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Event Notification Report for June 5, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/04/2009 - 06/05/2009

** EVENT NUMBERS **


43197 45109

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43197
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: PETE SNYDER
Notification Date: 02/28/2007
Notification Time: 05:40 [ET]
Event Date: 02/27/2007
Event Time: 22:26 [EST]
Last Update Date: 06/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DEBORAH SEYMOUR (R2)

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

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABILITY

"On February 27, 2007, at approximately 2200 hours, testing of the Unit 2 High Pressure Coolant Injection (HPCI) system was in progress in accordance with 0PT-09.2, HPCI System Operability Test following system maintenance. Soon after the HPCI turbine was started a high level alarm condition in the HPCI barometric condenser was experienced. Evidence suggests the most probable cause was due to failure of the 2-E41-F048, Condensate Pump Discharge Check Valve, to open. The adverse consequence of this check valve failing to open is inadequate cooling flow to the HPCI lube oil cooler. The HPCI turbine was removed from service per applicable plant procedures.

"At the time of discovery, the HPCI system was inoperable for scheduled maintenance. However, this equipment failure would have prevented the HPCI system from fulfilling its safety function. Limiting Condition for Operation (LCO) per Technical Specifications (TS) 3.5.1. 'ECCS - Operating' Condition D had been previously entered on 2/25/07 at 1500, which required maintaining the Reactor Core Isolation Cooling (RCIC) system operable and restoration of HPCI operability in 14 days.

All other ECCS systems are operable including RCIC. The LCO allowed outage time is due to expire on 3/11/07 at approximately 1500 hours.

The licensee notified the NRC Resident Inspector.


** UPDATE FROM TURKAL TO KNOKE AT 11:33 EDT ON 04/26/07 ***

"On February 28, 2007, at 0540 hours, the Control Room Supervisor made a notification (Event Number 43197) to the NRC Operations Center in accordance with 10 CFR 50.72(b)(3)(v)(D) (i.e., any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident). The notification was made as a result of an unexpected high level alarm condition for the High Pressure Coolant Injection (HPCI) system barometric condenser, which was received during the post-maintenance operability testing of the HPCI system. At the time of discovery, the HPCI system was inoperable; having been properly removed from service for planned maintenance. It was believed that check valve 2-E41-F048, which is in the discharge piping of the HPCI barometric condenser condensate pump, downstream of a connection from the HPCI lube oil cooler cooling water discharge line, did not open, as required, during the HPCI post maintenance operability run. With valve 2-E41-F048 closed, there is a potential for inadequate cooling flow for the HPCI lube oil and, as such, a potential that the HPCI system could be inoperable as a result.

"Basis for Retraction
Upon further review, it has been determined that the 2-E41-F048 functioned properly during the post-maintenance HPCI system operability testing. The valve was disassembled and inspected during the recent Unit 2 refueling outage and confirmed to be operating properly. As such, adequate HPCI lube oil cooling existed and HPCI could have fulfilled its intended safety function.

"Physical inspection of the HPCI lube oil cooler piping, during the Unit 2 refueling outage, revealed that the lube oil cooler outlet orifice was missing. The missing orifice can result in higher than design flows through the lube oil cooler and higher backpressure at the barometric condenser condensate pump discharge. The higher backpressure can affect the ability to pump down the barometric condenser vacuum tank. Additionally, during troubleshooting activities performed prior to the refueling outage, valve 2-E41-F058, which is in the discharge piping of the HPCl barometric condenser condensate pump, upstream of the connection from the HPCI lube oil cooler cooling water discharge line, showed evidence of sticking. Either of these conditions could have caused the barometric condenser high level alarm without affecting HPCI lube oil cooling. If the barometric condenser becomes completely full, a relief valve on the tank will lift and relieve water to the HPCI room sump. The room sump pump has adequate capacity to keep up with the maximum expected flow. Operability of the HPCI system will not be affected by this condition.

"The higher than design cooling water flow rate does not adversely affect the capability of the lube oil cooler to remove heat from HPCI system lube oil and, as such, does not affect HPCI operability. Additionally, physical inspection of the cooler during the refueling outage found no damage or erosion of the cooler internals, and the cooler was successfully pressure tested.

