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Event Notification Report for March 11, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/10/2008 - 03/11/2008

** EVENT NUMBERS **


44031 44032 44033 44035 44037 44039 44040 44049 44050

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General Information or Other Event Number: 44031
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MARSHFIELD CLINIC MINOCQUA CENTER
Region: 3
City: MINOCQUA State: WI
County:
License #: 141-1162-01
Agreement: Y
Docket:
NRC Notified By: LEONA DEKOCK
HQ OPS Officer: PETE SNYDER
Notification Date: 03/05/2008
Notification Time: 14:53 [ET]
Event Date: 01/10/2008
Event Time: [CST]
Last Update Date: 03/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3)
MICHELE BURGESS (FSME)
ILTAB (e-mail) ()

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

Event Text

AGREEMENT STATE REPORT - LOST IODINE-125 BRACHYTHERAPY SEEDS

"A permanent prostate seed implant was performed on 12/21/07. Following this case there were 18 unused seeds remaining. Unused seeds are kept in the original shielded container provided by the vendor and stored in the nuclear medicine hot lab until returned by the Radiation Safety Officer (RSO) to the vendor for ultimate storage and disposal. Unused seeds are normally returned once each quarter by the RSO.

"In this case, however, the nuclear medicine technologist transferred the 18 seeds from the shielded container to a lead-lined radioactive waster bin for the storage of dry-solid active waste such as gloves, absorbent pads, etc. potentially contaminated with Tc-99m. This waste bin is not used for medical waste such as syringes, sharps, etc.

"The dry-solid radioactive waste bins are held for decay-in-storage. Based on the preliminary information and a review of the radioactive waste disposal log, this particular bag was surveyed and disposed of on either 1/10/08 or 2/6/08. Since they use two bins and hold for radioactive decay until the other is full, it is not clear at this time as to which bag was disposed in the regular trash. Discovery of the lost material was through inquiries by the RSO concerning how many unused seeds were available this quarter for return. If the seeds were disposed of in the regular trash on 1/10/08, the activity lost would be 5.03 milliCuries; if disposed of in the regular trash on 2/6/08, the activity lost would be 3.68 milliCuries.

"The possible disposition of the licensed radioactive material at this time is the landfill. A detailed written description of the incident will be submitted within 30 days.

"The State of Wisconsin plans to investigate this incident on an upcoming inspection."

Wisconsin Event Report ID: WI080004

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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General Information or Other Event Number: 44032
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: INDUSTRIAL NUCLEAR COMPANY
Region: 1
City: NORTH ANDOVER State: MA
County:
License #: 27-9661
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHER
HQ OPS Officer: JOE O'HARA
Notification Date: 03/05/2008
Notification Time: 16:21 [ET]
Event Date: 03/05/2008
Event Time: [EST]
Last Update Date: 03/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
SCOTT FLANDERS (FSME)

Event Text

AGREEMENT STATE REPORT - ABANDONMENT OF MATERIALS MANUFACTURING FACILITY

The Commonwealth of Massachusetts called to report that one of their materials licensees has ceased business and terminated or dismissed a majority of their employees. The licensee is under an M&D order, and a review of an inventory of materials on the site indicates there are materials at the site which exceed the allowable quantities in Table 1 of the M&D order. Since the business is no longer staffed, the Commonwealth of Massachusetts has expressed concerns with security at the facility.

The issue was discussed in detail on a conference bridge with NRC Headquarters, Region 1, and Commonwealth of Massachusetts representatives.

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General Information or Other Event Number: 44033
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SKYRIDGE MEDICAL CENTER
Region: 4
City: DENVER State: CO
County:
License #: 1053-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOE O'HARA
Notification Date: 03/05/2008
Notification Time: 16:14 [ET]
Event Date: 03/05/2008
Event Time: [MST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SCOTT FLANDERS (FSME)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF Y-90 MICROSPHERES

The State provided the following information via facsimile:

"A medical licensee notified the Department of a misadministration during a Y-90 microsphere procedure, The problem was identified at the conclusion of the procedure when staff noted that 50% of the Y-90 microspheres were still in the application kit, resulting in a 50% underdose to the patient. The licensee's medical physicist, who is investigating the incident, was unsure if the problem was caused by a faulty injection valve or human error (e.g.. The valve was turned to the wrong position during the procedure). The licensee is Skyridge Medical Center Denver, CO, License 1053-01.

