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Event Notification Report for August 26, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2009 - 08/26/2009

** EVENT NUMBERS **


45275 45276 45278 45280 45285 45287 45296 45297 45299

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General Information or Other Event Number: 45275
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CENTURA HEALTH PENROSE - ST. FRANCIS HEALTH SERVICES
Region: 4
City: COLORADO SPRINGS State: CO
County: EL PASO
License #: 197-02
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 08/19/2009
Notification Time: 15:10 [ET]
Event Date: 08/06/2009
Event Time: [MDT]
Last Update Date: 08/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL DOSE DIFFERENT THAN PRESCRIBED

The following was received from the state via e-mail:

"This incident was reported by a medical licensee (Centura Health Penrose - St. Francis Health Services License # 197-02) on 08/06/2009.

"On 22 July 2009, at patient at Penrose Hospital was implanted with 70 Palladium-103 seeds, 2.5 U each on that day. The application was via a Mick applicator, using intra-operative planning with a Variseed planning system. It was noted on the C arm film taken at the completion of the implant that there was some clumping of the seeds in groups. A post implant CT scan was done on 23 July 2009. The results of the computerized dosimetry plan was evaluated on the 5 August 2009 and it was determined that the prostate gland was under dosed, receiving a dose to 90% of the prostate volume (D90) of 36.6% of the prescribed 125 Gy. The AU [Authorized User] written directive listed an expected range of D90 to be 90% to 135%. The discrepancy between actual dose and prescribed falls outside of the 20% tolerance for delivered dose according to [Colorado State Regulation] RH 7.21.1.1 (1). A full report is expected from the licensee within 30 days."


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: 45276
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SUNCOR ENERGY
Region: 4
City: DENVER State: CO
County: DENVER
License #: 615-02
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 08/19/2009
Notification Time: 15:43 [ET]
Event Date: 08/19/2009
Event Time: [MDT]
Last Update Date: 08/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - FLOW GAUGE SHUTTER UNABLE TO CLOSE

The following report was received from the state via e-mail:

"A Colorado Specific licensee, Suncor Energy (USA) Inc. (License # 615-02), reported that a fixed nuclear gauge was having shutter problems. The shutter was unable to be returned to a closed position during a routine check. The gauge is an Ohmart Vega Model SH-F2 containing 250 mCi of Cs-137 (serial number M-7105). The licensee plans to have a Ohmart Vega Technician on site within the next few weeks to take a look at the gauge and determine whether or not the gauge can be fixed or [if] it needs to be replaced."

The gauge is a flow gauge on a pipe in an oil refinery, and the shutter is normally open during facility operation. The radiological control area is normally maintained in force during operations, and remains in force. No inadvertent exposures are expected to have occurred.

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Power Reactor Event Number: 45278
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVE DEES
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2009
Notification Time: 20:38 [ET]
Event Date: 08/19/2009
Event Time: 15:49 [CDT]
Last Update Date: 08/25/2009
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):
WILLIAM JONES (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 CAUSED BY TURBINE TRIP

"Wolf Creek experienced a reactor trip at 1549 CDT. The first out annunciator was TURBINE TRIP and P9 Reactor TRIP. At approximately the same time the unit experienced a momentary loss of offsite power.

"The emergency diesel generators started [and loaded] as expected to supply power to the safety busses due to the loss of offsite power. Auxiliary Feedwater and Feedwater Isolation actuations occurred as expected. All control rods inserted into the core during the trip. All Reactor Coolant Pumps tripped due to the loss of offsite power. Decay heat was initially being removed by the Steam Generator Atmospheric Relief Valves.

"Presently the plant is stable in Mode 3. The 'D' Reactor Coolant Pump has been restarted. The licensee is continuing to investigate the cause of the trip."

The atmospheric relief valves lifted for approximately 10 minutes, however there was no primary to secondary leakage. Both A & B EDG's loaded for about 2 minutes. At the present time the electrical lineup is normal and the EDG's are shutdown. Plant is at Normal Operating Pressure and just below Normal Operating Temperature. Decay heat and S/G levels are being maintained with the Auxiliary Feedwater pumps.

The licensee has notified the NRC Resident Inspector. The Licensee may issue a press release on this event.

* * * UPDATE FROM DAVE DEES TO VINCE KLCO AT 1135 EDT ON 8/21/2009 * * *

The atmospheric relief valves lifted for approximately 2 minutes, not 10 minutes as stated above. Also the A & B EDG's did not load for only 2 minutes. Actually "the B Safety Bus was paralleled to its normal off site source and the B Emergency Diesel was realigned for auto-start at 1740. The A Safety Bus was paralleled to its normal off site source and the A Emergency Diesel was realigned for auto-start at 1844."

