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Event Notification Report for April 1, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/31/2009 - 04/01/2009

** EVENT NUMBERS **


44936 44937 44941 44945 44947 44948

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General Information or Other Event Number: 44936
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: HILL BROTHERS CONSTRUCTION COMPANY, INC.
Region: 4
City: TALLULAH State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/26/2009
Notification Time: 14:58 [ET]
Event Date: 03/26/2009
Event Time: [CDT]
Last Update Date: 03/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4)
ANGELA MCINTOSH (FSME)

Event Text

TROXLER MOISTURE DENSITY GAUGE DAMAGED AT CONSTRUCTION SITE

The following information was received from the State of Louisiana by Fax:

"On March 21, 2009, a soil moisture/density gauge operated by the licensee under radioactive material (RAM) reciprocity was struck by the axle of a moving pick-up truck while the source was fully extended into the soil and while soil measurements were being performed. During an initial phone interview with the gauge operator, he stated that the gauge plunger handle had been damaged. The operator stated that the source rod might have been bent during this incident.

"The gauge operator was able to retract the source into the shielded position. Radiation readings were taken through the entire process. The gauge operator stated that he succeeded in padlocking the source rod plunger handle with the source rod in the fully upright position even though the plunger handle had been partially damaged. The operator then secured the gauge in its transportation case and performed a survey of the transportation case.

"The operator stated that he got a highest reading of 1 mR/hr at the case surface on the side next to the base of the gauge. The gauge case was resurveyed before placing the gauge back into storage in the licensee's source vault. A leak test was performed but the results are not available at this time.

"The gauge is a Troxler Model 3440, serial #31096, containing 8 mCi of Cs-137, serial # 750-5735 and a 40 mCi source of AmBe241,serial #473180.

"Additional information will be forwarded once it is received. An inspector was sent to the temporary jobsite on March 25, 2009 to verify this information."

Louisiana Event Report ID: LA090010.

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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: 03/31/2009
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."

* * * UPDATE ON 3/27/09 AT 1405 FROM STEVE WHEELER TO MARK ABRAMOVITZ * * *

"This notification is an update to EN#44937 regarding the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. Discussion with the NPPD telecommunications vendor have identified that the planned troubleshooting and repair of Cooper's EOF communications equipment was completed non-intrusively. There was no actual interruption of the EOF communications equipment. Testing by the vendor, NPPD Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector and the State and Local Agencies will be notified that the CNS EOF communications equipment is fully functional."

Notified the R4DO (O'Keefe).

* * * UPDATE AT 1739 EDT ON 3/30/09 FROM ED MCCUTCHEN TO JOE O'HARA * * *

"This notification is a second follow up to Event Notification EN# 44937 of 3/26/09 at 1852 EDT which reported the planned troubleshooting of Emergency Off Site Facility (EOF) communications equipment. The first follow up reported that the planned troubleshooting was completed non-intrusively and that no actual interruption of EOF capability occurred.

"Subsequently the telecommunication provider has advised that further troubleshooting is required. Therefore, at approximately 2300 on 3/30/09, all five T-1 data lines to the 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."

Notified R4DO(Deese).

* * * UPDATE AT 0840 EDT ON 3/31/09 FROM ROY GILES TO DONALD NORWOOD * * *

"Third follow-up of event notification EN #44937.

"Discussions with the NPPD telecommunications vendor have identified that troubleshooting and repairs to the EOF communications equipment are complete [as of 0639 CDT]. Post-work testing by Telecommunications Department personnel and NPPD Emergency Preparedness Department personnel has been completed and all EOF communications equipment has been verified to be fully functional. The NRC Senior Resident Inspector will be informed."

Notified R4DO (Deese).

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Hospital Event Number: 44941
Rep Org: MEDICAL PHYSICS CONSULTANTS
Licensee: REGIONAL MEDICAL IMAGING - FLINT
Region: 3
City: FLINT State: MI
County:
License #: 21-26076-01
Agreement: N
Docket:
NRC Notified By: LAURA LUNA
HQ OPS Officer: PETE SNYDER
Notification Date: 03/27/2009
Notification Time: 12:30 [ET]
Event Date: 03/27/2009
Event Time: [EDT]
Last Update Date: 03/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
HIRONORI PETERSON (R3)
ANGELA MCINTOSH (FSME)

Event Text

MISSED CONFIRMATIONS LED TO PATIENT RECEIVING A HIGHER DOSE

A patient was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose.

