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Event Notification Report for June 17, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/16/2010 - 06/17/2010

** EVENT NUMBERS **


45999 46000 46002 46013 46014 46016 46017 46018 46019 46020

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General Information or Other Event Number: 45999
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MEDICAL COLLEGE OF WISCONSIN
Region: 3
City:  State: WI
County:
License #: 079-1104-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: JOE O'HARA
Notification Date: 06/10/2010
Notification Time: 11:18 [ET]
Event Date: 06/10/2010
Event Time: [CDT]
Last Update Date: 06/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY DOSE RECEIVED WAS GREATER THAN 20% OF PRESCRIBED DOSE

The following was received from the State via fax:

"On June 9, 2010, the Radiation Safety Officer (RSO) reported that earlier that day a patient undergoing an intravascular brachytherapy procedure was administered a dose to the coronary artery exceeding the prescribed dose by more than 20%. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 18.4 Gy; the dose delivered was 23 Gy. The treatment device is a Novoste Beta-Cath intravascular brachytherapy device containing Sr-90. The overdose was identified during the post-planning for the procedure. The treatment time for this procedure is based on the measured diameter of the coronary artery. Depending on the diameter, one or three treatment times is selected; in this case the wrong treatment time was selected. The RSO stated that this treatment time is supposed to be independently reviewed and approved on the written directive, which is to be signed by the authorized user. The written directive was not signed by the authorized user prior to administration. [Wisconsin] DHS inspectors will investigate this medical event on June 11, 2010."

Event Report No.: WI100008

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: 46000
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NRG TEXAS POWER LLC
Region: 4
City: THOMPSON State: TX
County:
License #: L02063
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2010
Notification Time: 12:15 [ET]
Event Date: 06/10/2010
Event Time: [CDT]
Last Update Date: 06/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE MALFUNCTIONS

"On June 11, 2010 at 1100 Central Daylight Time, the Agency, [Texas Department of Health,] was notified by the licensee that the shutters on six gauges failed in the open position. Three of the gauges were manufactured by Berthold [Model 7400D] and each contained 30 millicuries of Cesium (Cs) - 137 (S/N's: 2423, 2425, 2426). The other three gauges were manufactured by Ohmart/VEGA [Model SHD] and each contained 150 millicuries of Cs-137 (S/N's: 74452, 74453, 73491). The licensee stated that dose rates taken in the area were normal, since the shutters failed in their normal operating positions. The licensee has contacted the manufacturer to schedule a repair of the gauges. The Agency reminded the licensee to request an exemption to continue to use the gauges while their shutters are awaiting repair so that that the licensee would not violate a condition of their license."

A contractor is making arrangements for the gauges to be repaired by their manufacturers.

Texas Incident No: I-8753

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General Information or Other Event Number: 46002
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TEAM INDUSTRIAL SERVICES INC.
Region: 4
City: HUTCHINSON State: KS
County:
License #: 21-B875
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2010
Notification Time: 17:21 [ET]
Event Date: 06/11/2010
Event Time: 16:00 [CDT]
Last Update Date: 06/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)
JULIO LARA (R3DO)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY CAMERA SOURCE

At approximately 1600 CDT local time, a Kansas Licensee, Team Industrial Services Inc., reported that they had a radiography camera source become stuck during source retraction. While they were retracting the source, the stand tipped and resulted in the guide tube being bent such that the source could not be fully retracted. The licensee was able to secure the area easily since the shot was being conducted in a vault. Personnel exited the area and the licensee contacted their corporate RSO in Hammond, Indiana. There is no concern by the licensee of any over-exposure.

The State, after talking with the licensee's corporate RSO, authorized recovery by a person on-site who is listed under the NRC license in Indiana.

The State is expediting reciprocity paperwork to recognize the source recovery.

Kansas # KS-100005.

