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Event Notification Report for February 9, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/06/2009 - 02/09/2009

** EVENT NUMBERS **


44723 44744 44823 44826 44830 44836 44837 44839 44840 44841

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44723
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: WILLIAM STANG
HQ OPS Officer: JASON KOZAL
Notification Date: 12/15/2008
Notification Time: 22:47 [ET]
Event Date: 12/15/2008
Event Time: 16:16 [CST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (R3)

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

Event Text

UNANALYZED CONDITION DUE TO STEAM CHASE TEMPERATURE GREATER THAN 165F

"At 1616 on 12/15/08, a plant heating boiler trip resulted in a loss of a reactor building ventilation. The loss of reactor building ventilation resulted in maximum average main steam chase temperatures greater than or equal to 165F. High energy line break (HELB) analysis of piping in the steam chase assumes an initial average temperature prior to the break of 165F. Temperature greater than or equal to 165F in the steam chase challenges EQ qualification of the piping analysis. Abnormal procedures for loss heating boiler and ventilation system failure were entered. C.3 (Shutdown) and C.5-1300 (secondary containment control) were also entered. The plant heating boiler was restarted and ventilation restored prior to power reduction. All systems have been returned to normal."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED FROM DAVID BARNETT TO JOE O'HARA AT 1158 ON 2/6/09 * * *

The licensee is retracting this report based on the following:

"Monticello is retracting the event reported based on further evaluation, which found that the issue was not an unanalyzed condition that seriously degraded plant safety. The investigation of the event found the peak temperature achieved was 167.2 degrees F and the condition lasted for approximately 11 minutes. Engineering review of Safety System Components found no impact on the equipment for the temperature reached, Additionally, revised High Energy Line Break (HELB) calculations performed with an initial average Steam Chase Room temperature of 180 degrees F before a HELB determined that Safety System components could perform their safety functions. The station has identified the cause for the event and corrective actions will be tracked in the station's corrective action program.

"Since there was no impact on the equipment in either Environmental Qualification (EQ) or safety function, the temperature of the event was less than the revised calculation temperature, and the unanalyzed condition that existed in the initial event notification report no longer exists and did not result in a condition that seriously degraded plant safety, this event can be retracted."

The licensee informed the NRC Resident Inspector. Notified R3DO (Ring).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 44744
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/28/2008
Notification Time: 13:59 [ET]
Event Date: 12/28/2008
Event Time: 04:45 [CST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
GEORGE HOPPER (R2)
ERIC BENNER (NMSS)

Event Text

24 HOUR REPORT - ACTUATION OF LEAK DETECTION SYSTEM DUE TO MINOR PROCESS GAS LEAK

"On 12/28/2008 at 0445 the C-337 unit 5 cell 3 PGLD (process gas leak detection) head located on stage 8 actuated. Operators responded to the alarm and performed sampling in the area. The sample result indicated 3 ppm of HF at the stage 8 compressor. To stop the release the cell was taken off-stream and the pressure was reduced to below atmosphere. Investigation indicated that a UF6 release had occurred. The amount of material released has not been determined.

"The actuated PGLD head is Q safety system component. At the time of the incident the cell was operating in a mode which required the system to be operable. This is being reported based on SAR 6.9 Table 1, J.2 as an Unplanned Actuation of a Q Safety System.

"The NRC Senior Resident Inspector has been notified of this event."

The licensee states that a compressor seal appears to have failed. The amount of material released is characterized as on the order of a few grams. Material release was only in the vicinity of the compressor. There was nothing unusual or not understood and all systems functioned as required. There was no offsite release or personnel contamination resulted from this event.

* * * RETRACTION PROVIDED ON 02/06/09 AT 1427 FROM BEASLEY TO KLCO * * *

"A subsequent review by USEC Regulatory Affairs concluded that the UF6 Release Detection System detectors installed 'above the `B' seals on the axial flow compressors' (SAR 3.3.5.9.5), and the detectors for the instrument cubicles do not 'prevent or mitigate the consequences of postulated accidents that could result in a member of the general public located offsite being exposed to EG (Evaluation Guidelines)-1 or EG-2 guideline values' (SAR 4.2.2). Therefore, they do not meet the criteria to be classified as 'Q' (SAR 4.2.2).

