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Event Notification Report for May 15, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/14/2008 - 05/15/2008

** EVENT NUMBERS **


44182 44192 44193 44203 44204 44207 44213

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44182
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ANDREW SMOLINSKI
HQ OPS Officer: JOE O'HARA
Notification Date: 04/30/2008
Notification Time: 22:52 [ET]
Event Date: 04/30/2008
Event Time: 16:00 [CDT]
Last Update Date: 05/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
MONTE PHILLIPS (R3)

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

Event Text

TWO EMERGENCY DIESEL GENERATORS INOPERABLE

"Two emergency diesel generators found inoperable while two trains of residual heat removal are required to be Operable for core cooling.

"On 4/30 at 1600 it was discovered that the level in Emergency Diesel Generator Fuel Oil Storage tanks were not trending together. The two underground fuel oil tanks have a capacity of 35,000 gallons each (useable volume of 34,674 gallons). The tanks are connected with a siphon line between the tanks to ensure a passive means of transfer so one emergency diesel can use both tanks. The siphon line does not appear to be transferring fuel oil.

"KPS is in a refueling outage and in REFUELING SHUTDOWN mode with the vessel drained to 6" below the flange for reactor vessel reassembly. Both trains of RHR are required to be OPERABLE per TS 3.1.a.2.B.

"Technical Specification 3.7.c states that when its normal or emergency power source is inoperable, a system, train or component may be considered OPERABLE for the purpose of satisfying the requirements of its applicable LCO provided:
1. Its corresponding normal and emergency power source is OPERABLE; and
2. Its redundant system, train, or component is OPERABLE.

"Kewaunee Power Station (KPS) Technical Specifications Section 3.7.a.7 states that the reactor shall not be made critical unless both diesel generators are operable. The two underground storage tanks combine to supply at least 35000 gallons of fuel oil for either diesel generator and the day tanks for each diesel generator contain at least 1,000 gallons of fuel oil. The current volume is 29,700 gallons in Tank A and 21,500 gallons in Tank B.

Based on two trains found inoperable, this is reportable under:
10 CFR 50.72(b)(3)(ii) (8-Hr)
10 CFR 50.72(b)(3)(v)(B) (8-hr)

"Per TS 3.1.a.2.B the condition must be fixed immediately. Troubleshooting/investigation is in progress to determine repairs. Cause is being investigated."

Condition was found during engineering review of logs taken during operator rounds.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED AT 1641 EDT ON 05/14/08 FROM JACK GADZALA TO JEFF ROTTON * * *

"EN 44182 provided notification that the emergency diesel generator (EDG) fuel oil tanks were not capable of supplying the combined volume of fuel oil (35,000 gallons) from two storage tanks to either EDG as required by Technical Specification (TS) 3.7.a.7 for EDG operability. That notification was based on a conservative determination that a siphon line, which connects the two fuel oil storage tanks, was nonfunctioning.

"TS 3.7.a.7 requires both EDGs to be operable when the reactor is critical. Although the reactor was in refueling shutdown mode at the time of this event (i.e., not critical, and therefore not in the mode of applicability for TS 3.7.a.7), the EDGs provide a support function (emergency power) for the Residual Heat Removal (RHR) system; two trains of which were required to be operable for core cooling per TS 3.1.a.2.B.

"A subsequent review confirmed that the capability to transfer fuel from either storage tank to either EDG existed independent of the siphon line. The siphon line is not needed for transferring fuel oil from either tank to either EDG. There are alternate means available to transfer fuel oil to the EDGs; sufficient time is available to implement these alternate means of fuel oil transfer within the time available.

"Additional fuel oil supply margin existed due to the mode of operation at the time (refueling shutdown). The 35,000 gallon TS requirement is based on the expected fuel consumption of one EDG operating for seven days at continuous rated load, thus ensuring adequate time to restore off-site power or to replenish fuel. The amount of fuel in the storage tanks was sufficient for the EDGs to be capable of performing their support function for RHR in the refueling shutdown mode. As such, both RHR trains remained operable and TS 3.1 a.2.B was satisfied. Consequently, this condition did not meet the reportability criteria in 10 CFR 50.72.

"As a result, the notification made on 4/30/2008 (EN 44182) is hereby retracted."

