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Event Notification Report for July 31, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/30/2008 - 07/31/2008

** EVENT NUMBERS **


44179 44364 44368 44369 44371 44377 44379

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44179
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVID JESTER
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2008
Notification Time: 05:21 [ET]
Event Date: 04/29/2008
Event Time: 23:13 [EDT]
Last Update Date: 07/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CAROLYN EVANS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 32 Power Operation 32 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE DUE TO SEAL LEAK

"On 04/29/08 at approximately 2313 during testing of the Unit 1 HPCI system, a main pump seal developed a leak requiring the HPCI system to be secured. HPCI testing was in progress per OPT 09.2, HPCI System Operability Test, following recent Unit 1 refueling outage. At the time of discovery, the Unit 1 HPCI system had been declared inoperable due to surveillance testing activities which removed HPCI from the standby lineup. When the pump seal leak developed, operators secured HPCI and isolated the leak by closing the pump suction isolation valves and the keep fill supply valves. Investigation into the cause of the pump seal leakage is underway and the Unit 1 HPCI system will be placed under clearance for repair.

"The initial safety significance of this condition is considered to be minimal. The Reactor Core Isolation Cooling (RCIC) system as well as the other Unit 1 ECCS systems are operable at this time. Actions have been taken to protect redundant safety systems.

"The Unit 1 HPCI system has been removed from service and secured. Investigation is underway to determine the cause of the HPCI main pump leakage. The HPCI system will be placed under clearance for repair."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 7/31/08 AT 1447 EDT FROM TURKAL TO HUFFMAN * * *

"The HPCI pump uses seal purge water piping in combination with mechanical seals to limit shaft leakage. Investigation of this event found that inadequate post-maintenance venting of piping between the discharge of the HPCI booster pump and the suction of the HPCI main pump led to the seal faces overheating and subsequent failure. The failure of the seal and the leakage associated with it would not have prevented HPCI from performing its required functions. Water intrusion into the oil system is the limiting impact of the seal failure. The HPCI main pump seal failure event has been evaluated and it was determined that, given a worst-case seal failure, the HPCI pump would be able to operate for greater than the required 4.1 hours and, thereby, satisfy its accident, as well as transient, response requirements. On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"Investigation of this condition is documented in the corrective action program in Nuclear Condition Report (NCR) 277188.

"The NRC resident was notified of this retraction."

The R2DO (Henson) has been notified.

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General Information or Other Event Number: 44364
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: NEUTRON PRODUCTS INC
Region: 1
City: DICKERSON State: MD
County:
License #: MD-3102503
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2008
Notification Time: 10:57 [ET]
Event Date: 07/21/2008
Event Time: 18:20 [EDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OCCUPATIONAL OVEREXPOSURE

On July 22, 2008, the State of Maryland was informed by the Teletherapy Operations Manager for Neutron Products, Inc. that one of their teletherapy service engineers performing an Alcyon Co-60 source exchange in Brazil had received a potential overexposure.

During the source exchange, the engineer's electronic dosimeter alarmed. Immediate actions were taken to properly secure the source. Preliminary dosimetry readings for the service engineer indicated a potential whole body exposure of approximately 5,211 mrem and extremity reading at the right wrist exceeding 10R (off scale high). The service engineer's film badge was sent for immediate processing to Global Dosimetry with expected results available for evaluation by Thursday, 7/24.

The results from Global Dosimetry for the service engineer prior to the incident are as follows:

Monthly whole body (DDE, mrem) - 13,465 + 92 (Jan. - May) = 13,557
Left wrist (SDE, mrem) - 73,356 + 236 (Jan. - May) = 73,592
Right wrist (SDE, mrem) - 746 + 488 (Jan. - May) = 1,234

Brazilian regulatory personnel were onsite at the hospital at the time the incident occurred and were briefed within one (1) hour by the service engineer.


* * * UPDATE FROM ALAN JACOBSON TO JOHN KNOKE AT 0739 EDT ON 07/28/08 * * *

"Per our telephone conversation of today [between the state and the licensee], this is to update our initial verbal and written Twenty-Four Hour Notifications made July 22, 2008 regarding the incident in Sao Paulo, Brazil, and to summarize our employee's written account thereof.

