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Event Notification Report for March 24, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/21/2008 - 03/24/2008

** EVENT NUMBERS **


44070 44073 44075 44078 44085 44086 44087 44088 44089

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Power Reactor Event Number: 44070
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RICH KLINEFELTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/17/2008
Notification Time: 11:50 [ET]
Event Date: 03/17/2008
Event Time: 11:50 [EDT]
Last Update Date: 03/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL PERRY (R1)

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

Event Text

SAFETY PARAMETER DISPLAY SYSTEM (SPDS) AND EMERGENCY RESPONSE DATA SYSTEM (ERDS) UNAVAILABLE DUE TO PLANNED MAINTENANCE

"At approximately 1200 hours, on 03/17/2008, the Unit 1 SPDS and ERDS system will be removed from service to connect a temporary power supply to support a planned maintenance outage on the PICSY [Plant Indication Computer System] computer normal power supply. The installation of temporary power is expected to have a duration greater than 8 hours, but less than 24. During this time, control room hardwire indications will be available. An update will be provided when SPDS/ERDS becomes available.

"Since the Unit 1 SPDS/ERDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii)."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM RICH KLINEFELTER TO HOWIE CROUCH @ 1222 HRS. EDT ON 03/18/08 * * *

"This is a follow-up courtesy notification to EN# 44070. Unit 1 ERDS has been restored as PICSY is now on temporary power. Restoration to normal power is expected to occur on 3/21/08. SPDS remains out of service due to other planned outage activities."

The licensee has notified the NRC Resident Inspector. Notified R1DO (Perry).


* * * UPDATE FROM JIM HUFFORD TO JOHN KNOKE @ 0530 HRS. EDT ON 03/21/08 * * *

"This is a follow-up courtesy notification to EN# 44070. As at 0513, on 03/21/08, Unit I ERDS and PICSY are now fully restored. The planned outage activities are now complete."

The licensee will notify the NRC Resident Inspector. Notified R1DO (Neil Perry)

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General Information or Other Event Number: 44073
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WHIDBEY GENERAL HOSPITAL
Region: 4
City: COUPEVILLE State: WA
County:
License #: WM-M0217-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/17/2008
Notification Time: 18:00 [ET]
Event Date: 03/13/2008
Event Time: [PDT]
Last Update Date: 03/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
ANNA BRADFORD (FSME)

Event Text

AGREEMENT STATE REPORT OF LEAKING IODINE-125 SEED

The State of Washington Department of Health, Office of Radiation Protection, provided the following information via e-mail:

"On 10 March 2008 a patient was implanted with approximately 80 I-125 seeds. On 12 March 2008 (or 13 March 2008, it remains unclear as of this writing), the patient complained of pain and difficulty urinating. A cauterization was performed via the urethra. Upon removal of the cauterization equipment, some seeds also exited via the urethra. One seed, in particular, was visibly different from the rest. This seed was, upon closer observation, noted to be shorter than the others and, in fact, had been damaged. Cause of the damage (shear force during insertion or perhaps a result of the cauterization) has yet to be determined.

"A survey of the area including the patient using a Technical Associates TBM-3 showed contamination of the equipment and bodily fluids, while an external reading directly over the thyroid showed levels above background."

The activity of the damaged I-125 seed was less than 300 microcuries. Licensee is assessing possible overexposure to the patient, organ dose calculations underway by licensee consultant.

* * * UPDATE ON 3/21/2008 FROM ARDEN SCROGGS TO MARK ABRAMOVITZ * * *

The State provided the following information via email:

"On 10 March 2008 a patient was implanted with 102 I-125 seeds. On 13 March 2008 the patient complained of pain and difficulty urinating. A cauterization was performed via the urethra. Upon removal of the cauterization equipment, 'some' seeds also exited via the urethra. One seed, in particular, was visibly different from the rest. This seed was, upon closer observation, noted to perhaps be shorter than the others and, in fact, had been damaged. Cause of the damage (shear force during insertion or perhaps a result of the cauterization) has yet to be determined, although as of this writing the most logical conclusion would be over-heating from the cauterization procedure.

