Event Notification Report for September 16, 2008

RADIOGRAPHY CAMERA SOURCE FAILED TO RETURN TO SAFE POSITION

"On September 12, [the] RSO for Team Industrial Svcs. called to advise that an irregularity had occurred during a routine radiography shot [deleted]. A radiography crew had been working at the Archer Daniels Midland facility in Decatur, Illinois to perform a panoramic shot within a 5 inch thick steel vessel. Following the shot, the 100 Ci Co-60 source failed to return to the safe position within the camera. The crew called their local RSO, [deleted] and requested assistance. During [the local RSO's] travel to the site, the crew secured the Fabrication Shop where the vessel was located. [The local RSO's] first actions at the site were to confirm the area was secured and the appropriate barriers were in place such that exposures to any other individuals remained below regulatory limits for members of the public. (Prior to the work beginning, the area had been evacuated and remained that way during the duration of the event). The shot was described as a 'panoramic, horizontal shot at ground level that did not require support equipment.' The lead radiographer's pocket dosimeter at the time of the notification showed a total of 50 milliR for that day's activities. Preliminary evaluation by the crew suggested the source had become disconnected in that the expected number of 'cranks' on the drive cable exceeded the number necessary to return the source to the camera from the 14 foot length guide tube with extension and there was no evident increase in radiation exposure rate as had been expected from the camera. The manufacturer of the equipment/source, QSA Global, was contacted immediately and had been asked to be on 'standby' in the event their assistance for a source recovery is necessary. Team Industrial Services is authorized to perform source retrievals and has adequate procedures/equipment for that activity for when they choose to attempt a recovery on their own.

"Later, [the corporate RSO] reported that [the local RSO] confirmed the source disconnect at the scene by separating the guide tube from the camera and cranking the drive cable back to the camera. Additional lead and steel shielding was brought into the area via a remote overhead crane in the Fabrication Shop to allow for more direct observation. Dose rate at the camera location was measured as 200 milliR/h unshielded. With a leaded barrier, the dose rate was brought down to 100 milliR/h at the camera. The dose rate was further reduced by extending the crank assembly an additional 15 feet away from the camera. Based on technical instruction from QSA Global's expert, source recovery was attempted by modifying the connector on a drive cable that was then attached to the crank and threaded back through the camera. Team [Industrial Services] imposed a conservative 200 milliR total dose limit for the recovery operation and 500 milliR/h dose rate limit for area occupancy during [the local RSO's] attempts.

"After 2 hours of attempts to recover [the source] were unsuccessful, the maximum exposure received at that point was 60 milliR. Over twenty attempts took place however, positive connection with the source 'pigtail' could not be confirmed. A reevaluation of the arrangement suggested that the extension guide tube should be removed and the overall guide tube length be made more straight by remotely partially withdrawing the main guide tube from the vessel. Following those changes and a break, another attempt was made which was successful. The source was secured within the camera and no immediate damage to the source was evident from a field wipe test which showed background levels of radiation. The maximum recorded exposure to recovery personnel was approximately 140 milliR as measured by DRD. All associated equipment was returned to Team Industrial's permanent storage facility in Roxana, IL that same night by 23:00. Plans are to return the source with camera, drive cable and guide tubes to the manufacturer for further analysis as to a potential cause of the event. The radiography crew reported that prior to the days events, routine checks showed the equipment was in properly operating condition. They further insist that a 'misconnect' where the drive cable was not properly connected to the source did not occur in this case. The licensee has been advised that a 30 day report to the Agency is required. This item will remain open pending receipt of that report and the analysis of the manufacturer as to the state of the returned equipment."

Illinois Report Number: IL080051

LOST TRITIUM EXIT SIGNS

The licensee reported two tritium exit signs missing from stores in Crawfordsville, IN (SN 368230, manufacturer -Isolite, Activity - approximately 10 Ci) and South Hill, VA (SN 320031, manufacturer - unknown, activity - unknown). The missing signs were identified during a remove and replacement effort of the tritium exit signs company wide. Both signs were accounted for in an inventory of the signs in the spring of 2008. An investigation was performed by company personnel to determine the disposition of the signs. Upon completion of the investigation it was determined that the signs could not be located and their final disposition was unknown.