"The safety equipment actuation reporting criteria (SAR 6.9-1 J.2) requires NRC to be notified of actuations of "Q" systems resulting from events that have the potential for significant impact on the health and safety of personnel, which are defined in the criteria as those events where actual plant conditions existed that the system was designed to protect against. Since the referenced UF6 Release Detection System detectors do not meet the criteria to be classified as "Q" and do not protect against a postulated accident that could result in a member of the general public being exposed to EG-1 or EG-2 guideline values, the actuations would not be reportable under this criteria.

"Summary:
- the B-end seal PGLD [Process Head Leak Detector] head is not required to be 'Q'
- the postulated release from the B-end seal cavity does not have significant impact on personnel.
- A release from the B-end seal cavity is not a condition that the PGLD system is designed to protect against.

"The NRC Senior Resident Inspector has been notified of this event retraction."

Notified R2DO (Rudisail) and NMSS (Kotzalas).

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General Information or Other Event Number: 44823
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/02/2009
Notification Time: 12:25 [ET]
Event Date: 01/27/2009
Event Time: [EST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the State of North Carolina via facsimile:

"On January 27, 2009, a Therasphere (Y-90 microsphere) procedure was scheduled for a patient in Room 4, Special Procedures. The treatment was planned to deliver 110 Gy to the left lobe of the liver. The delivery apparatus was assembled according to manufacturer instructions, without incident. The treatment was initiated. During the first infusion, the Authorized User noticed fluid leakage at the outlet flow line and needle insertion at the source vial. The RSO was contacted. An attempt was made to continue the infusion. The liquid continued to leak at the outlet flow line and needle junction. No additional radioactivity was delivered to the patient. The procedure was terminated.

"Post procedure survey readings of the source vial indicated that approximately 65% of the intended radioactivity was delivered to the patient. This resulted in a dose of 70 Gy delivered to the left lobe of the liver.

"The Authorized User indicated that no adverse clinical symptoms are expected. This was the second treatment for this patient.

"The manufacturer (MDS Nordion) was notified of the device problem on 01/28/09.

"All liquid and contamination was contained by Radiation Safety personnel."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

* * * UPDATE AT 1425 ON 2/06/09 FROM ALBRIGHT TO KLCO* * *

Notified that the event is documented by the North Carolina Radioactive Materials Branch as incident NC-09-11.

Notified the R1DO (Gray) and FSME (McIntosh).

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General Information or Other Event Number: 44826
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SWEDISH HOSPITAL
Region: 4
City: ENGLEWOOD State: CO
County:
License #: 251-02
Agreement: Y
Docket:
NRC Notified By: MARK DATER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/03/2009
Notification Time: 10:45 [ET]
Event Date: 01/28/2009
Event Time: 15:45 [MST]
Last Update Date: 02/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
ANGELA McINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT LEAVES RADIATION THERAPY TREATMENT WITHOUT RECEIVING REQUIRED INSTRUCTIONS

Received from the state by facsimile:

The patient left the hospital without receiving the required radiation therapy instruction. "The patient and her husband were adamant about leaving without waiting any longer. This was an unreasonable patient's husband driving this situation and we [Swedish Hospital] see no need to change our release criteria or procedures because of aberrant behavior of a family member. The patient had this procedure twice before [September 2005 and April 2006]. The implant in 2005 delivered 0.99 GBq. At the time the exposure reading at one meter was 0.25 mR/hr. This most recent procedure delivered less activity, and I would anticipate an even smaller exposure risk at one meter."

Source: Y-90 SIR Spheres at approximately 0.9 GBq

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Power Reactor Event Number: 44830
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ERIC STRONG
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/05/2009
Notification Time: 14:34 [ET]
Event Date: 02/05/2009
Event Time: 14:13 [EST]
Last Update Date: 02/06/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JOHN WHITE (R1)
MARC DAPAS (RDAR)
MJ ROSS-LEE (EO)
JEFFERY GRANT (IRD)
JIM WIGGINS (ET)
MIKE INZER (DHS)
DENNIS VIA (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO LOSS OF CONTROL ROOM ANNUNCIATORS

At 1413 EST Ginna Station declared an Unusual Event due to the Loss of Main Control Board Annunciators E, F, G and H. There was ongoing maintenance at the time, however, no specific cause for the loss has been identified. The licensee confirmed that they have redundant indication available to monitor plant parameters. The unit is currently stable and operating at 100% power.