"No other details are available at this time.

"The Department has initiated an investigation of this incident."

* * * UPDATE ON 03/08/2008 AT 0847 EST FROM FSME (FLANNERY) TO ALEXANDER * * *

The NRC has reviewed this event and determined it to be a reportable medical event.

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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Fuel Cycle Facility Event Number: 44035
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:
HQ OPS Officer: PETE SNYDER
Notification Date: 03/05/2008
Notification Time: 19:10 [ET]
Event Date: 03/05/2008
Event Time: 08:00 [EST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
GEORGE HOPPER (R2)
EARL EASTON (NMSS)
FUELS OUO (E-MAIL) ()

Event Text

VACUUM DAILY INSPECTIONS NOT COMPLETED

"Raschig Ring Vacuum Cleaners (RRVCs) are used within BWXT's Research and Test Reactors and Targets (RTRT) radiologically controlled area to collect floor scrubbing solutions. There are no fissile solutions present in the area. The RRVCs are checked daily to ensure the vessels are adequately filled with Raschig rings. According to the form used to document the inspection, the last time the level was verified it was noted as 'good.' However, the inspection was last performed on January 28, 2008. The RTRT foreman had recently been assigned to the area and was not aware of the requirement to perform the daily check. On the morning of March 5, 2008 the foreman realized the check had not been performed and proceeded to inspect the RRVC. The level of the rings within the vacuum cleaner was judged to be inadequate (the form does not contain specific acceptance criteria). The rings were approximately 5 inches below the level of the hose intake. There was a minimal amount of contaminated floor scrubbing solution in the vacuum cleaner at the time of discovery. Only solutions from floor scrubbing are collected with RRVCs in RTRT. Fissile solutions are not generated in the area. The RRVC was immediately removed from service pending the results of an investigation.

"The initial filling of the vacuum cleaner with Raschig rings by an operator is an Item Relied on for Safety (IROFS). The vacuum cleaner was adequately filled with Raschig rings in September of last year during the semi-annual inventory. However, at the time of event the ring level was less than adequate, resulting in a degraded IROFS. The daily inspection of the Raschig ring level is a second IROFS to ensure an adequate ring level on an ongoing basis. The failure to perform this inspection is a failure of this IROFS. The remaining IROFS is the operator controls what is collected (and therefore the U235 concentration) with the RRVC. Only contaminated floor scrubbing solutions are vacuumed within in RTRT, not fissile solutions.

"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. There was a portion of the RRVC that contained no rings, but there was only a minimal amount solution in the vacuum cleaner. However, with the degradation of one IROFS and the loss of a second, double contingency could no longer be assured.

"BWXT is making this 24 hour report in accordance with 10 CFR 70, Appendix A (b)(2), 'Loss or degradation of items relied on for safety that results in failure to meet the performance requirements of 70.61.'

"The use of the RRVC in the RTRT area was immediately suspended by Nuclear Criticality Safety pending further investigation."

The Licensee notified the NRC Resident Inspector.

* * * UPDATE FROM C. YATES TO P. SNYDER ON 3/6/08 AT 1426 * * *

"As a result of the ongoing investigation supplemental information to this notification is being provided.

"The investigation identified that two other vacuum cleaners were not adequately filled with Raschig rings. One of these RRVCs is used within the Chemistry Lab. The ring level in this vacuum cleaner was approximately 3 inches below the level of the hose intake. The vacuum is used in the Chemistry Lab for floor scrubbing purposes. Although there are no fissile solutions in the lab, the NCS posting on the RRVC allows concentrations of up to 400 grams 235 to be collected. This is the same NCS posting on RRVCs in BWXT's Uranium Recovery facility.

"Although unlikely, it is possible that the Chem Lab RRVC could be transferred to Uranium Recovery and used to collect high concentration fissile solutions. The ring level of RRVCs used in Uranium Recovery is checked daily. Should the Chem Lab RRVC be moved to Uranium Recovery there are no documented controls to check the ring level before its use. Potentially, the Chem Lab RRVC containing an inadequate level of Raschig rings could have been used to collect a high concentration fissile solution.

