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Event Notification Report for March 27, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/26/2009 - 03/27/2009

** EVENT NUMBERS **


44832 44883 44930 44934 44935 44937 44938 44939

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44832
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: GARY AHRENS
HQ OPS Officer: VINCE KLCO
Notification Date: 02/05/2009
Notification Time: 21:36 [ET]
Event Date: 02/05/2009
Event Time: 15:39 [CST]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK RING (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

STEAM EXCLUSION DOOR GAP

"At 1539 on 02/05/2009 it was identified that a Steam Exclusion door seal was not flush with the door. The door seal gap was noted during a Fire Zone Inspection. It was determined that the door exceeded the allowed limit. This could have allowed steam from the Turbine Drive Auxiliary Feed Pump room into the emergency safeguards bus area. This could have resulted in both trains of ESF Equipment failing to perform their required functions. Upon discovery Specification 3.0.c was entered at 1539. Work was completed on the door to return it to functional status at 1601, and Technical Specification 3.0.c was exited at that time.

"The NRC Resident inspector has been notified."

* * * RETRACTION PROVIDED BY JACK GADZALA TO JASON KOZAL ON 3/26/09 AT 1102 * * *

"Retraction of EN 44832, both trains of Engineered Safeguards Features (ESF) equipment inoperable due to a degraded steam exclusion boundary door.

"EN 44832 provided notification that both trains of ESF equipment were inoperable due to degradation of a steam exclusion boundary door in the turbine driven auxiliary feedwater pump room on February 5, 2009.

"Subsequent engineering evaluation determined that the degraded door remained capable of fulfilling its steam exclusion function during the period when it was degraded. A degraded door seal had resulted in a slight gap to exist between the door and the sill. This gap could have allowed steam from the turbine driven auxiliary feedwater pump room into the emergency safeguards bus area. However, the force that would be exerted on the door by steam overpressure postulated under accident conditions, would compress the door seal sufficiently to reduce the gap such that the total allowed leak path criteria would not be exceeded.

"Therefore, the door remained functional and the supported ESF equipment in the emergency safeguards bus area remained operable.

"Consequently, this condition did not meet the reportabllity criteria in 10 CFR 50.72. As a result, the notification made on 02/05/2009 (EN 44832) is hereby retracted."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Peterson).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44883
Rep Org: UNION HOSPITAL INC
Licensee: UNION HOSPITAL INC
Region: 3
City: TERRE HAUTE State: IN
County:
License #: 13-1645701
Agreement: N
Docket:
NRC Notified By: DEAN TAYLOR
HQ OPS Officer: JOE O'HARA
Notification Date: 02/27/2009
Notification Time: 15:32 [ET]
Event Date: 02/26/2009
Event Time: [EST]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
HIRONORI PETERSON (R3)
PATRICE BUBAR (FSME)

Event Text

POTENTIAL LEAKING I-125 PROSTATE CANCER THERAPY SEED

A patient was being treated for prostate cancer. After a treatment of (15) I-125 seeds, the magazine used to inject the seeds into the patient was surveyed and the survey indicated that the magazine was contaminated. Initially, the staff believed that a seed may have been stuck inside the magazine. However, upon disassembly the staff determined that the magazine was empty. The prostate cancer therapy treatment continued without incident. The patient was x-rayed, and all seeds were accounted for. A survey of the room, instruments, and packaging material revealed no loose surface contamination. The contamination is confined to the inside of the magazine. The staff believes there are two potential scenarios to explain the contamination inside the magazine: (1) the seeds had external contamination when placed inside the magazine, or (2) during the autoclave a weak weld failed and the seed began to leak. If a seed is leaking iodine into the patient, then if left untreated, the patient could potentially receive a dose of 50 Rem to the thyroid gland. A physician has prescribed a treatment to block uptake to the thyroid, and the blood and urine samples thus far are inconclusive in determining if iodine is leaking into the patient. I-125 seed activity is .302 millicuries per seed. The patient is aware of the issue. Thyroid scans and urine assays will continue for the next four weeks to determine if radioactive iodine is present in sufficient quantities to indicate a leaking seed.