The licensee informed state and local agencies and the NRC Resident Inspector.

* * * UPDATE FROM DOUG GOMEZ TO DONALD NORWOOD AT 0458 ON 2/6/09 * * *

Based on testing, troubleshooting, and restoration of power to the Main Control Board Annunciators, Ginna Station exited the Unusual Event at 0435 hours on 2/6/09.

The licensee notified the NRC Resident Inspector.

Notified RDO (Gray), NRR EO (Hiland), IRD MOC (Grant), DHS (Kettles), and FEMA(LaForty).

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General Information or Other Event Number: 44836
Rep Org: FISHER CONTROLS INTERNATIONAL
Licensee: FISHER CONTROLS INTERNATIONAL
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MATTHEW FARRELL
HQ OPS Officer: VINCE KLCO
Notification Date: 02/06/2009
Notification Time: 15:54 [ET]
Event Date: 02/06/2009
Event Time: [CST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MARK RING (R3)
HAROLD GRAY (R1)
STEVEN RUDISAIL (R2)
JEFF CLARK (R4)
OMID TABATABAI-EMAIL (NRO)
TOM HERRITY-EMAIL (NRR)

Event Text

PART 21 REPORT - DEFECTIVE ASME SA-193, GRADE 6 CAP SCREW MATERIAL

The following information was obtained from Fisher Controls International via facsimile:

Fisher Information Notice (FIN 2009-01, dated February 2, 2009) was issued to notify customers of an issue reported to Fisher by Duke Energy.

"[Fisher has] informed [their] customers of record of this circumstance in accordance with 21.21 (b) of 10CFR21 because Fisher Controls International LLC, is not aware of each and every application or system design and cannot determine whether an anomaly could cause a defect or "failure to comply," relating to a substantial safety hazard. In particular, this Information Notice deals with customer orders that used improperly heat treated cap screws provided by Texas Bolt Company (Texas Bolt Order 204653, Certified by Texas Bolt Company, April 20, 1987). Receipt of this notice does not necessarily mean that the recipient has been shipped any of the subject equipment. It is expected that the recipients of this notice will review the information for applicability to their facilities, and if required, take the appropriate action as described in the section at the end of this notice.

"This notice applies only to customer orders processed by Posi-Seal International that used the 100 quantity lot of hex head cap screws identified by Texas Bolt Company Material Certification Report Number 001.87-1758, certified by Texas Bolt Company, April 20, 1987.

"Fisher was informed by Duke Energy that there have been failures of ASME SA-193 Grade B6 hex head cap screws at the Catawba Nuclear Station. These bolts are used on various size Posi-Seal butterfly valves to maintain a pressure seal on the outboard side of the valve body. Failure of these bolts will impair the pressure retaining capability of the valve body.

"Based on the experiences at Duke Energy, it is possible that a defective batch of cap screws were used by Posi-Seal around 1987. Fisher Controls International has attempted to determine a complete list of valve serial numbers that may have used bolts from this particular lot. Unfortunately, Fisher Controls International's review of available Posi-Seal records cannot provide validation of its completeness.

"It is recommended that customers verify if the QA documentation package, provided with the valve, contains a copy of the cap screw material certification attached to this information notice. If so, Fisher Controls International recommends that the subject cap screws be replaced.

"Fisher Controls requests that the recipient of this notice review it and take appropriate action in accordance with 10CFR21.

"If there are any technical questions or concerns, contact:

Michael Wedemeyer
Manager, Quality
Fisher Controls International LLC
205 South Center Street
Marshalltown, IA 50158
Fax: (641) 754-2854
Phone: (641) 754-2066
Michael.Wedemeyer@.Emerson.com"

Possible domestic constructions with defective cap screw material (Posi-Seal part number 131550, drawing number 5200-001) include McGuire, Catawba and Indian Point.

