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Event Notification Report for October 2, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/01/2009 - 10/02/2009

** EVENT NUMBERS **


45361 45383 45385 45387 45398 45402 45403

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45361
Facility: COOK
Region: 3 State: MI
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BEN HUFFMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/18/2009
Notification Time: 16:29 [ET]
Event Date: 09/18/2009
Event Time: 10:30 [EDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (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

INOPERABILITY OF BOTH EDG'S DUE TO VALVE FOUND OUT OF POSITION

"At 02:00 on Friday, September 18, 2009, the Unit 2 AB Emergency Diesel Generator (EDG) Air Jet Assist Control Air Shutoff valve, which is required to be open, was discovered closed. At 10:30 on Friday, September 18, 2009, it was determined that with the valve closed, the EDG Air Jet Assist may not be able to support the EDG fast speed start to meet the EDG's Operability requirements. This condition renders the Unit 2 AB EDG inoperable. The valve was repositioned and verified open at 02:15 on Friday, September 18, 2009, restoring the EDG to operable status. Similar valves were verified to be in the correct position on all other EDGs in both Units.

"The Unit 2 AB Emergency Diesel Generator Air Jet Assist Control Air Shutoff valve was last confirmed open on July 21, 2009. The time the valve became closed is not known. Since July 21, 2009, there have been 3 periods of inoperability for Unit 2 CD EDG, the redundant Emergency Diesel Generator. During each of these periods, both of the Unit 2 EDGs are assumed to be inoperable. The periods are as follows:

"August 10, 2009 at 09:31 until August 10, 2009 at 23:00
August 11, 2009 at 07:30 until August 11, 2009 at 23:16
September 9, 2009 al 00:02 until September 9, 2009 at 04:40

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(ii)(B) due to the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety."

The licensee has notified the NRC Senior Resident Inspector.


* * * RETRACTION ON 10/01/2009 AT 1634 EDT FROM JAMES SHAW TO DONALD NORWOOD * * *

"At 02:00 on Friday, September 18, 2009, the Unit 2 AB Emergency Diesel Generator (EDG) Air Jet Assist Control Air Shutoff valve, which is required to be open, was discovered closed. At 10:30 on Friday, September 18, 2009, it was determined that with the valve closed, the EDG Air Jet Assist may not be able to support the EDG fast speed start to meet the EDG's Operability requirements. This condition renders the Unit 2 AB EDG inoperable. The valve was repositioned and verified open at 02:15 on Friday, September 18, 2009, restoring the EDG to operable status.

"Since the last time the Turbocharger Air Jet Assist Control Air Shutoff valve was confirmed open, July 21, 2009, there were three periods where the redundant EDG was inoperable for planned maintenance and surveillance testing. During each of these periods, both of the Unit 2 EDGs are assumed to be inoperable. As such, Cook Nuclear Plant (CNP) submitted Event Notification 45361 in accordance with 10CFR50.72(b)(3)(ii)(B) due to the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"On September 25, 2009, CNP conducted two EDG fast speed starts, one with the Turbocharger Air Jet Assist Control Air Shutoff valve closed, and one with the valve open. Based on a review of the data collected and observed performance of the EDG, the determination has been made that having the Turbocharger Air Jet Assist Control Air valve closed does not adversely impact operability of an EDG.

"The circumstances discussed in the notification did not result in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"The licensee has notified the NRC Resident Inspector."

Notified R3DO (Lara).

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Hospital Event Number: 45383
Rep Org: VETERANS ADMINISTRATION SAN DIEGO
Licensee: VETERANS ADMINISTRATION
Region: 4
City: SAN DIEGO State: CA
County: SAN DIEGO
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN M LEIDHOLDT JR
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/26/2009
Notification Time: 16:31 [ET]
Event Date: 09/21/2009
Event Time: [PDT]
Last Update Date: 09/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
MICHAEL SHANNON (R4DO)
KEVIN HSUEH (FSME)

Event Text

MEDICAL EVENT - PATIENT UNDER DOSE

"This is a notification, pursuant to 10 CFR 35.3045, of a medical event that occurred at the VA San Diego Healthcare System in San Diego, California.

"A dosage of 194 millicuries of I-131 sodium iodide was administered to a patient through a feeding tube on September 21, 2009. The patient was kept in a shielded room at the facility. Daily measurements of the exposure rate at one meter from the patient showed only a small decrease, consistent with radioactive decay, but not the expected biological elimination. The feeding tube was replaced on September 25, 2009. The activity in the feeding tube after removal from the patient was estimated as over 80 millicuries. At this time, it is estimated that the patient received less than half of the administered dose.

"The basis for the medical event is that the total dosage delivered differs from the prescribed dosage by more than 20 percent. The facility has notified the patient of the medical event and is in the process of notifying the referring physician. The facility is in the process of assessing any possible medical effects on the patient.

