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Event Notification Report for April 29, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/28/2009 - 04/29/2009

** EVENT NUMBERS **


45011 45014 45018 45019 45025 45026 45027 45028 45029

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General Information or Other Event Number: 45011
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/23/2009
Notification Time: 11:46 [ET]
Event Date: 04/22/2009
Event Time: 09:00 [CDT]
Last Update Date: 04/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - MEDICAL MISADMINISTRATION

The following was received from the agreement state with a state control number of KY0901:

"At 1400 on 4/22/2009, the RSO of a medical licensee reported the misadministration of a radiopharmaceutical to a seven-month-old infant. The infant was scheduled for a renal scan and was ordered to receive a 2 mCi dose tagged with Tc-99m. The patient was inadvertently administered a 35 mCi dose of Sestamibi/Tc-99M.

"Event date: 4/22/2009. Discovery date: 4/22/2009. Report date: 4/22/2009.

"Licensee Reporting Party Information: University of Kentucky, Lexington KY 40506, License number: 202-049-22.

"Site of event: Lexington, KY.

"Event type: MD2 - Medical event.

"Event cause: Human error."

The patient was informed on 4/22/2009.

The intended diagnostic study was renal-glomerular filtration with dimercaptosuccinic acid (DMSA) radiopharmaceutical, with a 2 mCi (74 MBq) Tc-99m radionuclide.

The given diagnostic study was cardiac perfusion with sestamibi/cardiolite radiopharmaceutical, with a 34.9 mCi (1291.3 MBq) Tc-99m radionuclide. The dose exceeded the prescribed dose by 1650%. It is estimated that the heart received a dose of 2.84 rem, and the whole body does was 6.84 rem. The effect on the patient is unknown at this time.

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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General Information or Other Event Number: 45014
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: COVANTA HAVERHILL
Region: 1
City: HAVERHILL State: MA
County:
License #: N/A
Agreement: Y
Docket: 04-8427
NRC Notified By: J. THOMAS COULOMBE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/23/2009
Notification Time: 14:49 [ET]
Event Date: 04/16/2009
Event Time: [EDT]
Last Update Date: 04/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

COMMINGLED WASTE

The following was received from the commonwealth via fax:

"On April 16, 2009, the Covanta Haverhill trash-to-energy plant requested a routine DOT-E 11406 for the rejection of a shipment of commingled commercial and industrial trash. The shipment was returned to the point of origin in Peabody, which was the Casella Waste Systems facility at 295 Forest Street. The load was secured at 295 Forest Street in Peabody until their competent consultant could survey and process the load on April 21, 2009. The consultant separated out over 150 industrial smoke detectors from the front end loader. These devices were industrial smoke detectors. Most models contained Am-241 80 micro curies each; but many others contained 40 micro curies each of Radium-226. The consultant faxed a preliminary report to the [MA state] Agency on April 22, 2009 and pledged to follow-up with an accurate breakdown of the exact RAM and total activities involved as the information is developed. Complete information was not available as of the time of this report. This same consultant is also arranging for the legal disposition of the smoke detectors and assisting the Casella Waste Systems management in tracking down the source of the RAM."

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General Information or Other Event Number: 45018
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: VIRGINIA COMMOMWEALTH UNIVERSITY
Region: 1
City: RICHMOND State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: PETE SNYDER
Notification Date: 04/24/2009
Notification Time: 15:32 [ET]
Event Date: 04/24/2009
Event Time: [EDT]
Last Update Date: 04/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
DUNCAN WHITE (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

"On April, 23, 2009, the Virginia Department of Health (VDH) was notified by Virginia Commonwealth University (VCU) that a Nuclear Radiation Developments, Inc. 'Ionotron' containing an Am-241 source has been lost. The source is a model number A-001 with an activity of 20 microcuries on 12/75.

"The source was last inventoried on February 27, 2009. Since then, VCU began to clean up this storage location and placing unwanted material in a barrel for disposal through RSO, Inc. The barrel was picked up on April 1, 2009.

"VCU found the source missing when they went to take a picture for its disposal through the SCATR program. It is believed that the source was placed into the barrel and has been disposed of by RSO, Inc.

"VCU will submit the 30 day written report to VDH."

This report is VA number: VA-09-01.

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.