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

MANUAL REACTOR TRIP DURING TROUBLESHOOTING OF CONTROL ROD DRIVE MECHANISM MOTOR GENERATORS

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On September 16, 2008 at approximately 1400 hours Mountain Standard Time (MST) Palo Verde Nuclear Station Unit 3 experienced a manual reactor trip. At the time of the trip trouble shooting efforts were in progress to investigate abnormalities with the control element drive mechanism (CEDM) motor generators (MG). The MGs (2 - 100% each) normally operate in parallel to supply the necessary power to grip, move and hold the control element assemblies (CEA). During the trouble shooting activities the 'B' MG was removed from service. The 'A' MG initially provided power to the CEDMs but did not maintain the power.

"As a result of the pre-job briefing contingency actions, a manual reactor trip was ordered.

"All CEAs fully inserted into the core. No other emergency actuation signals were initiated and none were required. Off site power provided power to the class buses during and after the event. Decay heat removal is being provided by the steam bypass control system to the main condenser. No major equipment was inoperable prior to the event that contributed to the event.

"The unit is in Mode 3, Hot Standby, at normal temperature and pressure.

"The cause of the MG abnormality is under investigation."

Normal feedwater remained in service providing water to the steam generators.

The licensee notified the NRC Resident Inspector.

HIGH CONDUCTIVITY IN A POOL IRRADIATOR

"At 8:14 am on September 16, 2008, the radiation safety officer (RSO) called to report the pool water conductivity was above 100 microsiemens per centimeter on September 6, 2008. On September 4, 2008 the licensee noted some product (honey) had leaked out of the container into the pool. They thought this small amount of contaminate would be cleared out of the pool once it circulated through the water purifying tanks, however, the conductivity continued to increase until September 6, 2008 [when] it reached 120 microsiemens per centimeter. The licensee did not realize this was a reportable event per 10 CFR 36.83(a)(10) until he spoke to his corporate RSO last night (9-15-08). He then reported the incident to us [State of California] this morning. The licensee has been continuing to work to reduce the conductivity by adding new water purifying tanks. As of today, the water is still too cloudy to see the sources in the pool and the conductivity is at 57 microsiemens per centimeter and is continuing to reduce each day. Corrective actions to be taken include refresher training for the RSO to review the regulatory requirements for reportable events and instruction to customers regarding the correct packaging of their product so they do not have a similar incident in the future. The RSO will be providing the Department with a written report within 30 day as required and will continue to mitigate the conductivity and clarity of the pool water until it has reduced to normal levels. The licensee will notify us when the conductivity and clarity is at normal levels."

California Report Number - 091608

LOSS OF SHUTDOWN COOLING CAPABILITY

"On September 16, 2008 at 0734 the James A, FitzPatrick Nuclear Power Plant was shutdown and operating in the refueling mode (Mode 5), when shutdown cooling was lost. Shutdown cooling was lost while hanging a tagout on the Reactor Protection System (RPS). When removing fuses as directed by the tagout, isolation logic for Shutdown Cooling suction salve 10MOV-18 was actuated. This Suction Valve isolates the common shutdown cooling suction line to all Residual Heat Removal (RHR) Pumps. At the time of the isolation cavity flood-up was in progress and the time to boil was greater than 5.5 hours. The appropriate Technical Specification LCO Actions were entered and shutdown cooling was restored at 08:27.

"Power was restored to RPS and work in that system has been suspended pending the results our investigation into the cause of the event. Also additional controls have been established to review any electrical jumper/ protective tagging interactions prior to installation.

"The event has been entered into the corrective action program and a Licensee Event Report (LER) will be filed within 60 Days as required by 10 CFR 50.73(a)(2)(v).

"The resident inspector has been briefed and the state Public Service Commission (PSC) will also be notified."