"On July 21, 2008 at approximately 6:20 pm EDT, Neutron Products employee #502, informed us via telephone that he may have received an over-exposure while performing a source exchange on an Alcyon II teletherapy unit located in Sao Paulo, Brazil. On July 21, 2008, employee #502 and a radiation worker from Brazil were in the process of transferring the expended cobalt-60 source from the Alcyon II unit into Neutron's transfer cask in accordance with Specification P-9, Appendix XI. After engaging the source holder with the removal tool, #502 transferred the source holder from the Alcyon II unit head into the transfer cask. Once the source holder was in the transfer cask, #502 continued making preparations to complete the removal sequence.

"Employee #502 had completed all the steps of the removal sequence and was in the process of removing the removal tool from the transfer cask, when it was determined by audible alarms and before the tool was completely out of the cask, that the cobalt-60 source was still connected to the end of the removal tool. At that point, #502 reinserted the removal tool back into the cask and repeated the steps again to make sure that the Source was disengaged from the removal tool. Once he was sure that the source was no longer attached to the removal tool, the tool was removed from the cask, and all the covers installed. The transfer cask now contains both the expended and new sources.

"Immediately after the container was secured, both men read their SRD's and reported their dose as follows: #502: WB-5,211 mrem, Left Wrist-300 mrem, and Right Wrist-off Scale (10R dosimeter); Brazilian Worker: WB-533 mrem, Left Wrist-off scale (10R dosimeter), and, Right Wrist-4,100 mrem. The TLD's were sent via FED-EX to Global Dosimetry Solutions in Irvine, CA, for emergency reading and the results are as follows: #502: Monthly WB DDE-13,465 mrem, Quarterly WB DDE-11,126 mrem, Left Wrist SDE-73,356 mrem, and Right Wrist SDE-746 mrem. Brazilian Worker: Monthly WB DDE-702 mrem, Quarterly WB DDE-1,559 mrem, Left Wrist SDE-3,030 mrem, and Right Wrist SDE-8,542 mrem.

"Employee #502 will be returning home sometime this weekend. He will not be involved in any radiation work for the remainder of the year."

Notified R1DO (Trapp) and FSME (M. Burgess)

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General Information or Other Event Number: 44368
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXON MOBIL CHEMICAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2349-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/28/2008
Notification Time: 10:46 [ET]
Event Date: 08/01/2005
Event Time: [CDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE MALFUNCTION

This report was received from the state by facsimile.

"Exxon Mobil Chemical Company had an incident occur in August of 2005 and did not report the event. The event was discovered while an inspector was performing a reciprocity inspection on Ronan Engineering at Exxon on July 9, 2008. Ronan was contacted to package a nuclear gauge for transport and disposal. In August 2005, Exxon had a problem with a ThermoMeasure Tech 'SA-10' device that contained four 1000 mCi sources of Cs-137. The sources were QSA model CDC.93 with serial numbers 4421GN, 4424GN, 4425GN, and 4426GN in a rod configuration. In August 2005, the sources could not be returned to the shielded position to perform a shutter check. The facility returned the sources to the normal detent position for operation and continued to use the gauge. Ronan Engineering determined that the sources were encountering friction from the vessel source well. The vessel source well is part of the vessel and not part of the Ronan gauge. The gauge and sources were safely returned to the source holder, locked out, surveyed and leak tested on July 11, 2008. The gauge was shipped to ThermoMeasure Tech on July 11, 2008 for disposal."

Event Report ID: LA0800015

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General Information or Other Event Number: 44369
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: NEW IBERIA State: LA
County:
License #: LA-9098-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/28/2008
Notification Time: 11:20 [ET]
Event Date: 07/25/2008
Event Time: [CDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

This report was received from the state by facsimile.

"On July 25, 2008, TEAM Industrial Services reported that a source was stuck in the guide tube and could not be returned to the shielded position. The industrial radiography camera involved is a AEA 880 Delta with serial number D2847. The source involved is an AEA source with serial number 45020B that is 49.8 Ci of Ir-192. While the source was in the collimator, the stand that was being used to x-ray welds fell on the guide tube. The radiographers attempted to return the source to the shielded position but could not. The radiographers then returned the source to the collimator and set up a 1 mr/hr boundary around the source. They called the Radiation Safety Officer for TEAM. TEAM contacted QSA Global to retrieve the Ir-192 source. The source was retrieved on July 25, 2008 at 5:30 PM. The guide tube and stand have been taken out of service. The camera and crank-outs are being sent to QSA Global to be inspected."