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

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Hospital Event Number: 44192
Rep Org: BRIDGEPORT HOSPITAL
Licensee: BRIDGEPORT HOSPITAL
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-01060-01
Agreement: N
Docket:
NRC Notified By: DAVID WISHCO
HQ OPS Officer: PETE SNYDER
Notification Date: 05/08/2008
Notification Time: 09:31 [ET]
Event Date: 05/08/2008
Event Time: [EDT]
Last Update Date: 05/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ART BURRITT (R1)
MICHELE BURGESS (FSME)

Event Text

BRACHYTHERAPY UNDERDOSE TO 2 PATIENTS

The licensee discovered that 2 patients received underdoses from brachytherapy in January 2008. The underdoses were discovered May 7, 2008. The cause was related to a change in the input made to the treatment planning computer involving the magnification factor. The prescribed doses were 5500 centigray to the cervix of both patients and delivered dose was 2550 centigray. The patient's prescribing physician and oncologist have been informed and discussions are underway to determine future actions. The patients have not yet been informed.

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: 44193
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON SUBURBAN HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-099-26
Agreement: Y
Docket:
NRC Notified By: ANGELA BRITTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/08/2008
Notification Time: 15:18 [ET]
Event Date: 04/28/2008
Event Time: [CDT]
Last Update Date: 05/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1)
TERRANCE REIS (FSME)

Event Text

KENTUCKY AGREEMENT STATE REPORT - MEDICAL EVENT - PATIENT RECEIVED INCORRECT DOSE OF I-131

A patient was prescribed a dosimetric Bexxar I-131 dose of 5 mCuries for a lymphatic cancer uptake study. The patient received an I-131 dose of 44.5 mCuries that was actually intended for another patient.

The Doctor has notified the patient. The patient had taken a thyroid block prior to the misadministration. No adverse consequences are expected to the patient. The patient was subsequently given a therapeutic dose of I-131 which was adjusted to account for the misadministration of the dosimetric amount.

The State of Kentucky Radiation Health Department investigation is in progress.

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: 44203
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL INC.
Region: 1
City: BURLINGTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB WALKER
HQ OPS Officer: PETE SNYDER
Notification Date: 05/12/2008
Notification Time: 17:02 [ET]
Event Date: 05/12/2008
Event Time: 13:45 [EDT]
Last Update Date: 05/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
JIM WHITNEY (ILTA)
BRIAN McDERMOTT (IRD)
MICHELE BURGESS (FSME)
LEE (DHS)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING IRIDIUM-192 SOURCE

QSA Global reported to the Commonwealth of Massachusetts that a shipment containing a 149.2 Curie Ir-192 source that was originally shipped on 5/7/08 was missing. The shipment arrived in Miami and was transferred from FedEx to Amerijet. Amerijet reported to an agent of QSA Global, on 5/9/08, that the shipment could not be found at the time of its originally scheduled flight to Trinidad, its final destination.

As of 1345 on 5/12/08 Amerijet still could not locate the package. The company initiated a warehouse search. The signature that FedEx had on record as receiver was reported to be "not an eligible" receiver by Amerijet.

* * * UPDATE AT 1710 FROM BOB WALKER TO HOWIE CROUCH * * *

Amerijet has located the missing shipment in their Miami facility. The package is undamaged and will shortly resume transport to its final destination of Trinidad.

Notified ILTAB (Whitney), R1DO (Krohn), FSME (Reis), IRD (McDermott), and DHS (Lee).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

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General Information or Other Event Number: 44204
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: WAL-MART
Region: 4
City: GLENDALE State: AZ
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/12/2008
Notification Time: 18:54 [ET]
Event Date: 05/12/2008
Event Time: 14:30 [MST]
Last Update Date: 05/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
TERRANCE REIS (FSME)

Event Text

ARIZONA AGREEMENT STATE REPORT - CONTAMINATION EVENT DUE TO A BROKEN TRITIUM EXIT SIGN

The following information was provided by the Arizona Radiation Regulatory Agency via email on 5/12/08 @ 1854 EST:

"By letter dated May 7, 2008, the Licensee reported that their contractor had detected a broken 20 curie tritium exit sign at their Glendale store. A second contractor with a Certified Health Physicist, was called in to decontaminate and investigate the circumstances on April 25, 2008. The second contractor found up to 16,900 dpm/100 cm2 removable contamination on the wall where the sign had been located. On the floor beneath the sign, the contractor reported contamination up to 1,400 dpm/cm2. The date of breakage is unknown and could have actually occurred up to one year prior to discovery.