* * * RETRACTION PROVIDED BY DEAN TAYLOR TO JASON KOZAL 0N 03/26/09 AT 1125 * * *

The licensee's theory is that the seed in question had a bad weld that was not realized until the seed was exposed to the heat sterilization process. This is due to the fact that there was no contamination present prior to the sterilization process.

The licensee completed multiple thyroid scans and blood work on the patient with negative results. Additionally, the licensee performed multiple urine assays with negative results. The patient will continue with potassium iodine treatment for the next 2 years to minimize thyroid uptake. Based on this information the licensee is retracting this event.

Notified the R3DO (Peterson) and FSME (McIntosh).

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General Information or Other Event Number: 44930
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON DICKINSON INFUSION THERAPY SYSTEMS INC
Region: 4
City: BROKEN BOW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JOE O'HARA
Notification Date: 03/23/2009
Notification Time: 16:28 [ET]
Event Date: 03/22/2009
Event Time: [CDT]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - ABNORMAL EXCESS LOSS OF WATER INTO DRAIN SYSTEM FROM DE-IONIZATION SYSTEM

The following information was provided from the State of Nebraska via e-mail:

"The Nebraska DHHS [Department of Health and Human Services] was notified on March 23, 2009 at 0825 by the Radiation Safety Officer (RSO) for Becton Dickinson in Broken Bow, Nebraska. On March 22, 2009 in the evening, the RSO received a call from one of the pool irradiator operators. During the operator's weekly sterilizer checks, he noticed that the pool water make-up meter indicated the pool had used 1,103 gal for the week. Normal usage is about 120 gal/week. Investigation on the next morning revealed a bleed valve on the D.I. [de-ionizing] water system was cracked open, allowing D.I. water to flow to drain. This was not readily apparent because the hose goes down into the drain. The RSO closed the valve, recorded the current meter reading, noting the meter had used about 100 gal overnight. The RSO intends to check the reading Tuesday morning to see if closing the valve solved the problem. This water leaking does not affect the level of the pool water.

"Nebraska DHHS has notified Randy Erickson, NRC, Region IV

"Event report ID No. NMED NE090006"

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Power Reactor Event Number: 44934
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Notification Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
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):
STEVEN VIAS (R2)
MARY JANE ROSS-LEE ()
ANTHONY McMURTRAY (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 97 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP AND AUX FEED WATER START DUE TO LOSS OF AN OFF SITE POWER SOURCE

"At approximately 0452 on 03/26/09, Sequoyah Unit 1 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 1B and 1D Unit Boards. The 1B and 1D unit boards are the 6.9Kv electrical feeds to the 1-2 and 1-4 RCPs, respectively. RCPs 1-1 and 1-3 are running.

"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 1A Shutdown Board is being powered from the 1A EDG.

"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.

"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."

All rods inserted as expected. No safety related equipment is out of service. Unit 1 has no known Steam Generator Tube leaks.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44935
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JASON KOZAL
Notification Date: 03/26/2009
Notification Time: 08:29 [ET]
Event Date: 03/26/2009
Event Time: 04:52 [EDT]
Last Update Date: 03/26/2009
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):
STEVEN VIAS (R2)
MARY JANE ROSS-LEE (NRR)
ANTHONY McMURTRAY (IRD)

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

Event Text

AUTOMATIC REACTOR TRIP AND AUX FEED WATER START DUE TO LOSS OF AN OFF SITE POWER SOURCE

"At approximately 0452 on 03/26/09, Sequoyah Unit 2 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 2B and 2D Unit Boards. The 2B and 2D unit boards are the 6.9Kv electrical feeds to the 2-2 and 2-4 RCPs, respectively. RCPs 2-1 and 2-3 are running.

"ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 2A Shutdown Board is being powered from the 2A EDG.

"The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves.

"The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing."

All rods inserted as expected. No safety related equipment is out of service. Unit 2 has no known Steam Generator Tube leaks.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44937
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: EDWARD McCUTCHEN JR.
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/26/2009
Notification Time: 18:52 [ET]
Event Date: 03/27/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL OKEEFE (R4)

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

TROUBLESHOOTING EMERGENCY OFFSITE FACILITY COMMUNICATIONS

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) as an event that will result in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g. significant portion of control room indication, Emergency Notification System or offsite notification system.)