Notified the R4DO (Jones).

* * * UPDATE FROM DAVE DEES TO VINCE KLCO AT 1730 EDT ON 8/25/2009 * * *

"The initial report stated that there was no primary to secondary leakage. Actual primary to secondary leakage as measured on 8/14/2009 was a value of less than 0.722 gallons per day."

The licensee notified the NRC Resident Inspector.

Notified the R4DO (Miller)

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Power Reactor Event Number: 45280
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE BORGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/20/2009
Notification Time: 20:14 [ET]
Event Date: 08/20/2009
Event Time: 16:43 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD CONTE (R1DO)

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

Event Text

LOSS OF PLANT INTEGRATED COMPUTER SYSTEM RESULTING IN LOSS OF ERDS AND SPDS

"At 0950 the Plant Integrated Computer System started to fail as indicated by a loss of computer link to Generation. Investigation by computer maintenance personnel was initiated. The failure mode of the computer precluded accessing screens to allow use of Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS). Computer core thermal power indication remained available to the control room operators. Redundant, normal control room indications are still available to the operators. At 1217 hours on 08/20/09, a planned loss of computer core thermal power indication occurred due to ongoing computer maintenance activities.

"At 1458 hours on 08/20/09, the Plant Integrated Computer System was fully restored to service, including the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) functions. At 1643 hours on 08/20/09, the Plant Integrated Computer System started to fail again as indicated by loss of computer link to Generation. This problem with the computer again precluded accessing Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS). Core thermal power indication remained available via the plant computer system. However, anticipated troubleshooting actions will require a reduction in power by approximately 0.25-0.33% by reducing core flow.

"Due to the cumulative impacts of the loss of the plant computer system, this notification is being communicated ahead of the 8 hour unavailability of the Unit 2 SPDS and ERDS computer system. This is considered a Loss of Emergency Assessment Capability and therefore reportable under 10CFR50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM RICHARD KLINEFELTER TO CHARLES TEAL AT 1222 EDT ON 8/25/2009 * * *

As of 1200 hours, Unit 2 ERDS and SPDS (Safety Parameter Display System) were restored to normal operation.

The licensee has notified the NRC Resident Inspector. Notified R1DO (White).

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Power Reactor Event Number: 45285
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: MIKE MacLENNAN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/24/2009
Notification Time: 04:06 [ET]
Event Date: 08/24/2009
Event Time: 02:40 [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)

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

TSC AIR FILTRATION SYSTEM INOPERABLE DUE TO PLANNED MAINTENANCE

"Planned maintenance activities will commence today (August 24, 2009) on the Quad Cities Station Technical Support Center (TSC) ventilation air filtration system. The maintenance will be completed in approximately 36 hours, and is scheduled to be worked continuously to minimize out-of-service time.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing procedures; contingency plans are in place to expeditiously restore the TSC ventilation to an operable status. If TSC evacuation is warranted due to radiological conditions, the facility will be relocated in accordance with existing procedures.

"This event is reportable per 10CFR50.72(b)(3)(xiii) since the scheduled maintenance affects an emergency response facility.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM KEVIN O'SHEA TO CHARLES TEAL AT 1858 ON 8/25/09 * * *

The TSC air filtration system maintenance has been completed. The TSC has been returned to normal operation.

Notified R3DO (Orth).

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Power Reactor Event Number: 45287
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: PETE SNYDER
Notification Date: 08/24/2009
Notification Time: 13:01 [ET]
Event Date: 08/24/2009
Event Time: 09:00 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3DO)

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

EOF BACKUP DIESEL FAILURE AND EOF OUTAGE

"On August 24, 2009 at 0900 EDT the Fermi 2 Emergency Operations Facility (EOF) was declared unavailable due to failure of the EOF backup diesel generator to start during weekly testing. Fermi 2 is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event that EOF activation is necessary, the alternate EOF will be utilized. Activation and use of the alternate EOF is included in Fermi's Radiological Emergency Response Preparedness Plan. The alternate EOF has been verified available. Investigation into the failure of the EOF backup diesel generator start failure is in progress. Fermi will notify the NRC when EOF availability is restored. "

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM GREG MILLER TO HOWIE CROUCH @ 1534 ON 8/25/09 * * *

"Repairs have been made to the EOF backup diesel generator and it was successfully tested. The EOF is now available for use. The NRC Resident Inspector has been notified."

Notified R3DO (Orth).