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General Information or Other Event Number: 45019
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BF GOODRICH
Region: 1
City: TUSCALOOSA State: AL
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/24/2009
Notification Time: 16:33 [ET]
Event Date: 04/24/2009
Event Time: 11:20 [CDT]
Last Update Date: 04/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
DUNCAN WHITE (FSME)
ILTAB VIA E-MAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - TWO MISSING GENERAL LICENSED DEVICES

The following information was received via facsimile from the Alabama Office of Radiation Control:

"On the morning of April 24, 2009 at approximately 1120 am CDT, the Alabama Office of Radiation Control received a phone call from representatives of BF Goodrich in Tuscaloosa, Alabama advising the [State] Agency of the discovery of two missing general licensed devices containing radioactive material. The representatives of BF Goodrich indicated that on April 23, 2009, two NDC model 103 profile gauges containing 150 millicuries each of Am-241 were discovered to be missing. The gauges were installed at the facility but had not been in use for an extended period of time. The shutter for each of the devices were reported as closed. The serial numbers reported were 13311 and 13312. The gauges were possessed and used under a general license registration. Representatives of BF Goodrich continue to investigate the incident and will provide a written report within 30 days."

Alabama Incident 09-15


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.

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Power Reactor Event Number: 45025
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: THOMAS MORSE
HQ OPS Officer: VINCE KLCO
Notification Date: 04/28/2009
Notification Time: 00:55 [ET]
Event Date: 04/27/2009
Event Time: 17:30 [EDT]
Last Update Date: 04/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

RESIDUAL HEAT REMOVAL (RHR) PUMP TRIPPED WHILE IN OPERATION FOR SHUTDOWN COOLING

"On April 27, 2009, at approximately 1730 hours, with the plant in Mode 5 during refueling outage (RFO) 12, RHR 'A' pump tripped while operating in shutdown cooling. RHR 'A' was the primary decay heat removal shutdown cooling system. RHR 'B' was the backup decay heat removal shutdown cooling system. Preliminary investigation shows that jumper installation activities associated with plant testing resulted in a blown fuse and closure of the RHR shutdown cooling outboard common suction isolation valve (1E12F008). Closure of the 1E12F008 valve tripped the RHR 'A' pump and prevented the RHR 'B' pump from being used to initiate shutdown cooling from the control room. Operators were preparing to manually open 1E12F008 in parallel with activities to restore control from the control room.

"The plant entered Technical Specification 3.9.9, 'RHR - Low Water Level', Conditions A and C due to 1E12F008 isolating causing the loss of shutdown cooling. Action A.1 calls for verification of an alternate method of decay heat removal available for each inoperable RHR shutdown cooling subsystem in 1 hour and once per 24 hours thereafter. This was completed with the fuel pool cooling and cleanup system's two pumps and two heat exchangers cooled by NCC [Nuclear Closed Cooling System] (available due to the ability to reflood the upper pools with a hotwell pump through normal cavity reflood path) being one alternate system. A second alternate system was the utilization of the low pressure core spray to flood the vessel, returning to the suppression pool through safety relief valves, and a loop of RHR in suppression pool cooling. Actions for Condition C, to verify reactor coolant circulation by an alternate method and to monitor reactor coolant temperature were not met due to no reactor coolant flow past a valid temperature monitoring point. Approximate reactor coolant temperature was being trended using the reactor water cleanup system.

"The blown fuse was identified and replaced at approximately 1816 hours. The RHR 'B' pump was started at approximately 1834 hours. From the time that the RHR 'A' pump tripped (approximately 1730), until the RHR 'B' pump was started, the reactor temperature increased from 94 degrees F to 97 degrees F. Pre-determined time to boil had been calculated to be 9 hours. At approximately 1835 hours, TS 3.9.9 Condition C was exited due to the RHR 'B' shutdown cooling loop being placed in operation.

"This event is being reported as an event or condition that at the time of discovery could have prevented fulfillment of a safely function of structures or systems that are needed to remove residual heat under 10 CFR 50.72(b)(3)(v)(B).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 45026
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/28/2009
Notification Time: 12:00 [ET]
Event Date: 04/28/2009
Event Time: 09:53 [EDT]
Last Update Date: 04/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MIKE ERNSTES (R2)
JOHN THORP (NRR)

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

Event Text

EMERGENCY DIESEL AUTO-START DUE TO LOSS OF THE "B" RESERVE STATION SERVICE TRANSFORMER

"At 0953 hours on April 28, 2009, a loss of the 'B' Reserve Station Service Transformer resulted in a Degraded Voltage / Under Voltage automatic start of the Unit 2 'H' Emergency Diesel Generator. The Unit 2 'H' Emergency Diesel Generator is operating and supplying electrical power to the Unit 2 'H' 4160 Volt Bus. The Unit 2 'B' Charging Pump (2-CH-P-1B) and the Unit 2 'B' Component Cooling Water Pump (2-CC-P-1B) also auto started in response to the loss of power. [Procedure] 0-AP-10, 'Loss of Electrical Power', was entered to address the loss of the normal power source for the Unit 2 'H' Emergency Bus.