"A survey by the licensee of the area including the patient using a Technical Associates TBM-3 showed contamination of the equipment and bodily fluids, while an external reading directly over the thyroid showed levels above background.

"A CT scan was performed on 19 March 2008 to determine the number of seeds remaining in the patient. Results of that scan show the proper number, 92 seeds, remain in the patient of the total 102 implanted.

"Seed was damaged, probably from heat, but if not, then from some other mechanism. These were seeds from Best Medical International, Model 2301.

"Wipes of the remaining seeds showed contamination levels up to 500 nCi. While all seeds exhibited some detectable counts from the wipes, it is thought that one was actually leaking and had cross-contaminated the others while in storage together.

"Bioassay of the patient on 19 March 2008 showed a thyroid burden of 0.8 microcuries, a dose less than 1 Rem to the organ itself."

Notified the R4DO (Whitten) and FSME (Delligatti).

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General Information or Other Event Number: 44075
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TRACERCO
Region: 4
City: PARAMOUNT State: CA
County:
License #: 5474-07
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/18/2008
Notification Time: 18:17 [ET]
Event Date: 03/17/2008
Event Time: [PDT]
Last Update Date: 03/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT - SHIPPING CONTAINER ARRIVED DAMAGED WITH SOURCE OUTSIDE OF PIG AND CONTAINER

The State of California Radiologic Health Branch provided the following information via email:

"The licensee shipped a nominal 123 mCi Co-60 source via FedEx in a Type A package from a temporary job site in the State of Washington to their office in Paramount, CA. Upon arrival at the Paramount office, the Type A shipping container was observed to have been damaged, and the Co-60 source was found out of its shielded pig, and outside of the Type A container. Calculation assuming a point source shows that the radiation levels would have been ~170 mr/hr at one meter, ~1.8 R/hr at one foot, and ~1700 R/hr at one centimeter from the source.

"The Type A container is constructed of steel, with an inner lead storage pig, and was secured to a wooden shipping pallet. The Type A container has a collar that extends above the lead pig. The cover for the lead pig is secured by a rod that fits through the steel collar. The rod is secured in place by a lock on the rod. Upon receipt of the Type A container at the Paramount, CA facility, the wooden pallet was missing, the lock on the securing rod was missing, the securing rod was not inserted in the holes in the steel collar (therefore it was not securing the cover to the lead pig), and although the inner lead pig cover was in place, the source was found lying on top of the lead pig within the steel collar portion of the Type A container. It is surmised that the Type A container was dropped on the lock during transportation, such that the lock broke, the securing rod was displaced, the cover came off the lead pig, and the source came out of the lead pig. Either the Co-60 source lodged in the steel collar at that time, or the source fell out and someone picked it up and placed it on top of the lead pig within the steel collar of the Type A container (the latter appears more likely). The source is located at one end of an ~3 inch long rod.

"The licensee notified FedEx of the event. FedEx's consultant is investigating to determine where and how the damage to the Type A container occurred, and to evaluate the exposures to FedEx personnel. Transportation occurred exclusively on FedEx conveyances, so no significant non-FedEx personnel exposure is expected to have resulted during transportation. A licensee employee reinserted the source in the lead pig before removing the Type A container from the FedEx delivery truck. In doing so he handled the non-source end of the source rod with his bare fingers, while wearing extremity dosimetry. Calculated extremity dose is 100 to 200 mrem based on a 5-10 second handling time."