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General Information or Other Event Number: 45296
Rep Org: GENERAL ATOMICS
Licensee: GENERAL ATOMICS
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEITH ASMUSSEN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/25/2009
Notification Time: 15:17 [ET]
Event Date: 06/30/2009
Event Time: [PDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN WHITE (R1DO)
SCOTT SHAEFFER (R2DO)
STEVE ORTH (R3DO)
GEOFFREY MILLER (R4DO)
OMID TABATABAI (NRO)
JOHN THORP (NRR)

Event Text

PART 21 - RADIATION MONITOR DEFECT

"The defect is contained in the General Atomics Electronic Systems, Inc (GA-ESI) radiation monitoring system model RM-80 firmware. The RM-80 firmware anomaly was initially identified at the St. Lucie Nuclear Power Plant. The radiation monitor was part of the control room outside air intake ventilation radiation monitors.

"More specifically, if the radiation monitor is already in a high and or alert alarm state, and subsequently suffers a loss of power, then upon restoration of power to the unit, the RM-80 high and or alert alarm relays are not reenergized by the RM-80 firmware. This in turn prevents the relays that are located in the [RM]-80 from performing their safety related function.

"This error in the firmware only affects those plant sites that connect annunciator panels or other safety related equipment to the RM-80 Alert and High Alarm relays.

"Plant sites that use RM-80 radiation monitors will be advised to test their systems for this anomaly. When so requested, GA-ESI will provide all necessary information to plants on how to test their RM-80 radiation monitors, and how to receive firmware upgrades if the condition is found during testing."

General Atomics will notify the following affected plants: Beaver Valley, Braidwood, Byron, Callaway, Indian Point 2 &3, Limerick, River Bend, Shearon Harris, South Texas, St. Lucie, Waterford, and Wolf Creek.

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General Information or Other Event Number: 45297
Rep Org: USEC
Licensee: COLUMBIANA HI TECH
Region:
City:  State:
County:
License #:
Agreement: N
Docket:
NRC Notified By: ROBERT VAN NAMEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2009
Notification Time: 15:14 [ET]
Event Date: 08/10/2009
Event Time: [EST]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN WHITE (R1DO)
SCOTT SHAEFFER (R2DO)

Event Text

PART 21 REPORT - MISSING RETRACTING BALL IN BALL LOCK PINS ON URANIUM CYLINDER

"On August 10, 2009, a failure to comply was identified during USEC's routine refurbishment of a UX-30 transportation overpack. The overpack was being prepared for shipment of a clean empty 30B cylinder to a Russian facility where the cylinder would be filled with enriched uranium hexafluoride and returned to the Paducah Gaseous Diffusion Plant (PGDP). The failure to comply involves a missing retracting ball in a ball lock pin that is designed with two required retracting balls. Ten of these ball lock pins are used to hold the top and bottom half of the UX-30 overpack together during transport.

"The firm supplying the ball lock pins was Columbiana Hi Tech (CHT). USEC has received 3,732 ball lock pins from CHT since July 2008, in five separate purchase orders. This report is the only instance to USEC's knowledge that a ball lock pin has had a missing retracting ball. Six hundred eighty-six of these pins have been supplied by USEC to its shipping agent.

"USEC Quality Control inspected approximately one thousand one hundred sixty-four ball lock pins currently on site, but not yet installed, to insure the pins had both balls installed and the pins functioned correctly. This was completed on August 24, 2009. Not additional defective pins were discovered.

"The USEC shipping agent was ordered, on August 21, 2009, to return to PGDP the remaining uninstalled ball lock pins from the six hundred eighty-six supplied and in its possession. A USEC Quality Control inspection will verify both balls installed and the pins function correctly.

"USEC intends to perform an assessment of the supplier (CHT) to ensure the supplier is adequately implementing its quality programs and is ensuring its sub tier suppliers are meeting established quality requirements. This assessment is scheduled to be conducted beginning September 28, 2009, barring any unforeseen circumstances."

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Power Reactor Event Number: 45299
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOSHUA SISAK
HQ OPS Officer: VINCE KLCO
Notification Date: 08/25/2009
Notification Time: 21:15 [ET]
Event Date: 08/25/2009
Event Time: 19:35 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN WHITE (R1DO)

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

OFFSITE NOTIFICATION DUE TO A WATER LEAK CONTAINING TRITIUM

"Oyster Creek Nuclear Generating Station notified the New Jersey Department of Environmental Protection of a leak of water containing tritium from an underground condensate transfer pipe at the turbine building penetration of less than 20 gpm and concentration of approximately 10 million picocuries/milliliter.

"The leaking water is being pumped to storage drums and a plan is being developed to replace the six-inch condensate transfer piping which penetrates the turbine building inside a 42 Inch long sixteen inch diameter penetration sleeve. Previously, water was observed coming from the sleeve into the turbine building where it was draining to a sump. The leak coming out of the turbine building was uncovered during excavation to determine if the condensate was leaking to the soil."

The licensee notified the NRC Resident Inspector.

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