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Event Notification Report for September 22, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/19/2008 - 09/22/2008

** EVENT NUMBERS **


44493 44497 44498 44499 44504 44506 44507 44508

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General Information or Other Event Number: 44493
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: TEAM INDUSTRIAL SERVICES
Region: 3
City: DECATUR State: IL
County:
License #: IL-01136-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRARA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/16/2008
Notification Time: 15:02 [ET]
Event Date: 09/16/2008
Event Time: [CDT]
Last Update Date: 09/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE MARIE STONE (R3)
DUNCAN WHITE (FSME)

Event Text

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

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General Information or Other Event Number: 44497
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STERIS INC
Region: 4
City: ONTARIO State: CA
County:
License #: 6666-36
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: JASON KOZAL
Notification Date: 09/16/2008
Notification Time: 20:55 [ET]
Event Date: 09/16/2008
Event Time: [PDT]
Last Update Date: 09/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
KEVIN HSUEH (FSME)

Event Text

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

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Power Reactor Event Number: 44498
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SANDS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/17/2008
Notification Time: 11:40 [ET]
Event Date: 09/17/2008
Event Time: 10:17 [CDT]
Last Update Date: 09/21/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANNE MARIE STONE (R3)
JOHN THORP (NRR)
ERIC LEEDS (ET)
MARK SATORIOUS (R3)
BRIAN McDERMOTT (IRD)
VIA (FEMA)
HILL (DHS)

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

UNUSUAL EVENT DUE TO LOSS OF SHUTDOWN COOLING

Monticello lost the 1R offsite power transformer due to an industrial accident that grounded the bus and resulted in a fatality of an employee onsite. At the time of this event, the 2R offsite transformer was already out of service due to a previous event (see EN #44484). This effectively resulted in a loss of all normal offsite power. The 1AR safety related offsite power source remained available and the safety related buses are energized and diesels are available. However, shutdown cooling was lost during the event due to a Group 2 isolation and cannot be restored. The shutdown cooling suction isolation valves #2020 and #2030 have power but until the Group 2 logic can be reset the valves cannot be reopened. The licensee needs to repower the RPS bus to reset the logic. Based on the uncertainty in reestablishing shutdown cooling an Unusual Event was declared based on Emergency Director judgment (EAL HU5.1). Current reactor coolant temperature is approximately 110 degrees with a heatup rate of about 20 degrees an hour.

State and local authorities and the NRC resident inspector have been notified. The licensee will likely be making a press release.

* * * UPDATE AT 1417 EDT ON 09/17/08 FROM CORY JASKOWIAK TO S. SANDIN * * *

"On Wednesday, September 17, 2008 Monticello Nuclear Generating Plant (MNGP) experienced a loss of power to the station transformer resulting in a valid actuation of the following systems: Reactor Protection System (with the reactor shutdown), Containment Isolation, and Emergency Diesel Generators.

"The cause of the loss of power was due to contact of a 115kV transmission line by a manlift. A vendor employee was electrocuted. On-site Medical Emergency Response personnel responded until the individual was transported to North Memorial Medical Center. The individual was pronounced dead at North Memorial Medical Center.

"Notifications of offsite agencies and a media press release are in progress. 'This notification is being made in accordance 10CFR50.72(b)(2)(xi) and 10CFR50.72(b)(3)(iv)(A).'

"Licensee notified the NRC Resident Inspector." Notified R3IRC (Garza)

* * * UPDATE AT 1715 EDT ON 09/17/08 FROM R. BAUMER TO S. SANDIN * * *

"This is a follow-up to Event notification #44498. The station has completed notifications to off-site agencies and to the media. The station continues to troubleshoot and restore plant equipment and respond to media inquiries.

"NUE update - As of 1113 CDT shutdown cooling was restored." Notified R3 IRC.

* * * UPDATE AT 1220 EDT ON 9/21/08 FROM DAN NORHEIM TO JOHN KNOKE * * *

"Monticello Nuclear Generating Plant exited their Notification of Unusual Event at 1100 CDT on 9/21/08. The exit criteria is supported on the following information: (1) This event did not result in the loss or potential loss of a fission product barrier and did not change the status of the current fuel condition. All three fission barriers are intact and were maintained throughout the event. (2) There were no radiation releases as a result of the event. (3) Restoration of plant loads including shutdown cooling onto a normal offsite power source (the 1R transformer) has been completed. (4) The 1R transformer offsite power source was recovered and is being protected. Protection of the 1R transformer will continue until availability of the other offsite power source supplied from the 2RS/2R transformers has been restored. (5) Shutdown cooling is in service. (6) The site organization challenges in response to the injury event and loss of decay heat removal are no longer present."