CA Report Number 031708

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General Information or Other Event Number: 44078
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: LCI LINEBERGER CONSTRUCTION, INC.
Region: 1
City: LANCASTER State: SC
County:
License #: 664
Agreement: Y
Docket:
NRC Notified By: ANDREW ROXBURGH
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/19/2008
Notification Time: 16:08 [ET]
Event Date: 03/18/2008
Event Time: [EDT]
Last Update Date: 03/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The licensee provided the following information via facsimile:

"The South Carolina Department of Health and Environmental Control was notified at 9:00 a.m. on March 19, 2008 by the licensee that one of their moisture density gauges had been damaged at a work site near Lancaster, South Carolina. According to the licensee, the gauge was damaged after being struck by a large truck at a work location. The licensee reported moderate damage to the gauge and source rod but indicated that the source was in the shielded and locked position. The licensee placed the damaged gauge in its transportation case and transported it back to their business location. The gauge is a Troxler 3400 series containing 9 mCi of Cs-137 and 44 mCi of Am-241 :Be. [The state Duty Officer] is responding to this incident to perform surveys of the gauging device and any other necessary actions. This event is open pending the results of the licensee's and Department's [state] investigation. Notifications and updates will be made through the NMED system."

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Power Reactor Event Number: 44085
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: STEVE SANDIN
Notification Date: 03/21/2008
Notification Time: 16:40 [ET]
Event Date: 03/21/2008
Event Time: 09:13 [EDT]
Last Update Date: 03/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MIKE ERNSTES (R2)

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

Event Text

SYSTEM INJECTION DETERMINED INOPERABLE BY FAILURE TO REMOVE ELECTRICAL JUMPER PRIOR TO MODE CHANGE

"In accordance with Instrument Maintenance Instruction (IMI) 99.040, 'Auto Safety Injection (SI) Block, Feedwater Isolation Block, and Maintain Source Range In Service Jumpers,' jumpers were placed to block the SI automatic actuation logic and actuation relays during WBNs [Watts Bar Nuclear] Cycle 8 refueling outage. The automatic actuation function for SI is required in Modes 1, 2, 3, and 4 per Function 1.b of Table 3.3.2-1 of Technical Specification (TS) 3.3.2, 'ESFAS Instrumentation.' WBN entered Mode 4 at 0020 EDT on March 20, 2008 and Mode 3 at 0100 EDT on March 21, 2008. On March 21, 2008, it was discovered that the jumpers installed per IMI-99.040 had not been removed. Due to this, Limiting Condition for Operation (LCO) 3.0.3, was entered at 0913 EDT and exited at 0958 EDT when the system was restored. The jumpers being in place in Mode 4 and 3 rendered both trains of SI automatic actuation inoperable for approximately 33 hours and 38 minutes. This event is being reported under 10 CFR 50.72(b)(3)(v)(D), 'Event or Condition that could have Prevented Fulfillment of a Safety Function.'"

The licensee attributes the error to a combination of both procedural inadequacy (i.e., the step removing the jumper did not require verification) and personnel error.

The licensee informed the NRC Resident Inspector.

* * * UPDATE PROVIDED BY DOUGLAS HOLT TO JOE O'HARA AT 0213 ON 03/22/08 * * *

"This is a follow-up notification to EN#44085 to amend reported information. At 2133 on 3/21/08 when permissive P-11(Low Pressure and Low Steamline Pressure) blocks were cleared, the on-shift crew questioned the presence of the 'AUTO SI Blocked' alarm and determined that it should have been cleared when the SI automatic logic jumper was removed earlier in the day. The crew utilized the procedural guidance of GO-1 to cycle the reactor trip breakers and reinstate the automatic safety injection logic at 2206 on 3/21/08. The previous report that identified that LC0 3.0,3 was exited at 0958 EDT is to be amended. LCO 3.0.3 was exited at 2206 when SI automatic logic was completely reinstated by cycling the reactor trip breakers."

The licensee notified the NRC Resident Inspector.

Notified R2DO(Ernstes)

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Power Reactor Event Number: 44086
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ERNEST MATHES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/21/2008
Notification Time: 17:59 [ET]
Event Date: 03/21/2008
Event Time: 15:25 [CDT]
Last Update Date: 03/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JACK WHITTEN (R4)

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

Event Text

AUTOMATIC REACTOR SCRAM FROM A MAIN TURBINE TRIP

"Actuation of an RPS signal while the reactor was critical.