Event Report ID: LA0800016

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Other Nuclear Material Event Number: 44371
Rep Org: MEMORIAL HOSPITAL - SHERIDAN, WY
Licensee: MEMORIAL HOSPITAL - SHERIDAN, WY
Region: 4
City: SHERIDAN State: WY
County:
License #: 49-10982-02
Agreement: N
Docket:
NRC Notified By: THOMAS NANCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/28/2008
Notification Time: 14:26 [ET]
Event Date: 07/18/2008
Event Time: 10:00 [MDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)

Event Text

MEDICAL ERROR - WRONG CHEMICAL USED IN PATIENT TREATMENT

On the date described [07/18/08] an outpatient reported to the Nuclear Medicine Department for a Nuclear Medicine whole body bone scan. The technician drew up and injected the patient with 24.3 mCi mTc99 Sestamibi, I.V. instead of the proper cold kit which would have been Medronate. The error was not discovered until the patient returned 3 hours later for scanning and it was observed that the isotope was not properly tagged. Upon investigation, the reason for the poor tag was discovered. The patient was informed as well as the Department Manager, and the on-duty staff Radiologist. It was agreed by all that the patient would return on 07/21/08 to perform the study properly. According to the Radiation Absorbed Dose Table, the patient received the following:

Gallbladder Wall - 1.6 Rads, Small Intestine - 2.4 Rads, Upper Large Intestine Wall - 4.32 Rads, Lower Large Intestine Wall - 3.12 Rads, Stomach Wall - 0.48 Rads, Heart Wall - 0.40 Rads, Kidneys - 1.6 Rads, Liver - 0.48 Rads, Lungs - 0.24 Rads, Bone Surfaces - 0.56 Rads, Thyroid - 0.56, Testes - 0.24 Rads, Red Marrow - 0.40 Rads, Urinary Bladder Wall - 1.6 Rads, Total Body - 0.40 Rads.

It is believed that there was no ill effect on the patient. The technician has been re-instructed on the extreme importance of checking all the labels previous to preparing, drawing up and delivering any radioisotopes.

The licensee is still in the process of confirming that the ordering physician has been notified of this incident.

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Power Reactor Event Number: 44377
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TERRY BACON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/31/2008
Notification Time: 11:03 [ET]
Event Date: 07/31/2008
Event Time: 08:17 [CDT]
Last Update Date: 07/31/2008
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):
PATTY PELKE (R3)

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

REACTOR TRIP DURING TESTING

"Unit one (1) experienced a reactor trip during SP-1003 Analog Protection Functional Test. The yellow Tave channel was in test when the red Tave channel bistable failed causing an OTDT reactor trip. Applicable emergency operating procedures were entered and completed. The plant is now implementing 1C1.3, the normal plant shutdown procedure.

"All systems performed as expected with exception of 11 turbine driven auxiliary feed (AFW) pump auto started and tripped 50 seconds later on low suction / discharge pressure which the plant is continuing to investigate. All rods inserted and all other AFW system components are operating as expected."

Decay heat removal is from Main and Auxiliary Feedwater to the Steam Dump system. No safety or relief valves actuated. The plant is in a normal electrical lineup.

The licensee notified the NRC Resident inspector.

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Power Reactor Event Number: 44379
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: MARK JENKIN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/31/2008
Notification Time: 21:59 [ET]
Event Date: 07/31/2008
Event Time: 13:45 [CDT]
Last Update Date: 07/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PATTY PELKE (R3)

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

Event Text

POSTULATED HIGH-ENERGY LINE BREAK THAT COULD DISABLE BOTH TRAINS OF COMPONENT COOLING

"At 1345 Prairie Island staff declared both trains of Unit 2 Component Cooling (CC) system inoperable due to discovery that a postulated high energy line break (HELB) in the Turbine Building that could fail a CC line in the turbine building that would affect both trains of CC. The inoperability of Unit 2 CC caused entry into Technical Specification LCO 3.0.3. The CC line in question is not automatically isolated on a safety injection signal and the loss of CC inventory would eventually affect both trains of CC. Since a Unit 2 HELB could directly result in a loss of both trains of CC (a system that is required to meet the single failure criterion), the CC system does not meet the single failure criterion in the as-found configuration. Thus, in accordance with the guidance in NUREG 1022, this condition is reportable per 10 CFR 50.72(b)(3)(ii).

"The CC line in the Turbine Building was isolated at 1614 on 7/31/08 returning Unit 2 CC to operable status. Unit 2 remained at 100% power."

The isolated line went to a chemistry lab cooler that can be isolated during operation. The condition was discovered during a high-energy line break vulnerability walk-down. A similar line on Unit 1 was already isolated.

The NRC Resident Inspector has been notified.

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