"The barometric condenser condensate pump, barometric condenser vacuum pump, and barometric condenser water level instrumentation are not required to support operability of the HPCI system.

"Investigation of this condition is documented in the corrective action program in Nuclear Condition Report (NCR) 223820.

"On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"The NRC resident was notified of this retraction." Notified R2DO(Payne).


*** UPDATE FROM TURKAL TO KNOKE AT 09:30 EDT ON 06/04/09 ***

"On February 28, 2007, at 0540 hours, the Control Room Supervisor made a notification (EN 43197) to the NRC Operations Center in accordance with 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident'. The notification was made as a result of an unexpected high level alarm condition for the High Pressure Coolant Injection (HPCI) system barometric condenser, which was received during the post-maintenance operability testing of the HPCI system.

"Revised Basis for Retraction

"On April 26, 2007, EN 43197 was retracted. The basis for the retraction stated that the 2-E41-F048 functioned properly and adequate HPCI lube oil cooling existed. It also attributed the high level in the HPCI barometric condenser to either a missing lube oil cooler outlet orifice or potential sticking of valve 2-E41-F058 versus the originally believed malfunction of the 2-E41-F048 valve. In either case, the retraction stated that if the barometric condenser becomes completely full, a relief valve (2-E41-F018) on the tank will lift and relieve water to the HPCI room sump. The room sump pump has adequate capacity to keep up with the maximum expected flow. As such, operability of the HPCI system would not be affected by either a missing lube oil cooler outlet orifice or potential sticking of valve 2 -E41-F058.

"During the Unit 2 refueling outage, which began on February 28, 2009, it was discovered that the HPCI barometric condenser relief valve (2-E41-F018) had been assembled incorrectly and would not have functioned as described in the April 26, 2007 retraction of EN 43197. However, EN 43197 can be retracted without relying on proper operation of the relief valve. At the time of the event, the HPCI barometric condenser condensate pump, the HPCI barometric condenser vacuum pump, and the HPCI barometric condenser water level instrumentation were functioning properly and would have prevented condensate from reaching the HPCI turbine casing. On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector was notified of this revised retraction."

Notified R2DO (Mark Lesser)

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General Information or Other Event Number: 45109
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: BEST MEDICAL INTERNATIONAL, INC
Region: 1
City: RICHMOND State: VA
County:
License #: 059-18-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/01/2009
Notification Time: 11:10 [ET]
Event Date: 05/30/2009
Event Time: [EDT]
Last Update Date: 06/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST SHIPMENT OF I-125 BRACHYTHERAPY SEEDS

"On Saturday May 30, 2009 the Virginia Radioactive Materials Program received notification from Best Medical International, Inc. that a shipment of I-125 Brachytherapy seeds had been lost in transit by Fed-Ex. A follow-up telephone conversation on June 1, 2009 revealed the following:

"On Friday May 22, 2009, a shipment of 70 I-125 seeds was prepared for shipment to the University of New Mexico - Albuquerque for patient implant on Friday May 29, 2009. The source strength was 30.3 mCi at the time of shipment. On May 26, 2009, Best Medical noticed that the shipment had not been received by the University and contacted Fed-Ex. Fed-Ex initiated a search for the material. Best Medical contacted Fed-Ex on May 27th and was told that Fed-Ex could not find the shipment. The patient's treatment has been postponed."

* * * UPDATE FROM MIKE WELLING TO BILL HUFFMAN AT 1234 EDT ON 6/3/09 * * *

The State of Virginia has clarified the original report it made to the NRC to note that the shipment was inadvertently directed to Windsor Locks, CT instead of Memphis TN. Specifically, the State reports the following update:

"Further conversations on Wednesday, June 3 revealed the following:

"On Tuesday, June 2, 2009 Fed-Ex found the I-125 package in Windsor Locks, CT. The package was shipped back to Best Medical and received on June 3, 2009. According to Fed-Ex, the I-125 package was not placed in the shipping container for Memphis, TN. The package had an incorrect URSA (routing) label [and] the package was then sent from Springfield, VA to Windsor Locks, CT [instead]."

The R1DO (Perry) and FSME EO (McIntosh) have been notified.




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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