED TEMPERATURES

"In accordance with 10CFR Part 21, Nutherm International, Inc. has opened an evaluation for a potential reportable condition.

"Based on testing results of a production unit of a Nutherm Power Supply, part number 55320, the unit may not perform at elevated temperatures (at or above 120 F) at its rated nameplate output rating of 20 Amps indefinitely. Preliminary reviews indicate that at ambient air temperatures of 120 F or greater, the rectifier employed in the design may be limited to output currents of 15 Amps or less.

"There have been no reports from customers concerning failures of these units as a direct result of this issue. If a reportable condition exists TVA (Browns Ferry) and Exelon (Quad Cities, Dresden, Peach Bottom) will be contacted."

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Power Reactor Event Number: 43974
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK JENKINS
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/09/2008
Notification Time: 19:00 [ET]
Event Date: 02/09/2008
Event Time: 13:20 [CST]
Last Update Date: 02/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL SHANNON (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

SAFETY PARAMETER DISPLAY SYSTEM (SPDS) REMOVED FROM SERVICE FOR SCHEDULED MAINTENANCE

"On 02/09/08 at 05:20 CST, the Wolf Creek Nuclear Plant Information System (NPIS) was removed from service for a planned electrical bus maintenance, which results in the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) being inoperable. At 13:20 CST the maintenance exceed 8 hours as determined by WCNOC for meeting this reporting criteria.

"Wolf Creek Nuclear Operating Corporation is making this ENS notification pursuant to the criteria of 10 CFR 50.72(b)(3)(x)(xiii). There is no other loss of emergency assessment capability concurrent with the removal of the NPIS from service. Plant personnel entered the appropriate Off-Normal procedure and have obtained local readings for the equipment that is normally monitored by SPDS and NPIS during the planned maintenance.

"Nuclear Plant Information System was returned to service on 02/09/08 at 17:52 CST.

"The Senior NRC Resident has been briefed on this evolution and the planned return to service of the system."

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Power Reactor Event Number: 43976
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE REANDEAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2008
Notification Time: 01:48 [ET]
Event Date: 02/10/2008
Event Time: 22:07 [CST]
Last Update Date: 02/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 97 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO INCREASING REACTOR VESSEL LEVEL

"On February 10, 2008, at approximately 2207 hours CST, the 'B' Reactor Recirculation pump tripped from fast speed to off. The resultant reactor pressure vessel level swell resulted in reactor pressure vessel level being greater than 48 inches and rising. Per Clinton Power Station operating procedures, the 'A' Reactor Operator placed the mode switch to the 'shutdown' position initiating a manual reactor scram. All control rods inserted [fully]. CPS is currently stable in Mode 3."

Decay heat is being removed to the main condenser via the turbine bypass valves. Reactor level is being maintained using the motor driven reactor feedpump. No SRVs lifted during the transient. Licensee is in progress of restoring the electrical plant to a normal shutdown lineup.

The licensee notified the NRC Resident Inspector.

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