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Event Notification Report for May 7, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/06/2009 - 05/07/2009

** EVENT NUMBERS **


44904 44926 45034 45040 45041 45044 45045

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44904
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BRAD KIRKMON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/12/2009
Notification Time: 23:24 [ET]
Event Date: 03/12/2009
Event Time: 16:20 [EDT]
Last Update Date: 05/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)

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

HPCI DECLARED INOPERABLE

"This non-emergency 8-hour report is pursuant to 10CFR50.72(b)(3). On 03/12/09 at 1620, Operations performed [Standard Operating Procedure] S.O. 23.7.B-2 to swap the CST and Torus suctions in conjunction with scheduled I&C testing. While opening the HPCI Torus Inboard Suction valve MO-2-23-58, its travel stopped at approximately the 50% full open position. The HPCI system was declared inoperable per Technical Specification (T.S.) 3.5.1. The HPCI system remains available and the HPCI Torus Outboard Suction valve MO-2-23-57, was closed and de-energized for PCIV isolation as required by T.S. 3.6.1.3.

"Both MO-2-23-058 and the Unit 2 HPCl system are inoperable. The valve has been quarantined in accordance with station procedures and required Technical Specification actions have been taken. Reactor operation is unaffected and Unit 2 remains at 100% power. The inoperability of the HPCI system places the plant in a 14 day shutdown Tech Spec action statement. Further investigation of the cause of the valve failure is currently in progress."

RCIC has been verified operable.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM DAVE FOSS TO HOWIE CROUCH @ 0824 ON 5/6/09 * * *

"The purpose of this notification is to retract a previous report made on 3/12/09 at 2324 hours (EN# 44904). Notification of the event to the NRC was initially made as a result of declaring the Unit 2 High Pressure Coolant Injection (HPCI) system inoperable when unexpected conditions were found during performance of routine surveillance testing of HPCI. Specifically, it was noted that a motor-operated Suppression Pool suction valve for HPCI (MO-58) did not complete its stroke in the open direction during testing. The HPCI system was not operating at the time of the discovery.

"Since the initial report, Engineering has determined that HPCI was capable of performing its safety function. The evaluation determined that the MO-58 valve was capable of opening to a position sufficient to ensure that the HPCI safety function was met for design basis conditions. Additionally, since the torque switch is bypassed during actual design events, full motor torque would have been available which was sufficient to allow the valve to reach its full open position. It has also been determined that the valve was capable of closing on a signal to close automatically.

"During resolution of the HPCI MO-58 concern, the suction source from the Suppression Pool was isolated in accordance with Technical Specifications since MO-58 is considered as a Primary Containment Isolation Valve. This action was performed in accordance with station procedures and is considered planned maintenance.

"The NRC resident has been informed of the retraction."

Notified R1DO (Caruso).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44926
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [ ] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CHRIS LALLY
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/21/2009
Notification Time: 18:15 [ET]
Event Date: 03/21/2009
Event Time: 12:07 [EDT]
Last Update Date: 05/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANNE DEFRANCISCO (R1)

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

Event Text

HPCI DECLARED INOPERABLE FOLLOWING FAILURE OF VALVE TO FULLY OPEN DURING SURVEILLANCE TEST

"The Peach Bottom Atomic Power Station Unit 3 High Pressure Coolant Injection System (HPCI) was declared inoperable at 12:07 on March 21. 2009 when HPCI Outboard Suppression Pool Suction Valve, MO-3-23-057, failed to fully open during testing. At this time the cause of the failure of MO-3-23-057 to stroke fully open is unknown. Investigation is in progress."

This places Unit 3 in two (2) Tech Spec LCO Action Statements; 3.5.1 (14 day restoration with HPCI inop) and 3.6.1.3, Condition A (4 hour immediate action with verification every 31 days of Primary Containment Isolation Valves). Actions required by both have been completed.

The failure occurred during performance of the quarterly surveillance test.

The licensee informed the NRC Resident Inspector.