* * * UPDATE FROM DAVE WHITFILL TO STEVE SANDIN AT 1848 EDT ON 6/11/10 * * *

At 1725 CDT the source was successfully retracted. Notified R4DO (Powers) and FSME (Mauer).

* * * UPDATE FROM DAVE WHITFILL TO BILL HUFFMAN AT 1716 EDT ON 6/14/10 * * *

The State of Kansas provided the following additional details on this event via facsimile:

"Equipment involved: QSA Global model 880D exposure device s/n D3027, Iridium 192 s/n 59219B, 26.6 curies, with associated equipment including drive mechanism, guide tube. And a tungsten collimator.

"Description of incident: At approximately 3:15 pm, the magnetic stand used during the exposure set up fell at the conclusion of a radiographic exposure and impacted the source guide tube causing it to crimp and preventing the source assembly from returning to the fully shielded position within the exposure device.

"Actions taken to resolve: The exposures were conducted within a shielded room thereby providing radiation attenuation and enhancing control of the area during incident remediation activities. There were no exposures to unmonitored persons or members of the general public. The Radiographer immediately contacted emergency response personnel within Team Industrial Services, Inc. including the Corporate Radiation Safety Officer. The CRSO performed a preliminary assessment of the event and contacted Kansas Department of Health and Environment. A retrieval plan was developed and discussed with on site personnel. The plan used involved the placement of additional shielding (including available steel and bags of welding flux) at the source location using an overhead crane. This reduced the radiation levels to the point that the radiographer could approach the location of the crimp and remove the crimp by applying pressure using large adjustable pliers (i.e. channel-lock type). He then retracted the source into the fully shielded position within the exposure device, surveyed, and locked the device. The exposure for the complete activity including the radiographic operations was 120 mrem for the radiographer and 75 mrem for the assistant radiographer as registered on their assigned direct reading dosimeters.

"Corrective Actions taken: The damaged guide tube was immediately removed from service. An inspection of the device and drive assembly, including the drive cable and source assembly, will be conducted to determine if any damage occurred before releasing for continued use. An investigation into the use of the magnetic stand will be conducted to try to determine the problems associated with the use of this type of source positioning device."

Notified R4DO (Powers), R3DO (Kunowski), and FSME (Mauer).

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Power Reactor Event Number: 46013
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MICHAEL WHALEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2010
Notification Time: 13:38 [ET]
Event Date: 06/16/2010
Event Time: 08:59 [EDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DANIEL RICH (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation
2 N Y 98 Power Operation 98 Power Operation

Event Text

EARLY WARNING SYSTEM FOUND NON-RESPONSIVE DURING TESTING

"During performance of the Early Warning System (EWS) Polling Function Test the sirens did not respond. At 0859 hours [EDT] on June 16, 2010, the polling function test of the sirens was started. After four (4) sirens did not respond to the polling, the test was suspended and the Telecommunications group was notified. With Telecommunications monitoring the EWS primary base radio, the polling function test was run again. It was determined the audio signals from the status logger were being transmitted to the EWS primary base radio, however, the radio was not keying or transmitting the audio signal to the sirens. A check of the keying signal from the processor to the primary base radio was noted to be operating properly, however, the primary base radio was still not transmitting the audio signal to the sirens. Therefore, activation of the EWS by the state or local agencies would not have been possible. At 0925 hours, the EWS was switched to the back-up radio base station and tested satisfactory for proper radio function. The polling function test was performed with all 68 sirens responding as designed. All 68 sirens polled satisfactory during the last performance of the EWS Polling Function Test on June 2, 2010."

The licensee has notified the State and the NRC Resident Inspector. Local agencies will also be informed.