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Power Reactor Event Number: 44837
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: PETER JACKSON
HQ OPS Officer: VINCE KLCO
Notification Date: 02/07/2009
Notification Time: 12:18 [ET]
Event Date: 02/07/2009
Event Time: 10:59 [CST]
Last Update Date: 02/07/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JEFF CLARK (R4)
ELMO COLLINS (R4 R)
BRIAN McDERMOTT (IRD)
PATRICK HILAND (NRR)
JAMES WIGGINS (NRR)
BANNER (DHS)
GENE CANUPP (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 90 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO A FIRE ONSITE

Arkansas Nuclear One Unit 1 declared an Unusual Event per EAL 7.5 at 1059 CST based on a fire onsite. The fire occurred on the 354 foot elevation iso-phase bus deck of the turbine building. The fire was attributed to a failed bonnet on a manual valve which had unthreaded during operation releasing hydrogen in the vicinity of the hydrogen add station. The licensee extinguished the fire using water and posted a reflash watch. There were no reported personnel injuries. Offsite assistance was requested from the London Fire Department which arrived onsite after the fire had been extinguished.

The reactor was manually tripped with all control rods fully inserting. The plant is currently stable with decay heat removal via the steam dumps to the main condenser.

The licensee informed state/local agencies and the NRC Resident Inspector.

* * * UPDATE AT 1338 EST ON 2/7/09 FROM JACKSON TO SANDIN * * *

The Unusual Event was terminated at 1338 CST after confirmation that the fire was extinguished and a review of the exit criteria as defined in plant procedures. The licensee is performing a damage assessment at this time.

The licensee was in the process of informing state/local agencies and will inform the NRC Resident Inspector. Notified R4DO (Clark), NRR(Hiland), IRD (Grant), DHS (Banner) and FEMA (Canupp).

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Power Reactor Event Number: 44839
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: BRANDON ABNEY
HQ OPS Officer: VINCE KLCO
Notification Date: 02/08/2009
Notification Time: 18:08 [ET]
Event Date: 02/08/2009
Event Time: 11:25 [PST]
Last Update Date: 02/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JEFF CLARK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 75 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO A GOVERNOR VALVE FAST CLOSURE SIGNAL

"Following a downpower to 75% for replacement of DEH-SV-TRIP/B (solenoid for quadvoter valve) a reactor SCRAM occurred during the performance of the DEH [Digital Electric Hydraulic] quadvoter valve testing. The cause of the reactor SCRAM was Governor Valve Fast Closure signal due to DEH trip header pressure fluctuation. The cause of the DEH trip header pressure fluctuation is unknown and being investigated. All rods fully inserted. MSIVs remained open. No SRVs opened. RPV level is being controlled in the normal band using the feedwater and condensate systems. RPV pressure is being controlled in the normal band using the Bypass valves and Main Steam Line drains. All other safety systems operated as designed. Off-site power is available. All three emergency diesel generators are operable and available."

The licensee will be making a press release.

The licensee notified the NRC Resident Inspector.

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Research Reactor Event Number: 44840
Facility: REED COLLEGE
RX Type: 250 KW TRIGA MARK I
Comments:
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: STEPHEN FRANTZ
HQ OPS Officer: VINCE KLCO
Notification Date: 02/08/2009
Notification Time: 20:18 [ET]
Event Date: 02/08/2009
Event Time: 16:02 [PST]
Last Update Date: 02/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
JEFF CLARK (R4)
DAN HUGHES (NRR)

Event Text

TEST REACTOR EXCEEDED LICENSED POWER LIMIT DURING CALIBRATION

"Performing routine thermal power calibration of nuclear instruments at indicated power of 230 kW per SOP-33. Calculation indicated actual power of 263 kW after collecting data. Licensed power limit is 250 kW.

"No apparent cause for the calibration error. [The previous] calibration was successfully done on January 16, 2009."

The reactor was shutdown. All systems functioned as required. The licensee noted that the pool temperature was about 7 degrees Celsius cooler than the historical pool temperature.

The licensee will notify the NRR Project Manager and the State of Oregon.

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Power Reactor Event Number: 44841
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW NORRIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/09/2009
Notification Time: 04:31 [ET]
Event Date: 02/09/2009
Event Time: 04:15 [EST]
Last Update Date: 02/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN RUDISAIL (R2)

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

Event Text

TSC OOS DUE TO PLANNED HVAC MAINTENANCE

"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance being performed on the TSC HVAC. Alternate facilities are available to provide emergency functions and actions are proceeding to return the TSC to FUNCTIONAL status with high priority. A 10CFR50.54(q) evaluation has been performed for this planned maintenance activity and has determined that this work may be performed without prior NRC approval.

"The NRC Resident Inspector has been notified."

The licensee stated that the planned maintenance on the TSC HVAC and return to service of the TSC should be completed within 12 hours.

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