* * * RETRACTION FROM DAVE FOSS TO HOWIE CROUCH @ 0824 ON 5/6/09 * * *

"The purpose of this notification is to retract a previous report made on 3/21/09 at 1815 hours (EN# 44926). Notification of the event to the NRC was initially made as a result of declaring the Unit 3 High Pressure Coolant Injection (HPCI) system inoperable when unexpected conditions were found during performance of routine surveillance testing of HPCI. Specifically, it was noted that a motor-operated Suppression Pool suction valve for HPCI (MO-57) did not complete its stroke in the open direction during testing. The HPCI system was not operating at the time of the discovery.

"Since the initial report, Engineering has determined that HPCI was capable of performing its safety function. The evaluation determined that the MO-57 valve was capable of opening to a position sufficient to ensure that the HPCI safety function was met for design basis conditions. Additionally, since the torque switch is bypassed during actual design events, full motor torque would have been available which was sufficient to allow the valve to reach its full open position. It has also been determined that the valve was capable of closing on a signal to close automatically.

"During resolution of the HPCI MO-57 concern, the suction source from the Suppression Pool was isolated in accordance with Technical Specifications since MO-57 is listed as a Primary Containment Isolation Valve. This action was performed in accordance with station procedures and is considered planned maintenance.

"The NRC resident has been informed of the retraction."

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Hospital Event Number: 45034
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/30/2009
Notification Time: 14:51 [ET]
Event Date: 04/29/2009
Event Time: 13:30 [EDT]
Last Update Date: 04/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

MEDICAL EVENT INVOLVING AN UNDERDOSAGE DURING TREATMENT FOR LIVER CANCER

"At approximately 1:30 pm, on April 29, 2009 a medical event occurred at Indiana University Medical Center, NRC License No. 13-02752-03. This medical event involved the treatment of a patient with Y-90 microspheres (Nordion TheraSpheres). A dosage of 61.3 mCi was prescribed by the Authorized User. TheraSpheres are provided as a unit dosage and said dosage was assayed at 12:15 pm (4/29/09) to contain 60.1 mCi. Based upon a radiation monitoring device affixed to the TheraSphere delivery system, the pre-treatment reading was 7 milliroentgens per hour (mR/hr). Following the administration of the microspheres and four subsequent flushings of the delivery system, the radiation monitor exhibited a reading of 2 mR/hr, indicating that approximately 28.6% (17.2 mCi) of the dosage remained in the delivery system. When the subsequent flushing failed to reduce the remaining activity in the system, an independent measurement of the residual activity was performed to confirm that the entire dosage had not been delivered as prescribed.

"The vendor (Nordion) was notified of this event earlier today (4/29/09). Based upon discussions with their technical representatives, it is their opinion that the residual microspheres may be attached to the septum of the dose vial. For future treatments, the vendor representative suggested that the dose vial be given a good shake during the check-in and assay procedure to help dislodge any microspheres that may have adhered to the vial septum during shipment. They also suggested that during the administration process if the residual dosage appears to be present in the dose vial, tilting and tapping the dose vial and/or the acrylic box containing the dose vial may dislodge any microspheres that may adhere to the vial septum. These suggestions are being incorporated into the written procedures for TheraSphere treatments.

"The Radiation Safety Office attempted to perform some radiation measurements of the delivery system to determine the location of the residual activity. Due to the relatively high exposure rates from the residual radioactivity in the delivery system, it was not possible to definitively determine the distribution of the residual activity in the system at this time, mainly due to the potential for contamination and elevated radiation levels to RSO staff. More thorough evaluations may be possible once the radioactivity in the system diminishes due to radioactive decay.

"Notification of the referring physician of the occurrence of this medical event was made at 10:25 am today (4/30/09). The patient's wife was notified of the occurrence of the medical event at 10:30 am today."

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: 45040
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: PORT LAVACA State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/04/2009
Notification Time: 13:40 [ET]
Event Date: 04/15/2009
Event Time: [CDT]
Last Update Date: 05/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS LEVEL GAUGE SHUTTER STUCK OPEN

The following report was received from the Texas Department of State Health Services via e-mail:

"The licensee reported that during the performance of a routine six month inspection, the shutter on an Ohmart/VEGA level gauge model SH-F2, containing a 200 mCi Cesium (Cs) - 137 source, serial # 7548GK, would not properly close. The gauge is used as a level monitor on a vent stack. The source was left in its normal operating position and does not pose an exposure risk to individuals. Radiation levels in the area were measured and found to be normal. As a corrective action, the licensee lubricated the operating mechanism on the gauge. They again tried to operate the mechanism, but could not. They continued to lubricate the mechanism periodically in an effort to free the mechanism. The licensee contacted a service provider and arrangements were made for assistance in closing the shutter if needed. On 4/29/09, the licensee was able to close the mechanism and operate the shutter normally. There was no apparent damage to the shutter operating mechanism."