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General Information or Other Event Number: 46014
Rep Org: TYCO ELECTRONICS
Licensee: TYCO ELECTRONICS
Region: 1
City: ASHEVILLE State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SCOTT DAUBERT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2010
Notification Time: 15:30 [ET]
Event Date: 05/21/2010
Event Time: [EDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DANIEL HOLODY (R1DO)
DANIEL RICH (R2DO)
MICHAEL KUNOWSKI (R3DO)
WILLIAM JONES (R4DO)
PART 21 E-MAIL GROUP ()

Event Text

TYCO ELECTRONIC RELAY RECALL

The information below is a summary of a report received via facsimile from Tyco electronics:

"During normal assembly processing of nuclear E7000 relays, Tyco Electronics experienced an issue with a component. A retainer ring on the spindle assembly was found to have a hydrogen embrittlement issue that may fracture at some point in this products' life cycle. Further investigation revealed this condition is limited to one specific lot of retainer rings.

"Tyco purged this lot of retainer rings from their inventory and all 'work in process'. Tyco is able to account for all the retainer rings in this lot. Tyco's records indicate that some relays shipped to the [facilities listed below] were made using this specific retainer ring lot.

"Because the retainer ring did not meet stated requirements, Tyco is recalling the specific relays for replacement. Note that only the specific lot numbers listed [below] are affected by this recall. All other lots should function as intended.

"Item supplied are E7000 relays with serial numbers beginning with 1019. Certificates of Conformance stating exact relay description and serial numbers were sent to affected customers with Tyco's June 16, 2010 notification.

Tyco sold this safety-related item for specified and unspecified applications to the customers listed below:

South Carolina Electric & Gas Jenkinsville, SC 3 Relays
Entergy Nuclear Operations, Indian Point Energy Center Buchanan, NY 2 Relays
Exelon Generation Company/Braidwood Braidwood, IL 2 Relays
Trentec Curtis-Wright Flow Control Cincinnati, OH 1 Relay
Ergytech Houston, TX 1 Relay
Entergy Operations Inc. (Arkansas) Russellville, AR 1 Relay

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Power Reactor Event Number: 46016
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: DUSTIN WRIGHT
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/16/2010
Notification Time: 17:16 [ET]
Event Date: 06/16/2010
Event Time: 10:15 [CDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (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

Event Text

LOSS OF EMERGENCY SIRENS

"On June 16, 2010, at approximately 1015 hours (CDT), the Monticello Nuclear Generating plant determined that there was a loss of 48 out of 106 Emergency Preparedness sirens. No counties other than Sherburne County were affected. Availability of less than 70% of the total number of sirens is considered to be a loss of emergency off-site response capability and is reportable under 10 CFR 50.72(b)(3)(xiii), 'Loss of Emergency Preparedness Capabilities.' Notification to the public in the event of an emergency has not been compromised since a back-up notification method is provided in the station's Emergency Plan. At this time there is no estimated return to service time for the sirens.

"The station is working on restoration of the sirens. A follow-up notification of the return to service of the sirens will be provided once the issue is corrected.

"Sherburne County, the State of Minnesota, and the NRC Resident [Inspectors] have been informed of this event.

"Updated Information:

"At 1320 hours on June 16, 2010, sirens have been returned to service. Siren activation capability has been restored via the secondary method of activation. Investigation and repair of the primary method of siren activation continues."

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Power Reactor Event Number: 46017
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/16/2010
Notification Time: 17:22 [ET]
Event Date: 06/16/2010
Event Time: 12:33 [CDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM JONES (R4DO)

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 TO THE NEBRASKA DEPARTMENT OF ENVIRONMENTAL QUALITY

"Notification was made to the Nebraska Department of Environmental Quality regarding the inability to conform to the NPDES permit, since the discharges from the sludge pond to the Missouri River are uncontrolled at this time. As a result of high Missouri River levels, the sludge pond was overtopped. The discharges into this pond are subject to NPDES Requirements. The inputs into the sludge pond are described in the NPDES permit as low volume wastewater. There are three outfalls which discharge into the pond. Outfall 002B is described as Clearwell Discharge plus Outfall 004 Emergency Overflow. Outfall 002C is described as Floor Drains. Outfall 004 is described as Reverse Osmosis Reject and Boiler Blowdown Waste streams.