"The NHPP will perform a reactive inspection regarding the medical event. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, Cassandra Frasier, NRC Region III, of the medical event.

Additional information

"The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 04-15030-01. National Health Physics Program makes required notifications to NRC."

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: 45385
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: DENVER State: CO
County:
License #: 388-01
Agreement: Y
Docket:
NRC Notified By: JAMES JARVIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/28/2009
Notification Time: 12:14 [ET]
Event Date: 09/25/2009
Event Time: 13:00 [MDT]
Last Update Date: 09/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

The following agreement state report was received via e-mail:

"On September 25, 2009 (at approximately 14:45 MDT), the Colorado Department of Public Health and Environment was notified by the RSO for Team Industrial Services that a source disconnect had occurred within the prior 1-2 hours at a temporary jobsite located in Rifle, Colorado. The source remained disconnected at the time the RSO made the notification to the Department as no personnel working in the area were trained for source recovery operations. Once the radiographer in charge at the jobsite realized that a disconnect had occurred and the source could not be returned to the radiography device, the source was cranked/pushed out to the collimator to provide additional shielding.

"The RSO reported that the radiographer and radiographer assistant involved in the source disconnect had received approximately 1 mrem up to and including the time of the source disconnect. According to the RSO, the temporary jobsite was located adjacent to an oil or gas drilling rig site, but radiography operations were located at a sufficient distance so as not to impact other non-radiography personnel (members of the public) working in the vicinity. Additional (licensee) radiography crews working in the Rifle, CO area were dispatched to the jobsite where the disconnect had occurred to provide additional support and access control.

"On September 26, 2009 (at approximately 11:08 am MDT), the licensee notified the Department that the source recovery had been successfully completed by the RSO at about 1:30 am MDT that morning. The personnel involved in the source recovery - including the RSO - had received approximately 8 mrem each based upon pocket dosimeter readings.

"The event involved a radiography device containing 35.6 curies of Ir-192. The source had been in use for several months and the source was nearing the end of its useful life. The radiography device involved in the disconnect was a Sentinel Delta 880 (Serial #D4309) containing approximately 35.6 Ci of Ir-192. The Ir-192 source was a Model 424-9, Serial #53922B.

"The Department [Colorado Department of Health] recommended to the licensee that the device and source be returned to the manufacturer for further evaluation. The licensee is expected to submit a written report to the Department within 30 days of the incident.

"Colorado Incident #I09-19"

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General Information or Other Event Number: 45387
Rep Org: ALABAMA RADIATION CONTROL
Licensee: RONAN ENGINEERING
Region: 1
City: DEMOPOLIS State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/29/2009
Notification Time: 15:00 [ET]
Event Date: 09/14/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB (Email) ()

This material event contains a "Category 3" level of radioactive material.

Event Text

MISSING SHIPMENT OF GENERAL LICENSED DEVICES

This information was received from the State via facsimile:

"On the afternoon of September 28, 2009 at approximately 12:15 pm CDT, the Alabama Office of Radiation Control received a phone call from a representative of the Kentucky Radiation Health Program advising the Agency [Alabama Office of Radiation Control] of the discovery of two missing general licensed devices containing radioactive material. The representative of the Kentucky Radiation Health Program indicated that he was advised from Ronan Engineering representatives that two Ronan model RLL-1 source holders each containing 0.63 millicuries of Cs-137 were lost in transit by a commercial carrier. The shipment originated at Southfresh Feed, Demopolis, Alabama on September 14, 2009 with destination to Ronan Engineering, Florence, Kentucky scheduled for delivery on September 17, 2009. The carrier is YRC [Yellow Transportation Inc].

"According to Ronan Engineering representatives, the RLL-1 source holders are bolted to a pallet. The devices are eight inches wide, including mounting flange and twelve inches long. The housing is 4" x 4" x 12" long. Radioactive material labels, UN identification labels, and Ronan address labels are on the skid and devices.

"According to YRC representatives, YRC has sent out notifications to over 30 dispatch centers and are contacting customers in an attempt to locate the shipment. The shipment was last accounted for on September 18, 2009 at the YRC, Nashville, TN terminal.

"This is all the information that this Agency [Alabama Office of Radiation Control] has at this time and is current as of 2:00 pm CDT, September 29, 2009."

* * * UPDATE AT 0926 EDT ON 10/01/09 FROM DAVID TURBURVILLE TO S. SANDIN * * *

At 0750 CDT on 10/01/09, the Alabama Office of Radiation Control was informed that the missing shipment had been misrouted to the YRC Columbus, OH terminal. The shipment is currently enroute to its final destination, i.e., Ronan Engineering located in Florence, KY.