"At approximately 0000 on 3/27/09, all five of the T-1 data lines to the Emergency Offsite Facility (EOF) will be taken out of service to troubleshoot and repair malfunctioning phone company equipment. Multiple short duration outages will occur until the malfunction can be located and repaired. This outage will cause a loss of Plant Management Information System printer capability, Safety Parameter Display System (SPDS) capability, FTS 2001 system, Alternate Intercom system, Low Band base radio (the primary Downwind Survey team radio), State Notification Telephone System, Dose Assessment and some external phone lines at the EOF. This loss of capability affects only the off-site EOF. All other emergency communications from the site to the NRC are not affected.

"Compensatory measures being put into effect include SPDS information relayed via telephone from the Technical Support Center, dose assessment and offsite notifications and reports via alternate means, or relocate the on-call Emergency Director to the Control Room and make notifications to offsite agencies via the Control Room Communicator. CNS is in contact with communications personnel to restore the T-1 lines as quickly as possible in the event of a declared emergency.

"Region IV and the NRC Resident Inspector were notified of the planned loss of the T-1 lines. CNS will notify the NRC when all EOF equipment affected by the T-1 lines have been satisfactorily tested and verified to be operational."

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Power Reactor Event Number: 44938
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: GARY AHRENS
HQ OPS Officer: PETE SNYDER
Notification Date: 03/26/2009
Notification Time: 19:43 [ET]
Event Date: 03/26/2009
Event Time: 12:26 [CDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
HIRONORI PETERSON (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 94 Power Operation

Event Text

NON-FUNCTIONAL STEAM EXCLUSION BARRIER

This event was additionally reported under 10 CFR 50.72(b)(3)(v)(D), 'Mitigate the Consequences of an Accident.'

"On 03/26/2009 at 1226 CDT, an engineering analysis determined that a steam exclusion door would not provide adequate steam exclusion protection. A metal plate, that had been installed over the door's glass window, would fail under the steam overpressure postulated during a high energy line break. The metal plate was replaced with one of a stronger design. Permanent repairs were completed on the door at 1549 on 03/26/2009. While the original plate was installed, the barrier was non-functional. In accordance with TRM 3.0.9, Section A.1 all equipment supported by that steam exclusion barrier was immediately declared inoperable. This zone includes both trains of ECCS and support equipment (i.e., SI, RHR, ICS, CCW, etc.). TS 3.0.c was entered and exited during the time the door issue was identified and repaired.

"All 3 trains of Auxiliary Feedwater were declared inoperable due to AFW low suction pressure trip channels were declared inoperable per TS 3.4.b.5. Power was reduced to less than 1673 MWt per TS 3.4.b.3. All mode changes were suspended per TS 3.4.b.2.

"Therefore, this is reportable under 10 CFR 50.72 (b)(3)(v), 'Any event or condition that at the time of discovery could have prevented the fulfillment of a safety function,' and under 10 CFR 50.72(b)(3)(ii)(B) 'any event or condition that results in the nuclear plant being in an unanalyzed condition that significantly degrades plant safety.'"

Containment Fan Coil Unit A was not operational during this event.

"The licensee notified the NRC Resident Inspector."

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Fuel Cycle Facility Event Number: 44939
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: BOB STOKES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/26/2009
Notification Time: 21:16 [ET]
Event Date: 03/24/2009
Event Time: 13:30 [CDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
STEVEN VIAS (R2)
ABY MOHSENI (NMSS)

Event Text

BUILDING CONTAMINATED DURING MAINTENANCE

The licensee was troubleshooting a green salt filter leg when approximately 100 pounds of green salt was released from a secondary dust collector drop leg pipe. Four personnel were in the area wearing respiratory protection and anti-contamination clothing. The personnel left the area and access was restricted until 1030 on 3/26/2009. The green salt contaminated four floors of the building and the four personnel. Personnel contamination was removed with removal of the anti contamination clothing and subsequent showers. Most of the floor contamination was cleaned within four hours and the remainder was completed on 3/26/2009. No contamination was released outside the building.

The licensee notified the NRC Resident Inspector.

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