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Event Notification Report for January 20, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/19/2010 - 01/20/2010

** EVENT NUMBERS **


45628 45630 45632 45633 45634 45635 45636

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45628
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEE KELLY
HQ OPS Officer: PETE SNYDER
Notification Date: 01/13/2010
Notification Time: 22:43 [ET]
Event Date: 01/13/2010
Event Time: 11:25 [PST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BOB HAGAR (R4DO)

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

WRONG TRAIN OF EMERGENCY CORE COOLING SYSTEM REMOVED FROM SERVICE

"On January 13, 2010, at about 1125 PST, Train A suction piping from the SONGS Unit 3 Refueling Water Storage Tank (RWST) was determined to be inoperable following detection of weld flaw indications during ultrasonic testing. Due to miscommunication, operators mistakenly declared the Train B Emergency Core Cooling System (ECCS) header inoperable at about 1125 and removed DC control power to the Train B ECCS pumps. This resulted in both trains of Unit 3 ECCS being inoperable and entry into the Technical Specification (TS) 3.0.3 one-hour shut down action. At 1140 PST, the DC control power was restored to the Train B ECCS pumps, Train B ECCS was declared operable, and TS 3.0.3 was exited. SCE is reporting this in accordance with 10 CFR 50.72(b)(3)(v) as an event that could have prevented the fulfillment of a safety function.

"SCE is further evaluating the indications found on Train A piping to determine if the piping is capable of performing its safety function. At the time of this occurrence, Unit 2 was in a Steam Generator Replacement Outage, and Unit 3 was at approximately 100% power."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY LEE KELLY TO DONG PARK AT 1402 EST ON 1/19/10 * * *

"On January 13, 2010, SCE reported that both trains of Unit 3 Emergency Core Cooling System were inoperable for approximately 15 minutes because Train B ECCS was mistakenly taken out of service when weld flaw indications were found on Train A ECCS piping. This resulted in a condition that could have prevented the fulfillment of a safety function. Consequently, both trains of ECCS in Unit 3 were declared inoperable and the unit entered into Technical Specification 3.0.3 at 1134 PST (Time of Discovery). At 1140 PST, Train B ECCS was declared operable and TS 3.0.3 was exited.

"Event Notification 45628 was conservatively made because, although Train A ECCS piping remained capable of performing its safety function, this was not yet formally documented at the time the 8-hour report was due. Subsequently, an engineering evaluation was completed at 2308 PST on January 13, 2010, that demonstrates the as-found condition of the Train A ECCS piping was operable because the flaw meets the evaluation criteria of ASME Boiler and Pressure Vessel Code Case N-513-2. Since Train A ECCS piping was operable, this event did not constitute a condition that could have prevented the fulfillment of a safety function and is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"Consequently, SCE is retracting the phone report to the NRC on January 13, 2010. The NRC Resident Inspector will be informed of this report."

Notified R4DO (Werner).

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Hospital Event Number: 45630
Rep Org: QHG OF INDIANA
Licensee: QHG OF INDIANA
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01535-01
Agreement: N
Docket:
NRC Notified By: THOMAS M. KUMPURIS
HQ OPS Officer: JOE O'HARA
Notification Date: 01/14/2010
Notification Time: 16:00 [ET]
Event Date: 01/14/2010
Event Time: 14:00 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
ROBERT LEWIS (FSME)

Event Text

INCORRECT DOSE ADMINISTERED TO PATIENT

Two patients were to receive hyper thyroid therapy on 1/14/10, and the hospital prepared written directives for each patient. One patient was prescribed 25 milliCurie of I-131. The second patient was prescribed 30 milliCurie of I-131. The first patient arrived and the technician assayed and administered the 30 milliCurie dose for the patient who was to receive 25 milliCurie. The tech administered 31.4 milliCurie to the patient. This is a 25.6% difference than prescribed in the written directive for the patient. The patient and prescribing physician have not been informed. The hospital does not believe there is any long term medical consequence to the patient. The hospital management team is reviewing protocols to prevent recurrence of this event.

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: 45632
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: JEFF ZELL CONSULTING INC
Region: 1
City: CORAOPOLIS State: PA
County:
License #: 37-28531-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/14/2010
Notification Time: 19:28 [ET]
Event Date: 01/14/2010
Event Time: 14:45 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ROBERT LEWIS (FSME)
ILTAB via email ()
Canada via fax ()

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

Event Text

AGREEMENT STATE - MISSING MOISTURE DENSITY GAUGE

"Zell's former consultant HP (Health Physicist) informed DEP (Department of Environmental Protection) that [a] nuclear gauge was discovered [to be missing] while performing a 6-month inventory on January 13. An unsuccessful search for the missing nuclear density gauge (Humboldt Model 5001 EZ122; Ser. No. 5375) was concluded on January 14. The licensee notes the gauge cannot be accounted for at this time. Gauge contains about 10 milliCuries Cs-137 and 40 milliCuries Am-241 (as an Am/be neutron source)."

PA Event #: PA100001

Notified R1DO (Dimitriadis) and FSME (Lewis).

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

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Power Reactor Event Number: 45633
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/18/2010
Notification Time: 23:03 [ET]
Event Date: 01/18/2010
Event Time: 15:00 [CST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTINE LIPA (R3DO)
CANADA VIA FAX ()
WILLIAM RULAND (NRR)
ROBERT LEWIS (FSME)
This material event contains a "Less than Cat 3" level of radioactive material.

