Event Notification Report for December 09, 2009

BLIZZARD RESULTS IN GREATER THAN 50% SIREN COVERAGE LOSS

"On December 9 at 0800 CST, seven emergency notification system sirens in Kewaunee Power Station Emergency Planning Zone were reported out of service. It is expected the cause of the sirens to be out of service is the severe winter weather. The loss of these emergency notification sirens results in a lost population coverage of 56%. As a result, this event is being reported under 10CFR50.72(b)(3)(xiii) and guidance in NUREG-1022 as a major loss of off-site communications capability.

"It is unknown, at this time, when the sirens will be returned to service."

The licensee notified the NRC Resident Inspector.

EMERGENCY SIRENS FAILED TO ACTIVATE

"On December 9, 2009, at approximately 1101 EST, as a result of a scheduled full-volume test of the Indian Point Energy Center (IPEC) Alert Notification System (ANS), using microwave/radio activation pathway only, 37 of 172 sirens did not pass the test. The siren system was then configured to the normal configured (TCP/IP and microwave/radio activation pathways) and the siren system retested successfully following a silent test at approximately 1147 EST. The system is capable of being used to notify the public in an emergency. Prior to the full volume test today, a previous silent test using the radio/microwave pathway was successful. As a result of the 37 sirens that did not pass the test today, a press notice was provided. This courtesy notification is being provided under 10CFR50.72(b)(2)(xi).

"The condition was recorded in the IPEC corrective action program. The event remains under investigation."

The licensee notified the NRC Resident Inspector and FEMA. Additionally Westchester, Orange, Putnam, and Rockland counties were notified.

NOTIFICATION OF LOCAL LAW ENFORCEMENT DUE TO A SINGLE EMERGENCY SIREN ACTUATION

"At 1231 emergency siren P-007 located in the Mishicot, WI area inadvertently actuated. The siren covers 0.9% of total EPZ population. Severe weather, snow, ice and wind is occurring at this time.

"At 1340 siren actuation was verified and Manitowoc County Sheriff was notified of the sounding siren. At 1350, Point Beach performed a siren test, reset the siren and it is no longer alarming. Repair team has been dispatched to the siren location to troubleshoot and determine the cause of the actuation.

"The population coverage for siren P-007 is 0.9% and the siren malfunction is not reportable due to loss of population coverage. However, based on actuation and notification of the Manitowoc County Sheriffs Department, the event is reportable."

The NRC resident inspector has been notified.

BLIZZARD RESULTS IN SPURIOUS ACTUATION OF EMERGENCY SIREN

"At 1231 CST on 12/09/2009 Emergency Siren P-007 located in Mishicot, WI area inadvertently actuated. This siren accounts for a population coverage of 2.3%. Therefore, the KPS (Kewaunee Power Station) emergency siren coverage remains acceptable with P-007 non-functional.

"Point Beach Nuclear Plant notified the Manitowoc County Sheriff department of the actuated siren [See EN# 45553]. At 1350 CST Point Beach performed a siren test and reset the siren. The siren is no longer alarming. A repair team has been sent to the siren location to determine the cause of the actuation."

The NRC resident inspector has been notified.

WINTER STORM POWER OUTAGES CAUSE ALERT SIREN INOPERABILITY

"On December 9, 2009, at 1117 hours, 27% of the alert sirens in the Quad Cities Station Emergency Planning Zone were determined to be inoperable for greater than 60 minutes. This is considered a major loss of the Quad Cities off site notification capability. The alert sirens were disabled due to power outages caused by a winter storm. Efforts are underway at the time of this notification to restore the sirens.

"This report is being made due to the reduction in public notification capabilities in accordance with 10CFR50.72(b)(3)(xiii).

"A follow-up notification will be provided when the sirens have been restored."

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM MIKE MACLENNAN TO DONALD NORWOOD AT 0849 EST ON 12/10/2009 * * *

"Follow-up Notification - Repairs to the emergency sirens were completed as of 0100 hours. All sirens are restored."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Phillips).

AUTOMATIC REACTOR TRIP ON UNIT 2 AND EDG START ON BOTH UNITS DUE TO INADVERTENT LOSS OF "C" RESERVE STATION SERVICE TRANSFORMER

"At 1423 hours on 12/9/2009, electrical supply breaker L102 was inadvertently opened which caused electrical Bus 3 and the 'C' Reserve Station Service Transformer to de-energize. This caused the loss of 'F' Transfer Bus which resulted in a loss of power to the 1H and 2J Emergency Busses and an automatic start of the 1H and the 2J Emergency Diesel Generators. Both emergency diesel generators started and re-energized their associated emergency bus as designed.

"The Unit 2 'G' Bus, which supplies power to the Unit 2 Circulating Water Pumps, did not automatically transfer to the 'B' Reserve Station Service Transformer in a sufficiently short time to prevent the loss of the Unit 2 Circulating Water pumps. The loss of the Unit 2 Circulating Water pumps resulted in an automatic low vacuum turbine trip and a subsequent [Unit 2] reactor trip due to the turbine trip.

"The 2 'G' Bus did automatically transfer to the 'B' Reserve Station Service Transformer and is currently energized. The Unit 2 Auxiliary Feedwater pumps automatically started and provided flow to the steam generators. There were no issues with the Auxiliary Feedwater System operation.