"The filling of the vacuum cleaner with Raschig rings in accordance with American Nuclear Society Standard 8.5 is an Item Relied on for Safety (IROFS). The standard states, 'The level of the solution shall not exceed the level of uniformly packed rings.' The Chem Lab vacuum cleaner was not adequately filled with Raschig rings according to the standard. This IROFS was degraded. A second IROFS for the RRVC is the operator inspects the Raschig ring level according to ANS 8.5. The standard states, 'Raschig rings shall be inspected periodically to demonstrate their continued criticality control properties.' One of the required tests accounts for settling over time. The standard further states, 'If settling is detected, rings meeting specifications of this standard shall be added to restore full packing.' This second IROFS had failed given the level of the rings in the Chem Lab RRVC at the time of discovery. As such, no IROFS as documented in the Integrated Safety Analysis Summary remained. Double contingency had been lost.

"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. There was a portion of the RRVC that contained no rings, but there was only a minimal amount of solution in the vacuum cleaner. However, with the degradation of one IROFS and the loss of a second, double contingency could no longer be assured.

"BWXT is making this 1 hour report in accordance with 10 CFR 70, Appendix A, (a)(4)(ii) - An event or condition such that no items relied on for safety, as documented in the Integrated Safety Analysis summary, remain available and reliable in an accident sequence evaluated in the Integrated Safety Analysis, to perform their function: Prevent a nuclear criticality accident."

Notified R2DO (Hopper), NMSS (Easton) and Fuels OUO Group (e-mail).

* * * UPDATE FROM B. COLE TO P. SNYDER ON 3/7/08 AT 1752 * * *

The following "additional supplemental information is being provided to Event Notification #44035 as a result of the ongoing investigation.

"During the investigation of Event Notification #44035, a concern was expressed about the ability of a RRVC to suction solution above the level of the Raschig rings. It is BWXT's opinion that it is possible to collect solution above the level of the Raschig rings in the vacuum cleaner.

"The criticality safety of the RRVCs is based on American Nuclear Society Standard 8.5, 'Use of Borosilicate-glass Raschig Rings as a Neutron Absorber in Solutions of Fissile Material.' The standard states, 'The level of the solution shall not exceed the level of uniformly packed rings.' It is BWXT's opinion that it is credible for the solution to exceed the level of the Raschig rings in the RRVC.

"There is no immediate risk of a criticality or threat to the safety of workers or the public. It is BWXT's opinion that under certain conditions there is a potential for high concentration SNM bearing solutions to be collected above the level of the Raschig rings. According to internal spill procedures this condition is not likely, but is credible. As such, this potential condition is an unanalyzed condition where double contingency is lost.

"BWXT is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.

"The use of all RRVCs at the BWXT facility was immediately suspended by Nuclear Criticality Safety pending further investigation."

Notified R2DO (Hopper), NMSS (Easton), and Fuels OUO Group (E-mail).

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Power Reactor Event Number: 44037
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: JOHN TAYLOR
HQ OPS Officer: JOE O'HARA
Notification Date: 03/05/2008
Notification Time: 22:20 [ET]
Event Date: 03/05/2008
Event Time: 21:00 [EST]
Last Update Date: 03/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
GEORGE HOPPER (R2)

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

Event Text

CIRCUMFERENTIAL PIPING CRACK

"On March 5, 2008, a volumetric ultrasonic examination of a Reactor Coolant to Decay Heat System pipe weld was analyzed and determined to identify an unacceptable indication. This dissimilar metal weld is located on the nozzle to the Decay Heat System drop line piping, which is the common suction line from the Reactor Coolant System and is a 12 inch outer diameter pipe. The indication is circumferential, is 15 inches in length, and reaches a maximum localized depth of 65 percent through-wall in one location. The weld was previously partially inspected during the November 2007 refueling outage using manual ultrasonic examination and no indications were identified. The current inspection was done using newly qualified phased array ultrasonic examination techniques in response to industry operating experience regarding dissimilar metal weld flaws. The indication has been found unacceptable per paragraph IWB 3514.4 of the 1989 Addenda of ASME Section XI without further fracture mechanics analysis and is therefore considered reportable.

"Preparations for a weld overlay repair and further confirmatory manual ultrasonic testing examinations are in progress.

"The licensee notified the NRC Resident Inspector."