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

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

Event Text

MISSING RADIOACTIVE SOURCES GREATER THAN 10 TIMES THE LIMIT

"In 2009, a radioactive source inventory was conducted by a Prairie Island Radiation Protection Specialist. During the inventory, it was determined that two sources were missing that are greater than 10 times the quantity specified in 10CFR20 Appendix C. These two sources include a 0.07 [micro]Ci U-234 radiation monitor detector and a 0.2 [micro]Ci mixed gamma standard that contains 0.09 [micro]Ci of Am-241 (a 60 ml vial used for HPGe calibration.) The U-234 source is normally stored in the Hot I&C Shop and the mixed gamma standard with Am-241 is normally stored in the Hot Chemistry Lab. The inventory, that concluded on December 18, 2009, listed these sources as lost. Four other sources, that do not exceed 10 times any quantity specified in 10CFR20 Appendix C, were also unaccounted for during this inventory. Radiation Protection is still in the process of locating the missing sources that were identified during this inventory."

The licensee will provide information on the four other sources to the Operations Center on 1/19/2010.

The licensee has informed the NRC Resident Inspector.

* * * UPDATE FROM STEVE INGALLS TO DONG PARK @ 1547 EST ON 01/19/10 * * *

"The four sources that do not exceed 10 times any quantity specified in 10CFR20 Appendix C:

"Isotope Ci Content
"C-14 TLD check source 0.5 [micro]Ci
"Cs-137 check source 8.8 [nano]Ci
"mixed gamma calibration source 1.9 [micro]Ci
"mixed gamma calibration source 2.0 [micro]Ci

"The 2.0 [micro]Ci mixed gamma source (previously reported as 0.2 [micro]Ci) that contains 0.09 [micro]Ci of Am-241(60 ml vial used for HPGe calibration) has been located in the Hot Chemistry Lab. Investigation into the five remaining sources continues."

The licensee has informed the NRC Resident Inspector.

Notified R3DO (Pelke), NRR EO (Cunningham), FSME EO (Camper), and Canada via fax.

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 45634
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: GEOFF COOK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/18/2010
Notification Time: 23:43 [ET]
Event Date: 01/18/2010
Event Time: 19:50 [PST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (R4DO)
ROBERT KAHLER (NSIR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY OPERATIONS FACILITY INACCESSIBLE DUE TO ROAD FLOODING

"On January 18, 2010, at about 1950 PST, the access road to the SONGS MESA facilities became flooded after a day of rain. The San Onofre Emergency Operations Facility (EOF) is located at the MESA and because of the flooding, is inaccessible to passenger vehicles. While the EOF itself is operable, in the event of an emergency at San Onofre, SCE [Southern California Edison] would direct EOF emergency responders to the alternate EOF located in Irvine, California. SCE is reporting this occurrence to the NRC in accordance with 10CFR50.72(b)(3)(xiii).

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement outage and Unit 3 was operating at about 100% power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

* * * UPDATE FROM GEOFF COOK TO DONG PARK @ 1208 EST ON 01/19/10 * * *

"On January 18, 2010 at about 2101 PST, the MESA road flooding had dissipated sufficiently for car traffic to be passable. In the event of an emergency at San Onofre, there is no longer a need to redirect emergency responders to the alternate EOF located in Irvine, California. This report is to advise the NRC of this change in EOF access status. Also note that it is expected that rain will continue in the SONGS area during the week of January 17, 2010 and this status is subject to change.

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement Outage and Unit 3 was operating at about 100% power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

Notified R4DO (Werner) and NSIR (Kahler).

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Power Reactor Event Number: 45635
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: DANIEL DEAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/19/2010
Notification Time: 08:35 [ET]
Event Date: 01/19/2010
Event Time: 05:53 [EST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (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 FIRE DEPARTMENT ASSISTANCE REQUIRED FOR A FAILED RESIDENTIAL TRANSFORMER

"At 0553 hours on 01/19/2010, plant personnel noted smoke emanating from a residential transformer within the Protected Area which was not affecting plant operation. The on-site fire brigade was dispatched to investigate. Rochester Gas and Electric Corporation (RG&E) was notified to isolate the off-site power supply to the transformer. While awaiting the arrival of RG&E personnel, the on-site Fire Brigade noted that the transformer smoke was worsening along with increased noises from the transformer. The Ontario Fire Department was notified at 0715 hours to provide off site assistance.

"Ginna remains at 100% power, normal operating temperature of 574 degrees, and normal operating pressure of 2235 psig."

The transformer supplies power to office trailers.

The licensee notified the state and the NRC Resident Inspector.

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Power Reactor Event Number: 45636
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: GEOFF COOK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/19/2010
Notification Time: 11:20 [ET]
Event Date: 01/19/2010
Event Time: 04:30 [PST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG WERNER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY SIREN SPURIOUS ACTUATION

"On January 19, 2010, at about 0445 PST, the SONGS Control Room was notified of a spurious actuation of a SONGS emergency response siren located in the city of San Clemente.

"The actuation occurred on January 19, 2010 at about 0430 PST for a duration of approximately 30 minutes. Upon investigation the siren was put into a silent test mode and technicians were able to duplicate the sounding. The siren was subsequently put into an inoperable status pending investigation and the cause of the actuation is unknown at this time.

"SCE [Southern California Edison] personnel notified Orange County, the City of San Clemente and the City of Dana Point regarding the inadvertent actuation of part of the public notification system.

"In compliance with 10CFR50.72(b)(2)(xi), requiring licensees to report any event that results in notification to other government agencies, SCE is providing this notification to the NRC.

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement Outage and Unit 3 was operating at about 100 percent power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

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