"The device was a SRS Technologies, Inc. Serial number 304150, 20. The sign has been shipped to Canada to Shield Source, Inc., a Canadian licensee.

"The Agency is investigating the delay in reporting this event since the report was not made within 24 hours."

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Power Reactor Event Number: 44207
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: PETE SNYDER
Notification Date: 05/13/2008
Notification Time: 14:25 [ET]
Event Date: 05/14/2008
Event Time: 05:00 [CDT]
Last Update Date: 05/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DALE POWERS (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

EMERGENCY SIREN OUTAGE FOR UPGRADE

"Fort Calhoun Station will be experiencing a partial loss of emergency communications and notification capabilities on Wednesday, May 14, 2008. Omaha Public Power District will be completing an upgrade to the main radio system from approximately 05:00 - 09:00, Wednesday, May 14, 2008. During this time, mobility over the radio system (mostly rural use) and the Fort Calhoun Station Alert and Notification System (ANS) sirens will be out of service.

"Emergency Planning will notify the affected counties to have their back-up plan for the [alert and notification system] in place during that time.

"Post Maintenance Silent Testing will be performed upon completion of radio maintenance to verify siren communications."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1157 EDT ON 5/14/08 FROM MATZKE TO HUFFMAN * * *

The licensee reports that the siren outage commenced at approximately 0400 CDT this morning and is in progress. Currently, the estimated completion time for this activity is now approximately 1300 CDT today (5/14/08).

R4DO (Powers) notified.

* * * UPDATE PROVIDED AT 1847 EDT ON 05/14/08 FROM GUINN TO JEFF ROTTON * * *

"Update to Event Number 44207 - Fort Calhoun Unit 1 - Event Date 05/14/2008 - Emergency Sirens upgrade is complete. Post maintenance silence testing was performed. All sirens are functional.

"The NRC Resident Inspector, state, and local officials have been notified."

Notified R4DO (Powers)

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Power Reactor Event Number: 44213
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LEE GRZECK
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/14/2008
Notification Time: 13:16 [ET]
Event Date: 03/15/2008
Event Time: 16:35 [EDT]
Last Update Date: 05/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARVIN SYKES (R2)

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

Event Text

INVALID PRIMARY CONTAINMENT ISOLATION SYSTEM (PCIS) ACTUATION

"This 60-day telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1).

"On March 15, 2008, while resetting the main turbine in preparation for performing 1MST-RPS25R, 'RPS Turbine Stop Valve and Control Valve Closure Chan Cal,' a Group 1 isolation was received. Main Steam Lines (MSLs) A and B were isolated for local leak rate testing, however, the MSLs C and D were not. The inboard and outboard Main Steam Isolation Valves (MSIVs) for the C and D MSL closed as a result of this event.

"The isolation occurred during work associated with replacement of the main generator output breakers 22A and 22B. In order for the breakers to be removed, wiring that provides breaker position information was disconnected from the turbine control system (EHC). This resulted in a 'breaker closed' input to EHC. When the main turbine was reset, several logic interactions occurred resulting in the Group 1 isolation. No actual plant condition existed which required a Group 1 isolation and, with the Unit in Mode 4, Group 1 isolation is not required to be operable. Therefore, this actuation is considered to be invalid.

"The affected MSIVs and PCIS instrumentation operated properly. This was a full Group 1 isolation with only the MSIVs associated with the C and D MSLs closing since the A ad B lines were isolated when the actuation occurred. The invalid PCIS actuation was entered into the corrective action program (i.e., NCR 270475).

"The safety significance of this event was minimal. Plant equipment performed as expected. Group 1 isolation was not required to be operable in Mode 4.

"The Group 1 isolation was reset and a jumper was installed to prevent a subsequent invalid Group 1 isolation. Procedures will be developed or revised to disable the Group 1 Isolation during modes in which it is not required and to reset the main turbine during outages.

"The NRC Resident Inspector has been notified at this report."

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