"Unit 2 is operating at 100% power and an investigation has been initiated to determine the cause of the event and appropriate corrective actions.

"The NRC Resident Inspector has been notified."

There was no impact on Unit 1 operation. There was no loss of significant safety equipment as a result of the transformer loss. The licensee will continue to supply the 'H' 4160V bus with the 'H' Emergency Diesel Generator until compensatory measures are put in place. The loss of the 'H' bus places Unit 2 in a 72-hr shutdown action statement.

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Power Reactor Event Number: 45027
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: BILL STUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/28/2009
Notification Time: 17:41 [ET]
Event Date: 04/28/2009
Event Time: 15:27 [CDT]
Last Update Date: 04/28/2009
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):
WAYNE WALKER (R4DO)

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

AUTOMATIC REACTOR TRIP ON LOW STEAM GENERATOR LEVEL DUE TO FEEDWATER VALVE FAILURE

"Wolf Creek experienced a reactor trip at 1527 CDT. The RX trip resulted from low level in 'B' S/G. [The] 'B' Main Feedwater Regulating Valve [FRV] AE FCV-520 closed causing a loss of feedwater to the 'B' S/G. Initial investigation indicates that the FRV controllers lost power due to blown primary and backup fuses associated with its card rack.

"One intermediate range instrument (SE NI-36) stuck at 10E-10 amps requiring manual energization of source range instruments.

"Aux Feedwater and Feedwater Isolation actuations occurred as expected."

All control rods inserted into the core during the trip. There were no relief or safety valves actuated during the transient. The electrical plant is in the normal shutdown alignment with offsite power supply emergency busses. Decay heat is being removed via the steam dumps to condenser. The licensee is investigating the cause of the blown fuses.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45028
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: CURT STEFFES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/28/2009
Notification Time: 19:34 [ET]
Event Date: 04/28/2009
Event Time: 18:34 [CDT]
Last Update Date: 04/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

PROCESS COMPUTER REPLACEMENT IMPACTING ERDS AND SPDS

"During the current Unit 1 refueling outage, the plant process computer system will be taken out of service for approximately three weeks to support a planned modification which will install a new (upgraded) plant process computer system. During this timeframe, ERDS [Emergency Response Data System] and SPDS [Safety Parameter Display System] will be unavailable on Unit 1 which will remain in a shutdown condition. The computer outage will also render ERDS and SPDS unavailable on Unit 2 for approximately eight hours. Should the need arise, plant status information will be communicated to the NRC, [State, and local responders] using other available communication systems. The computer outage is expected to commence at 2200 CDT on 4/28/2009, and the process computer will be restored prior to Unit 1 startup currently scheduled for 05/21/2009.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a Major Loss of Assessment Capability."

The licensee will update this report when ERDS and SPDS is restored to Unit 2.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45029
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES W. FULLER
HQ OPS Officer: JOE O'HARA
Notification Date: 04/28/2009
Notification Time: 23:50 [ET]
Event Date: 04/28/2009
Event Time: 21:59 [EDT]
Last Update Date: 04/29/2009
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):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 18 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP INITIATED AS A RESULT OF A LOSS OF CONDENSATE FLOW

"At 2159 Sequoyah Unit 1 was manually tripped from 18% reactor power. The manual trip was in response to automatic isolation of all intermediate pressure feedwater heater strings resulting in a loss of all condensate flow. The feedwater heater strings isolated following a manual trip of the main turbine. The main turbine was manually tripped in response to a failed open moisture separator reheater relief valve. At the time of the event Sequoyah Unit 1 was raising power following a refueling outage.

"Following the reactor trip, all safety-related equipment operated as designed. Auxiliary feedwater automatically actuated as expected on loss of the operating main feedwater pump.

"The plant is currently being maintained in Mode 3 at NOT/NOP, approximately 547 F and 2235 psig, with auxiliary feedwater supplying the steam generators and steam dumps to main condenser removing decay heat.

"Maintenance activities have been initiated to repair the MSR relief valve.

Electrical lineup is normal with all safety related equipment operable. Licensee is investigation the cause for the relief valve failure.

The NRC Resident Inspector has been notified.

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Thursday, March 29, 2012