Notified R1DO (Miller), FSME (Villamar) and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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General Information or Other Event Number: 45398
Rep Org: TRANSNUCLEAR INC
Licensee: TRANSNUCLEAR INC
Region: 1
City: COLUMBIA State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TARA NEIDER
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/01/2009
Notification Time: 14:13 [ET]
Event Date: 10/01/2009
Event Time: [EDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MARIE MILLER (R1DO)
MIKE ERNSTES (R2DO)
GREG WERNER (R4DO)
DENNIS DAMON (NMSS)

Event Text

FASTENERS ON SPENT FUEL STORAGE DEVICES DID NOT MEET STANDARDS

"In accordance with 10 CFR 21.21, Transnuclear, Inc. is reporting a potential Part 21 violation. Transnuclear, Inc. has reason to believe that Hwa Shin Bolt Ind. Co. provided unsubstantiated certified material test reports (CMTR's) for certain small parts utilized in products fabricated in accordance with the requirements of 10 CFR 72 under general certificates 1004 and 1030. Transnuclear is in the process of performing a 10 CFR Part 21 [evaluation] but does not believe that this issue has safety significance. TN [Transnuclear] is reporting this issue because Hwa Shin may have supplied parts to others that may have safety significance.

"The parts were provided by Hwa Shin Bolt Ind. Co., Ltd. Having offices in Busan, Korea under subcontract to Hitachi Zosen Corporation, Ariake Works located in Kumamoto, Japan. Hitachi Zosen fabricated the components under contract to Transnuclear, Inc.

"A preliminary review of the fabrication records at Hitachi Zosen indicate that shipped components have parts supplied by Hwa Shin Bolt Ind. Co. as indicated in Attachment 1.

"No [dry storage canister] loadings have occurred at Cooper or Ginna. We are not certain of which [dry storage] canisters have been loaded, if any, at the other plants.

"All Hwa Shin material at the Hitachi Zosen facility has been identified and placed under the control of the Hitachi Zosen NCR system. No material received from Hwa Shin is being released for further use in fabrication of Dry Storage Canisters (DSCs) or other components subject to the requirements of 10 CFR 72. Nonconformance Reports (NCRs) are being issued for all components that contain Hwa Shin Material."

The licensee reported affected plants include Millstone, Susquehanna, Oyster Creek, Ginna, Brunswick, and Cooper.

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Fuel Cycle Facility Event Number: 45402
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2009
Notification Time: 19:49 [ET]
Event Date: 09/30/2009
Event Time: 19:10 [PDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)

Event Text

24 HOUR REPORT ON PROCESS EXHAUST HEPA FILTER DETERIORATON

"On September 30, 2009 at approximately 1910 (PDT) an Air Balance Tech at AREVA NP's Richland fuel fabrication plant discovered that the primary and secondary HEPA filters servicing the ammonium diuranate (ADU) area showed visible signs of deterioration. The apparent deterioration is being reported in accordance with 10CFR70.50.b.2.

"The K32A HEPA filters were examined at approximately 1910 PDT on September 30, 2009 based on a request to follow up on some observations the previous day of a dusting of powder and very low contamination downstream of the filters. Air flow was diverted to HEPA filters in a parallel upper housing in order to check the filters in the lower housing. Investigation showed apparent deterioration, cracked creases, of both the primary and final HEPA's.

"At approximately 2030 PDT the same day EHS&L personnel were informed of the event. The only processes running at the time were the Mop Water Furnace and Cylinder Wash. EHS&L ordered that these be shut down. Air monitor samples were pulled on the K-32A system. Air monitoring samples showed negligible release levels. A Health Safety Technician survey of the downstream side of the final HEPA housing of K-32A revealed no contamination.

"Potential dose to a member of the public and the effect on the environment are essentially negligible. External conditions are not known to have affected the event.

"A Corrective Action Report was written on October 1, 2009. The cause of the apparent deterioration is under active investigation. Steps to prevent recurrence will be developed as appropriate."

The licensee stated that records indicate that the primary filter was changed out in August and the final filter was changed out in March.

The licensee will notify the State and the NRC regional contact.

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Power Reactor Event Number: 45403
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK HANSEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/02/2009
Notification Time: 04:18 [ET]
Event Date: 10/01/2009
Event Time: 22:39 [EDT]
Last Update Date: 10/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARIE MILLER (R1DO)

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

Event Text

UNIT EXPERIENCED A VALID RPS ACTUATION DURING PLANT COOLDOWN ON LOW STEAM GENERATOR LEVELS

"On Thursday, October 1, 2009 @ 2239 hrs EDT Seabrook Station Unit 1 was in Mode 4 in the process of removing feedwater heating and raising steam generator levels during a plant cooldown. A valid actuation of the reactor protection system occurred when both the A and C steam generator [SG] levels were reduced to the SG low level reactor trip setpoint of less than 20%. This occurred twice on both the A and C steam generators approximately 10 minutes apart. Steam generator levels have since been restored to normal operating levels and plant is now in Mode 5.

"This is reportable under 50.72 (b)(3)(iv) as an event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. The reactor trip breakers were open and the emergency feedwater system removed from service when the event occurred.

"The licensee notified the NRC Resident Inspector."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012