The licensee has notified the NRC Resident Inspector, as well as state and local agencies. A media release will be issued. Notified R3DO (Stone), NRR EO (Galloway), IRD MOC (Clark), OPA (Burnell), DHS (S. Moore), and FEMA (D. Fuller).

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General Information or Other Event Number: 44499
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/17/2008
Notification Time: 13:52 [ET]
Event Date: 09/17/2008
Event Time: [CDT]
Last Update Date: 09/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHRIS EINBERG ()

Event Text

AGREEMENT STATE REPORT - BROKEN GAUGE

"On September 17, 2008 the licensee reported that a[n] Ohmart/Vega (OV) model SH-F1 has a sheared bolt on the shutter handle which prevents it from closing. This device (S/N 1297GK) contains 20mCi of Cs-137 in a model OV A-2100 sealed source capsule. The manufacturer has been notified and will see to the proper repair or replacement of the gauge. No public exposures are likely to approach regulatory limits and the vessel has been posted to prevent entry."

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General Information or Other Event Number: 44504
Rep Org: SPECTRUM TECHNOLOGIES
Licensee: SPECTRUM TECHNOLOGIES
Region: 1
City: SCHNECTADY State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDY REYNOLDS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/19/2008
Notification Time: 11:01 [ET]
Event Date: 09/15/2008
Event Time: [EDT]
Last Update Date: 09/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MIKE ERNSTES (R2)
VERN HODGE (NRR)
JOHN THORP (NRR)
ANNE MARIE STONE (R3)

Event Text

PART 21 - SIEMENS MODEL 353 PROCESS CONTROLLER TRANSFORMER FAILURE

The following information was received via facsimile.

"The defect concerns a decreased reliability of the transformer within the controller. The failure of the transformer can cause the controller to not power up when energized or to unexpectedly shut down during normal operation."

This notification is for the following controller models shipped between 2/21/2007 and 4/21/2008:
353A, Kit A
TGX:353A, Kit B
16353-68 Controller Board Kits for Design Level A
TGX:16353-302 Controller Board Kit for Design Level B

Affected licensees are Florida Power and Light (Duane Arnold) and Duke Energy (Oconee).

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Power Reactor Event Number: 44506
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILLY JOHNSON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/20/2008
Notification Time: 11:30 [ET]
Event Date: 09/20/2008
Event Time: 09:06 [EDT]
Last Update Date: 09/20/2008
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):
MIKE ERNSTES (R2)

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 DUE TO TURBINE TRIP

"At 0906 EDT Watts Bar Unit 1 experienced a Reactor trip in response to a Turbine trip. This caused an automatic AFW Pump start from P-4 coincident with Lo Tave signal. First indications are that the Exciter Field Breaker tripped open. The cause is under investigation. All ESF systems responded as designed with no other issues. The plant is currently stable and is being maintained in Mode 3. Plans for plant restart are pending awaiting the cause investigation."

All control rods fully inserted into the core. Plant decay heat removal is through the steam dumps to the main condenser. The offsite power is available and lined up to plant system loads.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44507
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BART CZECH
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/20/2008
Notification Time: 20:31 [ET]
Event Date: 09/20/2008
Event Time: 20:18 [EDT]
Last Update Date: 09/21/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANN MARIE STONE (R3)
JIM CALDWELL (RA)
ERIC LEEDS (NRR)
MELANIE GALLOWAY (NRR)
BRIAN MCDERMOTT (IRD)
GOMEZ (DHS)
KUZIA (FEMA)

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

Event Text

UNIT 1 MANUAL REACTOR TRIP FROM 100% POWER DUE TO A FIRE IN THE MAIN TURBINE

D.C. Cook Unit 1 declared an Unusual Event (EAL H4 & H5) due to a fire in the Main Turbine. The reactor was manually tripped from 100 percent. The fire occurred at the upper level of the turbine building (Level 633), and was extinguished by the fire suppression system and local fire brigade. Three fire pumps are running at this time. No injuries were reported.

All rods fully inserted, auxiliary feed water initiated and decay heat is being removed via atmospheric relief valves. Unit 1 is currently shutdown and stable in Mode 3, Hot Standby. Main steam stop valves are closed. Main condenser vacuum was broke. Unit 2 was not affected. All Unit 1 safety-related equipment is in-service and available. The licensee is currently assessing the extent of damage.