Texas Report Number I-8633

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General Information or Other Event Number: 45041
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: KELLOGG USA, INC
Region: 4
City: OMAHA State: NE
County:
License #: GL0552
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/04/2009
Notification Time: 13:53 [ET]
Event Date: 04/29/2009
Event Time: [CDT]
Last Update Date: 05/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
CHRISTEPHER MCKENNEY (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

The Nebraska Office of Radiological Health provided the following report via e-mail:

"The [Kellogg USA] facility was not able to locate four H-3 exit signs (SRB Model BXU20WS containing 17.51 Curies [each] of H-3, for serial #'s 217897, 217965, & SRB Model B100BX20 containing 17.51 Curies [each] of H-3 for serial #'s 220063 and 220071) while completing their annual inventory. They have made a number of searches and can not locate the four missing signs. The company is planning on the removal and proper disposal of all H-3 exit signs in the facility by 8/31/2009. The facility has 230 plus exit signs."

Nebraska Report NE090010


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: 45044
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE LARSON
HQ OPS Officer: PETE SNYDER
Notification Date: 05/06/2009
Notification Time: 06:22 [ET]
Event Date: 05/05/2009
Event Time: 23:27 [CDT]
Last Update Date: 05/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GREG PICK (R4DO)

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

VALID AUTO-START AND LOADING OF EMERGENCY DIESEL GENERATOR TO SAFETY BUS DUE TO UNDERVOLTAGE CONDITION

"A valid Engineering Safety Feature (ESF) actuation for emergency A/C power for the 15AA bus occurred at 2327 on 5/5/09 due to degraded voltage on ESF Transformer 12. ESF Transformer 12 was supplying power to the 15M bus due to Service Transformer 21 being out of service for maintenance. A fault occurred on the site power loop at switch 389-2901S causing breaker J3872 and breaker 5X01 to open de-energizing the site power loop and degrading the offsite power circuit 115kv voltage to the point that Division 1 Load Shedding and Sequencing (LSS) sensed a degraded voltage condition and performed a Load Shedding and Sequencing on the 15AA bus and started Division 1 Emergency Diesel Generator to power the 15AA bus. Division 1 Diesel Generator is now supplying power to the 15M bus. Operators implemented appropriate off normal event procedures to mitigate the transient. All systems responded as designed.

"The exact cause of the fault to switch 2109S is not known at this time."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45045
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAT LEAHY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/07/2009
Notification Time: 00:29 [ET]
Event Date: 05/06/2009
Event Time: 22:56 [EDT]
Last Update Date: 05/07/2009
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):
EUGENE GUTHRIE (R2DO)

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

MANUAL REACTOR TRIP DUE TO FEED REGULATING VALVE FAILURE

"On 5/6/09 at 2256 Sequoyah Unit-1 was manually tripped from 100% reactor power. The manual trip was in response to the failure of Loop 1 Feed Water Regulating Valve (FRV). Manual control was attempted to control level in Loop 1 Steam Generator however Loop 1 FRV failed to respond. A manual reactor trip was initiated as a result of this failure. In addition, Auxiliary Feedwater (AFW) initiated as required due to a Feedwater Isolation signal. The Loop 1 FRV did not isolate from the Feedwater Isolation signal, however the Loop 1 Feedwater Isolation Valve closed as designed.

"The Plant is currently being maintained in Mode 3 at NOT/NOP, approximately 547 [degrees] 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 Loop 1 FRV."

All rods inserted on the trip. No safety or relief valves lifted as a result of the transient. The plant is in its normal shutdown electrical lineup. No grid instabilities exist and there was no effect on Unit 2.

The licensee has notified the NRC Resident Inspector.

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