"At 1525 a generator trip signal on the main transformers initiated a reactor scram due to Turbine Stop and Control Valve fast closure. Safety relief valves operated initially to lower reactor pressure. Turbine bypass valves operated initially to lower reactor pressure. Turbine bypass valves are maintaining pressure control currently. Reactor recirc pumps A and B transferred to slow speed operation as expected. No ECCS initiations were received. Reactor level is being controlled with normal systems condensate and feedwater. Lowest level indicated was approximately -6" wide range. Level 3 initiations occurred to group 3 isolation valves. No valves operated, they are normally closed."

The site is investigating the cause of the trip. A probable cause is the "C" phase differential trip which was received from the main transformer.

All control rods fully inserted during the scram. The plant is on its normal shutdown electrical lineup.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44087
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RICH KLINEFELTER
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/22/2008
Notification Time: 11:01 [ET]
Event Date: 03/22/2008
Event Time: 10:35 [EDT]
Last Update Date: 03/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL PERRY (R1)

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

Event Text

LOSS OF SPDS/ERDS COMPUTER SYSTEM GREATER THAN 8 HOURS

"At 1035 hours, on 03/22/2008, the Unit 1 SPDS and ERDS system was removed from service to disconnect and remove a temporary power supply to support a planned maintenance outage on the PICSY computer normal power supply. The disconnection and removal of temporary power is expected to have a duration greater than 8 hours, but less than 24. During this time, control room hardwire indications will be available. An update will be provided when SPDS/ERDS becomes available.

"Since the Unit 1 SPDS/ERDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10 CFR50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector.

* * UPDATE FROM JIM HUFFORD TO JOHN KNOKE AT 0423 EDT ON 3/23/08 * *

"This is a follow-up courtesy notification to EN# 44087. As of 0213 EDT, on 03/23/08, Unit 1 ERDS and PICSY are now fully restored. The planned outage activities are now complete. No further maintenance scheduled."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44088
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/22/2008
Notification Time: 20:50 [ET]
Event Date: 03/22/2008
Event Time: 19:39 [EDT]
Last Update Date: 03/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
NEIL PERRY (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 Shutdown

Event Text

TURBINE TRIP RESULTING IN A REACTOR SCRAM

"Limerick Unit 1 automatically shutdown from a turbine trip at 1939 hrs on 03/22/08. The cause of the turbine trip is under investigation at this time. All control rods inserted as required. No ECCS [Emergency Core Cooling System] and no RCIC [Reactor Core Isolation Cooling] initiation occurred. No primary or secondary containment isolations were received.

"The plant is currently in Hot Shutdown maintaining normal reactor level with feedwater in service."

Minimum water level after the scram was 5 inches. Level 3 had been reached however all level 3 isolation valves were already shut. No SRVs lifted after the scram. Decay heat is being removed by steam loads with the turbine bypass valves available if needed. The plant is in its normal shutdown electrical lineup.

The licensee will issue a press release and has informed the NRC Resident Inspector.

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Power Reactor Event Number: 44089
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/24/2008
Notification Time: 01:56 [ET]
Event Date: 03/23/2008
Event Time: 22:16 [EDT]
Last Update Date: 03/24/2008
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):
NEIL PERRY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 94 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP - LOSS OF SPEED ON MBFP

"The Indian Point Unit 2 reactor was manually tripped from 94% power at 2216 on 3/23/08 due to a loss of speed on 22 main boiler feed pump (MBFP). Indian Point Unit 2 is currently in mode 3 with all automatic actions for a manual reactor trip occurring as required. Indian Point Unit 2 was in a coast down in advance of a scheduled refueling outage.

"The reactor was manually tripped as required by abnormal operating procedure 2-AOP-FW-001. All control rods inserted on the trip. No safety or relief valves lifted due to the trip. The motor driven aux feedwater pumps automatically started on low steam generator level and are being used to maintain steam generator level. Condenser steam dumps are maintaining reactor temperature. The Unit 2 electrical lineup is the normal shutdown electrical lineup. The licensee has notified the state Public Service Commission.

"Unit 3 was unaffected and remains in mode 1 at 100% power."

The licensee has notified the NRC Resident Inspector. The licensee expects to issue a media release.

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