* * * UPDATE FROM J. TAYLOR TO JOE O'HARA AT 1730 ON 3/10/08 * * *

"On March 8, 2008, further fracture mechanics evaluation of the circumferential indication on the Decay Heat System Drop Line determined that the requirements of the ASME Section Xl pipe code were maintained. Specifically, the acceptance criteria of the 1989 Edition Section XI, Table IWB-3641-1, -2, were met with an allowable value for flaw depth / wall thickness (a/t) of 0.75. Consequently, the 65% through wall indication would be considered acceptable for operation and the Degraded Condition Reporting Criteria would not be exceeded. Therefore, this event is not reportable under any 10CFR50.72 criterion. However, due to industry operating experience with dissimilar metals welds, this notification is being made voluntarily. Confirmatory manual ultrasonic testing examinations were completed which validated the presence of the indication originally found via phased array UT examination techniques. A full structural weld overlay repair is in progress which will be completed before returning Crystal River 3 to power operation. The repair effort has already successfully deposited the first weld layer over the location of the flaw. No Licensee Event Report will be submitted for this event."

The licensee notified the NRC Resident Inspector.

Notified R2DO(Hopper).

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General Information or Other Event Number: 44039
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CITGO REFINING & CHEMICAL CO., L.P.
Region: 4
City: CORPUS CHRISTI State: TX
County: NUECES
License #: L00243-000
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/06/2008
Notification Time: 12:30 [ET]
Event Date: 03/05/2008
Event Time: [CST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SANDRA WASTLER (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILURE

"On March 5, 2008 at 3:43 p.m., the agency [Texas Department of State Health Services] received a telephone call from the licensee reporting that the manufacturer was performing a gauge update replacement change on their level gauges when he discovered the shutter was stuck in the open position for this particular gauge. The manufacturer representative quickly removed the level gauge and took it to a remote area for closer examination.

"The initial thought was that the shutter was just stuck open, but upon closer examination, the manufacturer representative discovered that the shutter door was badly damaged by severe heat from the weather and could not be fixed on-site.

"The manufacturer representative then constructed and installed a temporary shield for the gauge and reported readings at 12 inches away of 4-7 Mr/hour. The licensee reports that the gauge has been placed in a sequestered area, with area caution signs and a 24-hour person surveillance while they await the Type A transport container ordered by the manufacturer representative for safe transport back to his company for repair or replacement.

"The licensee reports that the leak test performed was negative. The licensee also stated that this gauge has been in service for approximately 11 years without any problems. Since the licensee had the manufacturer out at their facility taking their 5010 series gauges out and replacing them with new series, the gauge is now in the possession/ownership of the gauge manufacturer.

"Gauge information: Texas Nuclear - Manufacturer, Model# - 5010A, Serial #- B-405, 1000 mCi in 1997

"Source information: Am-241 1000 mCi in 1997, Serial # - AO366, Mfg: Texas Nuclear

"Call to licensee's RSO for clarification on gauge information. He reported that the gauge is locked inside the Type A container and the Type A container is locked inside a caged storage area. The manufacturer will ship it out to their Sugar Land, Texas facility sometime today."

Texas Incident#: I-8489

* * * UPDATE FROM LATISCHA HANSON TO HOWIE CROUCH @ 1315 EST ON 03/07/08 * * *

"On 03/07/08 at 10:48 a.m., Incident Investigation Program (IIP) called the gauge manufacturer representative back and was able to speak with him. He stated the damage was from heat, but not from the weather; it was from the extreme heat of the coke vessel the gauge was attached to, which can reach temperatures up to ~900F. He told IIP that the shutter carousel has plastic which can change forms and melt within a couple of hours. He cannot estimate when this could have occurred between 11/20/07 and 03/5/08. He stated that he was still at the location, waiting for the transport truck to load the gauge and send it to his facility, Thermo Measuretech.

"On 03/07/08 at 11:00 am., II [Incident Investigator] placed a telephone call to the licensee's Radiation Safety Officer (RSO) to clarify when the gauge was last checked and if there was any possibility of public exposure between the time they last checked it and the gauge change on 03/05/08. He stated that there was absolutely no possibility of public exposure, due to the following facts:

"1) The coke drum vessel has extreme heat and the gauge housing is mounted in a wire cage within four inches of the vessel and also has a rain cover. He stated no one goes up there unless they are performing the gauge check.

"Besides the extreme heat of the vessel, there is an air gap that someone would have to stick their hand through to get to the gauge housing and he can't think of a situation where someone would want to reach through the heat and air gap to get to the gauge.

"2) He told us the last gauge check was on 11/20/07 and it was noted that the shutter door was hard to close, but that is not unusual due to the extreme vessel heat, dirt and grime that collect on it while there. He told us they perform this check every 3-5 years and this is the only time someone is in contact with the gauge.