The licensee will inform the NRC Resident Inspector.

Notified DOE (Morrone), USDA (Shaf) and HHS (Mammarelli) that the NRC entered Monitoring Mode at 2045 EDT.


* * * UPDATE AT 0005 EDT ON 09/21/08 FROM BRADDOCK LEWIS TO V. KLCO * * *

"On September 20, 2008 at 20:05 the DC Cook Unit 1 Reactor was manually tripped after a malfunction occurred on the main turbine generator causing high vibration. A fire in the Unit 1 Main Generator resulted from this malfunction. A Notification of Unusual Event was declared September 20, 2008 at 20:18 due to Event classifications H-4, Fire within the protected area not extinguished within 15 minutes and H-5, Toxic or Flammable gas release affecting plant operation. The Unit 1 Main Generator Fire was reported extinguished at September 20, 2008 at 20:28.

"The Unit 1 plant trip was uncomplicated and all Automatic Control systems functioned as expected. All control rods inserted on the Reactor trip. The Turbine and both Motor Driven Auxiliary Feedwater pumps automatically started and fed all four Steam Generators as designed. The Steam Generator Stop Valves were manually closed to arrest plant cooldown. The cause of the Main Generator fire has not yet been determined, but the investigation is ongoing. No radiological release resulted from this event.

"This event is being reported as a four hour report required by 10CFR50.72(b)(2)(iv)(B) due to the Reactor Protection System automatic actuation and as an eight hour report required by 10CFR50.72(b)(3)(iv)(A) for the automatic actuation of the Auxiliary Feedwater system. The Notification of Unusual Event was reported separately.

"Unit 1 is stable in Mode 3. Shutdown Margin was satisfactorily verified. The main condenser was isolated as the primary heat sink. Steam Generator Power Operated Relief Valves are removing core decay heat in automatic control due to breaking main condenser vacuum. Main condenser vacuum was broken to stop the Unit 1 main turbine generator due to high vibration. Preparations are in progress to cooldown Unit 1 to Mode 5, Cold Shutdown.

"The Fire Suppression Water System was actuated and one of two 565,000 gallon tanks was drained. The second 565,000 gallon Fire Suppression Water tank was placed in service to restore the Fire Suppression Water system function."

The licensee notified the NRC Resident Inspector, local and state authorities. The licensee will likely make a press release.

Notified R3RA (Caldwell), R3DO (Stone), NRR (Leeds and Galloway) IRD (McDermott), DHS (Gomez) and FEMA (Kuzia).

* * * UPDATE PROVIDED BY PAUL LEONARD TO JASON KOZAL AT 0414 ON 09/21/08 * * *

At 0409 the licensee terminated from the Notice of Unusual Event. The licensee has established the forced outage recovery team. No fires exist and no conditions conducive to fires exist due to the event. The licensee has established the integrity of the fire protection system.

Notified R3RA (Caldwell), R3DO (Stone), NRR (Galloway), IRD (Grant), DHS (Jason), DOE (Maroni), FEMA (Sweetser), USDA (Phillip), and HHS (Nathan).

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Power Reactor Event Number: 44508
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MATT SCHILLERSTROM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/21/2008
Notification Time: 02:13 [ET]
Event Date: 09/20/2008
Event Time: 21:35 [CDT]
Last Update Date: 09/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANN MARIE STONE (R3)
REGION 3 IRC (R3)

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

UNPLANNED LOSS OF SHUTDOWN COOLING DUE TO CONTAINMENT ISOLATION

"On Saturday, September 20, 2008, Monticello Nuclear Generating Plant (MNGP) experienced an actuation of the following systems: Reactor Protection System (with the reactor shutdown), Containment Isolation, and Emergency Diesel Generators.

"The apparent cause of the actuation was a pressure pulse in the reference leg of a Reactor level instrument that resulted when a CRD [Control Rod Drive] pump was started without the reference leg backfill system isolated from the CRD system.

"This notification is being made in accordance with 10CFR50.72(b)(3)(iv)(A)."

Due to the containment isolation, shutdown cooling was lost for approximately 90 minutes. Initial reactor temperature was ~95 degrees when the isolation occurred. When shutdown cooling was restored, reactor temperature had increased to ~120 degrees. The Emergency Diesel Generators started but did not load. The diesels have been restored to normal standby status.

The licensee has notified the NRC Resident Inspector.

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