"The Unit 2 'A' Charging Pump and the Unit 2 'A' Component Cooling Water pump automatically started as designed due to the loss of power. The Unit 1 'B' Charging Pump and the Unit 1 'B' Component Cooling Water pump automatically started as designed due to the loss of power. The Unit 2 'C' Station Service Bus was lost following the trip when the electrical system automatically transferred to the Reserve Station Service transformers. With the 'C' Reserve Station Service Transformer de-energized the 'C' Station Service Bus was unable to transfer to an energized transformer. This resulted in the loss of the Unit 2 'C' Reactor Coolant Pump. The 'A' and 'B' Reactor Coolant Pumps remain in service at this time.

"The reactor trip is reportable per 10CFR50.72(b)(2)(iv)(B).

"The Auxiliary Feedwater system, Emergency Diesel Generator system, Charging system actuations are reportable per 10CFR50.72(b)(3)(iv)(A).

"The electrical system is being returned to a normal lineup. The condensate and feedwater system remained in service to provide flow to the steam generators. Steam Dump operation to the condenser is not available due to low condenser vacuum, therefore steam is being released to the atmosphere from the Steam Generator Power Operated Relief Valves."

The licensee suspects that switchyard maintenance activities caused the L102 trip which initiated the chain of events. All rods inserted into the core during the trip. During the transient, some secondary relief valves lifted and properly reseated. There is no known primary to secondary leakage. During the event call, the licensee reported that the 'C' Reserve Station Service Transformer was returned to service.

The licensee notified the NRC Resident Inspector and will be notifying the Louisa County Administrator.

MANUAL SCRAM FOLLOWING HIGH TURBINE VIBRATION

"At 2310 EST, Vogtle Unit 1 was manually tripped from 24% reactor power while the main turbine was rolling at 1800 rpm, preparing for synchronization to the grid.

"As Vogtle 1 was preparing to bring the Unit 1 generator on line following a forced outage, high vibration levels were experienced on the HP turbine bearings while the Turbine was at rated speed and synchronization preparations were in progress. The Turbine was manually tripped in accordance with plant procedures. Vibrations continued to increase as the Turbine began to coast down, warranting that vacuum be broken in accordance with procedures.

"The reactor was manually tripped in anticipation of trip of the main feedwater pump (due to loss of condenser vacuum) and condenser vacuum was broken to slow the turbine. When condenser vacuum was broken, the in-service Main Feedwater Pump auto tripped as expected, causing an automatic actuation of the Motor Driven Auxiliary Feedwater system.

"The cause of high vibrations on the Turbine is being investigated.

"All systems responded as expected on the trip."

All control rods fully inserted into the core following the reactor trip. Atmospheric relief valves are being used to remove decay heat. There is no known primary to secondary leakage. The plant is in a normal post-trip electrical line-up.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - Cs-137 BRACHYTHERAPY SOURCE LEAKING

The following information was communicated to the NRC via a telephone notification on December 14, 2009:

On Wednesday, December 9, 2009, Bionomics personnel were at McLeod Regional Medical Center in Florence, SC to package several old sources for disposal. These packages remained at McLeod until the following day when Bionomics personnel picked them up for transport to the Bionomics facility in Oak Ridge, TN.

On Friday, December 11, 2009, a Bionomics worker reported that he had radioactive contamination on his clothing. On Sunday, December 13, 2009 it was ascertained that this radioactive contamination had come from the sources picked up at McLeod. A brachytherapy source containing 38 mCi of Cs-137 was found to be leaking. Bionomics contacted an HP consultant from the University of SC to have him perform radiation surveys at the McLeod facility. Radiation surveys found contamination in treatment areas, supply rooms, offices, and hallways. Highest contact readings were localized and were approximately 100 mR/hr. At this time it is believed that no radioactive contamination had been tracked outside of the McLeod facility.

The McLeod Radiation Safety Officer has surveyed all staff personnel - except for two individuals - that had been in the contaminated areas. No radioactive contamination was found on any of these individuals. The other two individuals will be surveyed today, Monday, December 14, 2009.

Bionomics personnel are presently on-site at the McLeod Medical Center performing decontamination. The Medical Center has closed the area to personnel and patients until decontamination is completed.

AGREEMENT STATE REPORT - MEDICAL EVENT - RADIOPHARAMACEUTICAL ADMINISTERED TO WRONG PATIENT

The following information was received via e-mail:

"On Wednesday, December 9, 2009, an 8 mCi dose of Tc-99m Sestamibi was administered via IV injection to an incorrect patient. The patient receiving the misinjection did not have a written order for the procedure in their medical chart. The event was reported to the RCP (Radiation Control Program) by telephone on Thursday December 10, 2009, as required in NRC 35.3045, 'Report and Notification of a Medical Event.'

"The misinjection was a result of the technologist failing to follow established written policy and procedure of verifying the patient I.D. with three identifiers: Name (patient spelling last name), DOB (verbalized by patient) and UMC Account Number and not using an interpreter as directed by policy. This procedure of patient identification has been established as a barrier to prevent such a situation from occurring. Failure to follow procedure is in direct violation of hospital policy and resulted in disciplinary action.

"The patient was immediately notified of the event. No adverse effect of the injection has been foreseen considering the activity of the radiopharmaceutical administered. The physician of the patient was also notified of the misinjection by telephone.

"The RSO has been notified of the misinjection and the details of the incident have been entered into the minutes of the radiation safety committee meeting for this quarter on December 10, 2009.

"This event is closed.

"Item Number: NV090001."

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.