"IIP asked him if he would fax us a copy of the November 2007 check. He affirmed he would. He stated that there were 5 other gauges that were exchanged, so we asked if he would include those gauges serial numbers for us as well.

"He reminded us that the normal operating position for the shutter is in the open position.

"3) The RSO updated us with the gauge transport process. He stated the truck was delayed yesterday due to their area experiencing high winds and hail storms and was expected in sometime today.

"IIP will continue to update this report with any additional information as it becomes available."

Notified R4DO (Cain) and FSME (Flannery).

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General Information or Other Event Number: 44040
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: LOUISIANA HEART HOSPITAL
Region: 4
City: LACOME State: LA
County: ST. TAMMANY PARISH
License #: LA-10747-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/06/2008
Notification Time: 15:29 [ET]
Event Date: 03/05/2008
Event Time: [CST]
Last Update Date: 03/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SANDRA WASTLER (FSME)

Event Text

LOUISIANA AGREEMENT STATE REPORT - PERSONNEL ANNUAL OVEREXPOSURE

Received the following information from the State of Louisiana via facsimile:

The licensee, Louisiana Heart Hospital in LaCome, LA., submitted a High Exposure Report to the State concerning one of their physicians. The physician's exposure by badge was 5,244 mrem for the 2007 calendar year. The cause of the overexposure was attributed to high workloads in the Cardiac Catherization Labs during the period.

Corrective actions taken include double badging the individual, including the addition of a waist badge beneath his lead apron, using additional shielding/distance and using special equipment such as pull-down lead shields.

Additionally, the licensee will review the individual's exposure quarterly to adjust workload and/or corrective actions.

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Other Nuclear Material Event Number: 44049
Rep Org: DELVAL SOIL & ENV. CONSULTANTS
Licensee: DELVAL SOIL & ENV. CONSULTANTS
Region: 1
City: DOYLESTOWN State: PA
County: DELAWARE
License #: 37-28256-02
Agreement: N
Docket:
NRC Notified By: MICHAEL SOWERS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/10/2008
Notification Time: 14:09 [ET]
Event Date: 03/10/2008
Event Time: 13:45 [EDT]
Last Update Date: 03/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAYMOND LORSON (R1)
MICHELE BURGESS (FSME)

Event Text

DAMAGED TROXLER MOISTURE DENSITY GAUGE

The RSO reported that while the technician was performing a soil test, a piece of construction equipment backed over the gauge. The incident occurred at the "Bodo tract" on the corner of Station Rd. and Con-Chester Pike (Rt. 322). The current status of the gauge is that the source rod is still in the test position. The technician has cordoned off the area awaiting the arrival of the RSO. The extent of damage to the gauge is unknown at this time.

The gauge is a Troxler model 3440 containing 40 mCi of Am-Be and 8 mCi Cs-137.

The RSO has notified Region 1 NRC (Gordon) and will be updating this report once the event is assessed.

* * * UPDATE FROM MICHAEL SOWERS TO HOWIE CROUCH @ 1752 EDT ON 03/10/08 * * *

The licensee RSO was able to retract the source back into the shield, however the shield has broken away from the gauge. Area radiation surveys did not indicate any contamination in the incident area. The licensee has transported the gauge back to their facility and will be conducting a leak test sample to send to Troxler.

Notified R1DO (Lorson) and FSME EO (Flanders).

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Power Reactor Event Number: 44050
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MARK IHLENFELDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/10/2008
Notification Time: 23:59 [ET]
Event Date: 03/10/2008
Event Time: 18:13 [CDT]
Last Update Date: 03/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK RING (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

HPCI INOPERABLE

"During performance of the quarterly high pressure coolant injection (HPCI) Surveillance Test, a technical specification step could not be completed due to observed system water flow and discharge pressure oscillations. These oscillations are presently under investigation. The tech spec step involved establishing flow conditions at a certain discharge pressure. The problem is either with the test return system or the control system. A formal troubleshooting plan is being developed to determine the root cause and corrective action required to re-establish operability of the HPCI system. The system remains inoperable due to the problem found during testing. If the problem is found to be caused by the control system, then it could have potentially impacted the ability of the HPCI system to mitigate the consequences of an accident."

HPCI is currently in a 14 day Tech Spec 3.5.1.h LCO.

The licensee notified the NRC Resident Inspector. The licensee will be notifying the Minnesota Duty Officer.

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