"Additionally, the high river levels have resulted in media inquiries regarding potential changes in plant operation. Public information personnel and management have responded to these inquiries with information on the impact of river level and preparations for additional actions should conditions warrant additional protective actions. The responses to these inquiries have been referenced in some publications. At the present time, the river appears to be at its crest, with no additional rise forecast. The current level is approximately 3.8 feet below the crest of the 1993 flood, which was the highest flood recorded at the site, and 5 feet below grade elevation. A press release is not planned at this time."

The sludge pond does not contain any contaminated material.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 46018
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: KEVIN KIRCHBAUM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2010
Notification Time: 19:20 [ET]
Event Date: 06/16/2010
Event Time: 17:10 [EDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DANIEL RICH (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 45 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP AFTER TWO CONTROL RODS DROPPED

"At 1710 EDT, Unit 1 was manually tripped due to two dropped control rods. All CEAs [Control Element Assemblies] fully inserted on the trip. Steam generator level control responded as expected and no pressurizer or power operated relief valves opened. RCS heat removal is being maintained by main feedwater and steam bypass control systems. All other systems functioned normally and the plant has stabilized at normal operating temperature and pressure in Mode 3. This non-emergency notification is being made pursuant 10 CFR 50.72(b)(2)(iv)(B) due to manual actuation of RPS."

The licensee characterized the manual trip as uncomplicated. The second rod dropped within a very short time of the first rod. The cause of the rod drops is still under investigation. The licensee noted that no activities involving the rod control system were in progress when the event occurred. The licensee was at 45% as part of its post outage power ascension unrelated to the rod drop. The manual reactor trip action was taken per procedure when the second rod dropped. The reactor trip had no impact on Unit 2 operation.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46019
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RAY SWAFFORD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2010
Notification Time: 21:01 [ET]
Event Date: 06/16/2010
Event Time: 12:58 [CDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DANIEL RICH (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 89 Power Operation 89 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION INOPERABLE

"On 06/16/10 at 1320 CDT, while performing 2-SR-3.3.6.1.6(3), HPCI Time Delay Relay Calibration, HPCI was discovered to be isolated. After review of the Integrated Computer System (ICS), HPCI [steam supply valve] had isolated at 1258 CDT. Cause of isolation is unknown with investigation in progress.

"This incident is reportable as an 8-hour ENS notification under 10CFR 50.72 (b)(3)(v) as '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.'

"It also requires a 60 day written report. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 46020
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/16/2010
Notification Time: 21:08 [ET]
Event Date: 06/16/2010
Event Time: 19:20 [EDT]
Last Update Date: 06/16/2010
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):
DANIEL RICH (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 98 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO A LIGHTNING STORM

"On 6-16-2010 at 1920 hours, Unit 2 experienced an automatic reactor trip/turbine trip from 98% power. A severe lightning storm was in progress at the time of the trip and a lightning strike appears to be the cause of the event. The reactor trip was actuated from Channel 1 and Channel 2 Over Temperature Delta T. All control rods fully inserted into the core during the trip. The control room staff responded to the trip in accordance with plant procedures and the unit is stable in Mode 3. This event is reportable per 10CFR50.72(b)(2)(iv)(B).

"The Auxiliary Feedwater pumps started as designed following the reactor trip and steam generator inventory was restored to normal operating level. The Auxiliary Feedwater pumps have been secured and returned to automatic. This event is reportable per 10CFR50.72(b)(3)(iv)(A) due to the ESF actuation.

"Decay heat is being removed by the condenser steam dump system. The 'A' loop wide range hot and cold leg thermocouples remain failed high and the 'B' loop wide range cold leg thermocouple also failed high during the event. The plant is in a normal shutdown electrical lineup."

The licensee has notified the NRC Resident Inspector and will notify the local authorities. See EN #41898 for similar occurrence.

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