When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose.

To prevent this same type of incident from happening in the future the hospital plans on changing current practice to confirm two different times that the prescribed dose and the requested dose from the pharmacy are the same.

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

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Power Reactor Event Number: 44945
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TOM STEC
HQ OPS Officer: JOE O'HARA
Notification Date: 03/30/2009
Notification Time: 23:04 [ET]
Event Date: 03/30/2009
Event Time: 18:43 [EDT]
Last Update Date: 03/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT OF SERVICE

"On March 30, 2009, at approximately 1843 hours EDT, the control room reported a loss of power to non-safety 480 volt busses F1C and F1D. Initial investigation revealed an instantaneous ground over-current (50G) relay had actuated. This relay actuation resulted in the supply breaker tripping and all associated loads being de-energized. This resulted in a loss of 120 VAC non-essential electrical power to a portion of the Emergency Response Data System (ERDS).

"In the event of an emergency, plant parameter data will be orally transmitted to the facilities through the status Board Ring Down circuit with back-up by the Private Branch Exchange, Off Premise Exchange, and various redundant intra-facility circuits throughout the emergency facilities. The ability to open and maintain an open line using the Emergency Notification System will not be affected and will be the primary means of transferring plant data to the NRC as a contingency until the ERDS can be returned to service during the period of unavailability.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii) as a condition that results in a major loss of emergency offsite communications capability. A follow-up notification will be made when the equipment is restored.

"The NRC Resident Inspector has been notified." The unit is currently defueled.

* * * UPDATE FROM TOM STEC TO JOE O'HARA AT 1600 EDT ON 3/31/09 * * *

Last evening, power was restored to ERDS following maintenance. ERDS is capable of performing its intended function. Notified R3DO(Orth)

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Power Reactor Event Number: 44947
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2009
Notification Time: 16:43 [ET]
Event Date: 03/31/2009
Event Time: 12:00 [CDT]
Last Update Date: 03/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ORTH (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY SIREN ACTIVATED FOR REASONS UNKNOWN

"On 3/31/2009 at 1323 CDT Prairie Island Nuclear Generating Plant was notified by the site's siren contractor (NELCOM) that Pierce County siren P-20 had falsely activated at around 1200 CDT. Pierce County notified NELCOM of the siren activation after receiving several calls from the public. No press release is planned for this event.

"Siren P-20 (1 of 52 sirens) has been removed from service and backup route alerting will be used in the event siren activation is required. The cause of the false activation is being investigated and will be repaired.

"The NRC Resident Inspector has been notified."

At 1544 CDT siren P-20 was repaired and returned to service.

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Power Reactor Event Number: 44948
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: NORA GRANETO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/01/2009
Notification Time: 00:10 [ET]
Event Date: 03/31/2009
Event Time: 18:50 [EDT]
Last Update Date: 04/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MEL GRAY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

VALID DIESEL START SIGNAL RECEIVED DURING MAINTENANCE TESTING OF DIESEL

"A valid actuation of the D23 Emergency Diesel Generator bus undervoltage minimum actuation logic occurred following manual operator action to mitigate a bus overvoltage condition during emergency diesel generator post maintenance testing . Due to the output breaker being opened, the D23 EDG experienced a undervoltage start signal. EDG undervoltage actuation instrumentation actuated, however, the EDG was in PTL (Pull-to-Lock) EDG shutdown. The event was caused by a failure of the emergency diesel generator voltage regulator most likely due to an intermittent failure of the #1 rectifier bank."

The licensee stated that the D23 EDG was powering an isolated safety related bus for a post-maintenance test when the overvoltage condition occurred. The operator opened the EDG output breaker and placed the EDG in PTL. With the bus de-energized, a valid start signal was sent to EDG D23. However, EDG D23 did not actually start because it was in PTL. No safety related equipment was lost when the bus was de-energized because the bus had been unloaded prior to the test.

The licensee has notified the NRC Resident Inspector.

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Thursday, March 29, 2012